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A Consensus Document on Bowel Preparation Before Colonoscopy

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A Consensus Document on Bowel Preparation Before Colonoscopy Consensus Statement A Consensus Document on Bowel Preparation Before Colonoscopy: Prepared by a Task Force From The American Society of Colon and Rectal Surgeons (ASCRS), The American Society for Gastrointestinal Endoscopy (ASGE), and The Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) Steven D. Wexner, M.D., Task Force Chair,1 David E. Beck, M.D.2 (ASCRS), Todd H. Baron, M.D.3 (ASGE), Robert D. Fanelli, M.D.4 (SAGES), Neil Hyman, M.D.5 (ASCRS), Bo Shen, M.D.6 (ASGE), Kevin E. Wasco, M.D.7 (SAGES) 1 Department of Colorectal Surgery, Cleveland Clinic Florida, Weston, Florida 2 Department of Colon and Rectal Surgery, Ochsner Clinic Foundation, New Orleans, Louisiana 3 Division of Gastroenterology and Hepatology, Mayo Clinic College of Medicine, Rochester, Minnesota 4 Surgical Specialists of Western New England, PC/Department of Surgery, Berkshire Medical Center, Pittsfield, Massachusetts 5 Department of Surgery, University of Vermont College of Medicine, Burlington, Vermont 6 Department of Gastroenterology/Hepatology, Cleveland Clinic Foundation, Cleveland, Ohio 7 Surgical Associates of Neenah, S.C., Neenah, Wisconsin This document appears simultaneously in the June 2006 issues of Diseases of the Colon & Rectum, Surgical Endoscopy, and Gastro- intestinal Endoscopy. This document was reviewed and approved by the SAGES Board of Governors, the ASCRS Standards Committee and Executive Council, and the ASGE Governing Board. Addendum provides manufacturers’ information for all products discussed in this document. Correspondence to: Steven D. Wexner, M.D., Department of Colorectal Surgery, Cleveland Clinic Florida, 2950 Cleveland Clinic Blvd., Weston, Florida 33331, e-mail: [email protected] Dis Colon Rectum 2006; 49: 792–809 DOI: 10.1007/s10350-006-0536-z * The American Society of Colon and Rectal Surgeons Published online: 02 May 2006 792 Vol. 49, No. 6 BOWEL PREPARATION FOR COLONOSCOPY 793 olonoscopy is the current standard method for (ASGE) technology committee report,40 this docu- C evaluation of the colon. Diagnostic accuracy ment reviews the available evidence to create guide- and therapeutic safety of colonoscopy depends on lines for bowel preparation before colonoscopy. The the quality of the colonic cleansing or preparation. various studies in the literature have been graded The ideal preparation for colonoscopy would reli- according to the Levels of Evidence Grade Recom- ably empty the colon of all fecal material in a rapid mendation scale proposed by Cook et al.41 (Table 2). fashion with no gross or histologic alteration of the colonic mucosa. The preparation also would not cause any patient discomfort or shifts in fluids or electrolytes and would be inexpensive.1 Unfortu- REGIMENS FOR COLONIC CLEANSING nately, none of the preparations currently available BEFORE COLONOSCOPY 1,2 meet all of these requirements. Diet A brief history of the evolution of bowel prepara- tion for colonoscopy will be discussed followed by Dosing. Dietary regimens characteristically incor- an evidence-based analysis of the various colon- porate clear liquids and low-residue foods during oscopy preparations, dosing regimens, and adjuncts one to four days. Regimens typically incorporate di- currently used. etary changes and oral cathartic and/or additional cathartic enemas.42 A cathartic, such as magnesium citrate or senna extract, often is used on the day EVOLUTION OF BOWEL PREPARATIONS before the procedure. Tap water enemas are admin- istered on the morning of and occasionally on the Colonoscopy preparations evolved from radiologic evening before the procedure. and surgical preparations.3 Early preparations used Evidence. Much of the evidence supporting these dietary limitations, cathartics, and enemas. Although regimens comes from studies of colon cleansing these preparations cleansed the colon, they were for radiography. Although the individual com- time consuming (48–72 hours), uncomfortable for ponents of these preparations vary widely, the com- the patient, and associated with fluid and electrolyte bination of dietary restrictions and cathartics has disturbances.4 A rapid preparation used high-volume proven to be safe and effective for colonic cleansing (7–12 liters) per oral gut lavage with saline/electro- for colonoscopy.6 In a recent study of inpatients lyte solution. This also was associated with severe undergoing colonoscopy, a clear liquid diet before fluid and electrolyte shifts and poor patient toler- administration of the bowel preparation was the ance. In 1980, Davis et al.5 formulated polyethylene only diet modification that improved the quality of glycol (PEG), an osmotically balanced electrolyte preparation.43 Although