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Hagen R, Nguyen MTT, Anderson JC, Birk JW. Navigating Bowel Preparation for Colonoscopy: A Comprehensive Overview. J Clin Gastroenterol 2025; 59:285-297. [PMID: 39761153 DOI: 10.1097/mcg.0000000000002124] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/08/2025]
Abstract
Colorectal cancer (CRC) is the third most common cancer in the United States. Early detection through colonoscopy significantly improves survival rates. Detecting colon polyps depends on the quality of bowel preparation. However, inadequate bowel preparation remains a significant issue in clinical practice. Efforts to address this challenge have led to the development of bowel preparation regimens emphasizing efficacy, tolerability, and safety. Bowel preparation options can be categorized by their osmotic and volume properties. Isosmotic solutions based on polyethylene glycol-electrolyte lavage solutions (PEG-ELS) are available in both low-volume PEG-ELS with ascorbic acid (PEG-Asc) (e.g., MoviPrep, PLENVU) and high-volume formulations (e.g., GoLYTELY, CoLyte), as well as sulfate-free high-volume PEG-ELS formulations (SF-PEG-ELS). Hyperosmotic solutions include oral sulfate solution (OSS) (e.g., SUPREP), sodium phosphate tablets (NaP) (e.g., OsmoPrep), oral sulfate tablets (OST) (e.g., SUTAB), flavored PEG with sulfate salts (FPSS) (e.g., SUFLAVE), and magnesium citrate. Hypoosmotic solutions consist of PEG-sports drink (PEG-SD). In addition, combination solutions are available, such as sodium picosulfate with magnesium citrate (SPMC) with laxatives (e.g., CLENPIQ), and OSS with SF-PEG-ELS (Suclear). Each regimen differs in terms of cost, volume, taste, contraindications, and potential adverse effects. Therefore, clinicians must carefully evaluate each patient to determine the most suitable regimen for their patients.
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Affiliation(s)
| | - Minh Thu T Nguyen
- Department of Medicine
- Division of Gastroenterology and Hepatology, Department of Medicine, University of Connecticut Health Center, Farmington, CT
| | - Joseph C Anderson
- Division of Gastroenterology and Hepatology, Department of Medicine, Dartmouth Hitchcock Medical Center, Lebanon, NH
| | - John W Birk
- Department of Medicine
- Division of Gastroenterology and Hepatology, Department of Medicine, University of Connecticut Health Center, Farmington, CT
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Reumkens A, van der Zander Q, Winkens B, Bogie R, Bakker CM, Sanduleanu S, Masclee AAM. Electrolyte disturbances after bowel preparation for colonoscopy: Systematic review and meta-analysis. Dig Endosc 2022; 34:913-926. [PMID: 35037327 PMCID: PMC9543544 DOI: 10.1111/den.14237] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/13/2021] [Revised: 01/11/2022] [Accepted: 01/12/2022] [Indexed: 12/13/2022]
Abstract
BACKGROUND AND STUDY AIMS We conducted a systematic review and meta-analysis of population-based studies to explore pooled prevalence and magnitude of electrolyte changes after bowel preparation for colonoscopy based on the most recent guidelines. PATIENTS AND METHODS PubMed and Cochrane were queried for population-based studies examining changes in electrolyte values after bowel preparation, published by July 1, 2021. We report prevalences of serum hypokalemia, hyponatremia, hyperphosphatemia, and hypocalcemia after bowel preparation and changes in mean electrolyte values after vs. before bowel preparation using sodium phosphate (NaP) and polyethylene glycol (PEG). RESULTS Thirteen studies met the inclusion criteria; 2386 unique patients were included. Overall, hypokalemia was found in 17.2% (95% CI 6.7, 30.9) in the NaP group vs. 4.8% (95% CI 0.27, 13.02) in the PEG group. The magnitude of potassium decrease after NaP bowel preparation was significantly increased compared to PEG (mean difference -0.38; 95% CI -0.49 to -0.27, P < 0.001). No study reported on major complications. CONCLUSIONS Hypokalemia was found in 17.2% of patients after bowel preparation with NaP and in 4.8% of patients with PEG, a finding that is clinically relevant with respect to choosing the type of bowel preparation. The magnitude of the potassium decrease after NaP was significantly higher compared to PEG. These data provide the evidence that supports the recommendation of the European Society of Gastrointestinal Endoscopy against routine use of NaP for bowel preparation.
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Affiliation(s)
- Ankie Reumkens
- Department of Internal Medicine and GastroenterologyZuyderland Medical CenterHeerlenThe Netherlands
- Division of Gastroenterology and HepatologyDepartment of Internal MedicineMaastricht University Medical CenterMaastrichtThe Netherlands
- NUTRIMSchool for Nutrition, Toxicology and MetabolismMaastricht University Medical CenterMaastrichtThe Netherlands
| | - Quirine van der Zander
- Division of Gastroenterology and HepatologyDepartment of Internal MedicineMaastricht University Medical CenterMaastrichtThe Netherlands
- GROWSchool for Oncology and Developmental BiologyMaastricht University Medical CenterMaastrichtThe Netherlands
| | - Bjorn Winkens
- Department of Methodology and StatisticsMaastricht University Medical CenterMaastrichtThe Netherlands
- CAPHRISchool for Public Health and Primary CareMaastricht University Medical CenterMaastrichtThe Netherlands
| | - Roel Bogie
- Division of Gastroenterology and HepatologyDepartment of Internal MedicineMaastricht University Medical CenterMaastrichtThe Netherlands
- GROWSchool for Oncology and Developmental BiologyMaastricht University Medical CenterMaastrichtThe Netherlands
| | - Christine Minke Bakker
- Department of Internal Medicine and GastroenterologyZuyderland Medical CenterHeerlenThe Netherlands
| | - Silvia Sanduleanu
- Division of Gastroenterology and HepatologyDepartment of Internal MedicineMaastricht University Medical CenterMaastrichtThe Netherlands
- GROWSchool for Oncology and Developmental BiologyMaastricht University Medical CenterMaastrichtThe Netherlands
| | - Ad A. M. Masclee
- Division of Gastroenterology and HepatologyDepartment of Internal MedicineMaastricht University Medical CenterMaastrichtThe Netherlands
- NUTRIMSchool for Nutrition, Toxicology and MetabolismMaastricht University Medical CenterMaastrichtThe Netherlands
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Risk of Renal Injury After the Use of Polyethylene Glycol for Outpatient Colonoscopy: A Prospective Observational Study. J Clin Gastroenterol 2019; 53:e444-e450. [PMID: 30358643 DOI: 10.1097/mcg.0000000000001140] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
GOAL The goal of this study was to estimate the risk of renal injury after the use of 3-L polyethylene glycol (PEG) before outpatient colonoscopy. BACKGROUND Population-based studies showed that the use of PEG was associated with renal injury, but this association has not been confirmed by prospective study. STUDY Patients ≥40 years of age with an estimated glomerular filtration rate ≥30 mL/min were screened for enrollment. Laboratory data were collected before, during, and after the colonoscopies. Patients with a ≥30% increase in baseline serum creatinine levels were followed until a peak level was detected. Renal injury included acute renal dysfunction (ARD) and acute kidney injury (AKI), defined as a 30% to 49% increase and ≥50% increase in creatinine levels compared with the baseline, respectively. RESULTS A total of 1163 patients (mean age, 55.7 y) completed the study. Baseline and first postcolonoscopy laboratory data were obtained an average of 17.0 days before and 17.3 days after the colonoscopies were performed, respectively. Renal injury was identified in 32 patients; 26 patients (2.2%) had ARD, and 6 patients (0.5%) had AKI. All patients with renal injury recovered fully during follow-up. In the subgroup analysis, the use of nonsteroidal anti-inflammatory drugs (NSAIDs) before colonoscopy was statistically associated with the development of AKI (odds ratio, 6.5; 95% confidence interval, 1.2-35.5; P=0.03). CONCLUSIONS This prospective study showed that the use of PEG was associated with a small risk of renal injury. NSAIDs use was statistically associated with AKI in the context of colonoscopy for which PEG was used for bowel preparation.
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Baker FA, Mari A, Nafrin S, Suki M, Ovadia B, Gal O, Kopelamn Y. Predictors and colonoscopy outcomes of inadequate bowel cleansing: a 10-year experience in 28,725 patients. Ann Gastroenterol 2019; 32:457-462. [PMID: 31474791 PMCID: PMC6686086 DOI: 10.20524/aog.2019.0400] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/30/2019] [Accepted: 06/05/2019] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Inadequate bowel preparation is still the main obstacle to a complete colonoscopy in many patients and necessitates many repeated procedures. We aimed to identify risk factors associated with inadequate bowel preparation and to better characterize these patients. METHODS This was a retrospective study that reviewed electronic reports of colonoscopy procedures over a 10-year period. Patients were divided into 2 groups: adequate vs. non-adequate bowel preparation. A multivariate analysis was performed to identify variables associated with inadequate bowel preparation, including age, sex, setting (inpatient/outpatient), preparation regimen and procedures' indications. We examined the effect of inadequate preparation on colonoscopy quality indicators. RESULTS Of the 28,725 patients included in the study, 6,702 (23.3%) had inadequate bowel preparation. In the multivariate analysis, advanced age (odds ratio [OR] 1.015, 95% confidence interval [CI] 1.013-1.017; P<0.01), male sex (OR 1.353, 95%CI 1.286-1.423; P<0.01) and a minority population (OR 1.635, 95%CI 1.531-1.746; P<0.01) were significantly associated with inadequate bowel preparation. The inpatient setting was among the most prominent factors associated with inadequate bowel preparation (OR 2.018, 95%CI 1.884-2.163; P<0.01). Adequate bowel preparation was associated with a higher polyp detection rate (26.8% vs. 23.6%; OR 1.22, 95%CI 1.109-1.347; P<0.01) and colorectal cancer (2.8% vs. 2.4%; OR 1.402, 95%CI 1.146-1.716; P<0.01), and higher frequencies of cecal (96.4% vs. 73.5%; OR 2.243, 95%CI 2.095-2.403; P<0.01) and terminal ileum intubation (8.1% vs. 5.4%; OR 1.243, 95%CI 1.088-1.434; P<0.01). CONCLUSION We outlined various factors associated with inadequate bowel preparation and confirmed its adverse effect on colonoscopy quality indicators.
