Effect of Bowel Preparation with Polyethylene Glycol on Quality of Capsule Endoscopy

Background and Aims  

Capsule endoscopy (CE) has the problem that lumen visualization is impaired by bubbles, bile, and debris. The benefits of bowel preparation are still controversial and the best method remains to be determined. The objective of this study was to evaluate the effect of the method of bowel preparation on the quality of visualization and on transit time.     

Improving the Quality of Inpatient Bowel Preparation for Colonoscopies

Background

Hospitalized patients completing bowel preparation for colonoscopy typically have preparations of poorer quality when compared to outpatient populations.

Aims

Our study aimed to evaluate the effectiveness of a performance improvement program in improving colonoscopy preparation for an inpatient population.

Methods

We identified a cohort of adult patients (n = 641) undergoing an inpatient colonoscopy during a 12-month period at an academic medical center and compared a multifactor intervention group to a historical baseline group. During this 12-month period, a performance improvement program including use of a dedicated gastrointestinal nurse facilitator, implementation of standardized order sets, and introduction of split bowel preparations in the inpatient setting was made available to the cohort group.

Results

The primary outcome was quality of bowel preparation for colonoscopy as rated by endoscopists using the modified Aronchick scale. When comparing the baseline group to the intervention group, the rate of acceptable preparations, characterized as excellent, good, or adequate, increased from 69.9 to 78.9%, which was statistically significant (p < 0.001).

Conclusions

A comprehensive performance improvement program improved the quality of colonoscopy preparation among inpatients. The use of a dedicated gastrointestinal nurse facilitator, implementation of standardized order sets, and introduction of split bowel preparations are recommended in the inpatient setting for an effective bowel preparation.

     

Importance of the Time Interval between Bowel Preparation and Colonoscopy in Determining the Quality of Bowel Preparation for Full-Dose Polyethylene Glycol Preparation

Background/Aims

The quality of bowel preparation (QBP) is the important factor in performing a successful colonoscopy. Several factors influencing QBP have been reported; however, some factors, such as the optimal preparation-to-colonoscopy time interval, remain controversial. This study aimed to determine the factors influencing QBP and the optimal time interval for full-dose polyethylene glycol (PEG) preparation.

Methods

A total of 165 patients who underwent colonoscopy from June 2012 to August 2012 were prospectively evaluated. The QBP was assessed using the Ottawa Bowel Preparation Scale (Ottawa) score according to several factors influencing the QBP were analyzed.

Results

Colonoscopies with a time interval of 5 to 6 hours had the best Ottawa score in all parts of the colon. Patients with time intervals of 6 hours or less had the better QBP than those with time intervals of more than 6 hours (p=0.046). In the multivariate analysis, the time interval (odds ratio, 1.897; 95% confidence interval, 1.006 to 3.577; p=0.048) was the only significant contributor to a satisfactory bowel preparation.

Conclusions

The optimal time was 5 to 6 hours for the full-dose PEG method, and the time interval was the only significant contributor to a satisfactory bowel preparation.     

A Clear Liquid Diet Is Not Mandatory for Polyethylene Glycol-Based Bowel Preparation for Afternoon Colonoscopy in Healthy Outpatients

Background/Aims

A dietary regimen consisting of a clear liquid diet (CLD) for at least 24 hours is recommended for colonoscopy preparation. However, this requirement results in problems in patient compliance with bowel preparation. The aim of this study was to evaluate the efficacy of a CLD compared with a regular diet (RD) for colonoscopy preparation using a polyethylene glycol (PEG) solution.

Methods

This was a multicenter, randomized, investigator-blind prospective study. A total of 801 healthy outpatients undergoing afternoon colonoscopy were randomized to either a CLD or RD in addition to a 4 L PEG regimen.

Results

The quality of bowel cleansing was not different between the CLD and RD groups in terms of the proportion with excellent or good preparation. In addition, no significant differences were observed between the two groups for polyp and adenoma detection rates and overall adverse events. Good compliance with bowel preparation was higher in the RD group than in the CLD group.

Conclusions

A CLD for a full day prior to colonoscopy should not be mandatory for PEG-based bowel preparation. Dietary education concerning the avoidance of high-fiber foods for 3 days before colonoscopy is sufficient, at least for healthy outpatients.     

Willingness to Undergo Split-Dose Bowel Preparation for Colonoscopy and Compliance with Split-Dose Instructions

Background  

Split-dose bowel preparations for colonoscopy have superior effectiveness compared with giving all the preparation the evening before colonoscopy. Some physicians believe that split-dose preparations would be unpopular with patients scheduled for early morning colonoscopies.     

