Efficacy of mosapride citrate with polyethylene glycol solution for colonoscopy preparation

Advanced intestinal regulation improves bowel preparation quality in patients with constipation: A systematic review and network meta-analysis

Background: Inadequate bowel preparation (IBP) has a critical influence on the colonoscopy procedure and is associated with significantly lower rates of detection of colorectal lesions. Constipation is an important risk factor of IBP, and some studies have attempted to address the bowel cleansing for constipated patients. However, there is still lack of consensus to guide the clinical work of bowel preparation (BP) for patients with constipation. Therefore, we aimed to perform a network meta-analysis to compare the overall efficacy of various regimens for BP in constipated patients. Methods: We performed a comprehensive search of PubMed, MEDLINE, EMBASE, Cochrane, and Web of science to identify randomized controlled trials (RCTs) of bowel preparation regimens in constipated patients, update to January 2021. Two investigators independently evaluated articles and extracted data. The odds ratio (OR) with a 95% confidence interval (CI) was used to combine dichotomous data of the primary outcome which was defined as adequate bowel preparation (ABP). Rank probability was used to exhibit the outcome of the network meta-analysis. Results: Eleven studies that included 1891 constipated patients were identified as suitable for inclusion. The proportion of ABP was associated with the administration of intensive regimen (OR 2.19, 95% CI 1.16-4.17, p = .02, I2 = 84%). Moreover, an intensive regimen had a significant efficacy and light heterogeneity when the same basic laxative program was used (OR 4.06, 95% CI 3.04-5.43, p < .0001, I2 = 0%). In the network meta-analysis, the protocol of a normal regimen + A (normal regimen plus advanced intestinal regulation) had a significant effect for bowel preparation compared with a normal regimen + IR (normal regimen plus irritating laxative regimen) (OR 5.21, 95% CI 1.18-24.55), H PEG (4L- polyethylene glycol) (OR 8.70, 95% CI 1.75-52.56), and normal regimen (NR) (OR 7.37, 95% CI 2.33-26.39). In the remaining protocols, no significant difference was observed in any comparison. No significant severe adverse events (AEs) associated with bowel preparation were reported in included studies. Conclusion: Intensive regimens could improve bowel cleansing quality for patients with constipation, and advanced intestinal regulation regimens may be superior to others.

Polyethylene glycol combined with linaclotide is an effective and well-tolerated bowel preparation regimen for colonoscopy: an endoscopist-blinded, randomized, controlled trial

BACKGROUND AND AIM

Bowel preparation is an important determinant of the quality of colonoscopy. The traditional split-dose regimen of 4 L polyethylene glycol (PEG) solutions for bowel preparation is effective but poorly tolerated. The aim of this was to study the efficacy and tolerability of using linaclotide as an adjunctive agent with low-volume PEG for bowel preparation.

METHODS

This was an endoscopist-blinded, randomized, controlled trial of 432 patients randomly assigned to three groups: 2 L PEG, 4 L PEG and 2 L PEG + 290 µg linaclotide (2 L PEG + L group). The primary outcome measure was efficacy of bowel preparation according to the Boston Bowel Preparation Scale (BBPS), with secondary outcomes of patients' tolerance, defecating frequency, complications, sleeping quality, cecal intubation rate, preparation-to-colonoscopy interval, withdrawal time, cecal intubation time, and adenoma and polyp detection rates.

RESULTS

The percentage of adequate bowel preparation in the 2 L PEG + L group was higher than that of the 2 L PEG group (87.9% vs. 77.0%; P = 0.017), but not the 4 L PEG group (87.9% vs. 91.4%; P = 0.339). In terms of the mean (SD) BBPS score for the total and segmental colons, the bowel cleansing efficacy of 2 L PEG + L was superior to that of 2 L PEG and similar to that of 4 L PEG. Patient's tolerance (including complications, willingness to repeat and sleeping quality) were compatible between the 2 L and 2 L + L group, and the 4 L group was the worst among these three groups.

CONCLUSION

Two liters of PEG combined with 290 µg linaclotide was an effective and well-tolerated bowel preparation regimen.

Efficacy of macrogol 4000 plus electrolytes in bowel preparation for colonoscopy in patients with chronic constipation

Background

Chronic constipation is a significant factor in poor bowel preparation for colonoscopy. Macrogol 4000 plus electrolytes (Movicol, EA Pharma, Tokyo, Japan), containing polyethylene glycol (PEG) and electrolytes, have been used recently to treat patients with constipation. However, prospective studies on the use of macrogol 4000 for bowel cleansing for colonoscopy are lacking. This study aimed to investigate the efficacy and safety of macrogol 4000 in addition to PEG administered in patients with chronic constipation.

Methods

This single-center, single-arm prospective study enrolled patients with chronic constipation who were scheduled to undergo colonoscopy. The primary endpoint was the proportion of good bowel preparation assessed using the Boston bowel preparation scale (BBPS) (6 or more points). The secondary endpoints were the time from when pPEG (MoviPrep, EA Pharma, Tokyo, Japan) was taken until colonoscopy could be started, amount of PEG taken, number of defecations, whether additional PEG doses were taken, and adverse events. Endoscopy-related endpoints included cecal intubation rate, insertion time, observation time, adenoma detection rate (ADR), and polyp detection rate (PDR). The tolerability of PEG and macrogol 4000 was assessed using a questionnaire.