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Affiliation(s)
- Fadi Abu Baker
- Department of Gastroenterology and Hepatology, Hillel Yaffe Medical Center, Hadera, Israel, Affiliated to the Technion Faculty of Medicine, Haifa, Israel
| | - Amir Mari
- Department of Gastroenterology, Nazareth EMMS Hospital, Affiliated to the Faculty of Medicine, Bar Illan University, Israel
| | - Smadar Nafrin
- Department of Gastroenterology and Hepatology, Hillel Yaffe Medical Center, Hadera, Israel, Affiliated to the Technion Faculty of Medicine, Haifa, Israel
| | - Muhammed Suki
- Department of Gastroenterology and Hepatology, Hillel Yaffe Medical Center, Hadera, Israel, Affiliated to the Technion Faculty of Medicine, Haifa, Israel
| | - Baruch Ovadia
- Department of Gastroenterology and Hepatology, Hillel Yaffe Medical Center, Hadera, Israel, Affiliated to the Technion Faculty of Medicine, Haifa, Israel
| | - Oren Gal
- Department of Gastroenterology and Hepatology, Hillel Yaffe Medical Center, Hadera, Israel, Affiliated to the Technion Faculty of Medicine, Haifa, Israel
| | - Yael Kopelamn
- Department of Gastroenterology and Hepatology, Hillel Yaffe Medical Center, Hadera, Israel, Affiliated to the Technion Faculty of Medicine, Haifa, Israel
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Kang MK, Jang BI, Park JS, Kim KO. Efficacy of ramosetron in combination with polyethylene glycol of preparing for a colonoscopy. Yeungnam Univ J Med 2019; 36:99-104. [PMID: 31620620 PMCID: PMC6784633 DOI: 10.12701/yujm.2019.00080] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2018] [Revised: 12/19/2018] [Accepted: 12/24/2018] [Indexed: 01/22/2023] Open
Abstract
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.
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Affiliation(s)
- Min Kyu Kang
- Department of Internal Medicine, Yeungnam University College of Medicine, Daegu, Korea
| | - Byung Ik Jang
- Department of Internal Medicine, Yeungnam University College of Medicine, Daegu, Korea
- Corresponding author: Byung Ik Jang, Division of Gastroenterology and Hepatology, Department of Internal Medicine, Yeungnam University College of Medicine, 170, Hyeonchung-ro, Nam-gu, Daegu 42415, Korea Tel: +82-53-620-3831, Fax: +82-53-623-8038, E-mail:
| | - Jun Suk Park
- Department of Internal Medicine, Yeungnam University College of Medicine, Daegu, Korea
| | - Kyeong Ok Kim
- Department of Internal Medicine, Yeungnam University College of Medicine, Daegu, Korea
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Lee JM, Keum B, Yoo IK, Kim SH, Choi HS, Kim ES, Seo YS, Jeen YT, Chun HJ, Lee HS, Um SH, Kim CD, Kim MG, Jo SK. Polyethylene glycol plus ascorbic acid for bowel preparation in chronic kidney disease. Medicine (Baltimore) 2016; 95:e4755. [PMID: 27603372 PMCID: PMC5023895 DOI: 10.1097/md.0000000000004755] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
The safety of polyethylene glycol plus ascorbic acid has not been fully investigated in patients with renal insufficiency. High-dose ascorbic acid could induce hyperoxaluria, thereby causing tubule-interstitial nephritis and renal failure. This study aims to evaluate the safety and efficacy of polyethylene glycol plus ascorbic acid in patients with chronic kidney disease.We retrospectively reviewed prospectively collected data on colonoscopy in patients with impaired renal function. Patients were divided into 2 groups: 2 L polyethylene glycol plus ascorbic acid (n = 61) and 4 L polyethylene glycol (n = 80). The safety of the 2 groups was compared by assessing the differences in laboratory findings before and after bowel cleansing.The laboratory findings were not significantly different before and after the administration of 2 L polyethylene glycol plus ascorbic acid or 4 L polyethylene glycol. In both groups, the estimated glomerular filtration rate was not influenced by the administration of the bowel-cleansing agent. Patients' reports on tolerance and acceptability were better in the 2 L polyethylene glycol plus ascorbic acid group than in the 4 L polyethylene glycol group.The 2 L polyethylene glycol plus ascorbic acid solution is a safe choice for bowel preparation before colonoscopy in patients with impaired renal function.
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Affiliation(s)
| | - Bora Keum
- Division of Gastroenterology and Hepatology
- Correspondence: Bora Keum, Division of Gastroenterology and Hepatology, Department of Internal Medicine, Korea University College of Medicine, Inchon-ro, Seongbuk-gu, Seoul, Korea (e-mail: )
| | | | | | | | | | | | | | | | | | - Soon Ho Um
- Division of Gastroenterology and Hepatology
| | | | - Myung Gyu Kim
- Division of Nephrology, Department of Internal Medicine, Korea University College of Medicine, Seongbuk-gu, Seoul, 02841, Korea
| | - Sang Kyung Jo
- Division of Nephrology, Department of Internal Medicine, Korea University College of Medicine, Seongbuk-gu, Seoul, 02841, Korea
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Fan XP, Zhu Q, Zhou YJ, Ma T, Xia CX, Huang HL. Comparative Study of Three Regimens of Bowel Preparation Before Transabdominal Ultrasonography of the Colon. ULTRASOUND IN MEDICINE & BIOLOGY 2016; 42:2140-2145. [PMID: 27181688 DOI: 10.1016/j.ultrasmedbio.2016.04.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/26/2015] [Revised: 04/02/2016] [Accepted: 04/06/2016] [Indexed: 06/05/2023]
Abstract
The objective of the study was to compare the efficacy of three bowel preparation regimens for transabdominal colon ultrasonography. A total of 192 consecutive patients were given one of three regimens (senna, magnesium sulfate or polyethylene glycol electrolyte powder) before ultrasonographic examinations. The cleaning grade (I = emptying; II = filled or filled + empty; III = I or II with some retention; and IV = retention [grades I and II were termed "qualified"]) and cleaning range (A = all seven colon sections were qualified; B = four to six sections were qualified; C = three or less sections were qualified) were evaluated retrospectively. Senna was found more effective than polyethylene glycol in terms of cleaning grade (p < 0.001), qualified rate (p < 0.001) and cleaning range (p = 0.003). Senna was better than magnesium sulfate in cleaning grade (p < 0.001). Our results suggest that senna seems to be the preferred regimen for bowel preparation before transabdominal colonic ultrasonography.
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Affiliation(s)
- Xiu-Ping Fan
- Department of Diagnostic Ultrasound, Beijing Tongren Hospital, Capital Medical University, Beijing, China
| | - Qiang Zhu
- Department of Diagnostic Ultrasound, Beijing Tongren Hospital, Capital Medical University, Beijing, China.
| | - Ya-Jing Zhou
- Department of Diagnostic Ultrasound, Beijing Tongren Hospital, Capital Medical University, Beijing, China
| | - Teng Ma
- Department of Diagnostic Ultrasound, Beijing Tongren Hospital, Capital Medical University, Beijing, China
| | - Chun-Xia Xia
- Department of Diagnostic Ultrasound, Beijing Tongren Hospital, Capital Medical University, Beijing, China
| | - Hui-Lian Huang
- Department of Diagnostic Ultrasound, Beijing Tongren Hospital, Capital Medical University, Beijing, China
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Harrison NM, Hjelkrem MC. Bowel cleansing before colonoscopy: Balancing efficacy, safety, cost and patient tolerance. World J Gastrointest Endosc 2016; 8:4-12. [PMID: 26788258 PMCID: PMC4707321 DOI: 10.4253/wjge.v8.i1.4] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/23/2015] [Revised: 09/15/2015] [Accepted: 11/11/2015] [Indexed: 02/05/2023] Open
Abstract
Effective colorectal cancer screening relies on reliable colonoscopy findings which are themselves dependent on adequate bowel cleansing. Research has consistently demonstrated that inadequate bowel preparation adversely affects the adenoma detection rate and leads gastroenterologists to recommend earlier follow up than is consistent with published guidelines. Poor preparation affects as many as 30% of colonoscopies and contributes to an increased cost of colonoscopies. Patient tolerability is strongly affected by the preparation chosen and manner in which it is administered. Poor tolerability is, in turn, associated with lower quality bowel preparations. Recently, several new developments in both agents being used for bowel preparation and in the timing of administration have brought endoscopists closer to achieving the goal of effective, reliable, safe, and tolerable regimens. Historically, large volume preparations given in a single dose were administered to patients in order to achieve adequate bowel cleansing. These were poorly tolerated, and the unpleasant taste of and significant side effects produced by these large volume regimens contributed significantly to patients’ inability to reliably complete the preparation and to a reluctance to repeat the procedure. Smaller volumes, including preparations that are administered as tablets to be consumed with water, given as split doses have significantly improved both the patient experience and efficacy, and an appreciation of the importance of the preparation to colonoscopy interval have produced additional cleansing.
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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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Xie Q, Chen L, Zhao F, Zhou X, Huang P, Zhang L, Zhou D, Wei J, Wang W, Zheng S. A meta-analysis of randomized controlled trials of low-volume polyethylene glycol plus ascorbic acid versus standard-volume polyethylene glycol solution as bowel preparations for colonoscopy. PLoS One 2014; 9:e99092. [PMID: 24902028 PMCID: PMC4047058 DOI: 10.1371/journal.pone.0099092] [Citation(s) in RCA: 57] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2013] [Accepted: 05/10/2014] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND Standard-volume polyethylene glycol (PEG) gut lavage solutions are safe and effective, but they require the consumption of large volumes of fluid. A new lower-volume solution of PEG plus ascorbic acid has been used recently as a preparation for colonoscopy. AIM A meta-analysis was performed to compare the performance of low-volume PEG plus ascorbic acid with standard-volume PEG as bowel preparation for colonoscopy. STUDY Electronic and manual searches were performed to identify randomized controlled trials (RCTs) that compared the performance of low-volume PEG plus ascorbic acid with standard-volume PEG as bowel preparation for colonoscopy. After a methodological quality assessment and data extraction, the pooled estimates of bowel preparation efficacy during bowel cleansing, compliance with preparation, willingness to repeat the same preparation, and the side effects were calculated. We calculated pooled estimates of odds ratios (OR) by fixed- and/or random-effects models. We also assessed heterogeneity among studies and the publication bias. RESULTS Eleven RCTs were identified for analysis. The pooled OR for preparation efficacy during bowel cleansing and for compliance with preparation for low-volume PEG plus ascorbic acid were 1.08 (95% CI = 0.98-1.28, P = 0.34) and 2.23 (95% CI = 1.67-2.98, P<0.00001), respectively, compared with those for standard-volume PEG. The side effects of vomiting and nausea for low-volume PEG plus ascorbic acid were reduced relative to standard-volume PEG. There was no significant publication bias, according to a funnel plot. CONCLUSIONS Low-volume PEG plus ascorbic acid gut lavage achieved non-inferior efficacy for bowel cleansing, is more acceptable to patients, and has fewer side effects than standard-volume PEG as a bowel preparation method for colonoscopy.