Physician Recommendations and Patient Adherence After Inadequate Bowel Preparation on Screening Colonoscopy

Background and Aims

It has been suggested that bowel preparation quality may influence decision-making about appropriate follow-up interval after screening colonoscopy. We sought: (1) to assess physician recommendations for timing of subsequent colonoscopy in average-risk patients with inadequate bowel preparation on initial screening, and (2) to measure the association between physician recommendations and patient adherence to repeat colonoscopy.

Methods

Patients undergoing average-risk screening colonoscopy from 2004 to 2009 found to have inadequate bowel preparation were identified. Physician recommendations for timing of subsequent colonoscopy and patient adherence to repeat colonoscopy were assessed through examination of endoscopy records. Data from repeat colonoscopies were collected through August 2010.

Results

There were 373 patients with inadequate bowel preparation on initial screening colonoscopy. There was a wide range of physician recommendations for timing of repeat colonoscopy: next day (4.6 % of patients), 2 days to 6 months (9.9 %), 7 months to 1 year (34.0 %), 2–5 years (38.3 %), 6–10 years (5.1 %), and timing not specified (8.0 %). Physicians were significantly more likely to recommend repeat colonoscopy within 1 year if any polyps were detected (OR = 2.2, p = 0.001). Patients instructed to have next day follow-up were significantly more likely to adhere to the recommendation compared to patients who were instructed to return after longer intervals (OR 4.4, p = 0.005).

Conclusions

Patients with inadequate bowel preparation on screening colonoscopy were subject to a wide range of physician recommendations for follow-up. Patient adherence to physician recommendations was significantly higher when repeat colonoscopy was recommended the next day.     

Head or Tail: The Orientation of the Small Bowel Capsule Endoscope Movement in the Small Bowel

Background and Aims  

The diagnostic accuracy of capsule endoscopy has been suggested to be influenced by the direction of the passage in the intestine. It is currently unknown if a head-first or a tail-first orientation are equally common during the descent through the small bowel. The aim of the study was to identify the orientation of the capsule along the migration through the small bowel.     

Update on Bowel Preparation for Colonoscopy

Purpose of review

Colonoscopy is the gold standard for visualization and diagnosis of conditions involving the colon and terminal ileum. It also facilitates screening and prevention of colorectal cancer, which is the second leading cause of cancer death in the USA. Adequate cleansing is essential for thorough visualization of the colon with successful detection of colon polyps.

Recent findings

While the original large-volume polyethylene glycol preparations are still commonly used, several lower volume regimens are widely available and selected based on provider and patient preferences. There remains a strong urge from patients for an even lower volume and more palatable regimen. Split-dose preparation is strongly recommended and additional data has come to support same-day preparation regimens as well. Despite extensive research and comparison of various preparation regimens, between 10 and 25% of patients continue to have inadequate colon cleansing on the day of colonoscopy. Several patient factors have been associated with poor preparation and this chapter will touch on scoring systems, which may be used to predict colon cleansing. Documentation of preparation quality is essential to guide the practitioner in timing of follow-up examination. We recommend the use of the Boston Bowel Preparation Scale (BBPS) which is a validated and reliable scale for evaluation of cleansing. In patients with an inadequate preparation, we emphasize the importance of repeat examinations with consideration of a more aggressive preparation regimen. We predict that dietary liberalization prior to colonoscopy will be more commonly practiced in the future as it improves both patient satisfaction and adherence.

Summary

Thorough bowel cleansing is essential for visualization of the colon with successful detection of colon polyps. While polyethylene glycol regimens are still the most commonly used for preparation, recommendations regarding dose timing and volume continue to evolve to optimize patient satisfaction and success of bowel cleanse. As the patients presenting for colonoscopy are evermore complex with medical comorbidities and extensive medication lists, a patient-centered approach to colonoscopy preparation will likely yield the highest rates of success.

     

Timing and frequency of bowel activity in patients ingesting sodium picosulphate/magnesium citrate and adjuvant bisacodyl for colon cleansing before colonoscopy

BACKGROUND:

Despite the wealth of research investigating bowel cleansing efficacy, there are very little data on the timing or frequency of bowel movements after each agent is ingested.

OBJECTIVE:

To examine the effect of each component of a three-day combined sodium picosulphate/magnesium citrate (PSLX) and bisacodyl regimen on the timing and frequency of bowel activity in patients undergoing colonoscopy.

METHODS:

Outpatients booked for colonoscopy were asked to complete a diary of their bowel preparation that tracked the timing of bowel movements. Bowel preparation quality was assessed using the Ottawa Bowel Preparation Scale. Bowel activity was compared with baseline and correlated with colon cleansing. Subgroup analysis was performed examining the effect of timing of the procedure and split-dose regimens.

