However, mucosal inflammation may be more frequent with magnesium-based bowel preparations. While no statistically significant differences between PEG and oral sodium phosphate OSP for overall colon cleansing have been reported, the routine use of OSP for bowel preparation should be avoided because of safety concerns. Only 10 were identified with PEG. Relative contraindications include active inflammatory bowel disease, parathyroidectomy, and delayed bowel transit.
Therefore, identification of its risk factors could be very important. Pregnancy and breastfeeding PEG is considered safe during pregnancy. Lower gastrointestinal bleeding In emergent colonoscopy to evaluate a patient with lower gastrointestinal bleeding, PEG is advisable. Urgent colonoscopy following a rapid colon preparation performed within 24 hours of admission is safe and may facilitate the detection and management of bleeding lesions. Situations bring out hypovolemia Comorbidities bring out hypovolemia such as diarrhea, vomiting, dysphagia, hyperglycemia, and diuretics use, which should be evaluated before the administration of bowel preparation agents.
Isotonic electrolyte-mixed fluid is advisable for intravenous fluid replacement. Some patients receiving PEG may achieve adequate bowel preparation without consuming the full 4 L.
Therefore, patients should discontinue the oral bowel-cleansing agent if their diarrhea becomes clear. Chronic kidney disease Information about renal function in patients is important in order to identify an appropriate bowel preparation agent. The most important factor in acute phosphate nephropathy after OSP use is pre-existing chronic kidney disease.
Kidney function should be evaluated in patients with any of the known predisposing conditions of kidney disease. With chronic kidney disease, OSP should be avoided. SPMC have a risk of hypermagnesemia in patients with kidney disease without dialysis. Thrombosis through arteriovenous fistulae for hemodialysis could be accompanied with dehydration and hypotension. Because PEG may expand intravascular volume, the schedule of dialysis should be adjusted according to the intravascular volume status.
In order to preserve the residual renal function, intravascular volume depletion should be avoided in patients with peritoneal dialysis. Heart failure PEG is the best oral bowel preparation agent for patients with heart failure. Because heart failure, a risk factor of acute phosphate nephropathy, is accompanied by a reduction in GFR, patients with significant heart failure should not receive OSP.
Liver cirrhosis Because liver cirrhosis is a risk factor for acute phosphate nephropathy by OSP, PEG is the best oral bowel preparation agent. Renal function during ACEI use is prone to aggravate during hypovolemia. ARB intensifies bicarbonaturia by promoting calcium and phosphate precipitation, the risk of acute phosphate nephropathy with OSP.
PEG is advisable in patients who use diuretics. In patients taking diuretics, intravascular volume status and electrolyte balance may be imbalanced. Therefore, discontinuation of diuretics should be considered with bowel preparation agent.
NSAIDs should be discontinued on the day of administration of oral bowel preparation agents and until 3 days after the colonoscopy. A low-fiber diet is an independent predictor of adequate bowel preparation. PEG-based bowel preparation is advisable in most situations in terms of safety concerns. References 1. Impact of colonoscopy preparation quality on detection of suspected colonic neoplasia.
Gastrointest Endosc ; Impact of colonic cleansing on quality and diagnostic yield of colonoscopy: the European Panel of Appropriateness of Gastrointestinal Endoscopy European multicenter study. Impact of bowel preparation on efficiency and cost of colonoscopy. Am J Gastroenterol ; Acceptability and side-effects of colonoscopy and sigmoidoscopy in a screening setting.
J Med Screen ; Consensus guidelines for the safe prescription and administration of oral bowel-cleansing agents. Gut ; Impact of low-residue diet on bowel preparation for colonoscopy.
Dis Colon Rectum ; Bisacodyl reduces the volume of polyethylene glycol solution required for bowel preparation. A randomized single-blind trial of standard diet versus fiber-free diet with polyethylene glycol electrolyte solution for colonoscopy preparation. ESGE recommends the use of enhanced instructions for bowel preparation.
ESGE suggests adding oral simethicone to bowel preparation. Weak recommendation, moderate quality evidence. ESGE recommends split-dose bowel preparation for elective colonoscopy. However, this study had two main drawbacks as no standardized bowel preparation protocol was used and patients with a previous history of inadequate bowel preparation were included in the model It is already known that the latter condition is enough to modify the bowel preparation protocol.
There is not enough evidence to recommend a specific strategy in patients with risk factors for poor bowel preparation. In recent years, several studies aimed to assess interventions to improve bowel cleansing in these patients. The ESGE recommends to use irrigation pumps during colonoscopy or to schedule a new colonoscopy the following day with an additional preparation whereas the ASGE suggests repeating the procedure with a high-volume enema or additional oral preparation 11 , In a prospective observational study of patients with a history of inadequate bowel preparation, an intensive bowel cleansing based on 3-day LRD, 4L PEG, and bisacodyl significantly improved bowel cleansing Indeed, patients in the former group showed a better rate of adequate bowel preparation without a significant difference in tolerance and neoplastic lesion detection rate.
Furthermore, the highest benefit was achieved in patients who did not receive 4L PEG in the index colonoscopy Poor bowel cleansing in diabetic patients has been associated with constipation, nausea, and vomiting after the administration of bowel preparation due to a delayed gastrointestinal emptying. Another concern in diabetic patients is hypoglycemia, which could occur during bowel preparation. Therefore, to adjust the diet and antidiabetic drugs seems to be reasonable for their safety.
