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Hagen R, Nguyen MTT, Anderson JC, Birk JW. Navigating Bowel Preparation for Colonoscopy: A Comprehensive Overview. J Clin Gastroenterol 2025; 59:285-297. [PMID: 39761153 DOI: 10.1097/mcg.0000000000002124] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/08/2025]
Abstract
Colorectal cancer (CRC) is the third most common cancer in the United States. Early detection through colonoscopy significantly improves survival rates. Detecting colon polyps depends on the quality of bowel preparation. However, inadequate bowel preparation remains a significant issue in clinical practice. Efforts to address this challenge have led to the development of bowel preparation regimens emphasizing efficacy, tolerability, and safety. Bowel preparation options can be categorized by their osmotic and volume properties. Isosmotic solutions based on polyethylene glycol-electrolyte lavage solutions (PEG-ELS) are available in both low-volume PEG-ELS with ascorbic acid (PEG-Asc) (e.g., MoviPrep, PLENVU) and high-volume formulations (e.g., GoLYTELY, CoLyte), as well as sulfate-free high-volume PEG-ELS formulations (SF-PEG-ELS). Hyperosmotic solutions include oral sulfate solution (OSS) (e.g., SUPREP), sodium phosphate tablets (NaP) (e.g., OsmoPrep), oral sulfate tablets (OST) (e.g., SUTAB), flavored PEG with sulfate salts (FPSS) (e.g., SUFLAVE), and magnesium citrate. Hypoosmotic solutions consist of PEG-sports drink (PEG-SD). In addition, combination solutions are available, such as sodium picosulfate with magnesium citrate (SPMC) with laxatives (e.g., CLENPIQ), and OSS with SF-PEG-ELS (Suclear). Each regimen differs in terms of cost, volume, taste, contraindications, and potential adverse effects. Therefore, clinicians must carefully evaluate each patient to determine the most suitable regimen for their patients.
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Affiliation(s)
| | - Minh Thu T Nguyen
- Department of Medicine
- Division of Gastroenterology and Hepatology, Department of Medicine, University of Connecticut Health Center, Farmington, CT
| | - Joseph C Anderson
- Division of Gastroenterology and Hepatology, Department of Medicine, Dartmouth Hitchcock Medical Center, Lebanon, NH
| | - John W Birk
- Department of Medicine
- Division of Gastroenterology and Hepatology, Department of Medicine, University of Connecticut Health Center, Farmington, CT
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2
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Winter FD. Colorectal cancer screening. Proc AMIA Symp 2024; 37:1001-1003. [PMID: 39440098 PMCID: PMC11492673 DOI: 10.1080/08998280.2024.2389755] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2024] [Revised: 07/29/2024] [Accepted: 07/31/2024] [Indexed: 10/25/2024] Open
Affiliation(s)
- F. David Winter
- Department of Internal Medicine, Baylor University Medical Center, Dallas, Texas, USA
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3
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Seyrafian S, Sebghatollahi V, Bastani B. Hyponatremia-induced generalized seizure after taking polyethylene glycol for colon preparation-A case report and brief review of the literature. Clin Case Rep 2022; 10:e6247. [PMID: 36052026 PMCID: PMC9413866 DOI: 10.1002/ccr3.6247] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2021] [Revised: 07/21/2022] [Accepted: 08/01/2022] [Indexed: 11/06/2022] Open
Abstract
Severe hyponatremia is life-threatening in hospitalized patients. We present an elderly female who developed severe hyponatremia, seizure, and loss of consciousness after taking polyethylene glycol (PEG) solution before colonoscopy. The risk of hyponatremia with PEG for colon preparation in elderly susceptible patients is high. We review the relevant literature.