RESULTS:

One hundred patients undergoing colon cleansing received bisacodyl 10 mg at 17:00 three days and two days before the day of colonoscopy. In one group, both sachets of PSLX were given the night before colonoscopy, while the second group, whose colonoscopies were scheduled after 11:00, ingested one sachet the night before and the second sachet at 06:00 on the day of colonoscopy. Patients had a mean of 1.7 bowel movements per day in the seven days before starting the cleansing regimen. Both doses of bisacodyl tablets resulted in a significant increase in the mean number of bowel movements compared with baseline (3.3/day first dose; 3.8/day second dose [P=0.03 and 0.001, respectively]). Each dose of PSLX also resulted in a significant increase in bowel movement frequency compared with baseline, with means of 4.4, 6.3 and 4.5 bowel movements after each dose. The mean time to the final bowel movement following the second sachet of PSLX was 8.9 h when taken the night before, and 3.9 h when taken the morning of the procedure. Bowel preparation quality significantly correlated with bowel frequency when total bowel movements were considered and when only the effects of bisacodyl were accounted for (P<0.01 for each).

DISCUSSION:

These data demonstrate that the addition of bisacodyl before PSLX ingestion has a significant additive effect on bowel frequency and correlates with bowel cleansing quality. The timing of the resulting bowel movements have practical implications for sleep and travel times to endoscopy suites.     

Subtypes of Irritable Bowel Syndrome Based on Abdominal Pain/Discomfort Severity and Bowel Pattern

Introduction  

Irritable bowel syndrome (IBS) has traditionally been classified by stooling pattern (e.g., diarrhea-predominant). However, other patterns of symptoms have long been recognized, e.g., pain severity. Our objective was to examine the utility of subtyping women with IBS based on pain/discomfort severity as well as predominant bowel pattern.     

Efficacy and Safety of Gum Chewing in Adjunct to High-Dose Senna for Bowel Cleansing Before Colonoscopy: A Single-Blind Randomized Controlled Trial

Background/Aims:

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

Patients and Methods:

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

Results:

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

Conclusions:

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

Peripheral Arthritis in the Course of Inflammatory Bowel Diseases

Background  

Musculoskeletal disorders are well-defined extra-intestinal manifestations of inflammatory bowel diseases (IBD). There is little data regarding the frequencies of IBD and extra-intestinal manifestations from Central and East Europe and Middle Eastern countries.     

The effects of thiopurine therapy on health-related quality of life in Inflammatory Bowel Disease patients

Background  

The effect of thiopurine immunomodulators on health-related quality of life (HRQoL) in patients with inflammatory bowel disease (IBD) has been controversial. The aims were to evaluate the HRQoL in patients with IBD treated with thiopurines and assess the short- and long-term impacts of the treatment on HRQoL.     

Small Bowel Capsule Endoscopy Impacts Diagnosis and Management of Pediatric Inflammatory Bowel Disease: A Prospective Study

Purpose  

Accurately classifying inflammatory bowel disease (IBD) type in pediatric patients may impact medical decision-making, direct therapy, and improve outcomes.     

Predictors of Suboptimal Bowel Preparation Using 3-l of Polyethylene Glycol for an Outpatient Colonoscopy: A Prospective Observational Study

Background

A 3-l polyethylene glycol (PEG) solution provided better bowel cleansing quality than a 2-l solution for outpatient colonoscopy. Predictors of suboptimal preparation using a 3-l PEG have not been previously reported.

Aims

To investigate the possible predictors of suboptimal bowel preparation using 3-l of PEG.

Methods

We analyzed a database of 1404 consecutive colonoscopies during a 27-month period at a community hospital. A split-dose PEG regimen was provided for morning colonoscopies, and a same-day PEG regimen was provided for afternoon colonoscopies. The level of bowel cleansing was prospectively scored according to the Boston Bowel Preparation Scale (BBPS). Possible predictors of suboptimal colon preparation, defined as a BBPS score <7, were analyzed using univariate statistics and multivariate logistic regression models.

Results

The mean age of the study population (46.7 % men) was 52.5 years (range 20–80 years, SD 11.1 years), and the majority of patients (77.6 %) underwent morning colonoscopies. A suboptimal bowel preparation was reported in 17.2 % of the observed colonoscopies. In the multivariate regression analysis, constipation (odds ratio [OR] 1.60, 95 % confidence interval [CI] 1.15–2.22), male gender (OR 1.68, 95 % CI 1.25–2.25), obesity (OR 1.76, 95 % CI 1.29–2.41), and inadequate (<80 %) PEG consumption (OR 5.4, 95 % CI 2.67–10.89) were independent predictors of a suboptimal colon preparation.

Conclusions

This prospective study identified that constipation, male gender, obesity, and inadequate intake of PEG were significant risk factors for suboptimal bowel preparation using a 3-l PEG solution for outpatient colonoscopy. Interventions of optimized colonoscopy preparation should be targeted at these patient populations.