Results

Forty patients were included in the analysis. The median BBPS was 7 (range 3–9) and ≥ 6 points in 37 cases (92.5%). The median time until colonoscopy can be started was 210 min (90–360 min), the median volume of PEG taken was 1500 mL (1000–2000 mL), and the median number of defecations was 7 (3–20). No adverse events were observed. Fourteen patients required an additional dose of PEG. Cecal intubation was achieved in all cases, the median insertion time was 6.0 min (range 2.3–22 min), and the median observation time was 8.8 min (range 4.0–16.0 min). The ADR and PDR were 60.0% and 75.0%, respectively. A proportion of patients rated the tolerability of macrogol 4000 and PEG as 95.0% and 50.0%, respectively.

Conclusions

Intake of macrogol 4000 in addition to PEG is effective and safe for colonoscopy in patients with chronic constipation.

Clinical trial registration statement This study was registered in the UMIN-CTR database (UMIN-ID000038315).

Safe and appropriate use of laxatives for colonoscopy

Background: Appropriate bowel preparation is essential for effective colonoscopy. Inadequate use of bowel preparation solutions reduces patient compliance, makes the detection of lesions such as adenoma difficult, and increases the risk of complication such as perforation. Current Concepts: A 4-L polyethylene glycol (PEG) solution can be safely used for bowel preparation, even in most individuals with underlying diseases. However, it requires a high preparation-volume intake and has poor patient compliance due to its unpleasant taste. Therefore, a 2- or 1- L sulfate-free, PEG-based laxative was developed to, reduce the amount of PEG and improve the taste. Furthermore, simethicon-containing laxative formulation was developed to eliminate gas bubbles. In addition, oral bowel preparation solutions with enema agents and prokinetics were used to improve bowel preparation, but no improvement was observed. Various alternative laxatives are available; however, PEG-based bowel preparation solutions are still recommended in most cases due to their stability. Discussion and Conclusion: Although a 4-L PEG solutions recommended for bowel preparation in most cases, several laxatives have been introduced to overcome its disadvantages. The laxative agent must be selected according to each patient’s specific characteristics. Moreover, the method of taking bowel preparation solutions and additional bowel preparation medications must be carefully chosen. In addition, patient education via various methods, such as using a smartphone, when taking a bowel preparation agent may help improve bowel preparation quality.

Pre-administration of super-low volume polyethylene glycol is as effective as senna laxative as bowel preparation for colonoscopy: a randomized controlled phase 2 trial

BACKGROUND AND PURPOSE

Senna laxatives are commonly used for bowel preparation before colonoscopies in Japan. However, this laxative frequently causes complications such as abdominal pain. This study aimed to establish a novel method of bowel preparation, which involved the pre-administration of super-low volume polyethylene glycol (PEG) for three days followed by the same-day administration of low volume PEG.

METHODS

This study was a prospective, multicenter, investigator-blinded, phase 2, randomized control trial. The intake of 13.9 g (120 mL) of PEG or 1 g of a senna laxative for 3 days before the examination was indicated for each group, and 2 L of PEG solution was used for preparation on the examination day. The primary endpoint was the efficacy of bowel cleansing, as assessed by the Boston bowel preparation scale. The secondary endpoints were the adenoma detection rate and occurrence of complications.

RESULTS

A total of 250 patients were initially enrolled. A total of 122 patients from each group were included in the intention-to-treat analysis. In the intention-to-treat analysis, the responder rates were the same for the two groups (56.6% vs 50.8%). Additionally, the adenoma detection rate did not differ between the two groups (34.9% vs 41.8%, P = 0.3795). In contrast, adherence was higher in the PEG group (93.4% vs 82.8%, P = 0.0101), and the occurrence of complications was lower in the PEG group (1.7% vs 16.4%, P = 0.0001).

CONCLUSION

The novel super-low volume PEG method for bowel preparation was as effective as the conventional method with senna laxatives.

Colonoscopy screening and surveillance guidelines

The Colonoscopy Screening and Surveillance Guidelines were developed by the Japan Gastroenterological Endoscopy Society as basic guidelines based on the scientific methods. The importance of endoscopic screening and surveillance for both detection and post-treatment follow-up of colorectal cancer has been recognized as essential to reduce disease mortality. There is limited high-level evidence in this field; therefore, we had to focus on the consensus of experts. These clinical practice guidelines consist of 20 clinical questions and eight background knowledge topics that have been determined as the current guiding principles.

Antiemetics improve the tolerance of polyethylene glycol for colonoscopy preparation: A randomized clinical trial

BACKGROUND

Bowel preparation is essential to the success of colonoscopy. However, many patients cannot finish the preparation due to nausea and vomiting when taking polyethylene glycol (PEG). Dopamine-2 receptor antagonists, such as domperidone and sulpiride, are classical antiemetic drugs. This study aimed to explore the effect of domperidone and sulpiride on reducing the discomforts associated with PEG.

METHODS

Patients scheduled for colonoscopy were enrolled and randomly allocated into 3 groups. Patients in the domperidone group (Dom group) or sulpiride group (Sul group) took 2 doses of domperidone or sulpiride before PEG. Patients in the control group (Con group) followed the regular routine of PEG. Discomforts during bowel preparation and the quality of bowel preparation were assessed.

