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Shahini E, Sinagra E, Vitello A, Ranaldo R, Contaldo A, Facciorusso A, Maida M. Factors affecting the quality of bowel preparation for colonoscopy in hard-to-prepare patients: Evidence from the literature. World J Gastroenterol 2023; 29:1685-1707. [PMID: 37077514 PMCID: PMC10107216 DOI: 10.3748/wjg.v29.i11.1685] [Citation(s) in RCA: 30] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/01/2022] [Revised: 02/02/2023] [Accepted: 03/07/2023] [Indexed: 03/17/2023] Open
Abstract
Adequate bowel cleansing is critical for a high-quality colonoscopy because it affects diagnostic accuracy and adenoma detection. Nevertheless, almost a quarter of procedures are still carried out with suboptimal preparation, resulting in longer procedure times, higher risk of complications, and higher likelihood of missing lesions. Current guidelines recommend high-volume or low-volume polyethylene glycol (PEG)/non-PEG-based split-dose regimens. In patients who have had insufficient bowel cleansing, the colonoscopy should be repeated the same day or the next day with additional bowel cleansing as a salvage option. A strategy that includes a prolonged low-fiber diet, a split preparation regimen, and a colonoscopy within 5 h of the end of preparation may increase cleansing success rates in the elderly. Furthermore, even though no specific product is specifically recommended in the other cases for difficult-to-prepare patients, clinical evidence suggests that 1-L PEG plus ascorbic acid preparation are associated with higher cleansing success in hospitalized and inflammatory bowel disease patients. Patients with severe renal insufficiency (creatinine clearance < 30 mL/min) should be prepared with isotonic high volume PEG solutions. Few data on cirrhotic patients are currently available, and no trials have been conducted in this population. An accurate characterization of procedural and patient variables may lead to a more personalized approach to bowel preparation, especially in patients undergoing resection of left colon lesions, where intestinal preparation has a poor outcome. The purpose of this review was to summarize the evidence on the risk factors influencing the quality of bowel cleansing in difficult-to-prepare patients, as well as strategies to improve colonoscopy preparation in these patients.
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Affiliation(s)
- Endrit Shahini
- Gastroenterology Unit, National Institute of Gastroenterology-IRCCS “Saverio de Bellis”, Castellana Grotte, Bari 70013, Italy
| | - Emanuele Sinagra
- Gastroenterology and Endoscopy Unit, Fondazione Istituto G. Giglio, Cefalù 90015, Italy
| | - Alessandro Vitello
- Gastroenterology and Endoscopy Unit, S.Elia-Raimondi Hospital, Caltanissetta 93100, Italy
| | - Rocco Ranaldo
- Department of Internal Medicine, “Mazzolani-Vandini” Hospital, Digestive Endoscopy, Ferrara 744011, Italy
| | - Antonella Contaldo
- Gastroenterology Unit, National Institute of Gastroenterology “S de Bellis” Research Hospital, Bari 70013, Italy
| | - Antonio Facciorusso
- Department of Medical Sciences, University of Foggia, Section of Gastroenterology, Foggia 71122, Italy
| | - Marcello Maida
- Gastroenterology and Endoscopy Unit, S.Elia-Raimondi Hospital, Caltanissetta 93100, Italy
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Chirila A, Nguyen ME, Tinmouth J, Halperin IJ. Preparing for Colonoscopy in People with Diabetes: A Review with Suggestions for Clinical Practice. J Can Assoc Gastroenterol 2022; 6:26-36. [PMID: 36789141 PMCID: PMC9915054 DOI: 10.1093/jcag/gwac035] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
Abstract
People with diabetes have an increased risk of adverse events during the peri-colonoscopy period, including hypoglycemia, lactic acidosis, diabetic ketoacidosis and acute kidney injury. This is secondary to inadequate dietary modification, the bowel preparation and antihyperglycemic agent modification. With the availability of many new diabetes agents, endoscopists need updated guidance. This review of current literature provides a practical approach to antihyperglycemic agent modification in the context of colonoscopy preparation, as well as guidelines on dietary changes, the bowel preparation itself and glucose monitoring.