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Affiliation(s)
- Shiva Seyrafian
- Isfahan Kidney Diseases Research CenterIsfahan University of Medical SciencesIsfahanIran
| | | | - Bahar Bastani
- School of MedicineSaint Louis UniversitySaint LouisMissouriUSA
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4
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Liang Y, Xin W, Xi L, Fu H, Yang Y, Yang G, Li X. Role of mechanical and oral antibiotic bowel preparation in children with Hirschsprung's disease undergoing colostomy closure and pull-through. Transl Pediatr 2021; 10:153-159. [PMID: 33633947 PMCID: PMC7882283 DOI: 10.21037/tp-20-306] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND Mechanical and oral antibiotic bowel preparation (MOABP) has been performed routinely before colorectal surgery in children, but the necessity was questioned recently. We evaluated the utility of MOABP in children with Hirschsprung's disease (HSCR) undergoing colostomy closure and pull-through. METHODS The medical records of pediatric patients with HSCR who underwent colostomy closure and pull-through in a single center from January 2010 to January 2020 were reviewed. The use of MOABP was noted. The incidence of postoperative complications, duration of postoperative antibiotic therapy, total hospital cost and length-of-stay were compared between patients receiving MOABP and no bowel preparation (NBP). RESULTS A total of 64 patients were included in the study: 33 received MOABP and 31 had NBP. The respective postoperative complications in the MOABP and NBP groups were: intra-abdominal infection (18.2% vs. 29.0%), wound infection (9.1% vs. 16.1%), anastomotic leak (0 vs. 0), intestinal obstruction (6.1% vs. 0) and enterocolitis (3.03% vs. 12.90%). The duration of antibiotic therapy was 4.91±4.21 and 5.23±3.77 days (P=0.75) and hospitalization was 18.21±7.26 and 16.26±6.63 days (P=0.27) respectively. The total hospital cost in the MOABP group (4,720.14±1,858.89 USD) was higher than in the NBP group (3,749.06±2,009.97 USD) (P=0.049). CONCLUSIONS We did not find any clear benefit of MOABP in children with HSCR before colostomy closure and pull-through. However, a multicenter randomized controlled trial is needed to more definitely determine the best preoperative approach for children with HSCR.
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Affiliation(s)
- Yuanyuan Liang
- Department of Pediatric Surgery, West China Hospital, Sichuan University, Chengdu, China.,West China School of Nursing, Sichuan University, Chengdu, China
| | - Wenqiong Xin
- Department of Pediatric Surgery, West China Hospital, Sichuan University, Chengdu, China.,West China School of Nursing, Sichuan University, Chengdu, China
| | - Ling Xi
- Department of Pediatric Surgery, West China Hospital, Sichuan University, Chengdu, China.,West China School of Nursing, Sichuan University, Chengdu, China
| | - Huan Fu
- Department of Pediatric Surgery, West China Hospital, Sichuan University, Chengdu, China.,West China School of Nursing, Sichuan University, Chengdu, China
| | - Yang Yang
- Department of Pediatric Surgery, West China Hospital, Sichuan University, Chengdu, China.,West China School of Nursing, Sichuan University, Chengdu, China
| | - Gang Yang
- Department of Pediatric Surgery, West China Hospital, Sichuan University, Chengdu, China
| | - Xiaoling Li
- West China School of Nursing, Sichuan University, Chengdu, China
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5
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Bor R, Matuz M, Fabián A, Szepes Z, Szántó K, Farkas K, Rutka M, Milassin Á, Pigniczki D, Bálint A, Tóth T, Molnár T. Efficacy, tolerability and safety of a split-dose bowel cleansing regimen of magnesium citrate with sodium picosulfate - a phase IV clinical observational study. REVISTA ESPANOLA DE ENFERMEDADES DIGESTIVAS 2020; 113:635-642. [PMID: 33371690 DOI: 10.17235/reed.2020.7073/2020] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
BACKGROUND There are contradictory results about the effect of magnesium citrate plus sodium picosulfate bowel cleansing agents on the fluid and electrolyte balance. Therefore, this study aimed to determine the efficacy, tolerability and safety of this medication in colonoscopy preparation. METHODS 233 patients were enrolled in this phase IV prospective observational study. The effectiveness of bowel cleansing was assessed using the Boston Bowel Preparation Scale (BBPS). Adequate cleansing was defined as BBPS ≥ 6 and excellent cleansing as BBPS > 7. Tolerability was examined using a standardized questionnaire. In the safety analysis, the change of serum electrolytes levels and renal function during bowel cleansing was assessed. RESULTS Adequate and excellent bowel cleansing were achieved 94.85% and 72.96% of cases, respectively. None or very mild symptoms were reported in 47.21% of cases. Statistically significant changes occurred in serum potassium (4.38±0.43 vs. 4.25±0.43 mmol/L, p<0.0001), urea (4.86±1.37 vs. 3.84±1.43 mmol/L, p<0.0001) and creatinine (male: 81.07±16.02 vs. 84.54±15.11 μmol/L; female: 69.32±12.22 vs. 72.96±12.11 μmol/L, p<0.0001) levels during the colonoscopy preparation. However, the number of patients with values outside of the normal range increased significantly only in the case of serum urea (3.95% vs. 26.97%, p<0.0001). CONCLUSION Magnesium citrate with sodium picosulfate is outstandingly effective, well tolerated and a safe agent in colonoscopy preparation. It caused significant, but non-clinically relevant changes in serum electrolytes levels and renal function.
