Review | Published:

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

The American Journal of Gastroenterology volume 109, pages 17141723 (2014) | Download Citation

Abstract

OBJECTIVES:

Current guidelines recommend early repeat colonoscopy when bowel preparation quality is inadequate, defined as inability to detect polyps >5 mm, but no data link specific bowel preparation categories or scores to this definition. Nevertheless, most physicians use a shortened screening/surveillance interval in patients with intermediate-quality preparation. We determined whether different levels of bowel preparation quality are associated with differences in adenoma detection rates (ADRs: proportion of colonoscopies with ≥1 adenoma) to help guide decisions regarding early repeat colonoscopy—with primary focus on intermediate-quality preparation.

METHODS:

MEDLINE and Embase were searched for studies with adenoma or polyp detection rate stratified by bowel preparation quality. Preparation quality definitions were standardized on the basis of Aronchick definitions (excellent/good/fair/poor/insufficient), and primary analyses of ADR trichotomized bowel preparation quality: high quality (excellent/good), intermediate quality (fair), and low quality (poor/insufficient). Dichotomized analyses of adequate (excellent/good/fair) vs. inadequate (poor/insufficient) were also performed.

RESULTS:

Eleven studies met the inclusion criteria. The primary analysis, ADR with intermediate- vs. high-quality preparation, showed an odds ratio (OR) of 0.94 (0.80–1.10) and absolute risk difference of –1% (−3%, 2%). ADRs were significantly higher with both intermediate-quality and high-quality preparation vs. low-quality preparation: OR=1.39 (1.08–1.79) and 1.41 (1.21–1.64), with absolute risk increases of 5% for both. ADR and advanced ADR were significantly higher with adequate vs. inadequate preparation: OR=1.30 (1.19–1.42) and 1.30 (1.02–1.67). Studies did not report other relevant outcomes such as total adenomas per colonoscopy.

CONCLUSIONS:

ADR is not significantly different with intermediate-quality vs. high-quality bowel preparation. Our results confirm the need for early repeat colonoscopy with low-quality bowel preparation, but suggest that patients with intermediate/fair preparation quality may be followed up at standard guideline-recommended surveillance intervals without significantly affecting quality as measured by ADR.

Access optionsAccess options

Rent or Buy article

Get time limited or full article access on ReadCube.

from$8.99

All prices are NET prices.

References

  1. 1.

    , , . Cancer statistics, 2012. CA Cancer J Clin 2012;62:10–29.

  2. 2.

    , , et al. American College of Gastroenterology guidelines for colorectal cancer screening 2009 [corrected]. Am J Gastroenterol 2009;104:739–750.

  3. 3.

    , , et al. Population-based surveillance by colonoscopy: effect on the incidence of colorectal cancer. Telemark Polyp Study I. Scand J Gastroenterol 1999;34:414–420.

  4. 4.

    , , et al. Randomized comparison of surveillance intervals after colonoscopic removal of newly diagnosed adenomatous polyps. The National Polyp Study Workgroup. N Engl J Med 1993;328:901–906.

  5. 5.

    , , et al. Efficacy in standard clinical practice of colonoscopic polypectomy in reducing colorectal cancer incidence. Gut 2001;48:812–815.

  6. 6.

    , , et al. Quality indicators for colonoscopy. Am J Gastroenterol 2006;101:873–885.

  7. 7.

    , , et al. Quality indicators for colonoscopy and the risk of interval cancer. N Engl J Med 2010;362:1795–1803.

  8. 8.

    , , . Impact of colonoscopy preparation quality on detection of suspected colonic neoplasia. Gastrointest Endosc 2003;58:76–79.

  9. 9.

    , , et al. Impact of colonic cleansing on quality and diagnostic yield of colonoscopy: the European Panel of Appropriateness of Gastrointestinal Endoscopy European multicenter study. Gastrointest Endosc 2005;61:378–384.

  10. 10.

    , , et al. Factors determining the quality of screening colonoscopy: a prospective study on adenoma detection rates, from 12,134 examinations (Berlin colonoscopy project 3, BECOP-3). Gut 2013;62:236–241.

  11. 11.

    , , et al. Standardized colonoscopy reporting and data system: report of the Quality Assurance Task Group of the National Colorectal Cancer Roundtable. Gastrointest Endosc 2007;65:757–766.

  12. 12.

    , , et al. Guidelines for colonoscopy surveillance after screening and polypectomy: a consensus update by the US Multi-Society Task Force on Colorectal Cancer. Gastroenterology 2012;143:844–857.

  13. 13.

    , , . The impact of colon cleanliness assessment on endoscopists’ recommendations for follow-up colonoscopy. Am J Gastroenterol 2007;102:2680–2685.

  14. 14.

    , , et al. The impact of fair colonoscopy preparation on colonoscopy use and adenoma miss rates in patients undergoing outpatient colonoscopy. Gastrointest Endosc 2013;78:510–516.

  15. 15.

    , . Comprehensive validation of the Boston Bowel Preparation Scale. Gastrointest Endosc 2010;72:686–692.

  16. 16.

    , , et al. Meta-analysis of observational studies in epidemiology: a proposal for reporting. Meta-analysis Of Observational Studies in Epidemiology (MOOSE) group. JAMA 2000;283:2008–2012.