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Affiliation(s)
- Alexandra Chirila
- Correspondence: Alexandra Chirila, MSc, Department of Medicine, University of Toronto, Toronto, Ontario, Canada, e-mail:
| | - Mary E Nguyen
- Department of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Jill Tinmouth
- Department of Medicine, University of Toronto, Toronto, Ontario, Canada,Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Ilana J Halperin
- Department of Medicine, University of Toronto, Toronto, Ontario, Canada,Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
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Agha OQ, Alsayid M, Brown MD. Bowel preparation in diabetic patients undergoing colonoscopy. Ann Gastroenterol 2021; 34:310-315. [PMID: 33948054 PMCID: PMC8079869 DOI: 10.20524/aog.2021.0599] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/23/2020] [Accepted: 01/12/2021] [Indexed: 12/12/2022] Open
Abstract
Diabetes mellitus is a risk factor for poor bowel preparation in patients who undergo colonoscopy, because of their decreased intestinal transit and slow gastric emptying. This might lead to neoplastic or preneoplastic lesions being missed, longer procedural time, a higher risk of procedure-related adverse events, significant cost burden, patient dissatisfaction, and the need for a repeat colonoscopy. Multiple strategies have been suggested to improve bowel preparation in these patients. Proposed pharmacologic strategies include adding magnesium citrate, bisacodyl, lubiprostone or pyridostigmine. Non-pharmacologic strategies include preferential procedure scheduling or using a diabetes-specific preparation protocol. In this article, we present a comprehensive review of the literature and provide specific recommendations to general practitioners and gastroenterologists for improving bowel preparation in patients with diabetes.
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Affiliation(s)
- Osama Qasim Agha
- Division of Internal Medicine, Creighton University School of Medicine, Phoenix, Arizona (Osama Qasim Agha).,Division of Internal Medicine, St Joseph's Hospital and Medical Center, Phoenix, Arizona (Osama Qasim Agha)
| | - Muhammad Alsayid
- Division of Digestive Diseases, Rush University Medical Center, Chicago, Illinois (Muhammad Alsayid, Michael D. Brown), USA
| | - Michael D Brown
- Division of Digestive Diseases, Rush University Medical Center, Chicago, Illinois (Muhammad Alsayid, Michael D. Brown), USA
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Martel M, Ménard C, Restellini S, Kherad O, Almadi M, Bouchard M, Barkun AN. Which Patient-Related Factors Determine Optimal Bowel Preparation? ACTA ACUST UNITED AC 2018; 16:406-416. [PMID: 30390208 DOI: 10.1007/s11938-018-0208-9] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
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.
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Affiliation(s)
- Myriam Martel
- Division of Gastroenterology, McGill University Health Center, McGill University, Montreal, Canada
| | | | - Sophie Restellini
- Department of Specialties of Internal Medicine, Division of Gastroenterology, Geneva University Hospital, Geneva, Switzerland
| | - Omar Kherad
- Internal Medicine, La Tour Hospital, University of Geneva, Geneva, Switzerland
| | - Majid Almadi
- Division of Gastroenterology, King Khalid University Hospital, King Saud University, Riyadh, Saudi Arabia
| | - Maïté Bouchard
- Division of Gastroenterology, McGill University Health Center, McGill University, Montreal, Canada
| | - Alan N Barkun
- Division of Gastroenterology, McGill University Health Center, McGill University, Montreal, Canada.
- Epidemiology and Biostatistics and Occupational Health, McGill University Health Center, McGill University, 1650 Cedar Avenue, D7.346, Montréal, Québec, H3G1A4, Canada.