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Affiliation(s)
- Qingsong Xie
- Division of Hepatobilitary and Pancreatic Surgery, Department of surgery, First affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, Zhejiang Province, China
- Key Laboratory of Combined Multi- Organ Transplantation, Ministry of Public Health, Hangzhou, Zhejiang Province, China
- Key laboratory of Organ Transplantation, Zhejiang Province, Hangzhou, Zhejiang Province, China
| | - Linghui Chen
- Division of Hepatobilitary and Pancreatic Surgery, Department of surgery, First affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, Zhejiang Province, China
- Key Laboratory of Combined Multi- Organ Transplantation, Ministry of Public Health, Hangzhou, Zhejiang Province, China
- Key laboratory of Organ Transplantation, Zhejiang Province, Hangzhou, Zhejiang Province, China
| | - Fengqing Zhao
- Division of Hepatobilitary and Pancreatic Surgery, Department of surgery, First affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, Zhejiang Province, China
- Key Laboratory of Combined Multi- Organ Transplantation, Ministry of Public Health, Hangzhou, Zhejiang Province, China
- Key laboratory of Organ Transplantation, Zhejiang Province, Hangzhou, Zhejiang Province, China
| | - Xiaohu Zhou
- Division of Hepatobilitary and Pancreatic Surgery, Department of surgery, First affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, Zhejiang Province, China
- Key Laboratory of Combined Multi- Organ Transplantation, Ministry of Public Health, Hangzhou, Zhejiang Province, China
- Key laboratory of Organ Transplantation, Zhejiang Province, Hangzhou, Zhejiang Province, China
| | - Pengfei Huang
- Division of Hepatobilitary and Pancreatic Surgery, Department of surgery, First affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, Zhejiang Province, China
- Key Laboratory of Combined Multi- Organ Transplantation, Ministry of Public Health, Hangzhou, Zhejiang Province, China
- Key laboratory of Organ Transplantation, Zhejiang Province, Hangzhou, Zhejiang Province, China
| | - Lufei Zhang
- Division of Hepatobilitary and Pancreatic Surgery, Department of surgery, First affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, Zhejiang Province, China
- Key Laboratory of Combined Multi- Organ Transplantation, Ministry of Public Health, Hangzhou, Zhejiang Province, China
- Key laboratory of Organ Transplantation, Zhejiang Province, Hangzhou, Zhejiang Province, China
| | - Dongkai Zhou
- Division of Hepatobilitary and Pancreatic Surgery, Department of surgery, First affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, Zhejiang Province, China
- Key Laboratory of Combined Multi- Organ Transplantation, Ministry of Public Health, Hangzhou, Zhejiang Province, China
- Key laboratory of Organ Transplantation, Zhejiang Province, Hangzhou, Zhejiang Province, China
| | - Jianfeng Wei
- Division of Hepatobilitary and Pancreatic Surgery, Department of surgery, First affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, Zhejiang Province, China
- Key Laboratory of Combined Multi- Organ Transplantation, Ministry of Public Health, Hangzhou, Zhejiang Province, China
- Key laboratory of Organ Transplantation, Zhejiang Province, Hangzhou, Zhejiang Province, China
| | - Weilin Wang
- Division of Hepatobilitary and Pancreatic Surgery, Department of surgery, First affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, Zhejiang Province, China
- Key Laboratory of Combined Multi- Organ Transplantation, Ministry of Public Health, Hangzhou, Zhejiang Province, China
- Key laboratory of Organ Transplantation, Zhejiang Province, Hangzhou, Zhejiang Province, China
| | - Shusen Zheng
- Division of Hepatobilitary and Pancreatic Surgery, Department of surgery, First affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, Zhejiang Province, China
- Key Laboratory of Combined Multi- Organ Transplantation, Ministry of Public Health, Hangzhou, Zhejiang Province, China
- Key laboratory of Organ Transplantation, Zhejiang Province, Hangzhou, Zhejiang Province, China
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Bang KB, Jeong EH, Jeong WS, Chae HB, Kim NH, Lee TH, Kim JY, Jung YS, Park JH, Sohn CI, Choi KY, Park DI. Efficacy of Bisacodyl Given as Part of a Polyethylene Glycol-based Bowel Preparation Prior to Colonoscopy in Hospitalized Patients: A Prospective Ramdomized Trial. THE KOREAN JOURNAL OF GASTROENTEROLOGY 2014; 64:268-77. [DOI: 10.4166/kjg.2014.64.5.268] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Affiliation(s)
- Ki Bae Bang
- Department of Internal Medicine, Kangbuk Samsung Hospital, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Eun Haeng Jeong
- Department of Internal Medicine, Kangbuk Samsung Hospital, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Woo Shin Jeong
- Department of Internal Medicine, Kangbuk Samsung Hospital, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Hyun Beom Chae
- Department of Internal Medicine, Kangbuk Samsung Hospital, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Nam Hee Kim
- Department of Internal Medicine, Kangbuk Samsung Hospital, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Tae Hoon Lee
- Department of Internal Medicine, Kangbuk Samsung Hospital, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Ji Yeon Kim
- Department of Internal Medicine, Kangbuk Samsung Hospital, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Yoon Suk Jung
- Department of Internal Medicine, Kangbuk Samsung Hospital, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Jung Ho Park
- Department of Internal Medicine, Kangbuk Samsung Hospital, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Chong Il Sohn
- Department of Internal Medicine, Kangbuk Samsung Hospital, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Kyu Yong Choi
- Department of Internal Medicine, Kangbuk Samsung Hospital, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Dong Il Park
- Department of Internal Medicine, Kangbuk Samsung Hospital, Sungkyunkwan University School of Medicine, Seoul, Korea
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Abstract
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.
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Affiliation(s)
- Ala I Sharara
- Division of Gastroenterology, Department of Internal Medicine, American University of Beirut Medical Center, Beirut, Lebanon.
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15
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Rex DK, Katz PO, Bertiger G, Vanner S, Hookey LC, Alderfer V, Joseph RE. Split-dose administration of a dual-action, low-volume bowel cleanser for colonoscopy: the SEE CLEAR I study. Gastrointest Endosc 2013; 78:132-41. [PMID: 23566639 DOI: 10.1016/j.gie.2013.02.024] [Citation(s) in RCA: 70] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/12/2012] [Accepted: 02/20/2013] [Indexed: 02/08/2023]
Abstract
BACKGROUND New bowel cleansers for colonoscopy that lead to improved efficacy, safety, and tolerability are needed. OBJECTIVE This study evaluated a nonphosphate, dual-action, low-volume, orange-flavored preparation containing sodium picosulfate and magnesium citrate (P/MC). DESIGN Multicenter, assessor-blinded, randomized, noninferiority study. SETTING University hospitals, academic medical centers, and private clinics across the United States. PATIENTS Adults preparing for colonoscopy. INTERVENTIONS P/MC versus 2 L of polyethylene glycol solution (2L PEG-3350) and two 5-mg bisacodyl tablets. MAIN OUTCOME MEASUREMENTS This phase 3 study investigated the efficacy, safety, and tolerability of split-dose administration of P/MC versus day-before dosing of 2L PEG-3350 and two 5-mg bisacodyl tablets (SEE CLEAR I study). Efficacy was evaluated by using the Aronchick and Ottawa scales; noninferiority and superiority analyses were performed. Safety was assessed by monitoring adverse events (AEs). Tolerability was measured via a patient questionnaire. RESULTS The intent-to-treat population consisted of 601 patients who self-administered P/MC (n = 304) or 2L PEG-3350 and bisacodyl tablets (n = 297). P/MC was superior to 2L PEG-3350 and bisacodyl tablets in overall colon cleansing (84.2% vs 74.4%; 1-sided 97.5% confidence interval [CI], 3.4) (Aronchick scores of excellent or good) and in cleansing of the ascending (89.5% vs 78.8%; 1-sided 97.5% CI, 4.9), mid (transverse and descending) (92.4% vs 85.9%; 1-sided 97.5% CI, 1.6), and rectosigmoid (92.4% vs 87.2%; 1-sided 97.5% CI, 0.4) segments of the colon (Ottawa scores of excellent, good, or fair). Commonly reported AEs related to the bowel preparations were nausea, vomiting, headache, and chills. Patient-reported tolerability, including ease of consumption and taste, was significantly higher for P/MC than 2L PEG-3350 and bisacodyl tablets (P < .0001). LIMITATIONS Because of differences in administration and volume of the bowel preparations, the study was designed to be a single-assessor, blinded study. CONCLUSIONS The bowel-cleansing effects and patient acceptability of split-dose P/MC were superior to day-before dosing with 2L PEG-3350 and bisacodyl tablets.