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Affiliation(s)
- Renáta Bor
- First Department of Medicine, University of Szeged, Hungary
| | | | - Anna Fabián
- First Department of Medicine, University of Szeged
| | | | - Kata Szántó
- First Department of Medicine, University of Szeged
| | | | | | | | | | - Anita Bálint
- First Department of Medicine, University of Szeged
| | - Tibor Tóth
- First Department of Medicine, University of Szeged
| | - Tamás Molnár
- First Department of Medicine, University of Szeged
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Sunder Shrestha P, Acharya U, Karki B, Pathak R, Acharya SP. Symptomatic Hyponatremia following Bowel Preparation for Colonoscopy: A Case Report. ACTA ACUST UNITED AC 2020; 58:938-940. [PMID: 34506430 PMCID: PMC7775008 DOI: 10.31729/jnma.5039] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2020] [Indexed: 01/04/2023]
Abstract
Colonoscopy is considered a gold standard tool for the diagnostic evaluation of colorectal diseases. Bowel preparation, a pre-requisite for colonoscopy, usually involves ingestion of purgatives for the cleansing of the bowel so that visualization is not obscured during the procedure. Commonly used preparations are sodium phosphate-based solutions, sodium picosulphate and polyethylene glycol. The use of such preparations is associated with electrolyte disturbances, commonly hyponatremia. Hyponatremia is usually seen with sodium phosphate based solutions and is rare with polyethylene glycol. Symptomatic hyponatremia, however, is rare following bowel preparation and is attributable to other factors as well, such as the age of patient, non-osmotic release of antidiuretic hormone and the procedure itself. In this report, we discuss a case of severe symptomatic hyponatremia observed in a 71-year-old gentleman who underwent polyethylene glycol based bowel preparation for colonoscopy.
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Affiliation(s)
| | - Utsav Acharya
- Department of Anaesthesiology, Maharajgunj Medical Campus, Maharjgunj, Kathmandu, Nepal
| | - Bipin Karki
- Department of Critical Care Medicine, Om Hospital and Research Centre, Chabahil, Kathmandu, Nepal
| | - Rahul Pathak
- Department of Gastroenterology, Maharajgunj Medical Campus, Maharjgunj, Kathmandu, Nepal
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Htet H, Segal J. New Ultra Low Volume Bowel Preparation and Overview of Existing Bowel Preparations. Curr Drug Metab 2020; 21:844-849. [PMID: 32778022 DOI: 10.2174/1567201817666200810112136] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2020] [Revised: 06/02/2020] [Accepted: 06/09/2020] [Indexed: 12/23/2022]
Abstract
BACKGROUND Adequate bowel cleansing is essential in achieving a good quality colonoscopy. However, one of the barriers to achieving high-quality bowel cleansing is the patient's tolerability. Different bowel preparations have been developed to improve tolerability while maintaining adequate bowel cleansing. OBJECTIVES We aim to explore the pros and cons of commonly used bowel preparations, particularly highlighting the new ultra-low volume bowel preparation. METHODS Extensive literature search was carried out on various databases to evaluate the effectiveness and side effects of different bowel cleansing agents, including findings of recent clinical trials on ultra-low bowel preparation. RESULTS Polyethylene glycol (PEG) has been commonly used as a bowel prep. Due to its high volume required to ingest to achieve an adequate effect, it has been combined with various adjuncts to reduce the volume to make it more tolerable. Magnesium and phosphate-based preps can achieve low volume, but they can be associated with multiple side effects, mainly electrolyte disturbances. Ultra low volume prep (NER1006) was achieved by combing PEG with ascorbic acid, and its efficacy and side effects were demonstrated in three noninferiority studies. CONCLUSION It is important to consider patient preferences, co-morbidities and tolerability, and efficacy and side effect profiles when choosing bowel prep for patients undergoing colonoscopy. New ultra-low bowel prep showed promising results in initial clinical trials, but further real-world post-marketing data will inform its value in clinical practice.
