Optimizing Adequacy of Bowel Cleansing for Colonoscopy: Recommendations From the US Multi-Society Task Force on Colorectal Cancer

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 20–25% of all colonoscopies are reported to have an inadequate bowel preparation (2, 3) 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) (4) 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 (3, 5, 6, 7) Bowel preparation formulations intended for precolonoscopy cleansing are assessed based on their efficacy, safety, and tolerability. 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 1980 (first year of approval of polyethylene glycol–electrolyte lavage solution [PEG-ELS]–based preparation by the Food and Drug Administration [FDA]) up to August 2013 using MEDLINE, PubMed EMBASE, Scopus, CENTRAL, and ISI Web of knowledge. 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 5832 patients enrolled in 21 centers across 11 countries examined the association of preparation quality and polyp identification during colonoscopy performed for a range of common indications. High-quality preparation was associated with identification of polyps of all sizes (odds ratio [OR], 1.73; 95% confidence interval [CI], 1.28–2.36), and with polyps greater than 10 mm in size (OR, 1.72; 95% CI, 1.11–2.67) (2) An analysis of a national endoscopic database examined the association of preparation quality and polyp identification in 93,004 colonoscopies (3) 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, 1.21; 95% CI, 1.16–1.25), but not polyps greater than 9 mm and/or suspected cancer (OR, 1.5; 95% CI, 0.98–1.11). Similarly, a single-center study based at a US Veterans Affairs Medical Center examined preparation quality and ADRs in 8800 colonoscopies performed between 2001 and 2010 (10) When comparing those examinations with an inadequate/poor preparation (n=829) with those with an adequate preparation (n=5162), overall polyp detection was reduced (OR, 0.66; 95% CI, 0.56–0.83). 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 (11, 12) Miss rates were the total adenomas found on the second examination divided by the total adenomas found on both examinations. In 1 study (11) there were 12,787 colonoscopies with 3047 (24%) suboptimal preparations (fair or poor). Repeat colonoscopy within 3 years in 216 individuals who achieved adequate preparation showed an overall adenoma miss rate of 42%, and a miss rate of 27% for lesions 10 mm or larger in size. The other study identified 373 average-risk screening patients with poor or inadequate preparation (12) Repeat colonoscopy in 133 patients (77% achieved excellent or good preparation) showed a overall adenoma miss A prospective study individuals after a complete colonoscopy and then a colonoscopy within 3 of the initial examination The patient adenoma miss rate increased as preparation quality on the In the patients with poor preparation the adenoma and advanced adenoma miss rates were and with and in those with excellent preparation that in the of a poor preparation, recommendations for follow-up evaluation and on shorter intervals In 1 study and were of preparations of to a preparation, a interval generally was recommended for a screening However, recommendations were for the from more than 5 years to an A of for found that follow-up evaluation in 3 years or for adenomas and a suboptimal preparation studies have examined recommendations for follow-up evaluation within the of study from in on in each quality was not reported in of the examinations. Bowel preparations than excellent were associated with more aggressive surveillance for those found with polyps or and/or A prospective single-center study of patients showed that when a poor preparation recommended follow-up intervals that more were with A prospective study that for each of bowel preparations deemed inadequate and colonoscopy at a the of colonoscopy overall were increased by of inadequate preparation are the for a for rates of adequate preparation and of cleansing Recommendations of a bowel cleansing regimen is recommended for colonoscopy (Strong recommendation, high-quality evidence). A regimen is an to for patients an examination (Strong recommendation, high-quality evidence). The second of preparation should the time of colonoscopy with of the at the procedure time (Strong recommendation, evidence). When preparation are the day from the the and a that the and detection of lesions. The of time between the of preparation and the of colonoscopy with the quality of the cleansing In 1 study the of good or excellent preparation of the by up to for each additional between the of the preparation and the of the colonoscopy that of the bowel cleansing is on the day of the efficacy with a with the regimen of the preparation the day the procedure to higher ADRs have of preparations for colonoscopy bowel cleansing is an to for patients with an colonoscopy In a prospective preparation provided on of and greater patient with to and and of for An guideline from the American Society of however, that of not endoscopic studies found that of bowel cleansing on the day of colonoscopy not that the rate of of bowel preparations is to other may be a greater than A second to is that patients for may be to up during the to the second of of and compliance with bowel preparation is and should not a to preparations for colonoscopy The of during to the is increased with during bowel cleansing Recommendation using a bowel cleansing regimen, recommendations can include either or the on the day colonoscopy recommendation, evidence). patients are to the day randomized trials that a the day colonoscopy is associated with of the preparation and or bowel cleansing The in trials were and included a and a and a this of are to a the day a for or all of the day colonoscopy can be considered for patients without other for inadequate additional should in efficacy if is of patient and for preparation Recommendations should provide both and patient instructions for all of the colonoscopy preparation and the of compliance (Strong recommendation, evidence). The the colonoscopy should that and are in for patients to achieve adequate colonoscopy preparation quality (Strong recommendation, low-quality evidence). A patient by patient and examinations and The of both and with instructions is an of adequate bowel preparation such as and should be and and should be across a range of and The of a patient on precolonoscopy preparation in bowel preparation quality than those achieved using instructions (OR, 95% CI, patient patients the colonoscopy provide to to review bowel preparation and and that patients have an for for in in an for screening colonoscopy rates In the of are by increased screening compliance and is to included and The of the and of the patient additional the quality of bowel preparation during colonoscopy Recommendations of bowel preparation should be assessed after all to have completed (Strong recommendation, low-quality evidence). of the rate of adequate cleansing should be conducted (Strong recommendation, evidence). preparation, as cleansing that a recommendation of a screening or surveillance interval to the of the should be achieved in or more of all examinations on a (Strong recommendation, low-quality evidence). the quality of the bowel preparation is a of the colonoscopy In trials cleansing quality is using that quality for In however, and of the in the can be by cleansing. the to is after the preparation quality in should be assessed after and For this the of a bowel preparation that scoring (eg, is not The US Multi-Society Task Force the of an adequate preparation is in which the can and a follow-up screening or surveillance interval for the colonoscopy that is for the examination Unfortunately, the in that to the at which the preparation the of an adequate preparation to the recommended screening or surveillance generally are In clinicians an of good, and In this excellent and good are widely as but that preparations in also are adequate (10) The recommended that clinicians the preparation adequate if after and the during the procedure was deemed adequate for the detection of lesions greater than 5 mm in size is not of a bowel preparation but the sizes of lesions that are to is to for scoring bowel cleansing that not and include that to adequate the Bowel to not and a Bowel of 5 or higher was associated with a rate of follow-up intervals A review of bowel preparation is in Appendix is used in that the for an adequate preparation should include the the screening or surveillance intervals based on the colonoscopy and that the to lesions greater than 5 mm in size the is a of adequacy and to screening and surveillance are to procedure reports into a that and quality national and of If the rate of adequate bowel preparation for an endoscopist is the recommended of an should be rates of inadequate preparations can patient to preparation for medical of inadequate preparation, or that and of the preparations Recommendations of a regimen should into the medical when the adequacy of bowel preparation reported from colonoscopies (Strong recommendation, evidence). A regimen of high-quality bowel cleansing (Strong recommendation, high-quality evidence). 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