Design and validation of an artificial intelligence system to detect the quality of colon cleansing before colonoscopy

BACKGROUND AND AIMS

Patients' perception of their bowel cleansing quality may guide rescue cleansing strategies before colonoscopy. The main aim of this study was to train and validate a convolutional neural network (CNN) for classifying rectal effluent during bowel preparation intake as "adequate" or "inadequate" cleansing before colonoscopy.

PATIENTS AND METHODS

Patients referred for outpatient colonoscopy were asked to provide images of their rectal effluent during the bowel preparation process. The images were categorized as adequate or inadequate cleansing based on a predefined 4-picture quality scale. A total of 1203 images were collected from 660 patients. The initial dataset (799 images), was split into a training set (80%) and a validation set (20%). The second dataset (404 images) was used to develop a second test of the CNN accuracy. Afterward, CNN prediction was prospectively compared with the Boston Bowel Preparation Scale (BBPS) in 200 additional patients who provided a picture of their last rectal effluent.

RESULTS

On the initial dataset, a global accuracy of 97.49%, a sensitivity of 98.17% and a specificity of 96.66% were obtained using the CNN model. On the second dataset, an accuracy of 95%, a sensitivity of 99.60% and a specificity of 87.41% were obtained. The results from the CNN model were significantly associated with those from the BBPS (P<0.001), and 77.78% of the patients with poor bowel preparation were correctly classified.

CONCLUSION

The designed CNN is capable of classifying "adequate cleansing" and "inadequate cleansing" images with high accuracy.

Agreement between the perception of colon cleansing reported by patients and colon cleansing assessed by a validated colon cleansing scale

AIMS

Patients' perception of their cleansing quality can guide strategies to improve cleansing during colonoscopy. There are no studies assessing the agreement between the quality of cleansing perceived by patients and cleansing quality assessed during colonoscopy using validated bowel preparation scales. The main aim of this study was to compare the cleansing quality reported by patients with the quality during colonoscopy using the Boston Bowel Preparation Scale (BBPS).

PATIENTS AND METHODS

Consecutive patients referred to an outpatient colonoscopy were included. Four drawings representing different degrees of cleansing were designed. Patients chose the drawing that most resembled the last stool. The predictive ability of the patient's perception and agreement between the patient's perception and the BBPS were calculated. A BBPS score of <2 points in any segment was considered inadequate.

RESULTS

Six hundred and thirty-three patients were included (age: 62.8±13.7 years, male: 53.4%). Overall, 107 patients (16.9%) had inadequate cleansing during colonoscopy, and in 12.2% of cases, the patient's perception was poor. The patient's perception compared to the quality of cleanliness during colonoscopy presented a positive and negative predictive value of 54.6% and 88.3%, respectively. The agreement between patient perception and the BBPS was significant (P<0.001), although fair (k=0.37). The results were similar in a validation cohort of 378 patients (k=0.41).

CONCLUSIONS

The cleanliness perceived by the patient and the quality of cleanliness using a validated scale were correlated, although fair. However, this measure satisfactorily identified patients with adequate preparation. Cleansing rescue strategies may target patients who self-report improper cleaning. Registration number of the trial: NCT03830489.

Preoperative Mechanical Bowel Preparation for Gynecologic Surgeries: A Systematic Review with Meta-analysis

OBJECTIVE

To assess the efficacy and safety of mechanical bowel preparation (MBP) before benign laparoscopic or vaginal gynecologic surgeries.

DATA SOURCES

Database searches of MEDLINE (PubMed), Embase (OVID), Cochrane Central Register of Controlled Trials, and Web of Sciences and citations and reference lists published up to December 2021.

METHODS OF STUDY SELECTION

Randomized clinical trials in any language comparing MBP with no preparation were included. Two reviewers independently screened 925 records and extracted data from 12 selected articles and assessed the risk of bias with the Cochrane risk-of-bias tool for randomized trials tool. A random-effects model was used for the analysis. Surgeon findings (surgical field view, quality of bowel handling and bowel preparation), operative outcomes (blood loss, operative time, length of stay, surgical site infection), and patient's preoperative symptoms and satisfaction were collected.