prolonged dietary restric- lavage solution. The standard 4-liter dosing regimen tions and cathartics are effective, these regimens are given the day before the procedure was established less than ideal because of the time commitment as safe and effective.6–8 PEG quickly became the required. Bgold standard^ for colonoscopy. However, poor Recommendations. Dietary modifications, such as compliance related to the salty taste, the smell from a clear liquid diet, alone are inadequate for colon- the sulfates, and the large volume of fluids required oscopy. However, they have proven to be a benefi- led to modifications of the PEG solutions and their cial adjunct to other mechanical cleansing methods dosing recommendations and reevaluations of (Grade IIB). other osmotic laxatives (e.g., sodium phosphate 9–16 17 [NaP]). Chang et al. developed a method of Enemas pulsed rectal irrigation combined with magnesium citrate. These regimens and their use continue to Dosing. Tap water or NaP enemas are admin- evolve.18–39 More recent studies have focused on istered on the evening before or the morning of identifying the Bideal^ preparation (Table 1), includ- the procedure. For colonic cleansing, they are ing parameters such as taste, electrolyte supplemen- usually administered in conjunction with dietary tation, and the timing and division of doses. restrictions or cathartics. In patients with poor or With this historic background and the precedent of incomplete cleansing, one or two NaP enemas are an American Society for Gastrointestinal Endoscopy useful in washing out the distal colon. Enemas are 794 WEXNER ET AL Dis Colon Rectum, June 2006 Table 1. Randomized, Controlled Trials Study (yr) No. of (reference) Patients Study Groups Main Outcome Cohen et al. 422 4l PEG vs. 4l PEG (sulfate-free) NaP better prep, better tolerated (1994)13 vs. 90 ml NaP Church (1998)24 317 4l PEG (night before) PEG day of procedure with vs. 4l PEG (day of procedure) better prep El-Sayed et al. 187 3l PEG + liquid diet vs. 3l PEG (split dose) Split-dose PEG with better prep, (2003)25 + bisacodyl + minimal diet restriction better tolerated Adams et al. 382 4l PEG vs. 2l PEG + bisacodyl PEG + bisacodyl better tolerated, (1994)26 prep equal Henderson et al. 242 4l PEG vs. 90 ml NaP Prep similar, NaP better tolerated (1995)27 Young et al. 323 2l PEG + bisacodyl vs. 90 ml NaP NaP better prep, better tolerated (2000)28 Poon et al. 200 2l PEG vs. 90 ml NaP Prep + tolerance similar (2003)19 Barclay (2004)29 256 135 ml NaP vs. 90 ml NaP 135 ml NaP better prep, poorer tolerance Law et al. 299 2–4l PEG vs. 45 ml NaP vs. 90 ml NaP 90 ml NaP best prep, (2004)30 better tolerated Schmidt et al. 400 Na picosulfate vs. NaP Prep equal, Na picosulfate (2004)31 better tolerated Golub et al. 329 4l PEG vs. 4l PEG + metoclopramide Preps equal, NaP better tolerated (1995)32 vs. 90 ml NaP Balaban et al. 101 90 ml NaP (liquid) vs. Liquid NaP better prep, (2003)33 40 tabs NaP (tablet) better tolerated Aronchick et al. 305 4l PEG vs. 90 ml NaP Preps equal, NaP tabs (2000)34 vs. 24–32 tabs NaP better tolerated Kastenberg et al. 845 4l PEG vs. 40 tabs NaP Prep equal, NaP tabs (2001)21 better tolerated Afridi et al. 147 4l PEG vs. 90 ml NaP + bisacodyl Prep equal, NaP + bisacodyl (1995)20 better tolerated Frommer (1997)14 486 3l PEG vs. 90 ml NaP (day before) NaP day of procedure best prep, vs. 90 ml NaP (day before, day of NaP better tolerated than PEG procedure) Ell et al. (2003)35 185 4l PEG (standard) vs. 4l PEG Standard PEG best prep, (sulfate-free) vs. 90 ml NaP tolerance similar Martinek et al. 187 4l PEGvs. 90 ml NaP PEG better prep, NaP (2001)36 (with/without cisapride) better tolerated Vanner et al. 102 4l PEG vs. 90 ml NaP NaP better prep, better tolerated (1990)37 Marschall and 143 4l PEG vs. 90 ml NaP Prep equal, NaP better tolerated Bartels (1993)38 Kolts et al. 113 4l PEG vs. 90 ml NaP vs. 60 ml Castor Oil NaP best prep, better tolerated (1993)39 than PEG PEG = polyethylene glycol; NaP = sodium phosphate; tabs = tablets; prep = preparation. useful in washing out the distal segment of bowel High-Volume Gut Lavage in patients with a proximal stoma or a defunction- alized distal colon (e.g., Hartmann’s). Various com- Dosing. Per oral gut lavage with high volumes mercial enema preparations are discussed in the (7–12 liters) of saline solution or balanced electrolyte adjunct section. solutions with or without a nasogastric tube have Evidence. The evidence is mostly anecdotal with been used for colonic preparation.2 Mannitol was no prospective trials (Grade IIIB). used in early formulations but abandoned secondary Recommendations. Use enemas in patients who to bacterial fermentation into hydrogen and methane present to endoscopy with a poor distal colon prepara- gas, which can cause explosion when electrocautery tion and in patients with a defunctionalized
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