In the Journals

ASGE recommends changes in bowel preparation before colonoscopy

The Standards of Practice Committee of the American Society for Gastrointestinal Endoscopy, or ASGE, has released an updated guideline on bowel preparation before colonoscopy.

“The new ASGE Standards of Practice bowel preparation guidelines represent a dramatic update and change from the prior one,” John R. Saltzman, MD, FACP, FACG, FASGE, AGAF, from Brigham and Women’s Hospital and Harvard Medical School, and co-author of the guideline, told Healio Gastroenterology. “Since the time of publication of the last guideline on bowel preps, there have been substantial advances in prep quality, safety and patient tolerability.”

John R. Saltzman, MD, FACP, FACG, FASGE, AGAF

John R. Saltzman

Brooks D. Cash, MD

Brooks D. Cash

Optimize results, improve care

According to committee chair Brooks D. Cash, MD, from the Digestive Health Center at University of South Alabama Health System, and member of the Healio Gastroenterology Peer Perspective Board, the new guideline includes “several notable recommendations designed to optimize results and improve patient care. Most notably, the committee recommended split-dosing of purgative, ideally with a portion administered within 3 to 8 hours of the procedure.”

Split-dosing “has been consistently shown to improve the quality of the preps,” Saltzman said, and according to the guideline, this subsequently improves both adenoma detection rate and patient tolerance.

Besides dosing, the guideline provides updated recommendations on bowel preparation solutions. “Several new preps are available that are low in volume and high in efficacy,” Saltzman said, and conversely, “the bowel prep that was most widely used at the time of the last guideline, aqueous phosphosoda, is no longer available due to safety concerns.”

The committee also “recommended against the use of metoclopramide as a preparation adjunct or the use of sodium phosphate- or magnesium citrate-based regimens in patients felt to be at increased risk for renal or electrolyte disturbances,” Cash said.

Another notable recommendation was a low-residue diet rather than a clear liquid diet before bowel preparation, Cash said. This dietary modification has been shown to be comparably effective to clear liquid diet and associated with increased patient satisfaction, according to the guideline.

Documentation emphasized

Finally, the guideline emphasizes the importance of documenting bowel preparation quality using one of several validated scoring systems.

“Clinicians should take care to document the adequacy of the bowel preparation in all colonoscopy reports,” Cash said. “Patients with inadequate preparation should be offered repeat colonoscopy within 1 year, and clinicians should consider using enhanced education and possibly more aggressive bowel preparations for patients who have had either an inadequate bowel preparation in the past or who have predictors of inadequate preparation. The most important predictor for an inadequate preparation is a previous history of an inadequate preparation, and review of previous colonoscopy reports or directed patient inquiry regarding the adequacy of previous bowel preparation experiences should be a routine practice.”

“Recognizing risk factors of inadequate preps and proactively knowing the measures that effectively can result in an adequate bowel prep is essential,” Saltzman said. “New quality indicators demand that physicians have adequate bowel preps in at least 85% of their outpatients, and it is, thus, critical for all physicians performing colonoscopy to be aware of the current state-of-the-art and science of bowel preparations.” – by Adam Leitenberger

Disclosure: Cash reports he is on the speakers bureau of Salix. Please see the full guideline for a list of all other authors’ relevant financial disclosures.