     

The Role of N-Acetyltransferase 2 Polymorphism in the Etiopathogenesis of Inflammatory Bowel Disease

Background and Purpose  

Inflammatory bowel disease (IBD) consists of ulcerative colitis (UC) and Crohn’s disease (CD), which are complex genetic disorders resulting from the interplay between several genetic and environmental risk factors. The arylamine N-acetyltransferase 2 (NAT2) enzyme detoxifies a wide spectrum of naturally occurring xenobiotics including carcinogens and drugs. Acetylation catalyzed by NAT2 is an important process in metabolic activation of arylamines to electrophilic intermediates that initiate carcinogenesis. The aim of our study was to determine whether there is any association between the susceptibility to inflammatory bowel disease among the variations of NAT2 genotypes.     

The Role of Oral Hygiene in Inflammatory Bowel Disease

Background  

The ‘hygiene hypothesis’ suggests that a reduction in the microbial exposure due to improved health measures has contributed to an immunological imbalance in the intestine and increased the incidence of autoimmune diseases such as inflammatory bowel diseases (IBD). Accordingly, we investigated associations between oral hygiene practices and IBD.     

A Korean experience of the use of Boston Bowel Preparation Scale: A Valid and Reliable Instrument for Colonoscopy-Oriented Research

Background/Aims:

Few bowel preparation scales have been validated. The Boston Bowel Preparation Scale (BBPS) is a novel bowel preparation scale in western countries. We validated the BBPS in Korean patients and assessed the relationship between the colon polyp detection rate and BBPS score.

Patients and Methods:

This study was a prospective, single-center trial. The BBPS is a 10-point scale that assesses bowel preparation after the completion of all cleansing maneuvers. We assessed three segment scores (the right side, transverse section, and left side) and total BBPS scores during screening colonoscopy. In addition, we compared the BBPS scores with clinically meaningful outcomes such as the polyp detection rate and colonoscope withdrawal times.

Results:

We enrolled 482 screening colonoscopies between January 2011 and January 2012. The mean (± standard deviation [SD]) BBPS score was 8.1 ± 1.1. Higher BBPS scores (≥8 vs <8) were associated with a higher polyp detection rate (44.9% vs. 33.0%, P = 0.042). The BBPS scores were inversely correlated with colonoscope withdrawal times (r = −0.167, P < 0.001).

Conclusions:

The BBPS is a valid and reliable measure for assessing bowel preparation during colonoscopy in Korean patients. The polyp detection rate is higher in patients with higher BBPS scores than in those with lower BBPS scores during a colonoscopic procedure.     

Effect of Meal Ingestion on Ileocolonic and Colonic Transit in Health and Irritable Bowel Syndrome

Background  

Postprandial symptoms in irritable bowel syndrome (IBS) have been associated with increased bowel contractility.     

Evaluation of Different Bowel Preparations for Small Bowel Capsule Endoscopy: A Prospective, Randomized, Controlled Study

Background and Study Aims

To obtain an adequate view of the whole small intestine during capsule endoscopy (CE) a clear liquid diet and overnight fasting is recommended. However, intestinal content can hamper vision in spite of these measures. Our aim was to evaluate tolerance and degree of intestinal cleanliness during CE following three types of bowel preparation.

Patients and Methods

This was a prospective, multicenter, randomized, controlled study. Two-hundred ninety-one patients underwent one of the following preparations: 4 L of clear liquids (CL) (group A; 92 patients); 90 mL of aqueous sodium phosphate (group B; 89 patients); or 4 L of a polyethylene glycol electrolyte solution (group C; 92 patients). The degree of cleanliness of the small bowel was classified by blinded examiners according to four categories (excellent, good, fair or poor). The degree of patient satisfaction, gastric and small bowel transit times, and diagnostic yield were measured.

Results

The degree of cleanliness did not differ significantly between the groups (P = 0.496). Interobserver concordance was fair (k = 0.38). No significant differences were detected between the diagnostic yields of the CE (P = 0.601). Gastric transit time was 35.7 ± 3.7 min (group A), 46.1 ± 8.6 min (group B) and 34.6 ± 5.0 min (group C) (P = 0.417). Small-intestinal transit time was 276.9 ± 10.7 min (group A), 249.7 ± 13.1 min (group B) and 245.6 ± 11.6 min (group C) (P = 0.120). CL was the best tolerated preparation. Compliance with the bowel preparation regimen was lowest in group C (P = 0.008).

Conclusions

A clear liquid diet and overnight fasting is sufficient to achieve an adequate level of cleanliness and is better tolerated by patients than other forms of preparation.