How to choose the best preparation for colonoscopy

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Abstract

The success and accuracy of colonoscopy is largely dependent on appropriate cleansing of the colon. The ideal bowel preparation should be safe, well-tolerated and effective. Although colonoscopy preparations are vastly better than the earliest barium enemas used in X-ray regimens, none of the currently available formulations sufficiently fulfills the above criteria. Currently used techniques of colon cleansing include dietary and cathartic methods, gut lavage and the administration of phosphates. All of these methods are efficacious, particularly when administered in a split dose (one the evening before and one just before the planned colonoscopy). Gut lavage methods are the safest method; however, dietary and cathartic methods are also reasonably safe. Low-dose phosphate preparations are well tolerated, but safety concerns have led to the withdrawal of some phosphate products from the US market. A new oral sulfate product that achieves a desirable balance of safety, tolerability in patients and efficacy will shortly be introduced. Physicians should be aware of the range of colonoscopy preparations available and their limitations, so that the best preparation can be chosen for an individual patient.

Key Points

  • The importance of adequate colon preparation should be stressed to all patients before their colonic procedure to achieve optimal compliance

  • Adequate colon preparation affords many benefits, such as improved surveillance and decreased study time, rates of complications and risk to the patient, should complications occur

  • Dietary and cathartic methods have relatively few adverse effects, but are less efficacious for colon preparation than other methods

  • Gut lavage, in its various forms, provides effective colon cleansing, but patients have reported volume-related intolerance

  • Phosphates provide effective cleansing with good tolerability, but may have serious adverse outcomes, such as acute kidney injury and metabolic disturbances

  • The ideal colonoscopy preparation, which combines efficacy with excellent tolerability in patients and minimal adverse effects, remains to be developed

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References

  1. 1

    DiPalma, J. A. Preparation for colonoscopy. In Colonoscopy (eds Waye, J. D. et al.) 210–219 (Blackwell Sciences, London, 2003).

  2. 2

    Toledo, T. K. & DiPalma, J. A. Review article: colon cleansing preparation for gastrointestinal procedures. Aliment. Pharmacol. Ther. 15, 605–611 (2001).

  3. 3

    ASGE Technology Status Evaluation Report. Colonoscopy preparations. Gastrointest. Endosc. 54, 829–832 (2001).

  4. 4

    Neidich, R. L. & Zuckerman, G. R. Patient preparation. In Colonoscopy: Principles and Techniques (eds Raskin, J. B. & Nord, H. J.) 53–82 (Igaku-Shoin, New York, 1995).

  5. 5

    Burke, C. & Church, J. Enhancing the quality of colonoscopy: the importance of bowel purgatives. Gastrointest. Endosc. 66, 565–573 (2007).

  6. 6

    Rex, D. K., Imperiale, T. F., Latinovich, D. R. & Bratcher, L. L. Impact of bowel preparation on efficiency and cost of colonoscopy. Am. J. Gastroenterol. 97, 1696–1700 (2002).

  7. 7

    Kavin, H., Sinicrope, F. & Esker, A. Management of perforation of the colon at colonoscopy. Am. J. Gastroenterol. 87, 161–167 (1992).

  8. 8

    Strocchi, A., Bond, J. H., Ellis, C. & Levitt, M. D. Colonic concentrations of hydrogen and methane following colonoscopic preparation with an oral lavage solution. Gastrointest. Endosc. 36, 580–582 (1990).

  9. 9

    DiPalma, J. A. et al. Comparison of colon cleansing methods in preparation for colonoscopy. Gastroenterology 86, 856–860 (1984).

  10. 10

    Monahan, D., Peluso, F. & Goldner, F. Combustible colonic gas levels during flexible sigmoidoscopy and colonoscopy. Gastrointest. Endosc. 38, 40–43 (1992).

  11. 11

    Meisel, J. L., Bergman, D., Graney, D., Saunders, D. R. & Rubin, C. E. Human rectal mucosa: proctoscopic and morphological changes caused by laxatives. Gastroenterology 72, 1274–1279 (1977).

  12. 12

    Lopez Morra, H. A., Fine, S. N. & Dickstein, G. Colon ischemia with laxative use in young adults. Am. J. Gastroenterol. 100, 2134–2135 (2005).

  13. 13

    Radaelli, F. et al. High-dose senna compared with conventional PEG-ES lavage as bowel preparation for elective colonoscopy: a prospective, randomized, investigator-blinded trial. Am. J. Gastroenterol. 100, 2674–2680 (2005).

  14. 14

    Dahshan, A., Lin, C. H., Peters, J., Thomas, R. & Tolia, V. A randomized, prospective study to evaluate the efficacy and acceptance of three bowel preparations for colonoscopy in children. Am. J. Gastroenterol. 94, 3497–3501 (1999).

