Effectiveness and safety of 1-L PEG-ASC versus other bowel preparations for colonoscopy: A meta-analysis of nine randomized clinical trials

Background and aimsA 1-L polyethylene glycol plus ascorbate (PEG-ASC) preparation has been recently developed to improve patients’ experience in colonoscopy. This meta-analysis aimed to evaluate the effectiveness and safety of 1-L PEG-ASC compared with those of other bowel preparations for colonoscopy.MethodsMEDLINE, Embase, Scopus, and the Cochrane Library were systematically searched for randomized controlled trials comparing 1-L PEG-ASC with other bowel preparations published through July 2022. A random-effects model was applied for pooling the results; heterogeneity was expressed as I².ResultsNine studies met the inclusion criteria and were included. The analysis showed significantly higher cleansing success (CS) (OR = 1.50; 95% CI = 1.25–1.81; p < 0.01, I² = 0%) and right-colon high-quality cleansing (HQC) (OR = 1.67; 95% CI = 1.21–2.31; p < 0.01, I² = 43%) with 1-L PEG-ASC compared to the other preparations.The pooled estimate of the adenoma detection rate (ADR) did not significantly differ between the two groups either in the overall (OR = 1.02; 95% CI = 0.87–1.20; p = 0.79, I² = 0%) or split-dosing regimen subgroup analysis (OR = 0.99; 95% CI = 0.84–1.18; p = 0.94, I² = 0%).A significantly higher pooled estimate of the number of patients with adverse events (AEs) (OR = 1.51; 95% CI = 1.23–1.84; p<0.01, I² = 0%) and incidence of AEs (IRR=1.33; 95% CI = 1.11–1.58; p<0.01, I² = 71%) was observed with 1-L PEG-ASC than with the other preparations. No serious AEs or deaths occurred.ConclusionsCompared to other preparations, 1-L PEG-ASC yielded higher overall CS, higher right-colon HQC rates, and similar ADR. The number of patients with AEs and incidence of the total AEs were significantly higher with 1-L PEG-ASC in the absence of serious AEs.     

Effectiveness and tolerance of duodenoscopic bowel preparation for colonoscopy]

BACKGROUND/AIMS: Bowel preparation for colonoscopy remains an unpleasant experience because oral solutions have unpleasant tastes and may provoke abdominal pain, nausea, vomiting, and sleep disturbance. Duodenoscopic bowel preparation is an alternative method for patients who are unwilling to take oral preparation solution or for those who are supposed to have both gastroscopic and colonoscopic examination on the same day. We assessed the effectiveness and tolerance of duodenoscopic bowel preparation. METHODS: Patients in group OA (orally administered) ingested 45 mL of sodium phosphate (NaP) in the evening before the day of procedure and in the morning on the day of colonoscopy, whereas patients in group EA (endoscopically administered) were prepared for the procedure by duodenoscopic infusion of 90 mL of NaP diluted with 180 mL of water into the second portion of the duodenum. After 4 hours, we assessed the overall quality of colonic cleansing, using a range of excellent to inadequate. The patients completed a questionnaire on their preparation-associated symptoms, tolerance, and preference. RESULTS: In group EA, sleep disturbance (p0.05) and nausea (p0.05) occurred less frequently than in group OA. Overall, the tolerance rating for preparation was higher in group EA. However, the quality of colonic cleansing and cecum intubation time was not different between the two groups. Patients in group EA who had ingested NaP in the past preferred duodenoscopic bowel preparation. CONCLUSIONS: Duodenoscopic bowel preparation may play a role in colonic cleansing especially for patients who are scheduled to undergo gastroscopic and colonoscopic examination on the same day and for those who are unwilling to ingest NaP.     