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Affiliation(s)
- Douglas K Rex
- Indiana University School of Medicine, Indianapolis, Indiana, USA
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16
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Bae SE, Kim KJ, Eum JB, Yang DH, Ye BD, Byeon JS, Myung SJ, Yang SK, Kim JH. A Comparison of 2 L of Polyethylene Glycol and 45 mL of Sodium Phosphate versus 4 L of Polyethylene Glycol for Bowel Cleansing: A Prospective Randomized Trial. Gut Liver 2013; 7:423-9. [PMID: 23898382 PMCID: PMC3724030 DOI: 10.5009/gnl.2013.7.4.423] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/29/2012] [Revised: 10/16/2012] [Accepted: 10/29/2012] [Indexed: 12/13/2022] Open
Abstract
Background/Aims Polyethylene glycol (PEG)-based gut lavage solutions are safe and effective, but require the intake of large volumes of fluid. The use of 2 L PEG plus 45 mL sodium phosphate (PEG2 plus NaP) was compared with 4 L PEG (PEG4) for bowel cleansing before colonoscopy. Methods Patients were randomized to the PEG2 plus NaP group or PEG4 group between January 1, 2009 and March 31, 2010. One hundred and thirty patients were included in the PEG2 plus NaP group, and 141 patients in the PEG4 group. Results The qualities of the bowel preparation, based on the Ottawa scale were not significantly different between the groups (4.8±2.25 for the PEG2 plus NaP group vs. 5.11±2.26 for the PEG4). In addition, there were no significant differences in side effects. Laboratory findings after bowel preparation, including electrolyte, phosphorus and creatinine levels, were within the normal ranges in both groups. Conclusions PEG2 plus NaP provides good cleansing that is similar to PEG4, but with a lower volume. However, because PEG2 plus NaP can cause serious side effects such as calcium deposition in the kidneys (i.e., nephrocalcinosis), this solution might be considered for the outpatients who cannot tolerate PEG4.
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Affiliation(s)
- Suh Eun Bae
- Department of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
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17
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van Vugt van Pinxteren MWJ, van Kouwen MCA, van Oijen MGH, van Achterberg T, Nagengast FM. A prospective study of bowel preparation for colonoscopy with polyethylene glycol-electrolyte solution versus sodium phosphate in Lynch syndrome: a randomized trial. Fam Cancer 2013; 11:337-41. [PMID: 22359099 PMCID: PMC3496479 DOI: 10.1007/s10689-012-9517-7] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Lynch gene carriers undergo regular surveillance colonoscopies. Polyethylene glycol-electrolyte solution (PEG) is routinely prescribed for bowel cleansing, but often poorly tolerated by patients. Sodium phosphate (NaP) may be an alternative. Prospective and random comparison of bowel preparation with PEG and NaP on colon cleansing and patients' acceptance. Patients, who previously underwent a colonoscopy, were invited to participate and randomly assigned to either PEG or NaP. They were asked to fill in a questionnaire about preparation tolerability and future preferences. The endoscopist filled out a report about the quality of colon cleansing. 125 Patients were included in the study. Nine (7%) were excluded because of missing data. The remaining 116 patients (53 PEG and 63 NaP) were included in the analysis. Baseline characteristics did not differ between groups. Before colonoscopy 20 (38%) patients using PEG experienced the preparation almost intolerable, in contrast to 7(11%) of those using NaP (P = 0.001). Eleven patients in the PEG group and 48 in the NaP group would prefer NaP in the future. The colonoscopy was poorly tolerated in 17% of the individuals in both groups (P = 0.963). The endoscopist observed a more than 75% clean colon in 83% of patients on PEG and in 71% of patients on NaP (P = 0.076), however the coecum (P = 0.025) and ascending colon was cleaner after PEG. Lynch patients tolerated NaP better and preferred this formula for future bowel preparation. Colon cleansing was suboptimal with both treatments with a tendency towards a cleaner proximal colon with PEG.
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Affiliation(s)
- Maria W J van Vugt van Pinxteren
- Department of Gastroenterology and Hepatology, Radboud University Nijmegen Medical Centre, P.O.Box 9101, 6500 HB, Nijmegen, The Netherlands.
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18
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Romero RV, Mahadeva S. Factors influencing quality of bowel preparation for colonoscopy. World J Gastrointest Endosc 2013; 5:39-46. [PMID: 23424015 PMCID: PMC3574611 DOI: 10.4253/wjge.v5.i2.39] [Citation(s) in RCA: 64] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/12/2012] [Revised: 10/08/2012] [Accepted: 12/01/2012] [Indexed: 02/05/2023] Open
Abstract
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.
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Affiliation(s)
- Ronald V Romero
- Ronald V Romero, Division of Gastroenterology, Department of Medicine, University Malaya Medical Centre, Kuala Lumpur 50603, Malaysia
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Aihara H, Saito S, Ohya T, Tamai N, Kato T, Tajiri H. A pilot study using reduced-volume oral sulfate solution as a preparation for colonoscopy among a Japanese population. Int J Colorectal Dis 2013; 28:83-7. [PMID: 23011548 DOI: 10.1007/s00384-012-1588-2] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/16/2012] [Indexed: 02/04/2023]
Abstract
BACKGROUND This pilot study sought to investigate the performance and safety of a reduced-volume oral sulfate solution for use as a bowel-cleansing regimen prior to colonoscopy in a Japanese population. METHODS Subjects followed a prescribed split-dose regimen in which the first portion was taken on the evening before colonoscopy and the second portion on the morning of the procedure. To determine the performance of this regimen, the quality of colon cleansing was assessed in each case using a validated four-point scale, and elapsed time to complete the preparation was recorded. Side effects and adverse events were investigated by blood sampling and questionnaire. RESULTS The successful preparation rate based on the colon-cleansing score was 97 % (30/31). Mean elapsed time to complete the preparation on the day of colonoscopy was 71 min. Serum levels of indirect bilirubin were significantly increased to abnormal levels following the preparation, although these changes were only transient. Preparation-related symptoms of nausea and vomiting were presented in only one case. CONCLUSIONS This pilot study showed the oral sulfate solution-based bowel preparation to be safe, easy, and quick to use for Japanese patients. A larger study is necessary to statistically verify these results.
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Affiliation(s)
- Hiroyuki Aihara
- Department of Endoscopy, Jikei University School of Medicine, 3-25-8, Nishi-shinbashi, Minato-ku, Tokyo, Japan.
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Kambe H, Yamaji Y, Sugimoto T, Yamada A, Watabe H, Yoshida H, Omata M, Koike K. A randomized controlled trial of sodium phosphate tablets and polyethylene glycol solution for polyp detection. J Dig Dis 2012; 13:374-80. [PMID: 22713087 DOI: 10.1111/j.1751-2980.2012.00588.x] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
OBJECTIVE The study was aimed to assess the efficacy of sodium phosphate (NaP) tablets and polyethylene glycol (PEG) on colon cleansing. METHODS A prospective, randomized trial was conducted at the Graduate School of Medicine, University of Tokyo. Participants who were scheduled for colonoscopy were included and randomized into either the NaP or PEG group. An interim analysis was programmed into the study design when approximately 50% of the enrolments were completed. The primary outcome was the detection rate of polyps with a diameter ≤5 mm. RESULTS A total of 92 patients were included in the analysis, of whom 44 were in the NaP group and 48 in the PEG group. The quality of colonic preparation was similar in both groups. The NaP group showed a higher detection rate of polyps with a diameter ≤5 mm than the PEG group (38.6% vs 18.8%, P = 0.004). A multivariate analysis showed that NaP and the withdrawal time of the colonoscope were independent factors associated with the detection of polyps with a diameter ≤5 mm. CONCLUSIONS NaP is certainly not inferior to PEG. In fact, the results suggest that diminutive polyp detection using NaP might be superior to that using PEG.
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Affiliation(s)
- Haruka Kambe
- Department of Gastroenterology, Graduate School of Medicine, University of Tokyo, Tokyo, Japan.
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21
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Belsey J, Crosta C, Epstein O, Fischbach W, Layer P, Parente F, Halphen M. Meta-analysis: the relative efficacy of oral bowel preparations for colonoscopy 1985-2010. Aliment Pharmacol Ther 2012; 35:222-37. [PMID: 22112043 DOI: 10.1111/j.1365-2036.2011.04927.x] [Citation(s) in RCA: 68] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
BACKGROUND Previous reviews of bowel preparation for colonoscopy have given contradictory answers. AIM To provide a definitive insight, using PRISMA-compliant methodology. METHODS A comprehensive literature review identified randomised controlled trials comparing bowel preparation regimens. Data for quality of bowel preparation were pooled in multiple meta-analyses exploring a range of inclusion criteria. RESULTS A total of 104 qualifying studies were identified, the majority of which involved comparisons of sodium phosphate (NaP) or polyethylene glycol (PEG). There was no significant difference demonstrated between NaP and PEG overall (OR = 0.82; 95% CI = 0.56-1.21; P = 0.36). Cumulative meta-analysis demonstrated that this conclusion has been qualitatively similar since the mid 1990s, with little quantitative change for the past 10 years. Amongst studies with previous day dosing in both study arms there was a significant advantage in favour of PEG (OR = 1.78; 95% CI = 1.13-2.81; P = 0.006). Studies focussing on results in the proximal colon also favoured PEG (OR = 2.36; 95% CI = 1.16-4.77; P = 0.012). PEG was also significantly more effective than non-NaP bowel preparation regimens (OR = 2.02; 95% CI = 1.08-3.78; P = 0.03). Other comparisons showed no significant difference between regimens. CONCLUSIONS Although there is no compelling evidence favouring either of the two most commonly used bowel preparation regimens, this may reflect shortcomings in study design. Where studies have ensured comparable dosage, or the clinically relevant outcome of proximal bowel clearance is considered, PEG-based regimens offer the most effective option.
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Affiliation(s)
- J Belsey
- JB Medical Ltd, The Old Brickworks, Little Cornard, Sudbury, UK.
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22
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Juluri R, Eckert G, Imperiale TF. Polyethylene glycol vs. sodium phosphate for bowel preparation: a treatment arm meta-analysis of randomized controlled trials. BMC Gastroenterol 2011; 11:38. [PMID: 21492418 PMCID: PMC3096583 DOI: 10.1186/1471-230x-11-38] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/04/2010] [Accepted: 04/14/2011] [Indexed: 02/06/2023] Open
Abstract
Background Results of meta-analyses of randomized trials comparing PEG and NaP are inconsistent and have not included trials comparing either or both preps to less traditional ones. AIM: To perform a meta-analysis by treatment arm. Methods Using MEDLINE and EMBASE, we identified English-language trials published from 1990 to 2008 that included PEG and/or NaP, and aggregated them by treatment arm into: 4 liter (L) PEG; 2 L PEG; split-dose PEG; two 45 ml doses of NaP +/- adjunctive medication; and NaP tablets. We compared prep quality and the proportion completing the prep. Results Among 71 trials (patient N = 10,201), excellent prep quality was present in 34% (CI, 26-41%) for 4 L PEG alone; 39% (CI, 26-51%) for 2 L PEG; 37% (CI, 28-46%) for split-dose PEG; 42% (CI, 33-51%) for NaP solution; 44% (CI, 38-51%) for NaP with adjunctive meds; and 58% (CI, 49-67%) for NaP tablets. Patients receiving NaP were more likely to complete the prep (97% [CI, 96-98%] vs. 90% [CI, 87-92%] for 4L PEG alone); however, completion rates for 2L PEG (98%) and split dose PEG (95%) were similar to NaP. Conclusions NaP tablets resulted in better prep quality and higher completion rates compared to other regimens. In comparisons limited by sample size, split dose PEG was not statistically different from NaP solution for completion rate or prep quality.