RESULTS

A total of 306 patients were enrolled. The participants in the Dom group and Sul group completed PEG better and had fewer abdominal discomforts than those in the Con group. The severity of nausea and abdominal fullness was lower in the Dom group and Sul group. The quality of bowel preparation was better in the Dom group and Sul group than Con group.

CONCLUSIONS

Domperidone and sulpiride could reduce the PEG-related discomfort and improve the quality of bowel preparation. This method may be a promising way to improve the satisfaction of bowel preparation for both patients and endoscopists.

The Effect of Gum Chewing on Abdominal Pain and Nausea Caused by Polyethylene Glycol Solution Used for Intestinal Cleansing Before Colonoscopy: An Endoscopist-Blinded, Randomized Controlled Trial

Gum chewing is known to have a positive effect on intestinal motility. Most studies have examined its effect on ileus, but there has been no discussion of the effects of polyethylene glycol used in preparation for colonoscopy. The purpose of this study was to determine the effect of gum chewing on abdominal pain and nausea caused by polyethylene glycol solution used for intestinal cleansing before colonoscopy. The study was planned as a single-center, randomized, controlled experimental study. The research sample was determined using power analysis (n = 60). Consecutive patients undergoing colonoscopy were randomized into the experimental and control groups. Patients in the gum group chewed mint-flavored sugar-free gum for 20 minutes every 2 hours until the start of colonoscopy after consuming 2 L of polyethylene glycol solution. Patients in the control group drank only polyethylene glycol solution. Examination of precolonoscopy pain and nausea revealed a statistically significant difference in the gum chewing group (p < .05). Patients using sugar-free gum experienced statistically significant fewer problems after colonoscopy. Gum chewing had a positive effect on abdominal pain and nausea. There are no drawbacks to presolution chewing, and it may be recommended for patients.

Sodium phosphate is superior to polyethylene glycol in constipated patients undergoing colonoscopy: a systematic review and meta-analysis

BACKGROUND

Constipation is an important and highly prevalent predictor of inadequate bowel preparation during colonoscopy. In North America, between 2 and 28% of the general population suffer from constipation. Despite the high prevalence of constipation, to our knowledge, no meta-analysis on the optimal bowel preparation for constipated patients has been performed. We aimed to systematically review the literature to determine the ideal bowel preparation regiment for patients with chronic constipation.

METHODS

A comprehensive search of electronic databases (MEDLINE, EMBASE, SCOPUS, and Web of Science) was performed. We included studies that assessed the quality of bowel preparation in constipated patients receiving different agents prior to colonoscopy. The primary outcome was colon cleanliness. Secondary outcomes included tolerability of the bowel preparation and serious adverse events.

RESULTS

Preliminary database search yielded 1581 articles after duplicates were removed. After screening of the titles and abstracts using the exclusion criteria, 358 full-text articles were retained. Full-text articles were reviewed and eight studies meeting the inclusion criteria were included for qualitative synthesis. Three randomized controlled trials identified a total of 1636 constipated patients, of whom 225 were eligible for meta-analysis. Of those, 107 (47.6%) received NaP and 118 (52.4%) received PEG. Patients receiving NaP before colonoscopy had a higher chance of a successful bowel preparation than patients receiving PEG (OR 1.87, CI 1.06 to 3.32, P = 0.003). In the studies comparing PEG to NaP, two found that NaP resulted in greater tolerability of the bowel preparation and one study found that PEG resulted in superior tolerability.

CONCLUSIONS

In chronically constipated patients undergoing colonoscopy, the use of NaP may result in superior colonic cleanliness when compared to PEG, however, quality of evidence was low. Further high-quality studies are required to delineate the optimal bowel preparation in patients with constipation.

A meta-analysis of randomized controlled trials of the addition of lubiprostone to bowel preparation before colonoscopy

AIM

Adequate bowel preparation is essential to the quality of colonoscopy. We performed a meta-analysis to determine the efficacy and safety of the addition of lubiprostone to the bowel preparation process prior to colonoscopy.

METHODS

Online databases, namely, PubMed, MEDLINE and Cochrane Library, were searched for randomized controlled trials that assessed the additive effect of lubiprostone on the quality of colon preparation in patients undergoing colonoscopy. Each included study was evaluated by the Jadad score to assess the quality of the study. The primary outcome was bowel preparation efficacy, defined as the proportion of patients with an excellent or poor preparation. The secondary outcomes included the length of the colonoscopy, polyp detection, and any adverse effects.

RESULTS

In total, 5 articles published between 2008 and 2016 fulfilled the selection criteria. The addition of lubiprostone to the bowel cleansing process significantly increased the proportion of patients with an excellent preparation (risk ratio [RR] = 1.68, 95% confidence interval (CI): 1.40-2.02, P < .00001) but did not decrease the procedural time or increase the polyp detection rate (mean difference = -0.52, 95% CI: -3.74-2.69, P = .75; RR = 1.16, 95% CI: 0.96-1.42, P = .13, respectively). There was no significant difference in the proportion of patients with any adverse events.