Esophagogastroduodenoscopy-assisted bowel preparation for colonoscopy

AIM: To compare the quality and tolerance of esophagogastroduodenoscopy (EGD)-assisted and conventional split-dose polyethylene glycol electrolyte solution for inpatient colonoscopy.METHODS: The study was a randomized controlled trial in hospitalized patients. Hospitalized patients undergoing colonoscopy the day following EGD for evaluation of gastrointestinal (GI) bleeding or other symptoms. Patients randomized to either EGD-assisted bowel prep [2 L polyethylene glycol (PEG) administered endoscopically into distal duodenum at time of EGD, plus 1 L PEG orally the following day] or conventional-PEG (2 L PEG orally the evening prior and 1 L PEG orally the following day). The main outcome measurements are bowel preparation quality and patient tolerance of bowel prep.RESULTS: Forty-two patients randomized to EGD-assisted bowel prep and 40 patients to conventional-PEG. Overall mean ± SD preparation quality was superior for EGD-PEG (4.1 ± 2.8) vs conventional-PEG (6.5 ± 3.1; P = 0.0005). Seventy-four percent of patients rated EGD-PEG as easy or slightly difficult to tolerate compared to 46% for standard-PEG (P = 0.0133). Mean EGD-procedural time was greater for EGD-assisted subject (24 ± 10 min) compared to conventional-PEG prep subjects (15 ± 7 min; P < 0.0001). Conscious sedation requirements did not differ between groups. There were no significant prep-related adverse events in either group.CONCLUSION: In selected hospitalized patients, compared to a conventional split-dose regimen, use of EGD to administer the majority of PEG solution improves patient tolerance and quality of bowel preparation for colonoscopy.     

Characteristics of inflammatory bowel diseases in patients with concurrent immune-mediated inflammatory diseases

Patients with inflammatory bowel disease (IBD) are more likely to have concurrent immune-mediated inflammatory diseases (IMIDs) than those without IBD. IMIDs have been observed to alter the phenotype and outcomes of IBD in recent studies. Several studies have found that IBD patients with concurrent IMIDs may have more extensive or severe disease phenotypes, and are considered to be at increased risk of requiring biologics and IBD-related surgeries, suggesting that having multiple IMIDs is a poor prognostic factor for IBD. Furthermore, IBD patients with primary sclerosing cholangitis and Takayasu arteritis are reported to have unique endoscopic phenotypes, suggesting concurrent IMIDs can influence IBD phenotype with specific intestinal inflammatory distributions. In this review, we discuss the pathogenesis, disease phenotypes, and clinical outcomes in IBD patients with concomitant IMIDs.     

结肠镜检查不同时间行肠道准备质量比较

目的 比较结肠镜检查时不同时间行肠道准备的质量.方法 将2019-10～2020-01该院接受结肠镜检查的非麻醉门诊及住院患者130例,按随机数字表法分为观察组(64例)和对照组(66例).观察组于清晨5:00～7:00口服结肠清洁剂,上午完成结肠镜检查.对照组于上午10:00～12:00口服结肠清洁剂,下午完成结肠镜...     

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

Background and aimPain and nausea are often reported during bowel cleansing (BC) for ileocolonoscopy (IC). We aimed to explore putative mechanisms associated with impaired tolerance to BC.MethodsA 1:1 (100 IBD and 100 controls) sex and age matched case–control study was performed. Patients completed the hospital anxiety and depression scale (HADS-A/HADS-D), visceral sensitivity index (VSI) and state-trait anxiety inventory, state scale (STAI-S), in addition to self-assessment of BC and abdominal pain and nausea ratings during BC. Endoscopists reported the Mayo score, Harvey Bradshaw index (HBI), simple endoscopic score for Crohn's disease, and Boston bowel preparation scale (BBPS).ResultsHigher VSI and depression scores were observed in IBD patients. VSI (P < 0.0001) and age (P = 0.008) showed a positive and negative association with abdominal pain during BC, respectively. HADS-A (P = 0.009) and female sex (P = 0.02) were positively associated with nausea during BC, while age (P = 0.02) showed a negative association. Disease activity was not associated with worse BBPS or nausea during BC, while a higher HBI was associated with more pain during BC (P = 0.0006). Nausea (P = 0.007) and abdominal pain (P = 0.003) during BC, and less previous ICs (P = 0.03) were independently associated with anxiety prior to IC (STAI-S). Significant correlations were found between VSI and STAI-S and disease activity.ConclusionHigher gastrointestinal-specific anxiety and co-morbid anxiety are associated with increased pain and nausea during BC, respectively. Pain and nausea during BC were in turn associated with higher anxiety levels at the moment of IC, potentially creating a “vicious circle”. Measures taken to reduce anxiety could improve BC and IC tolerance.     

