© Georg Thieme Verlag KG Stuttgart · New York
Bowel cleansing for colonoscopy: prospective randomized assessment of efficacy and of induced mucosal abnormality with three preparation agents
submitted 29 March 2010
accepted after revision 8 December 2010
04 May 2011 (online)
Background and study aims: Bowel-cleansing studies are frequently underpowered, poorly designed, and use subjective bowel cleansing assessments. Consensus on efficacy, tolerability, and preparation-induced mucosal abnormalities is lacking. This study aimed to clarify the differences in efficacy and preparation-induced mucosal inflammation of sodium phosphate (NaP), colonLYTLEY (PEG), and Picoprep (Pico).
Patients and methods: This was a prospective randomized single-blinded trial of ambulatory patients to assess the efficacy of bowel preparation and preparation-induced mucosal inflammation. Proceduralists who were blinded to the preparation taken, assessed both bowel cleansing by using the Ottawa bowel preparation assessment tool and preparation-induced mucosal inflammation.
Results: Of the 634 patients, 98 % ingested more than 75 % of the bowel preparation and data were complete for colonic preparation scoring in 99 %. The preparation used, time of procedure, and patient sex all independently impacted on bowel cleansing. NaP was less efficacious than PEG (P < 0.001) and Pico (P < 0.001) for morning procedures whereas all bowel preparations were equally efficacious for afternoon procedures. Preparation-induced mucosal inflammation was 10-fold greater with NaP (P = 0.03) and Pico (P = 0.03) compared with PEG.
Conclusions: This is the largest published prospective randomized blinded study on this topic and the first to evaluate the three major classes of preparation with a validated tool. The bowel preparation used, time of procedure, and patient sex all independently impacted on bowel cleansing. NaP gave the worst preparation for morning procedures whereas all preparations were equally effective for afternoon procedures. NaP and Pico induced mucosal inflammation 10-fold more frequently than PEG, a finding that requires further investigation.
- 1 Byrne M F. The curse of poor bowel preparation for colonoscopy. Am J Gastroenterol. 2002; 97 1587-1590
- 2 Belsey J, Epstein O, Heresbach D. Systematic review: oral bowel preparation for colonoscopy. Aliment Pharmacol Ther. 2007; 25 373-384
- 3 Cohen S M, Wexner S D, Binderow S R et al. Prospective, randomized, endoscopic-blinded trial comparing precolonoscopy bowel cleansing methods. Dis Colon Rectum. 1994; 37 689-696
- 4 Golub R W, Kerner B A, Wise Jr. W E et al. Colonoscopic bowel preparations – which one? A blinded, prospective, randomized trial. Dis Colon Rectum. 1995; 38 594-599
- 5 Frommer D. Cleansing ability and tolerance of three bowel preparations for colonoscopy. Dis Colon Rectum. 1997; 40 100-104
- 6 Schmidt L M, Williams P, King D, Perera D. Picoprep-3 is a superior colonoscopy preparation to Fleet: a randomized, controlled trial comparing the two bowel preparations. Dis Colon Rectum. 2004; 47 238-242
- 7 Law W L, Choi H K, Chu K W et al. Bowel preparation for colonoscopy: a randomized controlled trial comparing polyethylene glycol solution, one dose and two doses of oral sodium phosphate solution. Asian J Surg. 2004; 27 120-124
- 8 Tjandra J J, Chan M, Tagkalidis P P. Oral sodium phosphate (Fleet) is a superior colonoscopy preparation to Picoprep (sodium picosulfate-based preparation). Dis Colon Rectum. 2006; 49 616-620
- 9 Bitoun A, Ponchon T, Barthet M et al. Results of a prospective randomised multicentre controlled trial comparing a new 2-L ascorbic acid plus polyethylene glycol and electrolyte solution vs. sodium phosphate solution in patients undergoing elective colonoscopy. Aliment Pharmacol Ther. 2006; 24 1631-1642
- 10 Kastenberg D, Barish C, Burack H et al. Tolerability and patient acceptance of sodium phosphate tablets compared with 4-L PEG solution in colon cleansing: combined results of 2 identically designed, randomized, controlled, parallel group, multicenter phase 3 trials. J Clin Gastroenterol. 2007; 41 54-61
- 11 Lichtenstein G R, Grandhi N, Schmalz M et al. Clinical trial: sodium phosphate tablets are preferred and better tolerated by patients compared to polyethylene glycol solution plus bisacodyl tablets for bowel preparation. Aliment Pharmacol Ther. 2007; 26 1361-1370
- 12 Schanz S, Kruis W, Mickisch O et al. Bowel preparation for colonoscopy with sodium phosphate solution versus polyethylene glycol-based lavage: a multicenter trial. Diagn Ther Endosc. 2008; 2008 713 521
- 13 Hookey L C, Vanner S J. Pico-salax plus two-day bisacodyl is superior to pico-salax alone or oral sodium phosphate for colon cleansing before colonoscopy. Am J Gastroenterol. 2009; 104 703-709
- 14 Hsu C W, Imperiale T F. Meta-analysis and cost comparison of polyethylene glycol lavage versus sodium phosphate for colonoscopy preparation. Gastrointest Endosc. 1998; 48 276-282
- 15 Tan J J, Tjandra J J. Which is the optimal bowel preparation for colonoscopy – a meta-analysis. Colorectal Dis. 2006; 8 247-258
- 16 Rostom A, Jolicoeur E. Validation of a new scale for the assessment of bowel preparation quality. Gastrointest Endosc. 2004; 59 482-486
- 17 Rostom A, Jolicoeur E, Dube C et al. A randomized prospective trial comparing different regimens of oral sodium phosphate and polyethylene glycol-based lavage solution in the preparation of patients for colonoscopy. Gastrointest Endosc. 2006; 64 544-552
- 18 Zwas F R, Cirillo N W, el-Serag H B, Eisen R N. Colonic mucosal abnormalities associated with oral sodium phosphate solution. Gastrointest Endosc. 1996; 43 463-466
- 19 Rejchrt S, Bures J, Siroky M et al. A prospective, observational study of colonic mucosal abnormalities associated with orally administered sodium phosphate for colon cleansing before colonoscopy. Gastrointest Endosc. 2004; 59 651-654
- 20 Menees S, Higgins P, Korsnes S, Elta G. Does colonoscopy cause increased ulcerative colitis symptoms?. Inflamm Bowel Dis. 2007; 13 12-18
I. C. Lawrance, MD, PhD
The School of Medicine and Pharmacology
University of Western Australia