US Multi-Society Task Force on CRC revamps colonoscopy bowel prep to set new ‘benchmark’
Key takeaways:
- Endoscopy units and endoscopists are recommended to reach a bowel preparation adequacy rate of 90%.
- Adjunctive use of oral simethicone is suggested, but routine nonsimethicone adjuncts are not.
The U.S. Multi-Society Task Force on Colorectal Cancer has released updated guidance establishing a “reasonable benchmark” for the quality of bowel preparation prior to a colonoscopy exam.
The task force — comprised of ACG, AGA and ASGE — last updated its recommendations on the level of adequacy for bowel cleansing in 2014. The new guidance was simultaneously published in all three society journals: Gastrointestinal Endoscopy, Gastroenterology and The American Journal of Gastroenterology.
“Colorectal cancer remains the second most common cause of cancer death in the United State, and colonoscopy is considered the gold standard for evaluating the colon, including assessing causes of colon-related signs or symptoms and the detection of precancerous lesions,” Brian C. Jacobson, MD, MPH, FACG, AGAF, FASGE, director of program development for gastroenterology at Massachusetts General Hospital, and colleagues wrote in The American Journal of Gastroenterology. “It is well recognized that the adequacy of bowel preparation is essential for optimal colonoscopy performance.”
The authors added: “To date, there is no single accepted approach to this basic element of procedural preparation. For example, there are many options for colonic lavage with important variables including effectiveness, safety, palatability and cost. Similarly, there is no standard nomenclature for discussing bowel preparation, with terms such as ‘bowel preparation’ used at times to describe the process, the regimen or the quality of bowel preparation.”
To address considerable issues related to bowel preparation for colonoscopy among outpatients at low risk for inadequate bowel preparation, Jacobson and colleagues evaluated a series of clinically relevant questions, developed by experts with a clinical practice and research focus in colonoscopy and bowel preparation.
They then developed 21 population-intervention-comparator-outcomes questions, which were investigated through a comprehensive literature search of EMBASE, PubMed, Cochrane Reviews and the Cochrane Central Register of Controlled Clinical Trials from January 2013 through September 2023.
Jacobson and colleagues ultimately developed the original 21 PICO questions into a set of 25 recommendations intended to bolster bowel preparation prior to, during and following colonoscopy. Highlights include:
- The task force strongly recommends that patients undergoing colonoscopy receive both verbal and written patient education instructions for all components of the colonoscopy preparation.
- The task force strongly recommends limiting any dietary modifications to the day prior to colonoscopy for ambulatory patients at low risk for inadequate bowel preparation.
- When using a split-dose preparation for ambulatory patients at low risk for inadequate bowel preparation, the task force strongly recommends dietary modifications that include low-residue and low-fiber foods or full liquids for the early and midday meals on the day prior to colonoscopy.
- For ambulatory patients at low risk for inadequate bowel preparation, the task force strongly recommends against favoring one bowel preparation purgative as superior to others.
- The task force strongly recommends that bowel preparation selection include considerations for the patient’s medical history and medications, as well as the adequacy of bowel preparation reported from prior colonoscopies, when available.
- The task force strongly recommends against using hyperosmotic regimens in patients at risk for volume overload or electrolyte disturbances.
- The task force strongly recommends split-dose administration of bowel preparation purgatives for all patients, regardless of high-volume or low-volume preparation
- Although the taskforce strongly recommends a same-day regimen as an appropriate alternative to split dosing for patients undergoing an afternoon colonoscopy, they suggest that a same-day regimen for morning procedures is an inferior substitute.
- The task force suggests adjunctive use of oral simethicone for bowel preparation prior to colonoscopy, but suggests against routine use of nonsimethicone adjuncts.
- The task force strongly recommends that the term “adequate bowel preparation” only be used to indicate that standard screening or surveillance intervals can be assigned based on the colonoscopy findings.
- The task force strongly recommends routine tracking of the rate of adequate bowel preparations, at the levels of both individual endoscopists and endoscopy units.
- The task force strongly recommends that endoscopy unit-level and individual endoscopist-level bowel preparation achieve an adequacy rate of at least 90%.
“The ASGE/ACG recommends bowel preparation adequacy as a priority quality indicator for colonoscopy, with a performance target of 90% adequacy,” Jacobson and colleagues wrote. “While the definition of bowel preparation adequacy is not a standardized defined endpoint across the over 700 endoscopy practices participating [in the GI Quality Improvement Consortium], this value, coupled with the data from the Dutch Gastrointestinal Endoscopy Audit, suggests that an endoscopy unit-level and individual endoscopist-level bowel preparation adequacy rate of at least 90% is a reasonable benchmark.”
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