Postgrad MedJ3 1995; 71: 476-479 C) The Fellowship of Postgraduate Medicine, 1995 Original article Postgrad Med J: first published as 10.1136/pgmj.71.838.476 on 1 August 1995. Downloaded from The quest for a more acceptable bowel preparation: comparison of a polyethylene glycol/electrolyte solution and a mannitol/Picolax mixture for colonoscopy
Brian P Saunders, Tadahiko Masaki, Manabu Fukumoto, Steven Halligan, Christopher B Williams
Summary enemas.' Though effective, purge and enema Eighty-nine consecutive patients attend- regimes are time-consuming for patient and ing for day-case colonoscopy were ran- endoscopy staffalike and have been replaced by domly allocated either polyethylene gly- more rapid oral methods of bowel preparation. col/balanced electrolyte (PEG) mixture Oral lavage with either polyethylene glycol/ (n = 45) or a mannitol/Picolax mixture balanced electrolyte solution (PEG) or mag- (n = 44). Both preparations were admin- nesium citrate has gained widespread accep- istered in two fractions. Patients record- tability in the UK.2-4 In several clinical trials ed their experience of the preparation on PEG has been shown to consistently produce a questionnaire and one of two experi- good bowel cleansing in a high percentage of enced endoscopists (unaware of the type patients.2'5-7 However, some individuals are of preparation given) assessed the result unable to tolerate PEG because of the large of bowel cleansing. Carbon dioxide volume of solution necessary for cleansing and insufflation was used for all examina- the inherent salty taste of the mixture.8'-0 In tions. contrast, magnesium citrate (Picolax) is well Good/excellent bowel cleansing occur- tolerated by patients but results in a higher red in significantly more patients given failure rate compared to PEG.9 PEG, 43 (96%), than those allocated It has been our experience over several years mannitol/Picolax, 34 (77%), p = 0.01. that a mixture ofmagnesium citrate with man- More patients receiving mannitol/Pico- nitol (mannitol/Picolax) produces a sweet, low- lax were able to complete the preparation volume (2 x 500 ml fractions) lemon-tasting in full than patients receiving PEG (38 vs solution that is both well tolerated and effective http://pmj.bmj.com/ 27, p = 0.01). More patients found the taste in cleansing the bowel. No study has previously of mannitol/Picolax pleasant compared investigated the possible benefits of mannitol/ to PEG (46% vs 20%). Both preparations Picolax mixture. We therefore decided to assess had a similar side-effect profile. Of those the efficacy, acceptability and safety of man- patients tested, 13% receiving mannitol/ nitol/Picolax by comparing it to PEG as a Picolax had a postural drop in blood bowel preparation for day-case colonoscopy.
pressure and blood parameters sugges- on September 25, 2021 by guest. Protected copyright. tive of mild dehydration. Materials and methods A fractionated administration of PEG as a bowel preparation for day-case col- Eighty-nine consecutive patients attending for onoscopy is well tolerated and superior as day-case colonoscopy were randomised to a cleansing agent to a mannitol/Picolax receive either 4 1 ofPEG/electrolyte oral lavage combination. Provided carbon dioxide is (polyethylene glycol 236 g, sodium sulphate used as the insufflating agent, mannitol/ Picolax is an acceptable alternative in fit, young patients intolerant of PEG.