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Affiliation(s)
- Ravi Juluri
- Indiana University Health Physicians, Indianapolis, Indiana, USA.
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JULURI R, ECKERT G, IMPERIALE TF. Meta-analysis: randomized controlled trials of 4-L polyethylene glycol and sodium phosphate solution as bowel preparation for colonoscopy. Aliment Pharmacol Ther 2010; 32:171-81. [PMID: 20384609 PMCID: PMC4825682 DOI: 10.1111/j.1365-2036.2010.04326.x] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
BACKGROUND Randomized controlled trials (RCTs) comparing polyethylene glycol (PEG) with sodium phosphate (NaP) are inconsistent. AIM To compare the efficacy of and tolerance to PEG vs. NaP for bowel preparation. METHODS We used MEDLINE and EMBASE to identify English-language RCTs published between 1990 and 2008 comparing 4-L PEG with two 45 mL doses of NaP in adults undergoing elective colonoscopy. We calculated the pooled odds ratios (ORs) for preparation quality and proportion of subjects completing the preparation. RESULTS From 18 trials (n = 2792), subjects receiving NaP were more likely to have an excellent or good quality preparation than those receiving PEG (82% vs. 77%; OR = 1.43; 95% CI, 1.01-2.00). Among a subgroup of 10 trials in which prep quality was reported in greater detail, there were no differences in the proportions of excellent, good, fair or poor preparation quality. Among nine trials that assessed preparation completion rates, patients receiving NaP were more likely to complete the preparation than patients receiving 4-L PEG (3.9% vs. 9.8% respectively did not complete the preparation; OR = 0.40; CI, 0.17-0.88). CONCLUSION Among 18 head-to-head RCTs of NaP vs. 4-L PEG, NaP was more likely to be completed and to result in an excellent or good quality preparation.
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Affiliation(s)
- R. JULURI
- Department of Medicine, Division of Gastroenterology and Hepatology, Indiana University School of Medicine, Indianapolis, Indiana
| | - G. ECKERT
- Division of Biostatistics, Indiana University School of Medicine, Indianapolis, Indiana
| | - T. F. IMPERIALE
- Department of Medicine, Division of Gastroenterology and Hepatology, Indiana University School of Medicine, Indianapolis, Indiana,Clarian /Indiana University Digestive Disease Center, Indianapolis, Indiana,Regenstrief Institute, Inc, Indianapolis, Indiana
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Lee JW, Kim N, Cha BH, Lee BH, Hwang TJ, Jeong YJ, Choi TH, Kim HS, Myung HJ, Kim J, Jang JH, Kim YM, Kim JY, Park SW, Park HK, Suh S, Seo PJ, Song JC, Shin CM, Eum YO, Kwon JH, Kim JJ, Song BJ, Park YS, Lee DH. Comparison between Conventional 4 L Polyethylene Glycol and Combination of 2 L Polyethylene Glycol and Sodium Phosphate Solution as Colonoscopy Preparation. THE KOREAN JOURNAL OF GASTROENTEROLOGY 2010; 56:299-306. [DOI: 10.4166/kjg.2010.56.5.299] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Affiliation(s)
- Jung Won Lee
- Department of Internal Medicine, Seoul National University Bundang Hospital, Seongnam, Korea
- Department of Internal Medicine, Seoul National University College of Medicine and Liver Research Institute, Seoul, Korea
| | - Nayoung Kim
- Department of Internal Medicine and, Seoul National University Bundang Hospital, Seongnam, Korea
- Department of Internal Medicine, Seoul National University College of Medicine and Liver Research Institute, Seoul, Korea
| | - Byung Hyo Cha
- Department of Internal Medicine, Seoul National University Bundang Hospital, Seongnam, Korea
| | - Byoung Hwan Lee
- Department of Internal Medicine, Seoul National University Bundang Hospital, Seongnam, Korea
| | - Tae Jun Hwang
- Department of Internal Medicine, Seoul National University Bundang Hospital, Seongnam, Korea
| | - Yu Jeong Jeong
- Department of Internal Medicine, Seoul National University Bundang Hospital, Seongnam, Korea
| | - Tae Hyuck Choi
- Department of Internal Medicine, Seoul National University Bundang Hospital, Seongnam, Korea
| | - Hee-Sup Kim
- Department of Internal Medicine, Seoul National University Bundang Hospital, Seongnam, Korea
| | - Hyung-Joon Myung
- Department of Internal Medicine, Seoul National University Bundang Hospital, Seongnam, Korea
| | - Jangeon Kim
- Department of Internal Medicine, Seoul National University Bundang Hospital, Seongnam, Korea
| | - Je-Hyuck Jang
- Department of Internal Medicine, Seoul National University Bundang Hospital, Seongnam, Korea
| | - Yeo Myeong Kim
- Department of Internal Medicine, Seoul National University Bundang Hospital, Seongnam, Korea
| | - Jong Yeop Kim
- Department of Internal Medicine, Seoul National University Bundang Hospital, Seongnam, Korea
| | - Sang Wook Park
- Department of Internal Medicine, Seoul National University Bundang Hospital, Seongnam, Korea
| | - Hyun Kyung Park
- Department of Internal Medicine, Seoul National University Bundang Hospital, Seongnam, Korea
| | - Seungchul Suh
- Department of Internal Medicine, Seoul National University Bundang Hospital, Seongnam, Korea
| | - Pyoung Ju Seo
- Department of Internal Medicine, Seoul National University Bundang Hospital, Seongnam, Korea
| | - Joon Chang Song
- Department of Internal Medicine, Seoul National University Bundang Hospital, Seongnam, Korea
| | - Cheol Min Shin
- Department of Internal Medicine, Seoul National University Bundang Hospital, Seongnam, Korea
- Department of Internal Medicine, Seoul National University College of Medicine and Liver Research Institute, Seoul, Korea
| | - Young Ook Eum
- Department of Internal Medicine, Seoul National University Bundang Hospital, Seongnam, Korea
| | - Jung Hee Kwon
- Department of Internal Medicine, Seoul National University Bundang Hospital, Seoungnam, Korea
- Department of Internal Medicine, Seoul National University College of Medicine and Liver Research Institute, Seoul, Korea
| | - Jin Joo Kim
- Department of Internal Medicine, Seoul National University Bundang Hospital, Seoungnam, Korea
- Department of Internal Medicine, Seoul National University College of Medicine and Liver Research Institute, Seoul, Korea
| | - Byeong Jun Song
- Department of Internal Medicine, Seoul National University Bundang Hospital, Seoungnam, Korea
- Department of Internal Medicine, Seoul National University College of Medicine and Liver Research Institute, Seoul, Korea
| | - Young Soo Park
- Department of Internal Medicine, Seoul National University Bundang Hospital, Seoungnam, Korea
- Department of Internal Medicine, Seoul National University College of Medicine and Liver Research Institute, Seoul, Korea
| | - Dong Ho Lee
- Department of Internal Medicine, Seoul National University Bundang Hospital, Seoungnam, Korea
- Department of Internal Medicine, Seoul National University College of Medicine and Liver Research Institute, Seoul, Korea
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Comparison of two sodium phosphate tablet-based regimens and a polyethylene glycol regimen for colon cleansing prior to colonoscopy: a randomized prospective pilot study. Int J Colorectal Dis 2009; 24:1023-30. [PMID: 19475410 DOI: 10.1007/s00384-009-0735-x] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/13/2009] [Indexed: 02/04/2023]
Abstract
PURPOSE The aim of this pilot study was to compare the performance and safety of the newly developed sodium phosphate (NaP) tablet (with and without laxatives) and polyethylene glycol (PEG), as bowel-cleansing regimens prior to colonoscopy. METHODS A total of 35 patients were randomized to one of the following three groups: NaP + laxative, NaP, or PEG. Quality of colon cleansing was assessed using a validated four-point scale, and the primary outcome measures were the mean overall colon cleansing and microcrystalline cellu1ose (MCC)-remaining scores in each group. RESULTS The mean elapsed time for bowel cleansing in the NaP + laxative group (167.72 +/- 21.37 min) was significantly less than in the NaP group (218.00 +/- 20.58 min) and the PEG group (202.00 +/- 27.91 min; n = 11, 10, and 10 respectively; P < 0.05). The NaP + laxative group showed a superior overall colon-cleansing score compared to both the NaP and PEG groups and similarly, the overall colon MCC-remaining score in the NaP + laxative group was superior to the NaP group. Serum levels of inorganic phosphorus were significantly increased to abnormal levels in the NaP + laxative and NaP groups, but these increases were only transient. CONCLUSIONS This pilot study shows that NaP-based bowel preparations are easy, quick, and safe to use. Colonoscopic visualization is decreased by MCC when NaP is used alone but is improved by the addition of laxatives on the previous day. A larger study is necessary to statistically verify these results.