  15. 15

    Crapp, A. R., Tillotson, P., Powis, S. J., Cooke, W. T. & Alexander-Williams, J. Preparation of the bowel by whole-gut irrigation. Lancet 2, 1239–1240 (1975).

  16. 16

    Levy, A. G. et al. Saline lavage: a rapid, effective, and acceptable method for cleansing the gastrointestinal tract. Gastroenterology 70, 157–161 (1976).

  17. 17

    Skucas, J., Cutcliff, W. & Fischer, H. W. Whole-gut irrigation as a means of cleaning the colon. Radiology 121, 303–305 (1976).

  18. 18

    Rhodes, J. B., Zvargulis, J. E., Williams, C. H., Gonzales, G. & Moffat, R. E. Oral electrolyte overload to cleanse the colon for colonoscopy. Gastrointest. Endosc. 24, 24–26 (1977).

  19. 19

    Gilmore, I. T., Ellis, W. R., Barrett, G. S., Pendower, J. E. & Parkins, R. A. A comparison of two methods of whole gut lavage for colonoscopy. Br. J. Surg. 68, 388–389 (1981).

  20. 20

    Burbige, E. J., Bourke, E & Tarder, G. Effect of preparation for colonoscopy on fluid and electrolyte balance. Gastrointest. Endosc. 24, 286–287 (1978).

  21. 21

    DiPalma, J. A. & Brady, C. E. Colon cleansing for diagnostic and surgical procedures: polyethylene glycol-electrolyte lavage solution. Am. J. Gastroenterol. 84, 1008–1016 (1989).

  22. 22

    Schiller, L. R., Emmett, M., Santa Ana, C. A. & Fordtran, J. S. Osmotic effects of polyethylene glycol. Gastroenterology 94, 933–941 (1988).

  23. 23

    Davis, G. R., Santa Ana, C. A., Morawski, S. G. & Fordtran, J. S. Development of a lavage solution associated with minimal water and electrolyte absorption or secretion. Gastroenterology 78, 991–995 (1980).

  24. 24

    Goldman, J. & Reichelderfer, M. Evaluation of rapid colonoscopy preparation using a new gut lavage solution. Gastrointest. Endosc. 28, 9–11 (1982).

  25. 25

    Thomas, G., Brozinsky, S. & Isenberg, J. I. Patient acceptance and effectiveness of a balanced lavage solution (GoLytely) versus the standard preparation for colonoscopy. Gastroenterology 82, 435–437 (1982).

  26. 26

    Meadows, J. O. & Conyers, C. T. GoLytely: preparation of choice for colonoscopy [Abstract]. Gastrointest. Endosc. 29, 256 (1983).

  27. 27

    DiPalma, J. A. et al. Comparison of GoLytely versus standard colon cleansing methods for diagnostic radiology and colon surgery [Abstract]. Gastroenterology 86, 1063 (1984).

  28. 28

    Beck, D. E., Harford, F. J. & DiPalma, J. A. Comparison of cleansing methods in preparation for colonic surgery. Dis. Colon Rectum 28, 491–495 (1985).

  29. 29

    Solla, J. A. & Rothenberger, D. A. Preoperative bowel preparation: a survey of colon and rectal surgeons. Dis. Colon Rectum 33, 154–159 (1990).

  30. 30

    Berry, M. A. & DiPalma, J. A. Review article: orthograde gut lavage for colonoscopy. Aliment. Pharmacol. Ther. 8, 391–395 (1994).

  31. 31

    Berry, M. A. & DiPalma, J. A. Gastrointestinal lavage for colon cleansing. In Surgical Technology International VI (eds Szabo et al.) 97–100 (Universal Medical Press, San Francisco, 1997).

  32. 32

    Fordtran, J. S., Santa Ana, C. A. & Cleveland, M. A low-sodium solution for gastrointestinal lavage. Gastroenterology 98, 11–16 (1990).

  33. 33

    Tomlinson, T. L., DiPalma, J. A. & Mangano, F. A. Comparison of a new colon lavage solution (GoLytely-RSS) with a standard preparation for air-contrast barium enema. AJR Am. J. Roentgenol. 151, 947–950 (1988).

  34. 34

    DiPalma, J. A. & Marshall, J. B. Comparison of a new sulfate-free polyethylene glycol electrolyte lavage solution versus a standard solution for colonoscopy cleansing. Gastrointest. Endosc. 36, 285–289 (1990).

  35. 35

    Froehlich, F., Fried, M., Schnegg, J. F. & Gonvers, J. J. Palatability of a new solution compared with standard polyethylene glycol solution for gastrointestinal lavage. Gastrointest. Endosc. 37, 325–328 (1991).