Intestinal superinfections in patients with inflammatory bowel diseases

BackgroundIntestinal superinfections may occur in the setting of inflammatory bowel diseases (IBD), complicating the clinical picture and triggering flares of disease.AimsTo report our experience with intestinal superinfections in IBD patients over a three-year period.MethodsCharts of patients hospitalized for moderate-to-severe active disease during the observation period were reviewed, and data of patients with flares due to infections collected and analyzed.ResultsOverall, 15 out of 113 IBD patients (13.3%) had flare-ups related to intestinal infections; 143 acute flare-ups were thus documented, with 17 episodes (12%) related to infective agents, represented by Campylobacter jejuni (3 infections), Clostridium difficile (7 infections), and Cytomegalovirus (7 infections). All but two infections occurred in ulcerative colitis patients, and all responded to appropriate treatment.ConclusionsIntestinal superinfections may complicate the clinical picture of IBD patients, increasing the diagnostic and therapeutic burden. Appropriate early diagnostic and therapeutic measures are thus needed in these patients.     

Predictors of inadequate bowel preparation for colonoscopy

OBJECTIVE: Inadequate preparation of the bowel for colonoscopy can result in both missed pathological lesions and cancelled procedures. We looked prospectively at the quality of colonic preparation and evaluated potential associations between specific patient characteristics and inadequate colonic preparation. METHODS: Data were gathered on consecutive patients presenting for colonoscopy who received either a polyethylene glycol lavage or oral sodium phosphate bowel preparation. Patient demographic and medical history information was gathered before scheduled colonoscopy. The endoscopist evaluated the preparation quality during the procedure. Complete data were gathered on 649 of 714 eligible patients (90.8%). Possible predictors of inadequate colonic preparation were analyzed using univariate statistics and multivariate logistic regression models. RESULTS: An inadequate colonic preparation was reported in 21.7% of observed colonoscopies. Only 18% of patients with an inadequate colonic preparation reported a failure to adequately follow preparation instructions. A later colonoscopy starting time, a reported failure to follow preparation instructions, inpatient status, a procedural indication of constipation, taking tricyclic antidepressants, male gender, and a history of cirrhosis, stroke or dementia were all independent predictors of an inadequate colon preparation (all p < 0.05). A procedural indication of previous polypectomy was a negative predictor of inadequate colonic preparation (p < 0.05). CONCLUSION: Several patient characteristics were significantly associated with colonic preparation quality independent of preparation type, compliance with preparation instructions, and procedure starting time. This information may help to identify patients at an increased risk for inadequate colonic preparation for whom alternative preparation protocols would be appropriate.     

Increased risk for demyelinating diseases in patients with inflammatory bowel disease

BACKGROUND & AIMS: Reports of multiple sclerosis (MS), demyelination, and optic neuritis (ON) associated with anti-tumor necrosis factor alpha therapy resulted in warnings on prescribing instructions for infliximab, etanercept, and adalimumab. However, the underlying relationship between IBD and these neurologic conditions has not been established. METHODS: We performed a retrospective cohort study and a retrospective cross-sectional study using 1988 to 1997 data from the General Practice Research Database. A total of 7988 Crohn's disease and 12,185 ulcerative colitis patients were matched for age, sex, and primary care practice to 80,666 randomly selected controls. In the cohort study, incident cases of MS, demyelination, and/or ON (MS/D/ON) had to occur at least 1 year after registration with the physician and after the diagnosis of IBD. In the cross-sectional study, the diagnosis of MS/D/ON could either precede or follow the IBD diagnosis. RESULTS: In the cohort study, the incidence of MS/D/ON was higher in patients with Crohn's disease and ulcerative colitis compared with their matched controls, reaching statistical significance for ulcerative colitis (ulcerative colitis incidence rate ratio [IRR], 2.63; 95% confidence interval, 1.29-5.15; Crohn's disease IRR, 2.12; 95% confidence interval, .94-4.50). In the cross-sectional study, MS/D/ON was more prevalent in patients with Crohn's disease and ulcerative colitis compared with their matched controls (Crohn's disease odds ratio, 1.54; 95% confidence interval, 1.03-2.32; ulcerative colitis odds ratio, 1.75; 95% confidence interval, 1.28-2.39). CONCLUSIONS: Demyelinating diseases occur more commonly among patients with IBD than among non-IBD patients. Future studies should clarify whether treatment with tumor necrosis factor alpha blockers results in further increased incidence of MS/D/ON among IBD patients.     