Keywords: bowel cleansing, colonoscopy Common methods of bowel preparation Department of Endoscopy, St Mark's * purge + enema regimens (castor Hospital, City Road, Introduction oil/senna/bisacodyl + phosphate London EClV 2PS, UK enema(s) + 2-4 day dietary restriction) BP Saunders Adequate bowel preparation is a prerequisite * Picolax (Picolax 2 sachets ± dietary T Masaki for safe and accurate colonoscopy. To be suc- restriction) M Fukumoto cessful the preparation must be both acceptable * Picolax + senna (Picolax 11 - 2 S Halligan to the and effective in the sachets + senna ± dietary restriction) CB Williams patient cleansing * sodium phosphate (an osmotic cathartic given bowel. Traditional preparations involve diet- in two 90-ml administrations - under ary restriction for several days followed by a consideration for licence in the UK) Accepted 29 March 1995 purge (often with castor oil) and one or more Bowel preparations for colonoscopy 477
22.74 g, sodium chloride 5.86 g, potassium drank 3 1 of the solution at a rate of 250 ml/ chloride 2.97 g, aspartamine 0.2 g; Klean- 15 min, starting at 18.00 h the day before prep, Norgine Ltd, Oxford, UK) or one litre of colonoscopy followed by a further 1 1 at 06.00 h mannitol/Picolax mixture (mannitol 100 mg, the following morning. Patients with an after- Postgrad Med J: first published as 10.1136/pgmj.71.838.476 on 1 August 1995. Downloaded from sodium picosulphate 10 mg, magnesium oxide noon appointment for colonoscopy (n = 41) 3 g, citric acid 12 g). All patients were allowed a were asked to drink 2 1 the evening before and normal diet until the afternoon before the day 2 1 on the morning of the procedure. In the of colonoscopy and thereafter clear fluids only. mannitol/Picolax group, patients were ins- Patients receiving PEG were given the option tructed to drink 500 ml ofthe chilled solution at of chilling the solution which was then drunk 18.00 h the day before and a further 500 ml at according to the following protocol. Those 06.00 h on the morning of colonoscopy. They patients with a morning appointment (n = 4) were also asked to drink at least 1 1 of water in addition to their preparation. On arrival at the Endoscopy Unit all patients were given a questionnaire asking about their Table 1 Patients' experience of bowel preparation experience of the preparation, including taste, PEG Mannitol/Picolax ability to complete the preparation, side-effects (n = 45) (n = 44) probability encountered and whether or not they would be prepared to repeat the preparation if a future Ability to complete preparation colonoscopy were necessary (table 1). In the full 27 38 p = 0.01 first 42 patients, lying and standing blood >half 14 5 NS pressures were recorded and a venous blood
Dizziness http://pmj.bmj.com/ none 36 32 cording to a randomised block design (block mild 6 7 N size six) to aid concealment and ensure near severe 3 5 uniform allocation to the two treatment groups. Peri-anal soreness Data for cleansing of the colon, taste, ability to none 10 20 complete the preparation and patient side- mild 23 14 JNS effects were assessed using Fisher's exact test severe 12 10 Sleep disturbance after combining the data into 2 by 2 con- none 28 27 tingency tables. Because of multiple testing, on September 25, 2021 by guest. Protected copyright. mild 9 5 N significance demanded a calculated p-value of severe 8 2 less than 0.01. Abdominal cramps none 32 31 mild 9 8 JNS severe 4 5 Results Forty-five patients were randomised to receive PEG and 44 mannitol/Picolax. The two patient Table 2 Endoscopist's assessment of bowel preparation groups were similar with regard to age, sex, PEG Mannitol/Picolax indication for colonoscopy, findings at colono- (n= 45) (n = 44) scopy, history of constipation, laxative admin- istration, and drug history. Thirty-eight EXCELLENT: no more than small quan- 15 10 patients (86%) receiving mannitol/Picolax tities of clear fluid present were able to complete their preparation in full GOOD: small amounts of fluid residue, 28 24 = easily suctioned allowing a completely as opposed to 27 (60%,) given PEG (p 0.01). reliable examination More patients found the taste of mannitol/ FAIR: enough residue, fluid or solid to pre- 1 5 Picolax 'pleasant' compared to PEG (460o vs vent a completely reliable examination (ie, 20%o,p=O0.01). small polyps<5 mm could not be excluded) There were no significant differences bet- POOR: large amounts of residue present 1 5 ween the two preparations in the incidence of making endoscopic view uninterpretable; additional cleansing required nausea, vomiting, fullness, dizziness, ab- dominal cramps or peri-anal soreness. When 478 Saunders, Masaki, Fukumoto, Halligan, Williams