  36. 36

    Beck, D. E. & DiPalma, J. A. A new oral lavage solution vs. cathartics and enema method for preoperative colonic cleansing. Arch. Surg. 126, 552–555 (1991).

  37. 37

    Froehlich, F., Fried, M., Schnegg, J. F. & Gonvers, J. J. Low sodium solution for colonic cleansing: a double-blind, controlled, randomized prospective study. Gastrointest. Endosc. 38, 579–581 (1992).

  38. 38

    Raymond, J. M. et al. Tolerance, effectiveness, and acceptability of sulfate-free electrolyte lavage solution for colon cleaning before colonoscopy. Endoscopy 28, 555–558 (1996).

  39. 39

    Matter, S. E., Rice, P. S. & Campbell, D. R. Colonic lavage solutions: plain versus flavored. Am. J. Gastroenterol. 88, 49–52 (1993).

  40. 40

    Sharma, V. K. et al. Prospective, randomized, controlled comparison of the use of polyethylene glycol electrolyte lavage solution in four-liter versus two-liter volumes and pretreatment with either magnesium citrate or bisacodyl for colonoscopy preparation. Gastrointest. Endosc. 47, 167–171 (1998).

  41. 41

    Sharma, V. K., Steinberg, E. N., Vasudeva, R. & Howden, C. W. Randomized, controlled study of pretreatment with magnesium citrate on the quality of colonoscopy preparation with polyethylene glycol electrolyte lavage solution. Gastrointest. Endosc. 46, 541–543 (1997).

  42. 42

    Adams, W. J., Meagher, A. P., Lubowski, D. Z. & King, D. W. Bisacodyl reduces the volume of polyethylene glycol solution required for bowel preparation. Dis. Colon Rectum 37, 229–233 (1994).

  43. 43

    DiPalma, J. A., Wolff, B. G., Meagher, A. & Cleveland, M. Comparison of reduced volume versus four liters sulfate-free electrolyte lavage solutions for colonoscopy colon cleansing. Am. J. Gastroenterol. 98, 2187–2191 (2003).

  44. 44

    DiPalma, J. A., McGowan, J. & Cleveland, M. Clinical trial: an efficacy evaluation of reduced bisacodyl given as part of a polyethylene glycol electrolyte solution preparation prior to colonoscopy. Aliment. Pharmacol. Ther. 26, 1113–1119 (2007).

  45. 45

    Ell, C. & Gruss, H. Randomized and controlled clinical trial of polyethylene glycol with electrolytes and ascorbic acid in comparison to sodium phosphate for bowel preparation before colonoscopy [abstract]. Gastrointest. Endosc. 65, AB328 (2007).

  46. 46

    Di Palma, J. A., Cleveland, M., McGowan, J. & Herrera, J. L. A randomized, multicenter, placebo-controlled trial of polyethylene glycol laxative for chronic treatment of chronic constipation. Am. J. Gastroenterol. 102, 1436–1441 (2007).

  47. 47

    Siegel, J. D. & DiPalma, J. A. Potential combustible gas production from agents used for colon cleansing [abstract]. Am. J. Gastroenterol. 99, S289 (2004).

  48. 48

    Pockros, P. J. & Foroozan, P. GoLytely lavage versus a standard colonoscopy preparation. Effect on normal colon mucosal histology. Gastroenterology 88, 545–548 (1985).

  49. 49

    Rosch, T. & Classen, M. Fractional cleansing of the large bowel with “GoLytely” for colonoscopy preparation: a controlled trial. Endoscopy 19, 198–200 (1987).

  50. 50

    Aoun, E. et al. A randomized single-blind trial of split dose PEG-electrolyte solution without dietary restriction compared with whole dose PEG-electrolyte solution with dietary restriction for colonoscopy preparation. Gastrointest. Endosc. 62, 213–218 (2005).

  51. 51

    Rostom, A. et al. A randomized prospective trial comparing different regimens of oral sodium phosphate and polyethylene glycol-based lavage solution in the preparation of patients for colonoscopy. Gastrointest. Endosc. 64, 544–552 (2006).

  52. 52

    Parra-Blanco, A. et al. The timing of bowel preparation before colonoscopy determines the quality of cleansing, and is a significant factor contributing to the detection of flat lesions: a randomized study. World J. Gastroenterol. 12, 6161–6166 (2006).

  53. 53

    Martinek, J. et al. Cisapride does not improve precolonoscopy bowel preparation with either sodium phosphate or polyethylene glycol electrolyte lavage. Gastrointest. Endosc. 54, 180–185 (2001).

  54. 54

    Vanner, S. J. et al. A randomized prospective trial comparing oral sodium phosphate with standard polyethylene glycol-based lavage solution (GoLytely) in the preparation of patients for colonoscopy. Am. J. Gastroenterol. 85, 422–427 (1990).

