Optimizing Adequacy of Bowel Cleansing for Colonoscopy: Recommendations From the US Multi- Society Task Force on Colorectal Cancer. David A. Johnson. Alan N. Barkun. 2, Larry B. Cohen. 3, Jason A.
Dominitz. 4, Tonya Kaltenbach. Myriam Martel. 2, Douglas J. Robertson. 6,7, C. Richard Boland. 8, Francis M. Giardiello. 9, David A.
This extremely helpful guide, called the “Fatty Liver Diet Guide” is an ebook that deals with every aspect and ramification of being diagnosed with fatty liver. Top of Page. Who should have virtual colonoscopy? Virtual colonoscopy is recommended for men and women over age 40 with a family history of colorectal cancer, and for. Preparing For a Colonoscopy The Essential Steps in Preparing for Your Colonoscopy. ACG Institute. The primary mission of the ACG Institute for Clinical Research & Education is to advance the field of clinical gastroenterology through education and.
Lieberman. 10, Theodore R. Levin. 11 and Douglas K.
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Rex. 12. 1Eastern VA Medical School, Norfolk, Virginia, USA; 2. Mc. Gill University Health Center, Mc. Gill University, Montreal, Canada; 3. Icahn School of Medicine at Mount Sinai, New York, New York, USA; 4. VA Puget Sound Health Care System and University of Washington, Seattle, Washington, USA; 5.
Veterans Affairs Palo Alto, Stanford University School of Medicine, Palo Alto, California; 6. VA Medical Center, USA; 7. Geisel School of Medicine at Dartmouth, White River Junction, Vermont, USA; 8. Baylor University Medical Center, Dallas, Texas, USA; 9. Johns Hopkins University School of Medicine, Baltimore, Maryland, USA; 1. Oregon Health and Science University, Portland, Oregon, USA; 1.
Kaiser Permanente Medical Center, Walnut Creek, California, USA; 1. Indiana University School of Medicine, Indianapolis, Indiana, USA.
Am J Gastroenterol 2. September 2. 01. 4Correspondence: David A. Johnson, Eastern VA Medical School, Norfolk, Virginia, USA.
E- mail: dajevms@aol. Abstract. Colorectal cancer (CRC) is the second leading cause of cancer- related deaths in the United States (1).
Colonoscopy can prevent CRC by the detection and removal of precancerous lesions. In addition to CRC screening and surveillance, colonoscopy is used widely for the diagnostic evaluation of symptoms and other positive CRC screening tests. Regardless of indication, the success of colonoscopy is linked closely to the adequacy of preprocedure bowel cleansing. Unfortunately, up to 2. The reasons for this range from patient- related variables such as compliance with preparation instructions and a variety of medical conditions that make bowel cleansing more difficult to unit- specific factors (eg, extended wait times after scheduling of colonoscopy). Adverse consequences of ineffective bowel preparation include lower adenoma detection rates, longer procedural time, lower cecal intubation rates, increased electrocautery risk, and shorter intervals between examinations.
Lack of specific organ toxicity is considered to be a prerequisite for bowel preparations. Between cleansing efficacy and tolerability, however, the consequences of inadequate cleansing suggest that efficacy should be a higher priority than tolerability. Consequently, the choice of a bowel cleansing regimen should be based on cleansing efficacy first and patient tolerability second.
However, efficacy and tolerability are closely interrelated. For example, a cleansing agent that is poorly tolerated and thus not fully ingested may not achieve an adequate cleansing. The goals of this consensus document are to provide expert, evidence- based recommendations for clinicians to optimize colonoscopy preparation quality and patient safety.
Recommendations are provided using the Grades of Recommendation Assessment, Development and Evaluation (GRADE) scoring system, which weighs the strength of the recommendation and the quality of the evidence (8). Methods. Search Strategy. Computerized medical literature searches were conducted from January 1. We used a highly sensitive search strategy to identify reports of randomized controlled trials (9) with a combination of medical subject headings adapted to each database and text words related to colonoscopy and gastrointestinal agents, bowel preparation, generic name, and brand name.
The complete search terms are available in Appendix A. Recursive searches and cross- referencing also were performed using a “similar articles” function; hand searches of articles were identified after an initial search. We included all fully published adult human studies in English or French. A systematic review of published articles and abstracts presented at national meetings was performed to collect and select the evidence. A meta- analysis and consensus agreement were used to analyze the evidence. Expert consensus was used to formulate the recommendations.
