Inadequate bowel preparation can result in failed detection of prevalent neoplastic lesions and has been linked to an increased risk of procedural adverse events

The diagnostic accuracy and therapeutic safety of colonoscopy depends, in part, on the quality of the colonic cleansing or preparation.

Colonoscopy is the current standard method for imaging the mucosa of the entire colon. Large-scale reviews have shown rates of incomplete colonoscopy, defined as the inability to achieve cecal intubation and mucosal visualization effectively, between 10% and 20%.

Inadequate bowel preparation can result in failed detection of prevalent neoplastic lesions and has been linked to an increased risk of procedural adverse events. Numerous investigations designed to identify predictors of inadequate colonoscopy bowel preparation have found that inadequate preparation is more common in patients with the following characteristics: previous inadequate bowel preparation, non-English speaking, Medicaid insurance, single and/or inpatient status, polypharmacy (especially with constipating medications such as opiates), obesity, advanced age, male sex, and comorbidities such as diabetes mellitus, stroke, dementia, and Parkinson’s disease.

Poor adherence to preparation instructions, erroneous timing of bowel purgative administration, and longer appointment wait times for colonoscopy have also been associated with poor bowel preparation. Thus, it is important for clinicians to understand the numerous modifiable physician and patient-related factors that can lead to colonoscopy failure to reduce its incidence and provide patients with improved outcomes.

Recommendations

Bowel preparations should be individualised 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.

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.

Intensive education and more aggressive than standard bowel preparation regimens be considered for patients with predictors for inadequate preparation.

A low-residue diet be used in conjunction with FDA-approved purgatives for bowel preparation before colonoscopy.

Split-dose regimens for all patients and/or same day preparations for afternoon colonoscopies with a portion of the preparation taken within 3-8 hours of the procedure to enhance colonic cleansing and patient tolerance.

Sodium phosphate and magnesium citrate preparations should not be used in the elderly or patients with renal disease or taking medications that alter renal blood flow or electrolyte excretion.

Don’t use metoclopramide as an adjunct to oral bowel preparation.

Endoscopists should document the quality of the bowel preparation at the time of colonoscopy with regard to adequacy.

Patients with inadequate preparation be offered a repeat colonoscopy within one year.

References available on request.