CONCLUSION

The addition of lubiprostone to the bowel preparation regimen prior to colonoscopy is effective and safe.

Efficacy of mosapride citrate with a split dose of polyethylene glycol plus ascorbic acid for bowel preparation in elderly patients: A randomized controlled trial

BACKGROUND/AIMS

Old age is a risk factor of suboptimal bowel preparation. This study aimed to evaluate the efficacy of mosapride citrate with a split dose of polyethylene glycol (PEG) plus ascorbic acid for bowel preparation in elderly patients (aged ≥65 years) before they underwent a colonoscopy.

MATERIALS AND METHODS

This prospective investigator-blinded randomized study was conducted from November 2017 to October 2018. The patients were randomly divided into 2 groups, a mosapride group (mosapride citrate with a split-dose of PEG plus ascorbic acid) or a non-mosapride group (a split-dose of PEG plus ascorbic acid alone). Mosapride citrate 15 mg (Gastin CR) was administered once with each split-dose of the bowel preparation. The bowel preparation quality was assessed using the Boston Bowel Preparation Scale (BBPS).

RESULTS

A total of 257 patients were finally included and analyzed in our study. The total BBPS score was significantly higher in the mosapride group than in the non-mosapride group (8.53 vs 8.24, P = .033). The BBPS scores of the right colon and mid-colon were 2.75 vs 2.61 (P = .044) and 2.89 vs 2.79 (P = .030), respectively. The rate of adequate bowel preparation (BBPS ≥ 6) was similar in both groups (98.4% vs 98.5%, P = .968), while the rate of excellent bowel preparation (BBPS = 9) was higher in the mosapride group than in the non-mosapride group (73.8% vs 61.1%, P = .029). The total incidence of adverse events during the administration of the bowel cleansing agent, particularly abdominal fullness, was lower in the mosapride group (11.9% vs 30.5%, P < .001).

CONCLUSION

The administration of mosapride citrate with a split-dose of PEG plus ascorbic acid in elderly patients showed an increase in bowel preparation efficacy and reduced adverse events, particularly abdominal fullness, during the administration of a bowel cleansing agent.

A Randomized Trial of Split Dose 3 L Polyethylene Glycol Lavage Solution, 2 L Polyethylene Glycol Lavage Combined With Castor Oil, and 1 L of Polyethylene Glycol Lavage Solution Combined With Castor Oil and Ascorbic Acid for Preparation for Colonoscopy

Background: Castor oil (CaO) has the potential of halving the required volume of bowel preparation solution; however, no clinical trial investigated the efficacy of CaO on bowel preparation for colonoscopy in addition to polyethylene glycol (PEG).

Objectives: Our aim was to evaluate efficacy and safety of lower dose PEG together with 30 mL CaO alone or plus ascorbic acid (Asc) in bowel preparation before colonoscopy.

Methods: Two hundred and forty-six patients were allocated randomly to ingest 2 L PEG with 30 mL CaO, 1 L PEG with 30 mL CaO plus 5 g Asc, or 3 L PEG. We used Boston Bowel Preparation Scale (BBPS) to evaluate bowel preparation efficacy. We also determined other outcomes such as procedure time, polyp or adenoma detection rate, and adverse events (AEs).

Results: Of 282 patients recruited, 36 were excluded. Groups were matched for baseline characteristics except weight (P = 0.020) and body mass index (BMI) (P = 0.003). Patient's satisfaction was higher in 2 L PEG-CaO (P = 0.016) and 1 L PEG-CaO-Asc groups (P = 0·017). Patients' compliance was 67.5, 71.4, and 80.5% in 3 L PEG, 2 L PEG-CaO, and 1 L PEG-CaO-Asc groups (P = 0.014). Adequate bowel preparation rate was 75, 78.57, and 53.66% in 3 L PEG, 2 L PEG-CaO, and 1 L PEG-CaO-Asc groups (P = 0.021). There were no differences in terms of remaining outcomes.

Conclusions: Despite an increase in patients' satisfaction and compliance, 1 L PEG-CaO-Asc significantly decreased adequate bowel preparation rate. However, 2 L PEG-CaO improved the patients' satisfaction and compliance and increased adequate bowel preparation rate (Registration number, ChiCTR-IIR-17012418).

Efficacy of ramosetron in combination with polyethylene glycol of preparing for a colonoscopy

Background

Because of its efficacy and safety, polyethylene glycol (PEG) is generally used to prepare for colonoscopy. However, the side effects of PEG, including nausea, vomiting, abdominal discomfort, pain, and general weakness, tend to decrease patient compliance and satisfaction. The aim of this study is to investigate the efficacy and safety of PEG with 0.1 mg ramosetron on colonoscopy patients who had difficulty taking PEG due to side effects or large volume.

Methods

From January to August in 2012, 28 patients who visited Yeungnam University hospital for a colonoscopy were prospectively enrolled. All enrolled patients were previous history underwent colonoscopy using PEG only in our hospital. The efficacy and safety of ramosetron were assessed through the use of a questionnaire, and compared previous bowel preparation.

Results

Compared to previous examination, the patients using the ramosetron reported less nausea, vomiting, abdominal discomfort, and abdominal pain, as well as a higher degree of compliance and satisfaction of the patient. There were no side effects reported with the use of ramosetron. However, overall bowel preparation quality was not better than the previous examination.