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Madhoun MF, Chaudrey KK, Chisholm SS, Ahmed A, Frost B, Tierney WM. Efficacy and tolerability of various bowel preparations in diabetic patients: a randomized controlled trial. Endosc Int Open 2018; 6:E1157-E1163. [PMID: 30302371 PMCID: PMC6175603 DOI: 10.1055/a-0650-3908] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/25/2017] [Accepted: 02/08/2018] [Indexed: 12/13/2022] Open
Abstract
Background and study aims Diabetes mellitus (DM) is an independent risk factor for poor bowel preparation prior to colonoscopy. Bisacodyl is a stimulant laxative that may mitigate colonic dysmotility associated with diabetes. We hypothesized that adding bisacodyl to split-dose bowel preparation (SDBP) would improve the quality of bowel preparation among patients with diabetes. Patients and methods Adult outpatients aged 18 to 80 years undergoing colonoscopy were recruited. One hundred and eighty-six patients with diabetes were randomly assigned to 1 of 3 treatment arms: 1) conventional 4 L of polyethylene glycol electrolyte lavage solution (PEG-ELS; conventional bowel preparation [CBP]); 2) split-dose of 4 L PEG-ELS (split-dose bowel preparation [SDBP]); or 3) split-dose of 4 L PEG-ELS preceded by 10 mg of oral bisacodyl 10 (SDBP-B). The primary outcome measure was bowel cleansing as indicated by Boston Bowel Preparation Scale (BBPS) score. Endoscopists were blinded to the preparation used. Secondary outcome measures were safety and patient tolerability. Results Of the 212 patients randomized, only 186 received assigned bowel preparation. There were no differences among the three study groups with regard to age, indication, duration of DM, insulin use, narcotic use, or presence of end-organ diabetic complications. There was a trend toward better bowel preparation quality among those receiving SDBP and SDBP-B compared to those receiving CBP, but the trend was not statistically significant ≥ 6 BBPS; 67 % vs. 83 % vs. 75 %, P = 0.1). In terms of safety and tolerability, there were no differences among the three groups. Conclusion Adding bisacodyl to SDBP does not improve the quality of bowel preparation in patients with DM. Further efforts are needed to optimize colonoscopy bowel preparation in this population.
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Affiliation(s)
- Mohammad F. Madhoun
- Veterans Affairs Medical Center, Oklahoma City, Oklahoma, United States,Division of Digestive Diseases and Nutrition, Department of Internal Medicine, University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma, United States,Corresponding author Mohammad F. Madhoun, MD MS Director of EndoscopyVeterans Affairs Medical CenterAssociate Professor of MedicineUniversity of Oklahoma Health Sciences CenterDivision of Digestive Diseases and NutritionAndrews Academic Tower, Suite 7400800 Stanton L. Young BlvdOklahoma City, OK 73104+1-405-271-5803
| | - Khadija K. Chaudrey
- Veterans Affairs Medical Center, Oklahoma City, Oklahoma, United States,Division of Digestive Diseases and Nutrition, Department of Internal Medicine, University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma, United States
| | - Sian S. Chisholm
- Veterans Affairs Medical Center, Oklahoma City, Oklahoma, United States,Division of Digestive Diseases and Nutrition, Department of Internal Medicine, University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma, United States
| | - Aftab Ahmed
- Veterans Affairs Medical Center, Oklahoma City, Oklahoma, United States,Division of Digestive Diseases and Nutrition, Department of Internal Medicine, University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma, United States
| | - Belinda Frost
- Veterans Affairs Medical Center, Oklahoma City, Oklahoma, United States
| | - William M. Tierney
- Veterans Affairs Medical Center, Oklahoma City, Oklahoma, United States,Division of Digestive Diseases and Nutrition, Department of Internal Medicine, University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma, United States
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Piper MS, Saad RJ. Diabetes Mellitus and the Colon. CURRENT TREATMENT OPTIONS IN GASTROENTEROLOGY 2017; 15:460-474. [PMID: 29063998 PMCID: PMC6049816 DOI: 10.1007/s11938-017-0151-1] [Citation(s) in RCA: 43] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
OPINION STATEMENT Diabetes mellitus (DM) can affect the structure and function of the colon promoting commonly encountered lower gastrointestinal symptoms such as constipation, diarrhea, abdominal distention, bloating, and abdominal pain. Specific colonic disorders for which adults with DM are at greater risk include chronic constipation, enteropathic diarrhea, colorectal cancer (CRC), inflammatory bowel disease, microscopic colitis, and Clostridium difficile colitis. Smooth muscle structure and function, density of the interstitial cells of Cajal, and the health and function of the autonomic and enteric nerves of the colon are all potential affected by DM. These effects can in turn lead to alterations in colon motility, visceral sensation, immune function, endothelial function, and the colonic microbiome. The evaluation and treatment for slow transit constipation as well as pelvic floor dysfunction should be considered when constipation symptoms are refractory to initial treatment measures. DM-related medications and small bowel conditions such as celiac disease and small intestinal bowel overgrowth should be considered and excluded before a diagnosis of enteropathic diarrhea is made. Given the higher risk of CRC, adults with DM should be appropriately screened and may require a longer bowel preparation to ensure an adequate evaluation.