TABULATION, INTEGRATION, AND RESULTS

Thirteen studies (1715 patients) assessing oral and rectal preparations before laparoscopic and vaginal gynecologic surgeries were included. No significant differences were observed with or without MBP on surgical field view (primary outcome, risk ratio [RR] 1.01, 95% confidence interval [CI] 0.97-1.05, p = .66, I2 = 0%), bowel handling (RR 1.01, 95% CI 0.95-1.08, p = .78, I2 = 67%), or bowel preparation. In addition, there were no statistically significant differences in perioperative findings. MBP was associated with increased pain (mean difference [MD] 11.62[2.80-20.44], I2 = 76, p = .01), weakness (MD 10.73[0.60-20.87], I2 = 94, p = .04), hunger (MD 17.52 [8.04-27.00], I2 = 83, p = .0003), insomnia (MD 10.13[0.57-19.68], I2 = 82, p = .04), and lower satisfaction (RR 0.68, 95% CI 0.53-0.87, I2 = 76%, p = .002) compared with controls.

CONCLUSIONS

MBP has not been associated with improved surgical field view, bowel handling, or operative outcome. However, in view of the adverse effects induced, its routine use before benign gynecologic surgeries should be abandoned.

Determinants of symptom burden related to bowel preparation for colonoscopy

BACKGROUND

Symptoms developing during bowel preparation are major concerns among subjects who refuse the procedure.

AIMS

We aimed to explore the determinants of symptoms occurring during preparation among patients undergoing elective colonoscopy.

METHODS

This is a prospective multicenter study conducted in 10 Italian hospitals. A multidimensional approach collecting socio-demographic, clinical, psychological and occupational information before colonoscopy through validated instruments was used. Outcome was a four-category cumulative score based on symptoms occurring during preparation, according to the Mayo Clinic Bowel Prep Tolerability Questionnaire, weighted by intensity. Missing values were addressed through multiple imputation. Odds ratios (OR) and 95% confidence intervals (CI) were estimated through multivariate logistic regression models.

RESULTS

1137 subjects were enrolled. Severe symptoms were associated with female sex (OR=3.64, 95%CI 1.94-6.83), heavier working hours (OR=1.13, 95% CI=1.01-1.25), previous gastrointestinal symptoms (OR=7.81, 95% CI 2.36-25.8 for high score), somatic symptoms (OR=2.19, 95% CI=1.06-4.49 for multiple symptoms), day-before regimen (OR=2.71, 95%CI 1.28-5.73). On the other hand, age ≥60 years (OR=0.10, 95% CI 0.02-0.44) and good mood (p=0.042) were protective factors. A high-risk profile was identified, including women with low mood and somatic symptoms (OR=15.5, 95%CI 4.56-52.7).

CONCLUSIONS

We identified previously unreported determinants of symptoms burdening bowel preparation and identified a particularly vulnerable phenotype. Symptoms during preparation especially impact heavier working activity.

Effects of bowel preparation on intestinal bacterial associated urine and faecal metabolites and the associated faecal microbiome

Background

Urinary and faecal metabolic profiling have been extensively studied in gastrointestinal diseases as potential diagnostic markers, and to enhance our understanding of the intestinal microbiome in the pathogenesis these conditions. The impact of bowel cleansing on the microbiome has been investigated in several studies, but limited to just one study on the faecal metabolome.

Aim

To compare the effects of bowel cleansing on the composition of the faecal microbiome, and the urine and faecal metabolome.

Methods

Urine and faecal samples were obtained from eleven patients undergoing colonoscopy at baseline, and then at day 3 and week 6 after colonoscopy. 16S rRNA gene sequencing was used to analyse changes in the microbiome, and metabonomic analysis was performed using proton nuclear magnetic resonance (¹H NMR) spectroscopy.