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Affiliation(s)
- Hein Htet
- Department of Gastroenterology, St Richard's Hospital, Chichester, United Kingdom
| | - Jonathan Segal
- Department of Gastroenterology, St Mary's Hospital, London, United Kingdom
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8
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Risk factors analysis for surgical site infection following elective colorectal resection: a retrospective regression analysis. Chin Med J (Engl) 2020; 133:571-576. [PMID: 31996547 PMCID: PMC7065853 DOI: 10.1097/cm9.0000000000000670] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
Background: A surgical site infection (SSI) is a major post-operative complication from elective colorectal surgery; however, few studies have focused on evaluating the risk factors for SSI. This study aimed to analyze the relative correlation of medical and environmental factors as well as patient-related factors that contribute to the incidence of all types of SSI. Methods: A retrospective search for eligible patients was conducted using the patient database of the Gastrointestinal Surgery Center of the Third Affiliated Hospital of Sun Yat-sen University from January 2011 to August 2017. Pre-operative demographic and surgical data were extracted and recoded according to the study protocol. Univariate and multivariate analyses were performed to clarify factors affecting the incidence of SSI. Propensity analysis was conducted to minimize bias in the demographic characteristics to explore the prophylactic effect of pre-operative administration of oral antibiotics. Results: Univariate analysis of the baseline characteristics revealed that younger age (odds ratio [OR]: 0.378; 95% confidence interval [CI]: 0.218–0.657) and pre-operative oral antibiotic use (OR: 0.465; 95% CI: 0.255–0.850) were protective factors, while pre-operative anemia (OR: 4.591; 95% CI: 2.567–8.211), neoadjuvant chemotherapy history (OR: 2.398; 95% CI: 1.094–5.256), and longer surgical duration (OR: 2.393; 95% CI: 1.349–4.246; P = 0.002) were identified as risk factors for SSI. Multivariate analysis indicated that age (P = 0.003), surgical duration (P = 0.001), and pre-operative oral antibiotic use (P < 0.001) were independent factors that affect the incidence of SSI. Furthermore, a propensity-matched analysis confirmed the protective effect of oral antibiotic use, with a 1-day course of oral antibiotic producing a similar effect to a 3-day course. Conclusions: Age, surgical duration, and pre-operative oral antibiotic use were associated with the incidence of SSI. However, pre-operative oral antibiotic use was the only controllable factor. From the results of our study, pre-operative oral antibiotic use is recommended before elective colorectal surgery and a 1-day course is enough to provide the protective effect.