One RCT assessed the quality of bowel preparation of a multifactorial strategy compared to the conventional strategy in patients who received a split-dose high-volume PEG solution. In the multifactorial strategy, patients received an educational intervention by a trained nurse who explained the bowel preparation, provided printed instructions, and adjusted the dose of antidiabetic agents for the procedure.
A specific dietary plan consisting of a 4-day LRD and a liquid diet 8 h before the procedure was also provided. Conversely, patients allocated to the conventional strategy did not receive an educational intervention; they received written instructions that included recommendations for a 3-day LRD and 1-day liquid diet before the procedure.
A significantly higher rate of inadequate bowel preparation was reported in the conventional compared to the multi-strategy group 20 vs. Since it used a combination of different interventions, it was not clear what the effect of each strategy was by itself.
A recent RCT showed that bisacodyl plus simethicone and 2L PEG-citrate was more acceptable, increasing willingness to repeat the procedure and improved compliance when compared to 4L PEG without significant differences in the quality of bowel preparation Another RCT reported a significantly higher rate of adequate bowel cleansing in patients who received 10 mg bisacodyl and 2L PEG-electrolytes compared with those who only received 2L PEG-electrolytes There is limited data regarding the best bowel preparation in patients with previous colorectal resection due to the exclusion of these patients from most studies aiming to assess the quality of bowel preparation.
Based on expert opinions, high-volume bowel preparation has been recommended in these patients. Only one RCT that assigned these patients to receive a low- or high-volume split-dose preparation showed that the former was not inferior to the latter for adequate bowel cleansing quality, but tolerability was better in patients who received low-volume preparation All of them have been reported to be safe and to improve the quality of bowel preparation, though RCTs are lacking 58 — More evidence is thus needed to recommend them in clinical practice.
Poor bowel cleansing is a hodgepodge of situations as many conditions can cause it: poor compliance, poor tolerance, or a lack of efficacy. In such a way, we need different solutions for each specific condition. The next steps should therefore include studies that figure out the predictors of each of these conditions. Predictive models based on independent predictors of compliance or efficacy may help to better identify candidates suited for tailored strategies.
RCT using different educational strategies or cleansing protocols should be focused on selected groups of patients, such as a priori known non-compliant patients or a priori known hard-to-prepare patients. In this sense, no study has evaluated a specific intervention for bowel preparation after applying predictive models. Thus, we suggest to follow the recommendations summarized in Figure 1 in an effort to optimize the bowel cleansing in patients with increased risk of inadequate bowel preparation.
Figure 1. Recommendations to improve bowel cleansing in patients with increased risk for inadequate bowel preparation. Enhanced education additional audiovisual material or instructions improves bowel cleansing quality in these individuals. Based on this review we can make the following remarks: 1 low-volume preparation should be offered to non-selected patients who undergo a first-time colonoscopy or those who had an acceptable cleansing quality in the past with low-volume preparation protocols; 2 high-volume preparation should be reserved for those patients at risk of poor bowel preparation and predictive models may help to decide the best candidates for high-volume preparation; 3 adjuvants, such as bisacodyl, should be offered to patients with a past history of poor bowel preparation once poor compliance and tolerance have been ruled out; and 4 educational interventions focused on patient awareness and comprehension should be carried out in patients with past history of poor bowel preparation attributed to poor compliance.
All authors listed have made a substantial, direct and intellectual contribution to the work, and approved it for publication. The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest. Colorectal cancer screening: recommendations for physicians and patients from the U. Multi-Society task force on colorectal cancer.
Quality indicators for colonoscopy. Am J Gastroenterol. Efficacy of a multifactorial strategy for bowel preparation in diabetic patients undergoing colonoscopy: a randomized trial. Risk factors for inadequate bowel preparation: a validated predictive score.
Validated scales for colon cleansing: a systematic review. Boston bowel preparation scale scores provide a standardized definition of adequate for describing bowel cleanliness. Gastrointest Endosc. What level of bowel prep quality requires early repeat colonoscopy: systematic review and meta-analysis of the impact of preparation quality on adenoma detection rate. Low-residue versus clear liquid diet before colonoscopy: a meta-analysis of randomized, controlled trials.
Regime for bowel preparation in patients scheduled to colonoscopy: low-residue diet or clear liquid diet? Evidence from systematic review with power analysis. Medicine Baltimore. Bowel preparation before colonoscopy. Bowel preparation for colonoscopy: European society of gastrointestinal endoscopy ESGE guideline - update Optimal bowel cleansing for colonoscopy: split the dose!
A series of meta-analyses of controlled studies. Split-dose preparations are superior to day-before bowel cleansing regimens: a meta-analysis. Bowel preparations administered the morning of colonoscopy provide similar efficacy to a split dose regimen: a meta analysis. J Clin Gastroenterol. Same-day versus split-dose bowel preparation before colonoscopy: a meta-analysis.
Do adjuvants add to the efficacy and tolerance of bowel preparations? A meta-analysis of randomized trials. Enhanced instructions improve the quality of bowel preparation for colonoscopy: a meta-analysis of randomized controlled trials. Meta-analysis: the effect of patient education on bowel preparation for colonoscopy.
Endosc Int Open. Duration of the interval between the completion of bowel preparation and the start of colonoscopy predicts bowel-preparation quality.
Impact of single- vs. Split-dose preparation for colonoscopy increases adenoma detection rate: a randomised controlled trial in an organised screening programme.
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