Results

Microbiomic analysis demonstrated a reduction in alpha diversity (Shannon index) between samples taken at baseline and three days following bowel cleansing (p = 0.002), and there was no significant difference between samples at baseline and six weeks post colonoscopy. Targeted and non-targeted analysis of urinary and faecal bacterial associated metabolites showed no significant impact following bowel cleansing.

Conclusions

Bowel cleansing causes a temporary disturbance in bacterial alpha diversity measured in faeces, but no significant changes in the faecal and urine metabolic profiles, suggesting that overall the faecal microbiome and its associated metabolome is resistant to the effects of an induced osmotic diarrhoea.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12876-022-02301-1.

1L NER1006 can improve rates of adequate and high-quality bowel cleansing in the right colon: a post hoc analysis of two randomised clinical trials

BACKGROUND

The right colon is difficult to cleanse compared with other colon segments. This post hoc analysis of two randomised clinical trials (MORA and NOCT) examined whether 1L polyethylene glycol (PEG) NER1006 and two mid-volume alternatives could improve adequate and high-quality cleansing in the right colon among patients with complete cleansing assessments.

METHODS

Patients received NER1006 (N2D), 2L PEG plus ascorbate (2LPEG) or oral sulphate solution (OSS) as a 2-day evening/morning split-dosing regimen or NER1006 as a same-day morning-only dosing regimen (N1D). Patients had full segmental scoring assigned by treatment-blinded central readers using the Harefield Cleansing Scale. The right colon adequate (score ≥ 2) and high-quality (score ≥ 3) cleansing success of NER1006 (N2D and N1D) versus 2LPEG and OSS was analysed individually and as pooled groups (N2D vs. 2LPEG/OSS). We assessed the comparative right colon cleansing rates of the N2D versus 2LPEG/OSS in overweight males. We also performed a multivariable regression analysis to examine factors affecting cleansing in the right colon.

RESULTS

A total of 1307 patients were included. Pooled N2D showed significantly improved rates of adequate-level cleansing in the right colon compared with 2LPEG (97.5% [504/517] vs. 94.6% [246/260]; p = 0.020) and OSS (97.5% [504/517] vs. 93.8% [244/260]; p = 0.006). In MORA, the rate of adequate right colon cleansing did not significantly differ between N1D and 2LPEG (95.2% [257/270] vs. 94.6% [246/260]; p = 0.383). The rate of right colon high-quality cleansing was significantly improved with N2D or N1D vs. 2LPEG (p < 0.001 for both), and was numerically higher with N2D versus OSS (p = 0.11). In overweight males, NER1006 delivered numerically higher adequate (p = 0.398) and superior high-quality (p = 0.024) cleansing rates versus 2LPEG/OSS. Multivariable regression analysis showed NER1006 was associated with adequate and high-quality cleansing (p = 0.031 and p < 0.001), while time between preparation and colonoscopy was negatively associated (p = 0.034 and p = 0.006).

CONCLUSIONS

NER1006 delivered improved rates of adequate and high-quality right colon cleansing compared with 2LPEG and OSS. The increased rate of high-quality cleansing with NER1006 versus its comparators was also seen in overweight males.

Gastrointestinal endoscopy in cirrhotic patient: Issues on the table

Patients with liver cirrhosis are fragile and present specific clinical hallmarks. When undergoing to gastrointestinal (GI) endoscopy, these subjects require an individual pre evaluation, taking into account: Level of haemostasis impairment, the individual risk of infection, the impact of sedation on hepatic encephalopathy and other factors. The overall assessment of liver function, employing common scoring systems, should be also assessed in the preprocedural phase. Beside some common general problems, regarding GI endoscopy in cirrhotic subjects, also specific issues are present for some frequent indications or procedures. For instance, despite an increased incidence of adenomas in cirrhosis, colon cancer screening remains suboptimal in subjects with this disease. Several studies in fact demonstrated liver cirrhosis as a negative factor for an adequate colon cleansing before colonoscopy. On the other hand, also the routine assessment of gastroesophageal varices during upper GI endoscopy presents some concern, since important inter-observer variability or incomplete description of endoscopic findings has been reported in some studies. In this review we discussed in details the most relevant issues that may be considered while performing general GI endoscopic practice, in patient with cirrhosis. For most of these issues there are no guidelines or clear indications. Moreover until now, few studies focused on these aspects. We believe that targeting these issues with corrective measures may be helpful to develop a tailored endoscopic approach for cirrhosis, in the future.