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Effect of whole gut irrigation solutions on gastrointestinal smooth muscle activity. J Pediatr Surg 2009; 44:1719-24. [PMID: 19735814 DOI: 10.1016/j.jpedsurg.2009.02.007] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/14/2008] [Revised: 12/16/2008] [Accepted: 02/01/2009] [Indexed: 11/21/2022]
Abstract
BACKGROUND/PURPOSE It has been suggested that whole gut irrigation (WGI), which is a preparation method for large bowel surgery or colonoscopy, increases gastrointestinal motility by creating a gastrocolic reflex. An experimental study was performed to evaluate the effect of different WGI solutions on gastrointestinal smooth muscle activity. MATERIALS AND METHODS Thirty Wistar albino rats weighing 200 to 250 g were enrolled in the study. After anesthetization with thiopental sodium (50 mg/kg), proximal ileum, terminal ileum, and colon segments were removed via median laparotomy to obtain a control group. Four different groups (n = 6) were designated as having WGI with saline solution (SS), lactated Ringer's solution (RL), polyethylene glycol (PEG), and dibasic sodium phosphate (DNP). Bowel cleaning was performed by infusing solutions at a rate of 2 mL/min via gastric tube, until the stool was cleared. After completing the bowel cleaning, 2 cm of tissues were removed and suspended in Tyrode solution in an isolated organ bath with a resting tension of 1 g, to obtain carbachol and potassium chloride (KCl) responses. RESULTS The mean bowel cleaning times were 87.5 +/- 9.35, 81.6 +/- 9.83, 86.6 +/- 11.6, and 85.0 +/- 0.0 minutes in SS, RL, PEG, and DNP groups, respectively. The total amounts of solutions needed for cleaning were 156.67 +/- 21.6, 195.0 +/- 20.0, 197.5 +/- 32.8, and 70.0 +/- 0.0 mL, respectively. Although there was no difference in cleaning time between the groups, the amount of solution required was significantly less in the DNP group (P = .02). In the proximal ileum segments, though there was no difference in carbachol responses between groups, KCl responses were significantly increased in the RL group (P < .05). When we evaluated the terminal ileum responses, carbachol responses were significantly increased in RL and PEG groups (P = .011) and decreased in the DNP group (P = .049). The KCl responses were also significantly increased in the RL group with respect to the other groups (P < .05). Colon segments showed no difference in contractile responses with respect to different WGI solutions (P > .05, analysis of variance, post hoc Dunn's test). CONCLUSION The different WGI solutions demonstrated no significant differences in colon contractions. The increased contractile responses in the proximal and terminal ileum segments after WGI with RL may be related to the electrolyte composition of RL. Although the lower amount of DNP solution required to achieve bowel cleaning seems to be an advantage, the decreased ileal contractions can be assessed as a disadvantage of DNP irrigations.
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Lambert R. [Colonoscopy: maximizing detection and characterization]. GASTROENTEROLOGIE CLINIQUE ET BIOLOGIQUE 2009; 33:737-746. [PMID: 19683885 DOI: 10.1016/j.gcb.2009.07.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/28/2023]
Abstract
The endoscopic analysis of the colonic lumen with a flexible tube began around1960, at first with a gastrocamera, then with a fibrocolonoscope. After 1990, the electronic imaging brought a three points revolution with increased resolution of the image, transfer of the image on a television monitor giving access to multiple observers, electronic image processing. The recent colonoscopes have an increased resolution with more pixels in the Charged Coupled Device (CCD) sensor, a High Definition Television (HDTV) image and an electronic and/or optical zoom for magnification. Colonoscopy is now often performed in a similar environment to that of surgery. Therapeutic applications justify a strict strategy for endoscopic diagnosis. At first, detection of the lesion in standard vision, then characterization with the help of chromoscopy for the evaluation of morphology and with the help of magnification for the evaluation of the pit pattern. Then, comes the time for treatment decision between abstention, endoscopic resection or surgery. The legitimacy of the management is controlled in retrospective by the analysis of the tissue samples. Recent alternatives to colonoscopy (3D radiological imaging, colon capsule) should not invalidate the priority attributed to colonoscopy which associates treatment to the early detection of colorectal cancer and precursors.
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Affiliation(s)
- R Lambert
- Group of Screening, International Agency for Research on Cancer, 69372 Lyon cedex 08, France.
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Park DI, Park SH, Lee SK, Baek YH, Han DS, Eun CS, Kim WH, Byeon JS, Yang SK. Efficacy of prepackaged, low residual test meals with 4L polyethylene glycol versus a clear liquid diet with 4L polyethylene glycol bowel preparation: a randomized trial. J Gastroenterol Hepatol 2009; 24:988-91. [PMID: 19638081 DOI: 10.1111/j.1440-1746.2009.05860.x] [Citation(s) in RCA: 40] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
BACKGROUND AND STUDY AIMS A prepackaged low residue one-day diet (breakfast, lunch and dinner) has been recently developed to improve patient tolerance for bowel preparation prior to colonoscopy. The aims of this study were to evaluate the efficacy and tolerability of bowel preparation protocols based on a low residue diet and 4L polyethylene glycol (PEG) solution, and to compare these new options with the traditional liquid diet and the PEG 4L lavage. METHODS A total of 214 patients (mean age: 54.1 years; 120 male, 94 female) from four university hospitals were included in the analysis. Patients were randomized to receive a clear liquid diet and the PEG 4L regimen (106 patients) or the low residue test meals and the PEG 4L regimen (TM-PEG 4L, 108 patients). The colon cleansing efficacy of the different preparations was rated using the Ottawa bowel preparation scale. RESULTS No significant differences were observed between the treatment groups according to the Ottawa cleansing scale findings (PEG 4L: 2.97 vs TM-PEG 4L: 2.46, P = 0.063). The overall tolerability was higher in the TM-PEG 4L group than in the PEG 4L group (P = 0.036). No difference was found when the two groups were compared with regard to adverse events (P = 0.599). CONCLUSIONS A prepackaged low residue one-day diet provided cleansing efficacy similar to that of a clear liquid diet and offered the benefit of improved tolerability compared to the conventional PEG 4L regimen.
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Affiliation(s)
- Dong Il Park
- Department of Internal Medicine, Sungkyunkwan University School of Medicine, Seoul, South Korea
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Mamula P, Adler DG, Conway JD, Diehl DL, Farraye FA, Kantsevoy SV, Kaul V, Kethu SR, Kwon RS, Rodriguez SA, Tierney WM. Colonoscopy preparation. Gastrointest Endosc 2009; 69:1201-9. [PMID: 19481646 DOI: 10.1016/j.gie.2009.01.035] [Citation(s) in RCA: 45] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/23/2009] [Accepted: 01/23/2009] [Indexed: 01/10/2023]
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Belsey J, Epstein O, Heresbach D. Systematic review: adverse event reports for oral sodium phosphate and polyethylene glycol. Aliment Pharmacol Ther 2009; 29:15-28. [PMID: 18729847 DOI: 10.1111/j.1365-2036.2008.03837.x] [Citation(s) in RCA: 70] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
BACKGROUND Screening colonoscopy exposes healthy patients to the risk of serious adverse events associated with bowel preparation. Randomized controlled trials are not an effective method for evaluating this risk. AIM To search published literature in order to characterize the risk of adverse events associated with oral polyethylene glycol (PEG) or sodium phosphate (NaP). METHODS A systematic review identified case reports of any serious events associated with PEG or NaP. Reports to the Food and Drug Administration (FDA) were also examined. RESULTS Fifty-eight publications of significant events in 109 patients using NaP and 22 patients using PEG were identified. As the total number of prescriptions issued is unknown, rates for the two agents cannot be directly compared. Most commonly reported were electrolyte disturbances, renal failure and colonic ulceration for NaP and Mallory-Weiss tear, electrolyte disturbances and allergic reactions for PEG between January 2006 and December 2007; there were 171 cases of renal failure reported to the FDA following use of NaP and 10 following PEG. CONCLUSIONS Adverse events following bowel preparation are uncommon, but potentially serious. Given that many of these patients are healthy individuals undergoing screening, the benefit/risk ratio must be carefully considered when deciding which preparation to prescribe in individual patients.
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Affiliation(s)
- J Belsey
- JB Medical Ltd, The Old Brickworks, Sudbury, UK.
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31
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Ker TS. Prospective Comparison of Three Bowel Preparation Regimens: Fleet Phosphosoda, Two-Liter and Four-Liter Electrolyte Lavage Solutions. Am Surg 2008. [DOI: 10.1177/000313480807401032] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
In an attempt to improve patients’ tolerance for colon cleaning, three bowel preparation regimens: 90-mL Fleet phosphosoda (FPS), 2-L electrolyte lavage solution plus 20 mg oral bisacodyl, and 4-L lavage, were compared for efficacy and safety. A total of 912 patients were prospectively nonrandomized into three study groups. In Group A, 304 patients were given 45-mL Fleet phosphosoda at 9 AM and 6 PM the day before colonoscopy. In Group B, 304 patients were given four tablets of 5 mg bisacodyl at 12 PM the day before colonoscopy followed by 2 L electrolyte lavage by mouth at 6:00 PM the evening before colonoscopy. In Group C, 304 patients were given 4 L electrolyte lavage at 6:00 PM the evening before colonoscopy. All patients were kept on a clear liquid diet the day before colonoscopy. The bowel cleanliness was accessed by one colonoscopist. One registered nurse accessed the ease of the patient. In Group A (FPS), every patient finished the 90-mL Fleet phosphosoda. Colon cleanliness was 95.1 per cent. In Group B (2 L), three patients (0.6%) could not finish the laxative. Colon cleanliness was 95.9 per cent. In Group C (4 L), 22 patients (7.3%) could not finish the laxative preparation. Colon cleanliness was 95.3 per cent. The study found these three regimens can achieve equally good results of bowel preparation; however, the small volume laxative (FPS) has been accepted favorably by patients.
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Affiliation(s)
- Tim S. Ker
- Department of Colorectal Surgery, University of Southern California, Los Angeles, California
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32
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Abstract
Bowel preparation has been a much-debated issue for both colonoscopy and for colorectal surgery. While bowel preparation for colonoscopy is clearly mandatory for optimal intraluminal visualization, bowel preparation for surgery has recently been challenged. This review evaluates oral bowel preparation, based on evidence in the literature, in order to provide a practical guide for physicians and practitioners about oral bowel cleansing preparations in current use for both colonoscopy and for colorectal surgery.A MEDLINE search, limited to publications in English language, was done through Ovid including articles published from 1966 to 2007 about bowel preparation using terms 'pre-operative care' and 'colonoscopy' or 'surgical procedure' associated with 'polyethylene glycol' and 'sodium phosphate'. The references lists from the identified articles were also included in the review. No bowel preparation method meets the ideal criteria for bowel cleansing prior to colonoscopy. However, polyethylene glycol-electrolyte lavage solution (PEG-ELS) and sodium phosphate are the most commonly used bowel preparations before colonoscopy and colon surgery. Both preparations are safely used and effective; however, some precautions should be considered, particularly with sodium phosphate. In addition, the efficacy of low-volume PEG-ELS can be improved by the addition of preparation adjuncts. Timing and dose are important considerations regardless of the method used. Mechanical bowel preparation for surgery has been questioned, and shown to have no extra benefits and possibly the association with increased morbidity. Regardless of the evidence, there are many randomized controlled trials showing the lack of benefit of mechanical bowel preparation.