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9
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Lei P, Ruan Y, Yang X, Wu J, Hou Y, Wei H, Chen T. Preoperative mechanical bowel preparation with oral antibiotics reduces surgical site infection after elective colorectal surgery for malignancies: results of a propensity matching analysis. World J Surg Oncol 2020; 18:35. [PMID: 32046725 PMCID: PMC7014769 DOI: 10.1186/s12957-020-1804-4] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2019] [Accepted: 01/23/2020] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND Surgical site infections (SSIs) are a major postoperative complication after colorectal surgery. Current study aims to evaluate prophylactic function of oral antibiotic (OA) intake in combination with mechanical bowel preparation (MBP) relative to MBP alone with respect to postoperative SSI incidence. METHODS A retrospective analysis of eligible patients was conducted using the databases of the Gastrointestinal Surgery Centre, Third Affiliated Hospital of Sun Yat-sen University from 2011 to 2017. Data pertaining to postoperative hospital stay length, expenses, SSI incidence, anastomotic fistula incidence, and rates of other complications were extracted and compared. A propensity analysis was conducted to minimize bias associated with demographic characteristics. Subgroup analyses were performed to further explore protective effects of OA in different surgical sites. RESULTS The combination of OAs and MBP was related to a significant decrease in the incidence of overall SSIs, superficial SSI, and hospitalization expenses. The MBP + OA modality was particularly beneficial for patients undergoing left-side colon or rectum resections, with clear prophylactic efficacy. The combination of MPB + OA did not exhibit significant prophylactic efficacy in patients undergoing right hemi-colon resection. Age, surgical duration, and application of OA were all independent factors associated with the occurrence of SSIs. CONCLUSION These results suggest that the combination of OA + MBP should be recommended for patients undergoing elective colorectal surgery, particularly for operations on the left side of the colon or rectum. TRIAL REGISTRATION NCT04258098. Retrospectively registered.
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Affiliation(s)
- Purun Lei
- Department of Gastrointestinal Surgery, The Third Affiliated Hospital, Sun Yat-sen University, Guangzhou, 0086-510000, China
| | - Ying Ruan
- Department of Thyroid and Breast Surgery, The Third Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Xiaofeng Yang
- Department of Gastrointestinal Surgery, The Third Affiliated Hospital, Sun Yat-sen University, Guangzhou, 0086-510000, China
| | - Juekun Wu
- Department of Thyroid and Breast Surgery, The Third Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Yujie Hou
- Department of Gastrointestinal Surgery, The Sixth Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Hongbo Wei
- Department of Gastrointestinal Surgery, The Third Affiliated Hospital, Sun Yat-sen University, Guangzhou, 0086-510000, China
| | - Tufeng Chen
- Department of Gastrointestinal Surgery, The Third Affiliated Hospital, Sun Yat-sen University, Guangzhou, 0086-510000, China.
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Pratap K, Jiwrajka M, Weber L, Richardson A. Severe symptomatic hyponatraemia secondary to bowel preparation. BMJ Case Rep 2019; 12:12/10/e230385. [PMID: 31653623 DOI: 10.1136/bcr-2019-230385] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023] Open
Abstract
A 62-year-old woman presented to a rural Australian hospital for a planned admission to receive bowel preparation 1 day prior to an upper endoscopy and colonoscopy. This admission was complicated by seizures and reduced levels of consciousness in the setting of hyponatraemia secondary to bowel preparation. Given the limited resources in a remote/rural Australian hospital, transfer to a tertiary level hospital was required for review and management of this rare complication of bowel preparation.
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Affiliation(s)
- Krishan Pratap
- Gastroenterology, Royal Brisbane and Women's Hospital, Herston, Queensland, Australia
| | - Manasi Jiwrajka
- Gastroenterology, Royal Brisbane and Women's Hospital, Herston, Queensland, Australia
| | - Liam Weber
- Emergency Department, Roma Hospital, Roma, Queensland, Australia
| | - Alan Richardson
- Emergency Department, Roma Hospital, Roma, Queensland, Australia
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11
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Bowel preparation for colonoscopy may decrease the levels of testosterone in Korean men. Sci Rep 2019; 9:7080. [PMID: 31068639 PMCID: PMC6506588 DOI: 10.1038/s41598-019-43598-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2019] [Accepted: 04/26/2019] [Indexed: 12/27/2022] Open
Abstract
Although colonoscopy is commonly conducted for medical check-ups in Korea, investigations for the influence of bowel preparation on various health conditions are insufficient. This cross-sectional study investigated whether bowel preparation has an influence on serum levels of testosterone. A total of 1114 men were divided into the bowel preparation group and control groups. The median total and free testosterone levels were significantly lower in the bowel preparation group (14.89 and 0.26 nmol/L, respectively) than in the control groups (15.72 and 0.28 nmol/L, respectively). The level of total testosterone significantly increased with age in the bowel preparation group (r = 0.103). The differences in the levels of total and free testosterone between the 2 groups were more prominent in younger men than in older men. In multivariate regression models, bowel preparation was independently associated with the levels of total and free testosterone. In these models, the interaction between age and bowel preparation was significant for the levels of total and free testosterone. In conclusion, bowel preparation may independently decrease the serum levels of total and free testosterone. The decline in testosterone was more evident in younger men than in older men.