Comparison of Effectiveness between Abdominal Vibration Stimulation and Walking Exercise for Bowel Cleansing before Therapeutic Colonoscopy

Background/Aims

Adequate bowel preparation is important for successful colonoscopy. We aimed to evaluate the clinical feasibility and effectiveness of abdominal vibration stimulation in bowel preparation before therapeutic colonoscopy.

Methods

A single center, prospective, randomized, investigator-blinded study was performed between January 2016 and December 2016. Patients for therapeutic colonoscopy were prospectively enrolled and assigned to either the vibrator group or walking group. Patients who refused to participate in this study as part of the experimental group consented to register in the control group instead. During the preparation period, patients assigned to the walking group walked ≥3,000 steps, whereas those assigned to the vibrator group received abdominal vibrator stimulation and restricted walking. All patients received the same colon cleansing regimen: 4-L split-dose polyethylene glycol (PEG) solution.

Results

Three hundred patients who received PEG solution for therapeutic colonoscopy were finally enrolled in this study (n=100 per group). Bowel cleansing with abdominal vibration stimulation showed almost similar results to that with walking exercise (Boston Bowel Preparation Scale score for the entire colon: vibrator vs walking vs control, 7.38±1.55 vs 7.39±1.55 vs 6.17±1.15, p<0.001). There were no significant differences between the vibrator group and walking group regarding instances of diarrhea after taking PEG, time to first diarrhea after taking PEG, total procedure time, and patient satisfaction.

Conclusions

This study indicates that, compared with conventional walking exercise, abdominal vibration stimulation achieved similar rates of bowel cleansing adequacy and colonoscopy success without compromising safety or patient satisfaction.

Colonic Diverticular Bleeding Associated with Bowel Cleansers before Colonoscopy

To date, colonic diverticular bleeding associated with bowel cleansers has not been reported, and its endoscopic and pathological features remain largely unclear. We report a case of colonic diverticular bleeding associated with a bowel cleanser (137 g of polyethylene glycol [NIflec®]) before colonoscopy (CS). CS revealed colonic diverticular bleeding in the sigmoid colon. To our knowledge, this is the first report describing the endoscopic and pathological features of colonic diverticular bleeding associated with bowel cleansing before CS.

A low-residue diet before colonoscopy tends to improve tolerability by patients with no differences in preparation quality: a randomized trial

BACKGROUND

The pre-colonoscopy diet traditionally involves 24 h of a clear liquid diet (CLD) in combination with a lavage solution; however, this preparation is poorly tolerated.

AIM

To compare the impact on the quality of bowel cleansing and tolerability of a CLD versus a low-residue diet (LRD).

METHODS

We performed a randomized trial. Subjects were randomized to CLD or LRD the day before of elective colonoscopy. All subjects received a 4-L preparation of single-dose PEG beginning 16 h prior to colonoscopy. The Boston bowel preparation scale was used to evaluate bowel cleansing; an adequate-quality preparation was defined as a score ≥ 2 per segment.

RESULTS

A total of 205 subjects were included with a mean age (SD) of 55.6 (12.6) years; 133 (64.9%) of them were female. A total of 105 subjects were randomized to receive CLD and 100 to LRD. No significant differences in bowel preparation quality were observed between groups according to the section of colon: right colon (70% vs. 73%, p = 0.08), transverse colon (82% vs. 79%, p = 0.062), or left colon (80% vs. 78.7%, p = 0.28). There was a tendency toward less-frequent nausea (p = 0.08) and vomiting (p = 0.07) in patients with LRD. No differences between groups regarding ADR (12% vs. 10%) were noted.