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Affiliation(s)
- Sherief Shawki
- Department of Colorectal Surgery, Cleveland Clinic Florida, Weston, Florida, USA
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Szojda MM, Kuik DJ, Mulder CJJ, Felt-Bersma RJF. Colonic lavage with two polyethylene glycol solutions prior to colonoscopy makes no difference: a prospective randomized controlled trial. Scand J Gastroenterol 2008; 43:622-6. [PMID: 18415758 DOI: 10.1080/00365520701843001] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
OBJECTIVE It is suggested that bowel preparations for colonoscopy are easier to tolerate when a smaller volume of solution with a more pleasant taste is used. The aim of this study was to establish equivalence between a 3-l sulphate-free polyethylene glycol solution (SF-PEG) and a 4-l PEG solution in effectiveness, patients' acceptability and tolerability. MATERIAL AND METHODS The study comprised 110 patients scheduled for elective colonoscopy and randomized to receive either SF-PEG or PEG. Before colonoscopy, the patients completed a questionnaire on stool frequency, medication, concomitant diseases, the amount of solution ingested, willingness to re-take it, volume of other fluid taken and tolerance of bowel preparation, taste of the laxative and occurrence of abdominal cramps. Three experienced endoscopists, blinded to the type of preparation, assigned bowel-cleansing scores using a validated 5-point scale to assess cleansing effect. RESULTS Data were available for 102 patients (44 M (40%), mean age 53 years, range 23-83 years). No significant differences were found in cleansing the rectosigmoid (p = 0.71) or complete colon (p = 0.79). Diverticulosis, constipation, gender and body mass index (BMI) did not influence cleansing. There was no significant difference in compliance between the two groups (p = 0.61). No differences were found for tolerance, taste and abdominal cramps. Patients who received SF-PEG had a preference for the same preparation next time in comparison with patients who had PEG cleansing (17 (33%) versus 4 (8%), respectively) (p = 0.03). CONCLUSIONS Both preparations are comparable in their cleansing effect and toleration. However, patients prefer cleansing with a smaller volume of solution. Improving the acceptability of colonic preparation could improve willingness to undergo colonoscopies in the future.
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Affiliation(s)
- Maria M Szojda
- Department of Gastroenterology and Hepatology, VU University Medical Centre, Amsterdam, The Netherlands
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34
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Bretthauer M. Are sodium phosphate tablets better than polyethylene glycol solution plus bisacodyl tablets for bowel preparation? NATURE CLINICAL PRACTICE. GASTROENTEROLOGY & HEPATOLOGY 2008; 5:296-297. [PMID: 18461058 DOI: 10.1038/ncpgasthep1142] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/15/2008] [Accepted: 02/27/2008] [Indexed: 05/26/2023]
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Ell C, Fischbach W, Bronisch HJ, Dertinger S, Layer P, Rünzi M, Schneider T, Kachel G, Grüger J, Köllinger M, Nagell W, Goerg KJ, Wanitschke R, Gruss HJ. Randomized trial of low-volume PEG solution versus standard PEG + electrolytes for bowel cleansing before colonoscopy. Am J Gastroenterol 2008; 103:883-93. [PMID: 18190651 DOI: 10.1111/j.1572-0241.2007.01708.x] [Citation(s) in RCA: 172] [Impact Index Per Article: 10.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
OBJECTIVES Polyethylene glycol (PEG)-based gut lavage solutions are safe and effective, but require consumption of large volumes of fluid. We compared a new 2 L solution of PEG plus ascorbic acid (PEG + Asc) with standard 4 L PEG with electrolytes (PEG + E) for bowel cleansing before colonoscopy to determine efficacy, safety, and patient acceptability. METHODS Consenting adult inpatients scheduled to undergo colonoscopy were randomized to receive either 2 L PEG + Asc or 4 L PEG + E. Preparations were taken as split doses the evening before colonoscopy and the following morning. The PEG + Asc group took 1 L at each administration (i.e., total dose of 2 L). The PEG + E group took 2 L at each administration (i.e., total dose of 4 L). Bowel cleansing success was assessed via videotapes by independent, blinded raters. Statistical noninferiority was predefined as a difference of <15% in the lower limit of the 97.5% confidence interval for treatment difference. Patient views on the preparations were elicited. Adverse events were noted. RESULTS Successful gut cleansing was achieved in 136 of 153 (88.9%) cases of the PEG + Asc group and 147 of 155 (94.8%) cases of the 4 L PEG + E group (mean difference -5.9 [-12.0-infinity]). The difference fell within the predefined limit for noninferiority. Clinical and laboratory parameters showed no difference in safety profile. Patient ratings of acceptability and taste were better for the PEG + Asc group than for the PEG + E group (P < 0.025). CONCLUSIONS The combination of ascorbic acid and PEG-based bowel preparation reduces the volume patients have to drink without compromising efficacy or safety. The low-volume PEG + Asc preparation was more acceptable to patients, and should, therefore, improve effectiveness in routine practice.
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36
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Miki Jr P, Lemos CRDR, Popoutchi P, Garcia RLDS, Rocha JJRD, Feres O. Comparison of colon-cleansing methods in preparation for colonoscopy - Comparative efficacy of solutions of mannitol, sodium picosulfate and monobasic and dibasic sodium phosphates. Acta Cir Bras 2008; 23 Suppl 1:108-11; discussion 111. [DOI: 10.1590/s0102-86502008000700018] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
PURPOSE: Colonoscopy plays an essential role in the therapeutic and diagnostic approach in various colonic pathologies, the aim of the present study was to compare three solutions and their efficacy for the bowel preparation in adult patients submitted to elective colonoscopy. METHODS: Sixty patients were randomly divided into three groups of 20 each. Each group was submitted to a bowel preparation with one of the following solutions: 10% manitol, sodium picosulphate or sodium phosphate. The parameters evaluated were: taste, tolerance, associated side effects and quality of cleansing. Postural blood pressure and pulse rate as well as serum sodium, potassium, calcium and phosphate were compared. RESULTS: Sodium phosphate and 10% manitol solutions provided superior results in terms of colon cleansing compared to sodium picosulphate solution. All serum electrolytes evaluated were significantly altered in the three groups, without important clinical signs. DISCUSSION: High levels of serum phosphate were the most striking alteration in patients prepared with sodium phosphate solution, again with no clinical signs. Variations related to blood pressure and pulse rate suggested contraction of intravascular volume, with no clinical effects. CONCLUSION: Sodium phosphate and 10% manitol solutions are equivalent in providing good quality colon cleansing, with no significant side effects that could compromise the procedure.
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Burke CA, Church JM. Enhancing the quality of colonoscopy: the importance of bowel purgatives. Gastrointest Endosc 2007; 66:565-73. [PMID: 17725947 DOI: 10.1016/j.gie.2007.03.1084] [Citation(s) in RCA: 70] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/10/2007] [Accepted: 03/29/2007] [Indexed: 12/13/2022]
Affiliation(s)
- Carol A Burke
- Department of Gastroenterology and Hepatology, Cleveland Clinic, Cleveland, Ohio 44195, USA
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40
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Abstract
BACKGROUND There are many published trials of colon cleansing regimens for colonoscopy but no clear consensus regarding relative performance. AIM To identify high quality controlled trials comparing two or more bowel preparation regimens and to compare efficacy and tolerability. METHODS A comprehensive systematic review was carried out to identify candidate studies. Quality appraisal was carried out on all identified studies. Results were meta-analysed where possible and qualitatively compared if not. RESULTS Eighty-two studies qualified for analysis. Polyethylene glycol and sodium phosphate were the most frequently investigated preparations. There was no significant efficacy difference between the two, but sodium phosphate was better tolerated. Sodium picosulphate/magnesium citrate, a commonly prescribed preparation, was investigated in four studies, with no clear benefit over other regimens demonstrated. Safety was not recognized as a problem in the randomized controlled trials. Published case series demonstrate that sodium phosphate is associated with the highest risk of clinically significant electrolyte disturbances. CONCLUSION Shortcomings in study design limit the value of many of the studies. Based on these results, no single bowel preparation emerges as consistently superior. New preparations are required that combine better efficacy and tolerability, in addition to rigorous new validated study designs, allowing unequivocal comparisons to be made.
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Affiliation(s)
- J Belsey
- JB Medical Ltd, The Old Brickworks, Little Cornard, Sudbury, UK.
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41
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Barkun A, Chiba N, Enns R, Marcon M, Natsheh S, Pham C, Sadowski D, Vanner S. Commonly used preparations for colonoscopy: efficacy, tolerability, and safety--a Canadian Association of Gastroenterology position paper. CANADIAN JOURNAL OF GASTROENTEROLOGY = JOURNAL CANADIEN DE GASTROENTEROLOGIE 2007; 20:699-710. [PMID: 17111052 PMCID: PMC2660825 DOI: 10.1155/2006/915368] [Citation(s) in RCA: 98] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
INTRODUCTION The increased demand for colonoscopy, coupled with the introduction of new bowel cleansing preparations and recent caution advisories in Canada, has prompted a review of bowel preparations by the Canadian Association of Gastroenterology. METHODS The present review was conducted by the Clinical Affairs group of committees including the endoscopy, hepatobiliary/transplant, liaison, pediatrics, practice affairs and regional representation committees, along with the assistance of Canadian experts in the field. An effort was made to systematically assess randomized prospective trials evaluating commonly used bowel cleansing preparations in Canada. RESULTS Polyethylene glycol (PEG)-; sodium phosphate (NaP)-; magnesium citrate (Mg-citrate)-; and sodium picosulphate, citric acid and magnesium oxide (PSMC)-containing preparations were reviewed. Regimens of PEG 2 L with bisacodyl (10 mg to 20 mg) or Mg-citrate (296 mL) are as effective as standard PEG 4 L regimens, but are better tolerated. NaP preparations appear more effective and better tolerated than standard PEG solutions. PSMC has good efficacy and tolerability but head-to-head trials with NaP solutions remain few, and conclusions equivocal. Adequate hydration during preparation and up to the time of colonoscopy is critical in minimizing side effects and improving bowel cleansing in patients receiving NaP and PSMC preparations. All preparations may cause adverse events, including rare, serious outcomes. NaP should not be used in patients with cardiac or renal dysfunction (PEG solution is preferable in these patients), bowel obstruction or ascites, and caution should be exercised when used in patients with pre-existing electrolyte disturbances, those taking medications that may affect electrolyte levels and elderly or debilitated patients. Health Canada's recommended NaP dosing for most patients is two 45 mL doses 24 h apart. However, both safety and efficacy data on this dosing schedule are lacking. Many members of the Canadian Association of Gastroenterology expert panel administer both doses within 24 h, as studied in clinical trials, after careful one-on-one discussion of risks and benefits in carefully selected patients. Safety data on PSMC and combination preparations in North America are limited and clinicians are encouraged to keep abreast of developments in this area. CONCLUSIONS All four preparations reviewed provided effective bowel cleansing for colonoscopy in the majority of patients, with varying tolerability. Adequate hydration is essential in patients receiving the preparations.