asked if they would be prepared to repeat the preparation 39 patients (860o) in the PEG Properties of the ideal bowel group said they would compared to 41 (930O) in preparation the mannitol/Picolax group (non-significant). Postgrad Med J: first published as 10.1136/pgmj.71.838.476 on 1 August 1995. Downloaded from * high patient acceptability Good or excellent bowel cleansing occurred * easy administration in significantly more patients receiving PEG * rapid onset ofaction (96%) than those allocated mannitol/Picolax * effective in all types ofpatient (77%), p = 0.01. Rescheduling of the proce- * cheap dure and additional cleansing was necessary in * easily packaged one patient in the PEG group but five receiving * safe mannitol/Picolax. Of the 42 patients who underwent assess- ment of blood pressure and blood parameters, 20 received PEG and 22 mannitol/Picolax. Learning/summary points There was a postural drop in blood pressure * PEG is superior to mannitol/Picolax mixture (systolic drop of 20 mmHg on standing), raised as bowel preparation for day-case colonoscopy packed cell volume and raised serum osmolar- * a fractionated administration ofPEG may ity in three patients receiving mannitol/Picolax improve patient tolerability preparation. One patient receiving PEG had a * mannitol/Picolax is an acceptable bowel preparation in fit, young patients, intolerant of postural drop in blood pressure but this was not PEG, provided carbon dioxide is available for accompanied by any biochemical or haemato- insufflation logical abnormalities. Discussion administration had been split into two doses An 'ideal' bowel preparation for colonoscopy and that 36% ofpatients did not complete their would be easy to administer, have a rapid onset preparation in full. PEG was also well tolerated of action, produce satisfactory cleansing in by the majority of our patients, possibly a approaching 100% of all patients, be cheap, reflection of the split-administration regime. easily packaged and above all be safe and Rosch et al have demonstrated that a frac- acceptable to the patient. Prior to this study it tionated administration of the PEG mixture is was our impression that mannitol/Picolax mix- preferred by in-patients asked to drink up to 6 1 ture might come close to this ideal. Certainly it of solution.'3 Using our 4 1 split-administration is cheap (approximate cost per patient = regime in out-patients, we have recorded only a &0.60p) and easily packaged. This study has 6% incidence of vomiting. This compares also shown mannitol/Picolax mixture to be favourably with studies in which the full 4 1 is acceptable to the patient. 910% recorded its drunk continuously (the currently recom- taste as pleasant or tolerable and 86% were able mended method of administration), where a to complete it in full; probably a consequence of 10-20% incidence of vomiting has been the relatively small volume and split-admin- recorded.8'9"4 Of the 20 patients who both istration. However, mannitol/Picolax is clearly received PEG and were tested for postural http://pmj.bmj.com/ inferior as a cleansing agent to two-dose PEG changes in blood pressure and changes in blood even though the 770o good/excellent cleansing parameters, only one patient showed an abnor- rate compares favourably with preparation by mality: a postural drop in blood pressure in a two sachets of Picolax alone.9 56-year-old man who was also taking anti- Recently mannitol has been disregarded as a hypertensive medication. This low incidence of bowel preparation because of reports that its biochemical or haemodynamic abnormality
use may be associated with a build-up of further emphasises the beneficial safety profile on September 25, 2021 by guest. Protected copyright. potentially explosive gases." However the risk of the PEG mixture.'5 of combustion is only present if oxygen is used In conclusion two-dose PEG oral lavage is as the insufflating agent.'2 We routinely use superior as a cleansing agent to a mannitol! carbon dioxide insufflation to reduce post- Picolax mixture. The high patient acceptability procedure bloating which therefore allows of PEG seen in this study is likely to be related mannitol to be used safely. Of more concern to the split administration regime and we would than a risk of combustion was the finding of recommend this method of administration clinical and biochemical dehydration in three when using PEG. For younger patients patients receiving mannitol/Picolax. All were intolerant of PEG, mannitol/Picolax is an over 60 years old and we would therfore advise acceptable alternative as bowel preparation for caution in prescribing mannitol/Picolax to colonoscopy, provided carbon dioxide is used elderly patients and those with known cardiac as the insufflating agent during the procedure. or renal problems. We were surprised to find that such a high The authors would like to acknowledge the help of percentage (960o) of patients receiving PEG Margaret Boland and Michelle Taylor for their help in had excellent or good cleansing as rated by the running this study and Sharon Love for statistical endoscopist. This was despite the fact that the advice.
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Medical Anniversary LUCIEN-MARIE PAUTRIER, 2 AUGUST 1876 Lucien-Marie Pautrier (1876-1959) was born in Marseilles, France. He studied there and in Paris where he became a dermatologist with Louis Brocq at Saint Louis Hospital. His doctorate was an imposing 350-page document on atypical cutaneous tuberculosis (surely sarcoidosis). During the First World War he was in an artillery regiment and was awarded the Cross of Chevalier de la Legion d'Honneur. He became professor of dermatology at Strasbourg and at Lausanne. In his 1939 textbook on sarcoidosis, he opposed the tuberculous theory and regarded it as a reticulo-endotheliosis. He died in Strasbourg on 9 July 1959 and is buried in his birthplace. http://pmj.bmj.com/ on September 25, 2021 by guest. Protected copyright.