CONCLUSIONS

An LRD before colonoscopy resulted in a tendency toward improved tolerability by patients, with no differences in the quality of bowel preparation.

Novel 1 L polyethylene glycol-based bowel preparation (NER1006): proof of concept assessment versus standard 2 L polyethylene glycol with ascorbate - a randomized, parallel group, phase 2, colonoscopist-blinded trial

Background

Colonoscopy requires colon cleansing. For this, many polyethylene glycol (PEG)-based preparations still require a high preparation-volume intake. Using an increased osmotic load with ascorbate (Asc), five new low-volume PEG-based bowel preparations (LVPEG) were tested for clinical proof of concept.

Methods

This two-part, open-label study examined preparation-volumes of 1–1.25 L and total required fluid volumes of 2–3 L. Part 1, in healthy volunteers, used mean cumulative 24-h stool weight (target > 2750 g) to identify a lead candidate. Part 2 was endoscopist-blinded: patients undergoing screening colonoscopy were randomized before treatment with the selected lead, one of two variants of it, or the control 2 L PEG + Asc. Two primary endpoints were used for proof of concept demonstration: mean 24-h stool weight and bowel cleansing success (Harefield Cleansing Scale).

Results

A total of 120 subjects (30 per group) were enrolled/randomized 1:1:1:1 (max 40:60 gender ratio) per completed Part. In Part 1, LVPEG-3 achieved the largest mean stool weight (3399 g: P < 0.0001 vs target) and was selected for Part 2. In Part 2, stool weights exceeded the target, notably for LVPEG-4 (3215 g: P < 0.001), which achieved 100% cleansing success after a total required fluid intake of 2 L. The control achieved 90% cleansing success. Adverse events were few, gastrointestinal in nature and similar between groups.

Conclusions

LVPEG-4 achieved a clinically useful combination of cleansing, safety/tolerability and low consumption volume: 1 L preparation + 1 L required additional fluid. Named NER1006, LVPEG-4 demonstrated clinical proof of concept and warrants further investigation.

Trial registration

October 2012.

Identifier: NCT01714466. EudraCT: 2012–003052-37

The trial was prospectively registered.

Electronic supplementary material

The online version of this article (10.1186/s12876-019-0988-y) contains supplementary material, which is available to authorized users.

A systematic review and cost analysis of repeat colonoscopies due to inadequate bowel cleansing in five European countries

Background: Colonoscopies are carried out for a range of reasons including for the detection of colon cancer and investigation of abdominal and bowel related symptoms. Inadequate preparation can increase the burden of repeat procedures.Methods: A systematic review aimed to identify the rate of repeat colonoscopies due to inadequate bowel preparation in France, Germany, Italy, Spain and the United Kingdom. The information obtained populated a decision analytic model to estimate the cost implications of inadequate bowel cleansing in the same five countries. The model explored scenarios by comparing one and two-litre polyethylene glycol-based bowel preparation.Results: The systematic review identified 14 eligible studies reporting on the proportion of patients with inadequate bowel cleansing indicated for a repeat procedure. Data were available for Italy (27.5%-35.9%), Spain (63%) and the UK (24.5%) only. The decision analytic model demonstrates that improving the proportion of adequate bowel cleansing at first colonoscopy is likely to generate cost savings.Conclusions: Based on the available evidence, increasing the proportion of people who have adequate bowel cleansing at index colonoscopy will likely have financial benefits in Italy, Spain and the UK. A paucity of data, for France and Germany, limits the robustness of conclusions in these countries.

Which Patient-Related Factors Determine Optimal Bowel Preparation?

PURPOSE OF REVIEW

Adequate bowel cleansing before colonoscopy is a simple concept but the high rate of inadequate or incomplete bowel cleanliness and its consequences have been the subject of many studies, guidelines, and meta-analysis. The complexity resides in all the factors surrounding preparation intake such as type and regimen of bowel preparation, diets, compliance, and also patient-related factors that all influence quality of the bowel preparation. The purpose of this review is to focus specifically on patient-related factors and their challenges. Patients with lower GI bleeding are excluded from this review.