Evidence-based considerations on bowel preparation for colonoscopy

We recently read with interest the article, “Novel frontiers of agents for bowel cleansing for colonoscopy”. This is a practical narrative review, which could be of particular importance to clinicians in order to improve their current practice. Although we appreciate the venture of our colleagues, based on our in-depth analysis, we came across several minor issues in the article; hence, we present our comments in this letter. If the authors consider these comments further in their relevant research, we believe that their contribution would be of considerable importance for future studies.     

Venous and arterial thromboembolism in patients with inflammatory bowel diseases

The risk of thromboembolism (TE) is increased in patients with inflammatory bowel disease (IBD), mainly due to an increased risk of venous TE (VTE). The risk of arterial TE (ATE) is less pronounced, but an increased risk of cardiovascular diseases needs to be addressed in IBD patients. IBD predisposes to arterial and venous thrombosis through similar prothrombotic mechanisms, including triggering activation of coagulation, in part mediated by impairment of the intestinal barrier and released bacterial components. VTE in IBD has clinical specificities, i.e., an earlier first episode in life, high rates during both active and remission stages, higher recurrence rates, and poor prognosis. The increased likelihood of VTE in IBD patients may be related to surgery, the use of medications such as corticosteroids or tofacitinib, whereas infliximab is antithrombotic. Long-term complications of VTE can include post-thrombotic syndrome and high recurrence rate during post-hospital discharge. A global clot lysis assay may be useful in identifying patients with IBD who are at risk for TE. Many VTEs occur in IBD outpatients; therefore, outpatient prophylaxis in high-risk patients is recommended. It is crucial to continue focusing on prevention and adequate treatment of VTE in patients with IBD.     

Thromboxane analyses in patients with chronic inflammatory bowel diseases

Prostanoids are important for the pathogenesis of chronic inflammatory bowel diseases as mediators of inflammatory, immune and allergic reactions. The levels of thromboxane B2(TXB2), the stable hydrolysis product of thromboxane A2(TXA2) were determined in blood plasma of patients with chronic inflammatory bowel diseases. The platelet malondialdehyde (MDA) formation was determined as an indicator of the TXA2 synthetase activity. The TXB2 concentrations were measured radioimmunologically. The platelet MDA formation induced by N-ethylmaleimide was investigated with the thiobarbituric acid reaction. The investigated patients (n = 10) suffering from ulcerative colitis had a significant increasing (p less than 0.02) of the platelet MDA formation (mean = 4.39 nmol/10(9) platelets) in comparison to the normal group (n = 20; mean = 2.87; nmol/10(9) platelets). The increasing of TXB2 levels was not significantly different than in normal control subjects. The plasma concentrations of 6-keto-PGF1 were situated on the limit of detection.     

抗中性粒细胞胞浆抗体在炎性肠病中的意义

目的 研究抗中性粒细胞胞浆抗体（ＡＮＣＡ）在炎性肠病（ＩＢＤ）中的发生率、其针对的靶抗原及其与临床疾病活动性的关系。方法 用间接免疫荧光法对７６例溃疡性结肠炎（ＵＣ）、３６例克隆病（ＣＤ）及２１０例正常者进行ＡＮＣＡ的筛选测定,用ＥＬＩＳＡ检测ＡＮＣＡ针对的不同靶抗原。结果 ７６例ＵＣ患者中血清ＡＮＣＡ阳性者占７１．１％,均为核周型染色,明显高于ＣＤ患者ＡＮＣＡ的阳性率（８．３％,Ｐ〈０．００１）     