  55. 55

    Frommer, D. Cleansing ability and tolerance of three bowel preparations for colonoscopy. Dis. Colon Rectum 40, 100–104 (1997).

  56. 56

    Gremse, D. A., Sacks, A. I. & Raines, S. Comparison of oral sodium phosphate to polyethylene glycol-based solution for bowel preparation for colonoscopy in children. J. Pediatr. Gastroenterol. Nutr. 23, 586–590 (1996).

  57. 57

    Rex, D. K., Chasen, R. & Pochapin, M. B. Safety and efficacy of two reduced dosing regimens of sodium phosphate tablets for preparation prior to colonoscopy. Aliment. Pharmacol. Ther. 16, 937–944 (2002).

  58. 58

    DiPalma, J. A., Buckley, S. E., Warner, B. A. & Culpepper, R. M. Biochemical effects of oral sodium phosphate. Dig. Dis. Sci. 41, 749–753 (1996).

  59. 59

    Schwetz, B. A. Oral sodium phosphate. JAMA 286, 2660 (2001).

  60. 60

    Markowitz, G. S., Stokes, M. B., Radhakrishnan, J. & D'Agati, V. D. Acute phosphate nephropathy following oral sodium, phosphate bowel purgative: an under-recognized cause of chronic renal failure. J. Am. Soc. Nephrol. 16, 3389–3396 (2005).

  61. 61

    Pelham, R., Dobre, A., Van Diest, K. & Cleveland, M. Oral sodium phosphate bowel preparations: how much hydration is enough? [abstract] Gastrointest. Endosc. 65, AB314 (2007).

  62. 62

    Mackey, A. C., Shaffer, D. & Prizant, R. Seizure associated with the use of Visicol for colonoscopy. N. Engl. J. Med. 346, 2095 (2002).

  63. 63

    Berkelhammer, C., Ekambaram, A. & Silva, R. G. Low-volume oral colonoscopy bowel preparation: sodium phosphate and magnesium citrate. Gastrointest. Endosc. 56, 89–94 (2002).

  64. 64

    FDA alert (2009).

  65. 65

    Patel, V. et al. Intestinal and renal effects of low-volume phosphate and suflate cathartic solutions designed for cleansing the colon: pathophysiological studies in 5 normal subjects. Am. J. Gastroenterol. doi:10.1038/ajg.2008.124 (2009).

  66. 66

    Abdul-Baki, H. et al. A randomized, controlled, double-blind trial of the adjunct use of tegaserod in whole-dose or split-dose polyethylene glycol electrolyte solution for colonoscopy preparation. Gastrointest. Endosc. 68, 294–300 (2008).

  67. 67

    Hooks, S. B., Rutland, T. J. & DiPalma, J. A. Does lubiprostone decrease gastric and small bowel transit time and improve visualization of small bowel with capsule endoscopy [Abstract]? Am. J. Gastroenterol. 103, S503 (2008).

  68. 68

    Stengel, J. Z & Jones, D. P. Single-dose lubiprostone along with split-dose PEG solution without dietary restrictions for bowel cleansing prior to colonoscopy: a randomized, double-blind, placebo-controlled trial. Am. J. Gastroenterol. 103, 2224–2230 (2008).

  69. 69

    Taylor, E., Waye, J. & Palmon, R. Magnesium citrate (Magc) preparation for colonoscopy: onset and duration of bowel activity [Abstract]. Am. J. Gastroenterol. 103, S486 (2008).

  70. 70

    Sabri, M. et al. Colon cleansing with oral sodium phosphate in adolescents: dose, efficacy, acceptability, and safety. Am. J. Gastroenterol. 103, 1533–1539 (2008).

  71. 71

    Schuman, B. M. When should colonoscopy be the first study for active lower intestinal hemorrhage? Gastrointest. Endosc. 30, 372–373 (1984).

  72. 72

    Caos, A. et al. Colonoscopy after GoLytely preparation in acute rectal bleeding. J. Clin. Gastroenterol. 8, 46–49 (1986).

  73. 73

    Jensen, D. M & Machicado, G. A. Diagnosis and treatment of severe hematochezia. The role of urgent colonoscopy after purge. Gastroenterology 95, 1569–1574 (1988).

  74. 74

    Abuksis, M. et al. A patient education program is cost-effective for preventing failure of endoscopic procedures in a gastroenterology department. Am. J. Gastroenterol. 96, 1786–1790 (2001).

  75. 75

    Epocrates (2009).

  76. 76

    International drugstore (2009).

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Correspondence to Jack A. Di Palma.

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Competing interests

J. A. Di Palma is a medical director, consultant, has spoken for, and has received grant/research support from Braintree Laboratories, Inc., and is a consultant and is on the speakers bureau for Takeda Pharmaceutical Company Limited. K. E. Occhipinti declared no competing interests.

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