RECENT FINDINGS

Patient factors that may be associated with a poor bowel preparation were searched for in the literature. With regard to patient's characteristics, higher age, male gender, and socio-economic status (lower income, Medicaid, and lower education) were all associated with higher rates of inadequate bowel preparation. Comorbidities such as inflammatory bowel disease (IBD), in-patients, body mass index (BMI), cirrhosis, constipation, and neurological condition as well as some pharmacotherapy were also associated with inadequate bowel preparation. Studies identifying predictive patient factors as well as those studying these patients in particular showed variability in the strength of the patient factor associations. Patients taking tricyclic antidepressant, narcotics, and those with neurological conditions were identified to have a stronger association with worse bowel cleanliness. Those can be implemented with the current recommendations of split-dosing. Identifying individual factors that can impact the quality of bowel cleanliness can be challenging. Some have been well-studied in the literature such as age, in-patient status, or constipation and others such as male gender or higher BMI have required more studies to clearly conclude on any possible association. In many studies, simple recommendations like walking 30 min during the preparation, and additional instructions or support have also been added to instructions to improve motility and compliance.

Can coffee or chewing gum decrease transit times in Colon capsule endoscopy? A randomized controlled trial

BACKGROUND

A high rate of complete colon capsule endoscopy (CCE) investigations is required for a more widespread use of CCE. The objective of this study was to assess if coffee or chewing gum can increase excretion of the colon capsule within battery life time (excretion rate).

METHODS

One hundred eighty six screening participants with a positive immunochemical fecal occult blood test were included in this single-centre randomized controlled trial with blinding of the investigators to the randomization. Participants received instant coffee, chewing gum or nothing in addition to the standard bowel preparation.

RESULTS

The intention was to include 57 participants in the coffee group, 61 in the chewing gum group and 60 in the control group, on 8 participants data were missing. A total of 165 participants were included in a per protocol analysis. Exclusion was due to not receiving the allocated intervention (8 coffee, 4 chewing gum) and technical failure of the capsule (1 coffee). The excretion rate was 58% in the coffee group (n = 48), 63% in the chewing gum group (n = 57) and 55% in the control group (n = 60, p > 0.2). Transit times were similar in all groups. The excretion rate was low in participants who had transit times over 10 h (14%). A strong correlation was found between adequate cleansing and excretion of the capsule. There were no serious adverse events related to the interventions or CCE investigations.

CONCLUSIONS

Chewing gum and coffee did not improve excretion rate in this study. An effect of chewing gum could not be proven, possibly due to sample size. Since chewing gum might improve excretion rates, is cheap and has no known side effects, it needs to be considered in future bowel preparation trials for CCE.

TRIAL REGISTRATION

NCT02303756 , registered on December 1st 2014.

Aquanet Bowel Cleansing Device Versus Oral Sodium Picosulfate for Pre-Endoscopy Bowel Preparation: Propensity Score Analysis for Interventional Effectiveness Evaluation

Background

Colonoscopy procedures are commonly performed and have high success rates. However, poor or inadequate bowel preparation is one of the most common reasons for a repeated or failed colonoscopy. We therefore performed an observational study followed by propensity score modeling to evaluate and compare the quality of bowel preparation with the use of Aquanet bowel cleansing devices (BCDs) versus the use of oral sodium picosulfate solution.

Methods

We performed a prospective cross-sectional study to compare the quality of pre-endoscopic bowel preparation using a BCD with oral solution. Our major outcome of interest was the quality of bowel preparation as measured through the Boston bowel preparation (BBP) scale. Our main predictor was the method of bowel preparation. The bowel was prepared using either sodium picosulfate or the BCD.

Results

A total of 314 participants were part of this study. The average age of the participants was 54 years and most of the participants were females (81%). Sodium picosulfate was associated with better scores at each segment. After propensity scoring with a 1:1 match and further adjusting for the unbalanced variable (age), we found that despite the apparent superior cleansing performance of sodium picosulfate over the BCD, the difference was not statistically significant.