  17. 17.

    , , et al. The Newcastle-Ottawa Scale (NOS) for assessing the quality of nonrandomised studies in meta-analysis [Website]. 2013 Available from: .

  18. 18.

    , , et al. QUADAS-2: a revised tool for the quality assessment of diagnostic accuracy studies. Ann Intern Med 2011;155:529–536.

  19. 19.

    , , et al. A novel tableted purgative for colonoscopic preparation: efficacy and safety comparisons with Colyte and Fleet Phospho-Soda. Gastrointest Endosc 2000;52:346–352.

  20. 20.

    , , et al. The Boston bowel preparation scale: a valid and reliable instrument for colonoscopy-oriented research. Gastrointest Endosc 2009;69:620–625.

  21. 21.

    , . Validation of a new scale for the assessment of bowel preparation quality. Gastrointest Endosc 2004;59:482–486.

  22. 22.

    , , et al. Polyp and adenoma detection rates in the proximal and distal colon. Am J Gastroenterol 2013;108:993–999.

  23. 23.

    , , et al. Application of a conversion factor to estimate the adenoma detection rate from the polyp detection rate. Gastrointest Endosc 2011;73:493–497.

  24. 24.

    , . Cochrane Handbook for Systematic Reviews of Interventions Version 5.1.0 [updated March 2011]. The Cochrane Collaboration, 2011. Available from: .

  25. 25.

    , . What's the relative risk? A method of correcting the odds ratio in cohort studies of common outcomes. JAMA 1998;280:1690–1691.

  26. 26.

    , , et al. Recommendations for examining and interpreting funnel plot asymmetry in meta-analyses of randomised controlled trials. BMJ 2011;343:d4002.

  27. 27.

    , , et al. Nurse observation during colonoscopy increases polyp detection: a randomized prospective study. Am J Gastroenterol 2013;108:166–172.

  28. 28.

    , , et al. Different bowel preparation schedule leads to different diagnostic yield of proximal and nonpolypoid colorectal neoplasm at screening colonoscopy in average-risk population. Dis Colon Rectum 2011;54:1570–1577.

  29. 29.

    , , et al. Quality evaluation of colonoscopy reporting and colonoscopy performance in daily clinical practice. Gastrointest Endosc 2012;75:98–106.

  30. 30.

    , , et al. Impact of colonic cleansing on quality and diagnostic yield of colonoscopy: the European Panel of Appropriateness of Gastrointestinal Endoscopy European multicenter study. Gastrointest Endosc 2005;61:378–384.

  31. 31.

    , , et al. Modifiable endoscopic factors that influence the adenoma detection rate in colorectal cancer screening colonoscopies. Gastrointest Endosc 2013;77:381–389. e1.

  32. 32.

    , , et al. Quality indicators for colonoscopy in the Peruvian Japanese Policlinic: linked factors]. Acta Gastroenterol Latinoam 2011;41:288–295.

  33. 33.

    , , et al. Technical performance of colonoscopy: the key role of sedation/analgesia and other quality indicators. Am J Gastroenterol 2008;103:1122–1130.

  34. 34.

    , , et al. Factors determining the quality of screening colonoscopy: a prospective study on adenoma detection rates, from 12,134 examinations (Berlin colonoscopy project 3, BECOP-3). Gut 2013;62:236–241.

  35. 35.

    , , . The effect of colonoscopy preparation quality on adenoma detection rates. Gastrointest Endosc 2012;75:545–553.

  36. 36.

    , , . Shorter preparation to procedure interval for colonoscopy improves quality of bowel cleansing. Intern Med J 2013;43:162–168.

  37. 37.

    , , et al. Pilot validation of the Boston bowel preparation scale in China. Dig Endosc 2013;25:167–173.

  38. 38.

    , , et al. Natural history of untreated colonic polyps. Gastroenterology 1987;93:1009–1013.

  39. 39.

    , , et al. Burden of gastrointestinal disease in the United States: 2012 update. Gastroenterology 2012;143:1179–1187. e1–3.

Download references

Author information

Affiliations

  1. Section of Digestive Diseases, Yale University School of Medicine, New Haven, Connecticut, USA

    • Brian T Clark
    • , Tarun Rustagi
    •  & Loren Laine
  2. VA Connecticut Healthcare System, West Haven, Connecticut, USA

    • Loren Laine

Authors

  1. Search for Brian T Clark in:

  2. Search for Tarun Rustagi in:

  3. Search for Loren Laine in:

Competing interests

Guarantor of the article: Loren Laine, MD.

Specific author contributions: B.T. Clark and T. Rustagi: study design, literature search, collection of data, analysis and interpretation of data, and drafting of the manuscript; L. Laine: study design, collection of data, analysis and interpretation of data, and drafting of the manuscript. All authors approved the final draft submitted.

Financial support: This study was supported by NIH T32 DK007017 (to B.T.C.)

Potential competing interests: None.

Corresponding author

Correspondence to Loren Laine.

Supplementary information

About this article

Publication history

Received

Accepted

Published

DOI

https://doi.org/10.1038/ajg.2014.232