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Affiliation(s)
- Marc S Piper
- Providence-Park Hospital, Michigan State University College of Human Medicine, Lansing, MI, USA
| | - Richard J Saad
- Michigan Medicine at the University of Michigan, 3912 Taubman Center, 1500 E. Medical Center Dr., Ann Arbor, MI, 48109, USA.
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Mandolesi D, Frazzoni L, Bazzoli F, Fuccio L. The management of 'hard-to-prepare' colonoscopy patients. Expert Rev Gastroenterol Hepatol 2017; 11:731-740. [PMID: 28594580 DOI: 10.1080/17474124.2017.1338947] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Effective bowel cleansing is crucial for high quality colonoscopy. A notable portion of patients still present with low quality bowel preparation prior to their colonoscopy, compromising the overall quality of their colonoscopy. Areas covered: This review focuses on the main strategies that can improve the cleansing quality with a special interest on those clinical conditions that have been associated with a poor bowel preparation quality, such as patients with chronic constipation, history of bowel resection, liver cirrhosis, diabetes mellitus and chronic kidney disease. The review provides a practical and evidence-based approach to help clinicians in the management of 'hard-to-prepare' patients. Expert commentary: In the past few years, the quality of colonoscopy has become a hot topic and bowel cleansing is a crucial part of it; however, the approach to patients with an increased risk of poor bowel preparation quality is still not always supported by high-quality evidence, since most of these patients are routinely excluded from the clinical studies. Trials focused on this subgroup of patients are recommended to provide tailored bowel preparation regimens and guarantee high-quality procedures.
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Affiliation(s)
- Daniele Mandolesi
- a Gastroenterology Unit, Department of Medical and Surgical Sciences , University of Bologna, S.Orsola-Malpighi Hospital , Bologna , Italy
| | - Leonardo Frazzoni
- a Gastroenterology Unit, Department of Medical and Surgical Sciences , University of Bologna, S.Orsola-Malpighi Hospital , Bologna , Italy
| | - Franco Bazzoli
- a Gastroenterology Unit, Department of Medical and Surgical Sciences , University of Bologna, S.Orsola-Malpighi Hospital , Bologna , Italy
| | - Lorenzo Fuccio
- a Gastroenterology Unit, Department of Medical and Surgical Sciences , University of Bologna, S.Orsola-Malpighi Hospital , Bologna , Italy
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Evaluation of the effect of GLP-1 agonists on quality of bowel preparation for colonoscopy in patients with diabetes. PRACTICAL DIABETES 2017. [DOI: 10.1002/pdi.2110] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
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Inadequate Bowel Cleansing Efficacy of Split-dose Polyethylene Glycol for Colonoscopy in Type 2 Diabetic Patients: A Prospective and Blinded Study. J Clin Gastroenterol 2017; 51:240-246. [PMID: 27136960 DOI: 10.1097/mcg.0000000000000536] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
BACKGROUND/AIMS Split-dose polyethylene glycol (PEG) is considered a standard bowel preparation regimen for colonoscopy in the general population. However, it is not clear whether the regimen is optimal for colonoscopy in diabetic patients. The aim of this study was to compare the efficacy and tolerability of split-dose PEG for diabetic versus nondiabetic patients. METHODS This is a single-center, prospective, investigator-blinded study. A total of 55 consecutive nondiabetic and 50 diabetic patients ingested 2 L PEG solution on the day before the procedure and then 2 L of the solution on the day of colonoscopy. The quality of bowel preparation was graded using the Ottawa scale. RESULTS There was a significant difference in bowel preparation quality, with a worse preparation except for mid colon in diabetic group (total score: 7.06±1.69 vs. 5.54±1.97, P<0.001; right colon: 2.28±0.57 vs. 1.81±0.72, P<0.001; mid colon: 1.70±0.54 vs. 1.56±0.66, P=0.253; rectosigmoid colon: 1.70±0.76 vs. 1.14±0.62, P<0.001; fluid volume: 1.38±0.53 vs. 1.01±0.59, P=0.001). About 70% of nondiabetic patients had an adequate preparation compared with only 40% of diabetic patients (P=0.003). Diabetic group had longer cecal intubation time (6.4±3.6 vs. 4.5±2.4, P=0.002) and total procedure time (22.1±7.6 vs. 18.1±8.5, P=0.015). Compliance and adverse events were not significantly different. In diabetic group, inadequate bowel preparation had a significant association with higher fasting plasma glucose (136.9±21.8 vs. 121.8±19.4 mg/dL, P=0.016). CONCLUSIONS Diabetic patients had a worse preparation quality and longer cecal intubation and total procedure time compared with nondiabetic patients. These data suggest that split-dose PEG preparation regimen is not sufficient for optimal bowel preparation in diabetic patients undergoing colonoscopy.
