With up to 25 percent of all colonoscopies reporting inadequate bowel preparation, the U.S. Colorectal Cancer Multisociety Task Force has published new consensus guidelines aimed at improving compliance with at least 85 percent of bowel preparations.
Inadequate bowel preparation has serious consequences, including reduced adenoma detection, longer operative times, and shorter intervals between exams, according to the article published in the October issue of Gastroenterology.
Professor David A. Johnson (Chief, Division of Gastroenterology, Eastern Virginia School of Medicine), and colleagues conducted a systematic review of the medical literature published between January 1980 and August 2013, which also included articles and abstracts published and presented at national meetings. They chose 1980 as the first year because it coincided with FDA approval of polyethylene glycol electrolyte solutions for basic preparation.
The new working group guidelines have been reviewed and approved by American Gastroenterology, the American College of Gastroenterology and the American Society of Gastrointestinal Endoscopy Directors.
”Ineffective bowel cleansing for colonoscopy can lead to missed precancerous lesions and increase the cost of associated early repeat procedures,” write Professor Johnson and colleagues. “Efficacy and tolerability of bowel preparation are important and relevant goals, but effectiveness is paramount, as inadequate cleansing can have significant consequences.”
The guidelines cover a number of areas, including
Adequate preparation
Preparation should be adequate to allow for the detection of polyps larger than 5 mm.
If it is truly inadequate during colonoscopy, it should be re-examined within 1 year using a more aggressive preparation protocol.
If deemed adequate, follow screening guidelines.
Dosage and timing
Use a split – dose cleanser.
Same day protocols are acceptable for split-dosing, especially for afternoon procedures.
The second dose should be started 4 to 6 hours before the start of the procedure.
Diet during cleansing
Stay until the evening before the procedure applying low residual or full liquid.
Patient education
Provide verbal and written instructions to the patient.
Ensure that appropriate support is very much in place.
Quality of preparation
Assess after all appropriate efforts that removal of residual debris is appropriate enough.
Measure adequacy rate regularly.
Each physician checks for at least 85% adequacy of cleanliness.
FDA-approved drugs
Consider the patient’s medical history, medication use, and prior procedures when selecting an appropriate regimen.
Use a split-dose regimen of 4L polyethylene glycol electrolyte lavage solution.
OTC drugs
Regardless of the drug, use a split-dose regimen.
Use with caution in certain populations, such as patients with chronic renal lesions.
Additional agents
The use of conventional adjuvant medications is not recommended.
Patient preference/willingness
Split-dose correlates with stronger willingness compared to day-before regimens.
Low-dose medications correlate with a strong willingness to undergo repeat procedures.
Special Populations
For the elderly, children and adolescents, specific preparation protocols were not recommended due to insufficient evidence.
Sodium phosphate (NaP) medications are not recommended for children younger than 12 years of age or with high-risk medication complicating factors.
Avoid the use of NaP in patients with known or suspected inflammatory bowel disease.
Consider the use of additional enterolaxatives in patients with inadequately prepared risk factors.
Use low volume or extended duration delivery in patients following bariatric surgery.
Use direct tap water enemas in pregnant women.
Evidence is insufficient to recommend a specific regimen for patients with a history of spinal cord injury.
Remedial options
Patients with brown effluent despite compliance with the preparation protocol should use high volume enemas.
Particularly for patients receiving isoprostane-based sedation, consider enemas via the action domain.