Conclusion

In case of the use of ramosetron in combination with PEG for bowel preparation, patients experienced a higher rate of compliance and tolerance. Looking forward, ramosetron may become an option of pretreatment for bowel preparation.

Impact of gum chewing on the quality of bowel preparation for colonoscopy: an endoscopist-blinded, randomized controlled trial

BACKGROUND AND AIMS

Gum chewing can accelerate motility in the GI tract; clinical studies suggested gum chewing can reduce postoperative ileus. However, no trial has investigated the effect of gum chewing on bowel preparation for colonoscopy in addition to polyethylene glycol (PEG). The objective of this study was to investigate whether gum chewing before colonoscopy can increase the quality of bowel preparation.

METHODS

This was a single-center, randomized controlled trial. Consecutive patients undergoing colonoscopy were randomized to the gum group or the control group. Patients in the gum group chewed sugar-free gum every 2 hours for 20 minutes each time from the end of drinking 2 L of PEG to the beginning of colonoscopy. Patients in the control group only received 2 L of PEG before colonoscopy. The quality of bowel preparation, procedure time, adenoma detection rate, patients' tolerance, and adverse events were compared.

RESULTS

Three hundred patients were included in the study (150 in the control group, 150 in the gum group). More than 90% of patients in both groups were satisfied with the process of bowel preparation, and the incidence of adverse events was comparable in the 2 groups (41.3% vs 46.0%, P = .42). The mean Boston Bowel Preparation Scale score was 6.2 ± 1.4 and 6.1 ± 1.2 in the control group and the gum group, respectively, and the difference between the 2 groups was not significant (P = .51).

CONCLUSIONS

This study indicates that gum chewing does not improve the quality of bowel preparation for colonoscopy, but it can improve patients' satisfaction with the process of bowel preparation and does not have negative effects on cleanliness. (Clinical trials registration number: NCT02507037.).

Optimizing bowel preparation for colonoscopy: a guide to enhance quality of visualization

Colonoscopy is an important screening and therapeutic modality for colorectal cancer. Unlike other screening tests, colonoscopy is dependent on pre-procedure bowel preparation. If the bowel preparation is poor, significant pathology may be missed. Many factors are known to improve bowel preparation. This review will highlight those factors that may optimize the bowel preparation, including choice of bowel preparation, grading or scoring of the bowel preparation, special factors that influence preparation, and diet prior to colonoscopy that affects bowel preparation. The aim of the review is to offer suggestions and guide endoscopists on how to optimize the bowel preparation for the patients undergoing colonoscopy.

Combination could be another tool for bowel preparation?

Optimal bowel preparation increases the cecal intubation rate and detection of neoplastic lesions while decreasing the procedural time and procedural-related complications. Although high-volume polyethylene glycol (PEG) solution is the most frequently used preparation for bowel cleansing, patients are often unwilling to take PEG solution due to its large volume, poor palatability, and high incidence of adverse events, such as abdominal bloating and nausea. Other purgatives include osmotic agents (e.g., sodium phosphate, magnesium citrate, and sodium sulfate), stimulant agents (e.g., senna, bisacodyl, and sodium picosulfate), and prokinetic agents (e.g., cisapride, mosapride, and itopride). A combination of PEG with an osmotic, stimulant, or prokinetic agent could effectively reduce the PEG solution volume and increase patients’ adherence. Some such solutions have been found in several published studies to not be inferior to PEG alone in terms of bowel cleansing quality. Although combination methods showed similar efficacy and safety, the value of these studies is limited by shortcomings in study design. New effective and well-tolerated combination preparations are required, in addition to rigorous new validated studies.

A Randomized Controlled Trial Evaluating a Low-Volume PEG Solution Plus Ascorbic Acid versus Standard PEG Solution in Bowel Preparation for Colonoscopy

Evaluation of polyethylene glycol electrolyte lavage solution containing ascorbic acid (PEG-ASC) has been controversial in the point of its hyperosmolarity, especially in old population. So we therefore designed the present study to compare the efficacy, acceptability, tolerability, and safety of 1.5 L PEG+ASC and 2 L standard PEG electrolyte solution (PEG-ELS), not only in the general population, but also in patients of advanced age. Randomization was stratified by age (<70 years or 70> years), and hematological and biochemical parameters were compared in each age group, especially with respect to the safety profile of each regimen. As a result, the 1.5-L PEG-ASC regimen had higher patient acceptability than the 2-L PEG-ELS regimen. Tolerability, bowel cleansing, and safety were similar between regimens. However, we demonstrated significant statistical changes in the hematological and biochemical parameters after taking bowel preparation solutions, not only in the PEG+ASC group, but also in the PEG-ELS group. No significant differences in the safety profile were found between subjects aged less than 70 years and those aged 70 years or more; nevertheless, regardless of age, proper hydration is needed throughout the bowel preparation process.