Achieving the best bowel preparation for colonoscopy

Bowel preparation is a core issue in colonoscopy, as it is closely related to the quality of the procedure. Patients often find that bowel preparation is the most unpleasant part of the examination. It is widely accepted that the quality of cleansing must be excellent to facilitate detecting neoplastic lesions. In spite of its importance and potential implications, until recently, bowel preparation has not been the subject of much study. The most commonly used agents are high-volume polyethylene glycol (PEG) electrolyte solution and sodium phosphate. There has been some confusion, even in published meta-analyses, regarding which of the two agents provides better cleansing. It is clear now that both PEG and sodium phosphate are effective when administered with proper timing. Consequently, the timing of administration is recognized as one of the central factors to the quality of cleansing. The bowel preparation agent should be administered, at least in part, a few hours in advance of the colonoscopy. Several low volume agents are available, and either new or modified schedules with PEG that usually improve tolerance. Certain adjuvants can also be used to reduce the volume of PEG, or to improve the efficacy of other agents. Other factors apart from the choice of agent can improve the quality of bowel cleansing. For instance, the effect of diet before colonoscopy has not been completely clarified, but an exclusively liquid diet is probably not required, and a low-fiber diet may be preferable because it improves patient satisfaction and the quality of the procedure. Some patients, such as diabetics and persons with heart or kidney disease, require modified procedures and certain precautions. Bowel preparation for pediatric patients is also reviewed here. In such cases, PEG remains the most commonly used agent. As detecting neoplasia is not the main objective with these patients, less intensive preparation may suffice. Special considerations must be made for patients with inflammatory bowel disease, including safety and diagnostic issues, so that the most adequate agent is chosen. Identifying neoplasia is one of the main objectives of colonoscopy with these patients, and the target lesions are often almost invisible with white light endoscopy. Therefore excellent quality preparation is required to find these lesions and to apply advanced methods such as chromoendoscopy. Bowel preparation for patients with lower gastrointestinal bleeding represents a challenge, and the strategies available are also reviewed here.     

行走功能状态与老年人结肠镜检查前肠道准备的相关性

目的探讨老年人行走功能状态与结肠镜检查前肠道准备质量的关系。方法选取2017年1月至2018年3月北京老年医院消化科住院期间行结肠镜检查的153例老年患者。检查前通过Barthel指数评价患者行走功能,并根据行走是否独立将患者分为行走正常组82例及行走困难组71例。2组患者采取相同的肠道准备方法,记录肠道清洁完成情况并计算清洁有效率。采用SPSS 19.0统计软件进行分析。根据数据类型,组间比较采用独立样本t检验或χ2检验。相关性分析采用Spearman秩相关检验。结果与行走困难组比较,行走正常组患者完整服用肠道清洁剂的比例显著升高[87.8%(72/82) vs63.4%(45/71),P0.01]。而在未完整服用肠道清洁剂的患者中,与行走困难组比较,行走正常组患者因不能忍受频繁排便的比例显著降低,差异有统计学意义[8.54%(7/82) vs 30.99%(22/71),P=0.001],但因不良反应导致未完整服用肠道清洁剂的比例2组差异无统计学意义[3. 66%(3/82) vs 5. 63%(4/71),P=0.705]。Spearman秩相关分析显示,行走功能状态与肠道准备清洁质量呈正相关(r=0.333,P0.01)。结论老年患者行走功能状态与结肠镜检查前肠道准备质量相关,行走困难影响患者肠道准备质量。     

Efficacy and safety of oral sodium phosphate versus polyethylene glycol solution for bowel preparation for colonoscopy

OBJECTIVE: To assess the acceptability, safety and effectiveness of an oral sodium phosphate solution (Exelyte) for colon preparation prior to colonoscopy, compared with a polyethylene glycol solution (Peglec). METHOD: A colonoscopist-blinded, prospective, randomized, observational clinical study. PATIENTS: One hundred patients undergoing colonoscopy for various indications were randomized (n = 50 each) to receive either 90 mL of oral sodium phosphate mixed with 300 mL clear liquid and then consume about 4-5 glasses of water, or 2 liters of polyethylene glycol solution. RESULT: Sodium phosphate showed a safety profile similar to that of polyethylene glycol. However, patients tolerated it better. The colonoscopist reported similar cleansing of bowel in both groups. CONCLUSION: Oral sodium phosphate is well tolerated, is safe and provides bowel cleansing similar to that with a polyethylene glycol solution.