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Abstract
OBJECTIVE The objective of this study was to determine the relationship between bowel preparation and surgical site infections (SSIs), and also other postoperative complications, after elective colorectal surgery. BACKGROUND SSI is a major source of postoperative morbidity/costs after colorectal surgery. The value of preoperative bowel preparation to prevent SSI remains controversial. METHODS We analyzed 32,359 patients who underwent elective colorectal resections in the American College of Surgeons National Surgery Quality Improvement Program database from 2012 to 2014. Univariable and multivariable analyses were performed; propensity adjustment using patient/procedure characteristics was used to account for nonrandom receipt of bowel preparation. RESULTS 26.7%, 36.6%, 3.8%, and 32.9% of patients received no bowel preparation, mechanical bowel preparation (MBP), oral antibiotics (OA), and MBP + OA, respectively. After propensity adjustment, MBP was not associated with decreased risk of SSI compared with no bowel preparation. In contrast, both OA and OA + MBP were associated with decreased risk of any SSI (adjusted odds ratio 0.49, 95% confidence interval 0.38-0.64; and adjusted odds ratio 0.45, 95% confidence interval 0.40-0.50, respectively) compared with no bowel preparation. OA and MBP + OA were associated with decreased risks of anastomotic leak, postoperative ileus, readmission, and also shorter length of stay (all P < 0.05). Bowel preparation was not associated with increased risk of cardiac/renal complications compared with no preparation. CONCLUSIONS The use of MBP alone before elective colorectal resection to prevent SSI is ineffective and should be abandoned. In contrast, OA and MBP + OA are associated with decreased risks of SSI and are not associated with increased risks of other adverse outcomes compared with no preparation. Prospective studies to determine the efficacy of OA are warranted; in the interim, MBP + OA should be used routinely before elective colorectal resection to prevent SSI.
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Azcune Echeverria O. Severe hyponatremia secondary to preparation for colonoscopy with sodium picosulfate/magnesium citrate. REVISTA ESPANOLA DE ENFERMEDADES DIGESTIVAS 2018; 111:249. [PMID: 30511577 DOI: 10.17235/reed.2018.5832/2018] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
The number of colonoscopies performed in Spain has been progressively increasing in recent years with the program of early detection of colon cancer. The preparation for this test is the key to greater profitability and the choice of the solution to be administered, decisive. The adverse effects that we can observe; usually are mild, but they can entail other more serious ones, like electrolytic imbalances as we present in this case.
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Janssen Lok M, Miyake H, O'Connell JS, Seo S, Pierro A. The value of mechanical bowel preparation prior to pediatric colorectal surgery: a systematic review and meta-analysis. Pediatr Surg Int 2018; 34:1305-1320. [PMID: 30343324 DOI: 10.1007/s00383-018-4345-y] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/11/2018] [Indexed: 12/29/2022]
Abstract
PURPOSE The use of mechanical bowel preparation (MBP) before pediatric colorectal surgery remains the standard of care for many pediatric surgeons, though the value of MBP remains unclear. The aim of this study was to systematically review and analyze the effect of MBP on the incidence of postoperative complications; anastomotic leakage, intra-abdominal infection, and wound infection, following colorectal surgery in pediatric patients. METHODS Embase, MEDLINE, Web of Science, and CINAHL databases were searched to compare the effect of MBP versus no MBP prior to elective pediatric colorectal surgery on postoperative complications. After critical appraisal of included studies, meta-analyses were conducted using a random-effect model. RESULTS 1731 papers were retrieved; 2 randomized controlled trials and 4 retrospective cohort studies met the inclusion criteria. The overall quality of evidence was low. MBP before colorectal surgery did not significantly decrease the occurrence of anastomotic leakage, intra-abdominal infection, or wound infection compared to no MBP. CONCLUSIONS On the basis of the existing evidence, the use of MBP before colorectal surgery in children seems not to decrease the incidence of postoperative complications compared to no MBP. To overcome confounding factors such as antibiotic prophylaxis, age and type of operation, a multicentre prospective study is suggested to validate these results.