Conclusion

This study reinforces previous reports regarding the quality, safety and comfort of BCDs, indicating that this technique should be considered for colonoscopy preparation. In the future, randomized controlled trials should be performed to validate these preliminary findings.

Efficacy of Prucalopride in bowel cleansing before colonoscopy: Results of a pilot study

Colonoscopy is a crucial diagnostic instrument for colorectal cancer screening and an adequate bowel preparation is definitely decisive for the success of the procedure. Especially in elderly patients, bowel cleansing is considered a big issue, because it is often poorly tolerated for many reasons (like inability to swallow large volume of liquids or unlikable taste); this can cause a suboptimal preparation that may lead to miss a neoplastic lesion. There is relatively little data about how to improve preparation tolerability. The purpose of our pilot study was to analyze the effect of prucalopride (Resolor^®), a highly selective serotonin 5HT4 receptor agonist used for chronic constipation for its ability to stimulate gastrointestinal peristalsis, undertaken the day before colonoscopy, followed by half volume of polyethylene glycol solution. We found that this can be a good and safe method to achieve an adequate and better-tolerated colon cleansing.

Standard bowel cleansing is highly ineffective in cirrhotic patients undergoing screening colonoscopy

BACKGROUND

Few data are available on tolerability and quality of standard bowel cleansing for colonoscopy in patients with chronic disease.

AIM

We seek to evaluate the tolerability and results of lavage solution for colonoscopy in cirrhotic patients in comparison with controls.

METHODS

Fifty-three cirrhotic and fifty-two normal subjects undergoing colonoscopy were prospectively enrolled in the study. Data regarding tolerability of lavage solution were harvested at the pre-procedure visit. Data on level of bowel cleansing and other endoscopic variables were recorded after the procedure.

RESULTS

Rate of failure to complete the prescribed bowel preparation and incidence of side effects during its administration were similar between cirrhotic and normal subjects. Despite this, cirrhotic patients exhibited an insufficient level of bowel preparation with approximately half exhibiting bad colon cleansing level (49% versus 5% control, p<0.001).

CONCLUSION

Alternative bowel cleansing protocols are needed for cirrhotic subjects to better match their colonoscopic screening needs.

Safety and usefulness of Laghu shankha prakshalana in patients with essential hypertension: A self controlled clinical study

BACKGROUND

Yoga and Ayurveda texts emphasize the role of cleansing the bowel as an important component of management of hypertension (HTN). Observations during our clinical experience and pilot studies on Laghu shankha prakshalana kriya (LSP), a yogic bowel cleansing technique, appeared to be safe and complimentary.

OBJECTIVE

To test the safety and effectiveness of LSP in patients with essential hypertension.

MATERIALS AND METHODS

This self control study recruited 32 patients with mild to moderate essential HTN admitted for a week long residential integrated yoga therapy program at the integrative health home in Bengaluru. Patients had a daily routine of 6 hours of integrated approach of yoga therapy (IAYT) module for HTN that included physical postures, relaxation sessions, pranayama and meditations. LSP, an additional practice, that involved drinking of luke-warm water (with or without a herbal combination, triphala) followed by a set of specific yoga postures that activates defecation reflex, was administered on 2(nd) (LSP without triphala) and 5(th) day (LSP with triphala). Assessments (sitting blood pressure and pulse rate) were done just before and after both the sessions of LSP. Secondary outcome measures such as body mass index (BMI), symptom scores, medication scores, fatigue, state and trait anxiety, general health and quality of life were assessed on 1(st) and 6(th) day of IAYT intervention.