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Affiliation(s)
- Alan Barkun
- Division of Gatroenterology, McGill University Health Center, Montreal, Canada
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42
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Harris JK, Vader JP, Wietlisbach V, Burnand B, Gonvers JJ, Froehlich F. Variations in colonoscopy practice in Europe: a multicentre descriptive study (EPAGE). Scand J Gastroenterol 2007; 42:126-134. [PMID: 17190772 DOI: 10.1080/00365520600815647] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
OBJECTIVE The volume of colonoscopies performed is increasing and differences in colonoscopy practice over time and between centres have been reported. Examination of current practice is important for bench-marking quality. The objective of this study was to examine variations in colonoscopy practice in endoscopy centres internationally. MATERIAL AND METHODS This observational study prospectively included consecutive patients referred for colonoscopy from 21 centres in 11 countries. Patient, procedure and centre characteristics were collected through questionnaires. Descriptive statistics were performed and the variation between centres while controlling for case-mix was examined. RESULTS A total of 6004 patients were included in the study. Most colonoscopies (93%; range between centres 70-100%) were performed for diagnostic purposes. The proportion of main indications for colonoscopy showed wide variations between centres, the two most common indications, surveillance and haematochezia, ranging between 7-24% and 5-38%, respectively. High-quality cleansing occurred in 74% (range 51-94%) of patients, and 30% (range 0-100%) of patients received deep sedation. Three-quarters (range 0-100%) of the patients were monitored during colonoscopy, and one-quarter (range 14-35%) underwent polypectomy. Colonoscopy was complete in 89% (range 69-98%) of patients and the median total duration was 20 min (range of centre medians 15-30 min). The variation between centres was not reduced when case-mix was controlled for. CONCLUSIONS This study documented wide variations in colonoscopy practice between centres. Controlling for case-mix did not remove these variations, indicating that centre and procedure characteristics play a role. Centres generally were within the existing guidelines, although there is still some work to be done to ensure that all centres attain the goal of providing high-quality colonoscopy.
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Affiliation(s)
- Jennifer K Harris
- Institute for Social and Preventive Medicine, University of Lausanne, Lausanne, Switzerland
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43
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Ker TS. Comparison of Reduced Volume versus Four-Liter Electrolyte Lavage Solutions for Colon Cleansing. Am Surg 2006. [DOI: 10.1177/000313480607201015] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
In an attempt to improve patient tolerance for colon cleaning, a reduced-volume regimen with a 2-liter electrolyte lavage solution plus 20 mg of oral bisacodyl was compared with the standard 4-liter lavage for efficacy and safety. Three hundred patients were prospectively randomized into two study groups. One group of 150 patients was given four tablets of 5 mg bisacodyl at 12:00 PM the day before their colonoscopy, followed by 2 liters of electrolyte lavage by mouth at 6:00 PM the evening before their colonoscopy. Another group of 150 patients were given 4 liters of electrolyte lavage at 6:00 PM the evening before their colonoscopy. All patients were on a clear liquid diet the day before their colonoscopy. No enema was given in either groups. The bowel cleanliness was accessed by one colonoscopist. One registered nurse accessed the comfort of patient. In the 2-liter group, only one (0.6%) patient could not finish the laxative. Colon cleanliness was 80 per cent to 100 per cent, with an average of 95.9 per cent. In the 4-liter group, 11 (7.3%) patients could not finish the laxative preparation. Colon cleanliness was 78 per cent to 100 per cent, with an average of 95.3 per cent. The study that found the 2-liter electrolyte lavage solution with four tablets of bisacodyl can achieve equally good results in bowel preparation and favorable acceptance by patients compared with the 4-liter lavage.
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Affiliation(s)
- Tim S. Ker
- From the University of Southern California, Los Angeles, California
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44
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Wexner SD, Beck DE, Baron TH, Fanelli RD, Hyman N, Shen B, Wasco KE. A consensus document on bowel preparation before colonoscopy: prepared by a task force from the American Society of Colon and Rectal Surgeons (ASCRS), the American Society for Gastrointestinal Endoscopy (ASGE), and the Society of American Gastrointestinal and Endoscopic Surgeons (SAGES). Surg Endosc 2006; 20:1147-60. [PMID: 16763922 DOI: 10.1007/s00464-006-0152-y] [Citation(s) in RCA: 36] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2006] [Accepted: 02/26/2006] [Indexed: 02/06/2023]
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45
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Wexner SD, Beck DE, Baron TH, Fanelli RD, Hyman N, Shen B, Wasco KE. A consensus document on bowel preparation before colonoscopy: prepared by a task force from the American Society of Colon and Rectal Surgeons (ASCRS), the American Society for Gastrointestinal Endoscopy (ASGE), and the Society of American Gastrointestinal and Endoscopic Surgeons (SAGES). Gastrointest Endosc 2006; 63:894-909. [PMID: 16733101 DOI: 10.1016/j.gie.2006.03.918] [Citation(s) in RCA: 211] [Impact Index Per Article: 11.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Affiliation(s)
- Steven D Wexner
- Department of Colorectal Surgery, Cleveland Clinic Florida, Weston, Fla
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46
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Wexner SD, Beck DE, Baron TH, Fanelli RD, Hyman N, Shen B, Wasco KE. A consensus document on bowel preparation before colonoscopy: prepared by a task force from the American Society of Colon and Rectal Surgeons (ASCRS), the American Society for Gastrointestinal Endoscopy (ASGE), and the Society of American Gastrointestinal and Endoscopic Surgeons (SAGES). Dis Colon Rectum 2006; 49:792-809. [PMID: 16741637 DOI: 10.1007/s10350-006-0536-z] [Citation(s) in RCA: 62] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Affiliation(s)
- Steven D Wexner
- Department of Colorectal Surgery, Cleveland Clinic Florida, Weston, Florida 33331, USA.
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Abstract
OBJECTIVE To assess which bowel preparation agent is most effective. METHODS A search of randomized trials between January 1990 and July 2005 was obtained, using MEDLINE and PubMed databases, and the Cochrane Central Register of Controlled Trials. Meta-analysis was performed using the Forest plot review. RESULTS Sodium phosphate (NaP) was more effective in bowel cleansing than polyethylene glycol (PEG) - odds ratio 0.75 (95%CI: 0.65-0.88; P = 0.0004); and sodium picosulphate (SPS) - odds ratio 0.52 (95%CI: 0.34-0.81; P = 0.004). PEG and SPS were comparable in bowel cleansing ability, odds ratio 1.69 (95%CI: 0.92-3.13; P = 0.09). NaP was more easily completed by patients compared to PEG, odds ratio 0.16 (95%CI: 0.09-0.29; P < 0.00001). More patients were able to complete SPS than PEG, but this was not statistically significant - odds ratio 0.56 (95%CI: 0.28-1.13; P = 0.11). NaP and PEG were comparable in terms of adverse events, odds ratio 0.98 (95%CI: 0.82-1.17; P = 0.81), although NaP resulted in more asymptomatic hypokalaemia and hyperphosphataemia. NaP and SPS appeared to have similar incidence of adverse events. PEG resulted in more adverse events than SPS, odds ratio 3.82 (95%CI: 1.60-9.15; P = 0.003). CONCLUSIONS NaP was more effective in bowel cleansing than PEG or SPS and was comparable in terms of adverse events. Patients have more difficulty completing PEG than NaP and SPS. Biochemical changes associated with a small-volume preparation like NaP, albeit largely asymptomatic, mandate caution in patients with cardiovascular or renal impairment.
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Affiliation(s)
- J J Y Tan
- Department of Colorectal Surgery, Royal Melbourne Hospital and Epworth Colorectal Centre, Melbourne, Australia
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Mathus-Vliegen EMH, Kemble UM. A prospective randomized blinded comparison of sodium phosphate and polyethylene glycol-electrolyte solution for safe bowel cleansing. Aliment Pharmacol Ther 2006; 23:543-52. [PMID: 16441475 DOI: 10.1111/j.1365-2036.2006.02777.x] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
BACKGROUND Polyethylene glycol-electrolyte solution (PEG-ELS) is routinely prescribed for bowel cleansing. Sodium phosphate (NaP) may be an effective but potentially hazardous alternative. AIM To investigate the safety of prescription of either agent, without being informed of the patient's medical history. METHODS One hundred consecutive patients were randomly allocated to PEG-ELS or NaP. Prior to and after the bowel cleansing, blood was sampled for renal function and electrolytes. Patients answered questionnaires about complaints and ease of intake, and endoscopists rated the quality of bowel preparation. RESULTS Eleven patients were identified with a theoretical contraindication for NaP, of whom nine should have been discovered by taking a detailed clinical history. Actually, six of them received NaP with a doubling of serum phosphate levels or hypokalaemia in four. In subjects without a contraindication to the use of NaP, hyperphosphataemia developed in 39% and hypocalcaemia in 5%. Patients tolerated NaP better and completed the preparation more often. Endoscopists rated the quality of bowel preparation equivalent, except for a better cleansed ascending colon with PEG-ELS. CONCLUSIONS The 11% potentially hazardous allocation to NaP and the 39% incidence of hyperphosphataemia with NaP do not justify an 'over-the-counter' prescription. Taking a detailed history and, when in doubt, using PEG-ELS will safeguard against inappropriate administration of NaP.
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Affiliation(s)
- E M H Mathus-Vliegen
- Department of Gastroenterology and Hepatology, Academic Medical Centre, University of Amsterdam, Amsterdam, The Netherlands.
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