Guideline
Bowel preparation before colonoscopy

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General considerations

It is important that patients are educated and engaged in the colonoscopy preparartion process,13 and it has been shown that effective education significantly improves the quality of bowel preparation.14 Patient counseling along with written instructions that are simple and easy to follow and in their native language should be provided to patients,15 and patient education may improve with the use of visual aids.16 Recently, educational booklets were shown to improve bowel preparation and

Timing of preparation

Giving part (usually half) of the bowel preparation dose on the same day as the colonoscopy (termed split-dose) results in a higher-quality colonoscopy examination compared with ingestion of the entire preparation on the day or evening before colonoscopy.31, 32, 33, 34, 35, 36, 37, 38, 39 A higher-quality bowel preparation due to this split-dose has been demonstrated to increase the adenoma detection rate.40 In addition to a higher-quality bowel preparation, split-dosing also improves patient

Regimens for colonic cleansing before colonoscopy

The currently available preparations commonly used for colonoscopy preparation are summarized in Table 2. For the purposes of this document, the classification of preparations as high-volume denotes that the preparation requires at least 4 L of cathartic consumption. Preparations described as low-volume preparations require smaller volumes of cathartic consumption, but the reader should understand that the recommended additional fluid intake with so-called low-volume preparations may approach 4

Laxatives

Laxatives such as bisacodyl and/or magnesium citrate are administered in some regimens to reduce the volume of lavage solution required and hence volume-related symptoms, such as abdominal bloating and cramping. Bisacodyl is a diphenylmethane derivative that is poorly absorbed in the small intestine and is hydrolyzed by endogenous esterases. Its active metabolites stimulate colonic peristalsis.107 One study of bisacodyl as a preparation adjunct found that the laxative shortened the duration of

Documentation of preparation quality

It is important for preparation quality to be properly documented in colonoscopy reports. The U.S. Multi-Society Task Force on Colorectal Cancer defines an adequate examination as one that allows confidence that lesions other than small (≤5 mm) polyps were generally not obscured by residual colonic contents.123 In clinical practice, preparation quality should be graded after efforts to remove residual effluent and fecal debris have been completed. Validated scoring systems that have been

Inadequate bowel preparation

Inadequate bowel preparation for colonoscopy can result in missed lesions, canceled procedures, increased procedural time, increased costs, and a potential increase in adverse event rates.127, 128 In patients with fair bowel preparations, 28% to 42% had adenomas found when the examination was repeated within 3 years, including up to 27% with advanced adenomas.128, 129, 130 It has been estimated that intraprocedural cleansing accounts for 17% of total colonoscopy procedural time.131 One study

Recommendations

  • 1.

    We recommend that bowel preparations be individualized by the prescribing provider for each patient based on efficacy, cost, safety, and tolerability considerations balanced with the patient’s overall health, comorbid conditions, and preferences. ⊕⊕⊕⊕

  • 2.

    We recommend that verbal counseling regarding preparation administration be provided to patients along with written instructions that are simple and easy to follow and in their native language. ⊕⊕⊕○

  • 3.

    We suggest intensive education and more aggressive

Disclosure

The following authors disclosed financial relationships relevant to this article: Dr Khashab is a consultant for and on the Advisory Board of Boston Scientific, is a consultant for Olympus America, and has received research support from Cook Medical. Dr Chathadi is a consultant for Boston Scientific. Dr Fisher is a consultant for Epigenomics. Dr Cash is on the Speakers’ Bureau of Salix. Dr Hwang is on the Speakers’ Bureau of Novartis, has received a grant from Olympus, and is a consultant for

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    This document was developed by the ASGE Standards of Practice Committee. This document was reviewed and approved by the Governing Board of the ASGE.

    Drs Saltzman and Cash contributed equally to this article.

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