A prospective randomized controlled trial of AJG522 versus standard PEG+E as bowel preparation for colonoscopy

Polyethylene glycol- (PEG-) based bowel preparations for colonoscopies are often poorly tolerated due to the large volumes of fluid intake required. We compared low-volume "modified" PEG + ascorbic acid (AJG522) with standard PEG with electrolytes (PEG+E) in addition to a stimulant laxative and an agent to improve bowel function for the bowel cleansing before colonoscopy to evaluate its efficacy, safety, and acceptability. Outpatients scheduled to undergo colonoscopy were randomized to receive either AJG522 or PEG+E. Bowel cleansing conditions were assessed via macroscopic fecal findings by blinded and independent investigators. A survey of the patients' feedback regarding the preparation was conducted by questionnaire. Successful cleansing was achieved in all cases, except for 4 cases in the PEG+E group, at 3 hours after taking the preparation. The fecal properties were significantly clearer in the AJG522 group than in the PEG+E group at 2 hours after taking each preparation (P=0.013). Although the total liquid volume of the bowel preparation was not reduced, the AJG522 preparation could significantly reduce the required volume of the preparation (P<0.0001). Moreover, the patients in the AJG522 group had better acceptability (P=0.010). There were no significant differences in the safety profiles between groups (UMIN000013892).

Orange juice intake reduces patient discomfort and is effective for bowel cleansing with polyethylene glycol during bowel preparation

BACKGROUND

Many patients report discomfort because of the unpleasant taste of bowel preparation solutions.

OBJECTIVE

This study aimed to determine whether adding orange juice to 2 L of polyethylene glycol plus ascorbic acid is effective for reducing patient discomfort and improving palatability during bowel preparation.

DESIGN

This was a single-blinded, randomized controlled trial.

SETTINGS

The study was conducted at a tertiary referral hospital and a generalized hospital.

PATIENTS

Consecutive outpatients and inpatients were randomly allocated to drink 2 L of polyethylene glycol-ascorbic acid or 2 L of polyethylene glycol-ascorbic acid with orange juice in a single dose or a split dose.

MAIN OUTCOME MEASURES

Tolerability, palatability score, willingness, and related adverse events were investigated by questionnaires. Bowel cleansing was rated using the Aronchick scale. Each score was graded on a 5-point scale.

RESULTS

A total of 107 patients, 53 in the orange juice group and 54 in the polyethylene glycol-ascorbic acid group who underwent elective colonoscopy were enrolled. The palatability score (mean ± SD) was higher in the orange juice group than in the control group (2.36 ± 0.76 vs 1.78 ± 0.88; p = 0.005). Nausea was less frequent in the orange juice group (26.4% vs 59.3%; p = 0.001). Total amount of bowel preparation ingested was not significantly different between the groups (p = 0.44). The bowel preparation score (mean ± SD) was not significantly different (1.49 ± 0.80 vs 1.43 ± 0.77; p = 0.94). Willingness to repeat the same process was higher in the orange juice group (90.4% vs 66.7%; p = 0.003).

LIMITATIONS

This study is limited because only ambulatory patients were enrolled.

CONCLUSIONS

Orange juice intake before drinking 2 L of polyethylene glycol-ascorbic acid for colonoscopy can reduce patient discomfort, resulting in improved acceptability and patient compliance. This method is as effective for bowel cleansing as polyethylene glycol.

A Randomized Prospective Study of Bowel Preparation for Colonoscopy with Low-Dose Sodium Phosphate Tablets versus Polyethylene Glycol Electrolyte Solution

Optimal bowel preparation is essential for the safety and outcome of colonoscopy. A solution containing polyethylene glycol (PEG) is often used as a bowel cleansing agent, but some patients are intolerant of PEG, and this may lead to discontinuation of colonoscopy. Sodium phosphates (NaP) tablets are designed to improve patient acceptance and compliance. The objective of this study was to compare bowel preparation efficiency and patient acceptance of a 30 NaP tablet preparation (L-NaP) and a 2 L PEG preparation. Patients were randomized into either the L-NaP or PEG group. The primary endpoint was the efficiency of colon cleansing as assessed by a validated four-point scale according to the Aronchick scale by endoscopists and was verified by blinded investigators. The secondary endpoints were patients' tolerability and acceptance. Colon-cleansing efficiency was not significantly different between the two preparations. However, patients' overall judgment was significantly in favor of L-NaP, reflecting better acceptance of L-NaP than PEG. Additionally, more patients favored L-NaP over PEG in a hypothetical future occasion requiring colonoscopy.

Adjuncts to colonic cleansing before colonoscopy

Pre-procedural cleansing of the bowel can maximize the effectiveness and efficiency of colonoscopy. Yet, efficacy of the current gold standard colonic preparation method - high-volume oral administration of purgative agents 12-24 h prior to the procedure - is limited by several factors, such as patient compliance (due to poor palatability and inconvenience of the dosing regimen) and risks of complications (due to drug interactions or intolerance). Attempts to resolve these limitations have included providing adjunctive agents and methods to promote the colonic cleansing ability of the principal purgative agent, with the aim of lessening unpleasant side effects (such as bloating) and reducing the large ingested volume requirement. Several promising adjunctive agents are bisacodyl, magnesium citrate, senna, simethicone, metoclopramide, and prokinetics, and each are being investigated for their potential. This review provides an up to date summary of the reported investigations into the potencies and weaknesses of the key adjuncts currently being applied in clinic as supplements to the traditional bowel preparation agents. While the comparative analysis of these adjuncts showed that no single agent or method has yet achieved the goal of completely overcoming the limitations of the current gold standard preparation method, they at least provide endoscopists with an array of alternatives to help improve the suboptimal efficacy of the main cleansing solutions when used alone. To aid in this clinical endeavor, a subjective grade was assigned to each adjunct to indicate its practical value. In addition, the systematic review of the currently available agents and methods provides insight into the features of each that may be overcome or exploited to create novel drugs and strategies that may become adopted as effective bowel cleansing adjuncts or alternatives.