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Johnson DA, Barkun AN, Cohen LB, Dominitz JA, Kaltenbach T, Martel M, Robertson DJ, Boland CR, Giardello FM, Lieberman DA, Levin TR, Rex DK. Optimizing adequacy of bowel cleansing for colonoscopy: recommendations from the US multi-society task force on colorectal cancer. Gastroenterology 2014; 147:903-924. [PMID: 25239068 DOI: 10.1053/j.gastro.2014.07.002] [Citation(s) in RCA: 288] [Impact Index Per Article: 26.2] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Affiliation(s)
| | - Alan N Barkun
- McGill University Health Center, McGill University, Montreal, Canada
| | - Larry B Cohen
- Icahn School of Medicine at Mount Sinai, New York, New York
| | - Jason A Dominitz
- VA Puget Sound Health Care System and University of Washington, Seattle, Washington
| | - Tonya Kaltenbach
- Veterans Affairs Palo Alto, Stanford University School of Medicine, Palo Alto, California
| | - Myriam Martel
- McGill University Health Center, McGill University, Montreal, Canada
| | - Douglas J Robertson
- VA Medical Center, White River Junction, Vermont; Geisel School of Medicine at Dartmouth, White River Junction, Vermont
| | | | | | | | | | - Douglas K Rex
- Indiana University School of Medicine, Indianapolis, Indiana
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Optimizing adequacy of bowel cleansing for colonoscopy: recommendations from the US Multi-Society Task Force on Colorectal Cancer. Am J Gastroenterol 2014; 109 Suppl 2:S39-59. [PMID: 25223578 DOI: 10.1038/ajg.2014.272] [Citation(s) in RCA: 95] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
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Optimizing adequacy of bowel cleansing for colonoscopy: recommendations from the U.S. multi-society task force on colorectal cancer. Gastrointest Endosc 2014; 80:543-562. [PMID: 25220509 DOI: 10.1016/j.gie.2014.08.002] [Citation(s) in RCA: 101] [Impact Index Per Article: 9.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
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Lim YJ, Hong SJ. What is the best strategy for successful bowel preparation under special conditions? World J Gastroenterol 2014; 20:2741-2745. [PMID: 24659865 PMCID: PMC3961988 DOI: 10.3748/wjg.v20.i11.2741] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/08/2013] [Revised: 10/18/2013] [Accepted: 11/05/2013] [Indexed: 02/06/2023] Open
Abstract
Adequate bowel preparation is important for successful colonoscopic examination. Several effective colonic cleansing agents are available and routinely prescribed, but each carries its own limitations and benefits from particular dosing regimens. The most frequently prescribed colonic cleansing agent, the polyethylene glycol (PEG) cathartic solution, suffers from low patient compliance in general, due to its unpalatable taste and smell coupled with the large ingested volumes required. However, PEG is preferred over other cathartics for use in individuals of advanced age, sufferers of chronic kidney disease, heart failure and inflammatory bowel disease, and women who are pregnant or lactating. The laxative agents sodium phosphate (NaP) and sodium picosulfate plus magnesium citrate have been applied and have improved patient compliance and tolerance. NaP, however, should be avoided in individuals with impaired renal function or plasma clearance, such as those with chronic kidney disease, who are taking drugs that affect renal function, or who suffer from heart failure. Other special conditions that may affect an individual’s tolerance of the cathartic agent or ability to complete the administration routine include stroke, severe constipation, hematochezia, suspicious lower gastrointestinal bleeding, and mental disorders such as dementia. All ingestible bowel preparation solutions can be instilled into the stomach and duodenum through nasogastric tube or esophagogastroduodenoscope with the aid of a water irrigation pump for patients with difficulties swallowing or ingesting the large volumes of fluid required. In addition, dietary regimens based on clear liquids and low-residue foods for 1-4 d prior to the colonoscopy may be supplemental bowel preparation strategies. Achieving an effective and safe cleansing of the bowel is important for successful colonoscopy in all patients, so full knowledge of the individual’s condition and capabilities is necessary to select the most appropriate colonic cleansing agent and delivery regimen.
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