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Colorectal cancer task force issues optimal bowel prep guidelines for colonoscopy
Inadequate bowel cleansing for colonoscopy causes missed precancerous lesions and higher costs associated with early repeat procedures, according to new consensus guidelines on optimizing bowel preparation released by the US Multi-Society Task Force on Colorectal Cancer.
“When prescribing bowel preparation for their patients, health care professionals need to be aware of medical factors that increase the risk of inadequate preparation, as well as nonmedical factors that may predict poor compliance with instructions,” David A. Johnson, MD, co-author of the guidelines, professor of internal medicine and chief of the division of gastroenterology, Eastern Virginia Medical School, said in a press release. “Gastroenterologists should use this information when determining whether to use a more effective or aggressive bowel preparation regimen, as well as the level of patient education needed about the prep.”
David A. Johnson
The guidelines were developed based on a systematic review of literature published between January 1980 and August 2013, and provide expert recommendations for optimizing colonoscopy preparation quality and patient safety.
Quality assessment, detection rate and follow-up intervals
Inadequate bowel preparation is associated with reduced adenoma detection rates. The guidelines recommend a preliminary assessment of preparation quality, and if inadequate for detecting polyps greater than 5 mm, additional cleansing strategies or terminating and rescheduling the procedure are advised. If preparation is deemed inadequate after colonoscopy, the procedure should be repeated within 1 year, unless advanced neoplasia is detected, in which case a shorter interval should be applied. Rate of adequate colon cleansing should be routinely measured, and should be achieved in at least 85% of procedures per physician.
Selection of bowel preparation
Physicians are advised to consider patient medical history, medications and adequacy of bowel preparation reported from prior colonoscopies when selecting a bowel-cleansing regimen. A split-dose regimen is strongly recommended for elective colonoscopy, but a same-day regimen is an acceptable alternative, especially for afternoon procedures. FDA-approved split-dose 4 L PEG-ELS is recommended, but lower-volume PEG formulations are comparable in healthy nonconstipated patients. OTC agents have variable efficacy, are enhanced with split-dosing and are generally safe except in certain populations. Routine use of adjuncts to colon cleansing is not recommended.
Dosing, timing, diet and patient educationrecommendations
The second and last doses of split preparation should begin 4 to 6 hours and at least 2 hours before the procedure, respectively. Dietary recommendations for split-dose regimen include low-residue or full liquids until the evening before the procedure. Oral and written instructions for all components of the colonoscopy preparation with emphasis on the importance of compliance should be provided to the patient, and support and process measures for achieving adequate preparation quality should be ensured by the physician.
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Perspective
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In the US, colonoscopy is considered the gold standard for colon cancer screening. Bowel cleansing is a critical component of a high-quality colonoscopy. An inadequate preparation obscures the view of the endoscopist and hinders his or her ability to detect and remove precancerous lesions, or adenomas. Unfortunately, gastroenterologists have all too commonly encountered this situation; consequences can include a combination of understandably upset patients, aborted exams and recommendations for sooner exams.
These guidelines present a collaboration between the major gastroenterology societies (American College of Gastroenterology, American Gastroenterological Association and the American Society for Gastrointestinal Endoscopy) in addressing this common and important issue. It provides comprehensive recommendations, rates the evidence in support of these recommendations, and a brief review of the existing medical literature.
In this era of limited resources, our goal is that every colonoscopy is a high-quality exam. In this way, physicians can focus limited time, space and efforts on screening more people, as opposed to repeating colonoscopies because of inadequate preparations.