Efficacy and safety of gum chewing in adjunct to high-dose senna for bowel cleansing before colonoscopy: a single-blind randomized controlled trial

BACKGROUND/AIMS

Inadequate bowel cleaning leads to a suboptimal colonoscopic examination. Gum chewing has been reported to have a favorable effect on postoperative bowel functions. We conducted this study to establish if gum chewing added to high-dose senna before colonoscopy promotes bowel cleaning.

PATIENTS AND METHODS

In this randomized controlled study, consecutive outpatients scheduled for elective colonoscopy were randomized into two groups. Group 1 patients (n = 65) used senna solution 150 mL (300 mg senna) the night before colonoscopy. The patients also used sennoside tablet 80 mg daily for 3 days before the colonoscopy. Patients in group 2 (n = 64) were additionally advised to chew sugarless gum half an hour three-times daily after meals for these 3 days. The overall quality of colonoscopy cleaning was evaluated using the Aronchick scale by a single endoscopist who was blinded to the intervention. Difficulty of procedure, patients' tolerance, and adverse events were also evaluated.

RESULTS

A total 129 patients were enrolled in the study. Superior cleaning was found in gum chewing group when compared with other group particularly in the cecum and ascending colon. Cecal intubation time was significantly shorter in the gum-chewing group (8.6 ± 5.1 and 7.1 ± 2.8 min, P = 0.03). Adverse events were more common in group 1 compared to the gum-chewing group.

CONCLUSIONS

Gum chewing enhances colonoscopy bowel preparation quality. Moreover, it is a physiologically sound, safe, and an inexpensive part of the colonoscopy bowel preparation. Gum chewing could be advised in addition to high-dose senna containing bowel preparation.

Role of mosapride in improvement of bowel preparation before colonoscopy in patients with constipation

AIM: To investigate the role of mosapride in improvement of bowel preparation before colonoscopy in patients with constipation.

METHODS: Ninety patients with chronic constipation who requested colonoscopy were randomly and equally divided into three groups: A, B and C. Group A was given polyethylene glycol solution, group B was treated by mosapride plus polyethylene glycol solution, and group C was given mosapride alone. The extent of intestinal cleanliness and the incidence of side effects were compared between the three groups.

RESULTS: The colon cleaning score was significantly higher in groups C and B than in group A (7.13 ± 1.12, 6.65 ± 1.18 vs5.81 ± 1.19, both P < 0.05). The frequency of bowel movement in group C was significantly higher than that in group A (7.15 ± 1.61 vs 6.54 ± 1.52, t = 2.724, P = 0.023). The intestinal bubble score showed no statistically significant difference among the three groups (F = 0.359, P = 0.699). The incidence of side effects also did not differ significantly among the three groups (16.67%, 13.33% and 6.67%, χ² = 1.450, P = 0.484).

CONCLUSION: Mosapride can effectively improve bowel preparation before colonoscopy in patients with constipation.

The modern bowel preparation in colonoscopy

Adequate bowel preparation is essential for optimal colonoscopy. Suboptimal bowel preparation occurs in 25% to 40% of cases and is associated with canceled procedures, prolonged procedure time, incomplete examination, increased cost, and missed pathology. There are several effective formulations for colon cleansing with a good safety profile. Split dosing should be implemented whenever possible in an effort to enhance tolerance and adherence, and improve mucosal visibility and overall quality of the examination. In this review, modern bowel preparations are discussed including their mechanism of action, mode of use, safety, and how to optimize outcomes.

Applicability of second-generation colon capsule endoscope to ulcerative colitis: a clinical feasibility study

BACKGROUND AND AIM

Colon capsule endoscopy has already been used for colon visualization and detection of polyps but its applicability to inflammatory bowel disease is still unconfirmed. The aim of this study was to assess the feasibility of evaluating the severity of mucosal inflammation in patients with ulcerative colitis (UC) using a second-generation colon capsule endoscope (CCE-2).

METHODS

Forty patients with histological confirmed diagnosis of UC were enrolled. Low-volume (2 L) polyethylene glycol solution with prokinetics (mosapride citrate and metoclopramide) regimen was used for the bowel preparation. In Phase 1, consisting of 10 patients, to confirm appropriate CCE-2 bowel preparation for UC. In Phase 2, consisting of 30 patients, CCE-2 was performed with a fixed bowel preparation regimen. CCE-2 findings were recorded for 8 h starting from capsule ingestion and conventional colonoscopy was subsequently performed on the same day. CCE-2 procedure completion rate and the colon cleansing level with a 4-point grading scale (poor, fair, good, and excellent) were evaluated in Phase 2. Correlations between Matts endoscopic scores as judged by CCE-2 and conventional colonoscopy were calculated.