The GRADE system was used to rate the strength of the recommendations. The guideline was reviewed by committees of and approved by the governing boards of the member societies of the Multi- Society Task Force on Colorectal Cancer (American College of Gastroenterology, American Gastroenterological Association, and American Society of Gastrointestinal Endoscopy). Effect of Inadequate Preparation on Polyp/Adenoma Detection and Recommended Follow- Up Intervals. Recommendations. Preliminary assessment of preparation quality should be made in the rectosigmoid colon, and if the indication is screening or surveillance and the preparation clearly is inadequate to allow polyp detection greater than 5 mm, the procedure should be either terminated and rescheduled or an attempt should be made at additional bowel cleansing strategies that can be delivered without cancelling the procedure that day (Strong recommendation, low- quality evidence). If the colonoscopy is complete to cecum, and the preparation ultimately is deemed inadequate, then the examination should be repeated, generally with a more aggressive preparation regimen, within 1 year; intervals shorter than 1 year are indicated when advanced neoplasia is detected and there is inadequate preparation (Strong recommendation, low- quality evidence). If the preparation is deemed adequate and the colonoscopy is completed then the guideline recommendations for screening or surveillance should be followed (Strong recommendation, high- quality evidence). Inadequate colonic preparation is associated with reduced adenoma detection rates (ADRs).
A large prospective European study of 5. High- quality preparation was associated with identification of polyps of all sizes (odds ratio . An analysis of a national endoscopic database examined the association of preparation quality and polyp identification in 9. Colon preparation (as entered by the endoscopist at the time of the procedure) was dichotomized into adequate (excellent, good, and fair/adequate) and inadequate (fair, inadequate, and poor). In adjusted models, adequate preparation was predictive of detection of all polyps (OR, 1.
CI, 1. 1. 6–1. 2. OR, 1. 5; 9. 5% CI, 0. Similarly, a single- center study based at a US Veterans Affairs Medical Center examined preparation quality and ADRs in 8. When comparing those examinations with an inadequate/poor preparation (n=8. OR, 0. 6. 6; 9. 5% CI, 0. Two retrospective single- center studies examined the association of preparation quality and adenoma miss rates when the preparation was considered inadequate and the examination was repeated within a short interval (1.
Miss rates were the total adenomas found on the second examination divided by the total adenomas found on both examinations. In 1 study (1. 1) there were 1. Repeat colonoscopy within 3 years in 2. The other study identified 3. Repeat colonoscopy in 1. A single prospective Korean study evaluated 2. The patient adenoma miss rate increased as baseline preparation quality decreased on the Aronchick scale.
In the 1. 9 patients with poor preparation the adenoma and advanced adenoma miss rates were 4. P=. 0. 24). Surveys report that in the setting of a poor preparation, endoscopists’ recommendations for follow- up evaluation vary and err on shorter return intervals (1. In 1 study 6. 5 board- certified gastroenterologists and 1.
With a “nearly perfect” preparation, a 1. However, recommendations were quite variable for the lower- quality preparations, ranging from more than 5 years to an immediate repeat procedure. A survey of gastroenterologists (n=1. Several studies have examined actual recommendations for follow- up evaluation within the framework of clinical practice. One study abstracted charts from 1. North Carolina practices on 1. Preparation quality was not reported in 3.
Bowel preparations rated less than excellent were associated with more aggressive surveillance for those found with no polyps or small and/or medium adenomas. A prospective single- center study of 2.
P=. 0. 1) (1. 7). A prospective study estimated that for each 1% of bowel preparations deemed inadequate and requiring repeat colonoscopy at a shortened interval, the costs of delivering colonoscopy overall were increased by 1% (5).
These substantial adverse effects of inadequate preparation are the rationale for establishing a target for rates of adequate preparation (see later). Dosing and Timing of Colon Cleansing Regimens. Recommendations. Use of a split- dose bowel cleansing regimen is strongly recommended for elective colonoscopy (Strong recommendation, high- quality evidence). A same- day regimen is an acceptable alternative to split dosing, especially for patients undergoing an afternoon examination (Strong recommendation, high- quality evidence).
The second dose of split preparation ideally should begin 4–6 h before the time of colonoscopy with completion of the last dose at least 2 h before the procedure time (Strong recommendation, moderate- quality evidence). Split- dose regimens.
When preparation agents are administered entirely the day before colonoscopy, chyme from the small intestine enters the colon and accumulates, producing a film that coats the proximal colon and impairs detection of flat lesions. The length of time between the last dose of preparation and the initiation of colonoscopy correlates with the quality of the proximal colon cleansing (1.
In 1 study the chance of good or excellent preparation of the right colon decreased by up to 1. Splitting” implies that roughly half of the bowel cleansing dose is given on the day of the colonoscopy. Overwhelmingly consistent data show superior efficacy with a split dose compared with the traditional regimen of administering the preparation the day before the procedure (1. Split dosing leads to higher ADRs (2.