RESULTS

There was significant (P < 0.001, paired t test) reduction in blood pressure (systolic and diastolic) and pulse rate immediately after both the sessions (LSP with and without triphala). There were no adverse effects reported during or after LSP. There was no significant difference between the two techniques (P < 0.505, independent samples t test), although the percentage change appeared to be higher after triphala LSP session. The number of visits to clear the bowel during the procedure was significantly (P < 0.001, independent samples t test) higher after LSP with triphala than LSP without triphalā. After weeklong IAYT, there were significant reductions in blood pressure (P < 0.001), BMI (P < 0.004), medication score (P < 0.001), symptoms score (P < 0.001), fatigue (P < 0.001), state and trait anxiety (STAI, P < 0.001), scores of general ill health (GHQ, P < 0.001), and increase in comfort level (P < 0.001) and quality of sleep (P < 0.001).

CONCLUSION

LSP (a part of IAYT) is a safe and useful procedure for patients with essential hypertension. LSP with triphala is more useful.

Anxiety is associated with impaired tolerance of colonoscopy preparation in inflammatory bowel disease and controls

BACKGROUND AND AIM

Pain and nausea are often reported during bowel cleansing (BC) for ileocolonoscopy (IC). We aimed to explore putative mechanisms associated with impaired tolerance to BC.

METHODS

A 1:1 (100 IBD and 100 controls) sex and age matched case-control study was performed. Patients completed the hospital anxiety and depression scale (HADS-A/HADS-D), visceral sensitivity index (VSI) and state-trait anxiety inventory, state scale (STAI-S), in addition to self-assessment of BC and abdominal pain and nausea ratings during BC. Endoscopists reported the Mayo score, Harvey Bradshaw index (HBI), simple endoscopic score for Crohn's disease, and Boston bowel preparation scale (BBPS).

RESULTS

Higher VSI and depression scores were observed in IBD patients. VSI (P<0.0001) and age (P=0.008) showed a positive and negative association with abdominal pain during BC, respectively. HADS-A (P=0.009) and female sex (P=0.02) were positively associated with nausea during BC, while age (P=0.02) showed a negative association. Disease activity was not associated with worse BBPS or nausea during BC, while a higher HBI was associated with more pain during BC (P=0.0006). Nausea (P=0.007) and abdominal pain (P=0.003) during BC, and less previous ICs (P=0.03) were independently associated with anxiety prior to IC (STAI-S). Significant correlations were found between VSI and STAI-S and disease activity.

CONCLUSION

Higher gastrointestinal-specific anxiety and co-morbid anxiety are associated with increased pain and nausea during BC, respectively. Pain and nausea during BC were in turn associated with higher anxiety levels at the moment of IC, potentially creating a "vicious circle". Measures taken to reduce anxiety could improve BC and IC tolerance.

A low-volume polyethylene glycol plus ascorbate solution for bowel cleansing prior to colonoscopy: the NORMO randomised clinical trial

BACKGROUND

Patient acceptability of the preparation is a key factor in the success of colonoscopy, yet standard polyethylene glycol solutions are poorly tolerated owing to their high volume (4L) and low palatability. This study compared the efficacy, safety and acceptability of a 2L polyethylene glycol+ascorbate solution with a standard 4-L polyethylene glycol solution.

METHODS

Adults referred for colonoscopy were randomised to 2-L polyethylene glycol+ascorbate (n=202) or 4-L polyethylene glycol solution (n=198). Colon cleansing success was assessed using the Harefield Cleansing Scale(©) and the Aronchick scale. Safety and acceptability were also assessed.

RESULTS

Successful cleansing was achieved in 94.1% and 90.9% of subjects with the 2-L and 4-L solutions respectively using the Harefield Cleansing Scale(©) and 94.6% and 90.0% using the Aronchick scale (non significant). Despite better acceptability and tolerability, no superiority over the standard 4-L preparation was demonstrated. Fewer treatment-related adverse events were reported with the 2-L solution (80.2% versus 89.9%, p=0.011). More subjects were willing to take the 2L PEG+ascorbate solution again (87% versus 51%, p<0.001), found it easier to drink (80% versus 70%, p=0.025), with a better taste (p=0.01).

CONCLUSIONS

Two-litre polyethylene glycol+ascorbate solution, with a similar high degree of cleansing and superior acceptability and tolerability, presents an alternative to 4-L polyethylene glycol when compliance is an issue.