RESULTS

CCE-2 procedure was completed within 8 h in 69% of the patients. The proportion of patients with good or excellent cleansing level was below 50%. However, Matts endoscopic scores determined by CCE-2 showed a strong correlation with scores obtained by conventional colonoscopy (average ρ = 0.797).

CONCLUSIONS

Although modifications in bowel preparation are needed, CCE-2 might be feasible for assessing the severity of mucosal inflammation in patients with UC.

Factors influencing quality of bowel preparation for colonoscopy

Recent technological advances in colonoscopy have led to improvements in both image enhancement and procedural performance. However, the utility of these technological advancements remain dependent on the quality of bowel preparation during colonoscopy. Poor bowel preparation has been shown to be associated with lower quality indicators of colonoscopy performance, such as reduced cecal intubation rates, increased patient discomfort and lower adenoma detection. The most popular bowel preparation regimes currently used are based on either Polyethylene glycol-electrolyte, a non-absorbable solution, or aqueous sodium phosphate, a low-volume hyperosmotic solution. Statements from various international societies and several reviews have suggested that the efficacy of bowel preparation regimes based on both purgatives are similar, although patients’ compliance with these regimes may differ somewhat. Many studies have now shown that factors other than the type of bowel preparation regime used, can influence the quality of bowel preparation among adult patients undergoing colonoscopy. These factors can be broadly categorized as either patient-related or procedure-related. Studies from both Asia and the West have identified patient-related factors such as an increased age, male gender, presence of co-morbidity and socio-economic status of patients to be associated with poor bowel preparation among adults undergoing routine out-patient colonoscopy. Additionally, procedure-related factors such as adherence to bowel preparation instructions, timing of bowel purgative administration and appointment waiting times for colonoscopy are recognized to influence the quality of colon cleansing. Knowledge of these factors should aid clinicians in modifying bowel preparation regimes accordingly, such that the quality of colonoscopy performance and delivery of service to patients can be optimised.

Can mosapride citrate reduce the volume of lavage solution for colonoscopy preparation?

AIM: To evaluate the possibility of reducing the volume of polyethylene glycol (PEG)-electrolyte solution using adjunctive mosapride citrate for colonoscopy preparation.

METHODS: This was a single-center, prospective, randomized, investigator-blinded, non-inferiority study involving 252 patients of both sexes, aged from 20 to 80 years, scheduled for screening or diagnostic colonoscopy in our department. A total of 126 patients was randomized to receive 1.5 L PEG-electrolyte solution plus 15 mg of mosapride (1.5 L group), and 126 received 2 L PEG-electrolyte solution plus 15 mg of mosapride (2 L group). Patients completed a questionnaire on the acceptability and tolerability of the bowel preparation process. The efficacy of bowel preparation was assessed using a 5-point scale based on the Aronchick scale. The primary end point was adequate bowel preparation rates (score of excellent/good/fair) vs (poor/inadequate). Acceptability and tolerability, as well as disease detection, were secondary end points.

RESULTS: A total of 244 patients was included in the analysis. There were no significant differences between the 2 L and 1.5 L groups in age, sex, body mass index, number of previous colonoscopies, and the preparation method used previously. The adequate bowel preparation rates were 88.5% in the 2 L group and 82.8% in the 1.5 L group [95% lower confidence limit (LCL) for the difference = -14.5%, non-inferiority P = 0.019] in the right colon. In the left colon, the adequate bowel preparation rates were 89.3% in the 2 L group and 81.1% in the 1.5 L group (95% LCL = -17.0%, non-inferiority P = 0.066). Compliance, defined as complete (100%) intake of the PEG solution, was significantly higher in the 1.5 L group than in the 2 L group (96.8% vs 85.7%, P = 0.002). The proportion of abdominal distension (none/mild/moderate/severe) was significantly lower in the 1.5 L group than in the 2 L group (36/65/22/3 vs 58/48/18/2, P = 0.040). Within the subgroup who had undergone colonoscopy previously, a significantly higher number of patients in the 1.5 L group than in the 2 L group felt that the current preparation was easier than the previous one (54.1% vs 28.0%, P = 0.001). The disease detection rate was not significantly different between the two groups.

CONCLUSION: Although the 1.5 L group had better acceptability and tolerability, 15 mg of mosapride may be insufficient to compensate for a 0.5-L reduction of PEG solution.

Bowel preparation prior to colonoscopy: a continual search for excellence

Bowel preparation prior to colonoscopy is essential to maximize the benefits of colonoscopy. Numerous bowel preparations have been studied, ranging from 4 L polyethylene glycol (PEG) to split-dose regimens to 2 L PEG with an adjunct laxative (senna, bisacodyl, ascorbic acid). Due to the large volume of PEG required for adequate bowel preparation, many studies have focused on reducing this large volume to only 2 L PEG with the addition of an adjunct. Recently, a randomized controlled trial by Tajika et al showed that the addition of mosapride to only 1.5 L PEG was non-inferior to mosapride and 2 L PEG for bowel cleansing but did provide improvements in patient tolerance. This study offers yet another potential bowel preparation for patients undergoing colonoscopy and may trigger further studies with 1.5 L PEG with an adjunct. In this letter, we discuss the current state of bowel preparation prior to colonoscopy and offer information to guide clinicians on choosing the appropriate bowel preparation for their patients.