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Affiliation(s)
- Maarten Janssen Lok
- Division of General and Thoracic Surgery, The Hospital for Sick Children, University of Toronto, 555 University Avenue, Toronto, ON, M5G 1X8, Canada
| | - Hiromu Miyake
- Division of General and Thoracic Surgery, The Hospital for Sick Children, University of Toronto, 555 University Avenue, Toronto, ON, M5G 1X8, Canada
| | - Joshua S O'Connell
- Division of General and Thoracic Surgery, The Hospital for Sick Children, University of Toronto, 555 University Avenue, Toronto, ON, M5G 1X8, Canada
| | - Shogo Seo
- Division of General and Thoracic Surgery, The Hospital for Sick Children, University of Toronto, 555 University Avenue, Toronto, ON, M5G 1X8, Canada
| | - Agostino Pierro
- Division of General and Thoracic Surgery, The Hospital for Sick Children, University of Toronto, 555 University Avenue, Toronto, ON, M5G 1X8, Canada.
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Effectiveness of mechanical bowel preparation versus no preparation on anastomotic leakage in colorectal surgery: a systematic review and meta-analysis. Updates Surg 2018; 71:227-236. [PMID: 29564651 DOI: 10.1007/s13304-018-0526-4] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2017] [Accepted: 03/11/2018] [Indexed: 02/08/2023]
Abstract
It has been a standard practice to perform mechanical bowel preparation (MBP) prior to colorectal surgery to reduce the risk of colorectal anastomotic leakages (CAL). The latest Cochrane systematic review suggests there is no benefit for MBP in terms of decreasing CAL, but new studies have been published. The aim of this systematic review and meta-analysis is to update current evidence for the effectiveness of preoperative MBP on CAL in patients undergoing colorectal surgery. Consequently, PubMed, MEDLINE, Embase, CENTRAL and CINAHL were searched from 2010 to March 2017 for randomised controlled trials (RCT) that compared the effects of MBP in colorectal surgery on anastomotic leakages. The outcome CAL was expressed in odds ratios and analysed with a fixed-effects analysis in a meta-analysis. Quality assessment was performed by the cochrane risk of bias tool and grades of recommendation, assessment, development and evaluation (GRADE) methodology. Eight studies (1065 patients) were included. The pooled odds ratio showed no significant difference of MBP in colorectal surgery on CAL (odds ratio (OR) = 1.15, 95% CI = 0.68-1.94). According to GRADE methodology, the quality of the evidence was low. To conclude, MBP for colorectal surgery does not lower the risk of CAL. These results should, however, be interpreted with caution due to the small sample sizes and poor quality. Moreover, the usefulness of MBP in rectal surgery is not clear due to the lack of stratification in many studies. Future research should focus on high-quality, adequately powered RCTs in elective rectal surgery to determine the possible effects of MBP.
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Levine SM, Sinno S, Cannavo D, Baker DC. Selective Serotonin Reuptake Inhibitor-Induced Hyponatremia and the Plastic Surgery Patient. Plast Reconstr Surg 2017; 139:1481-1488. [PMID: 28207561 DOI: 10.1097/prs.0000000000003329] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Cosmetic plastic surgery procedures continue to increase in frequency, and a greater number of them now occur outside of an acute-care hospital setting. In addition, antidepressant use is also rising, with a greater number of patients taking selective serotonin reuptake inhibitors to aid in a variety of mood and anxiety disorders. Americans spend more than $86 billion each year on antidepressants, as 34 million people in the United States are taking at least one of these medications. Many side effects of selective serotonin reuptake inhibitors are well known and not clinically relevant to practicing surgeons. Hyponatremia, however, is a well-documented side effect of these medications that has received relatively little attention in the surgical literature. Postoperative hyponatremia results because of a decrease of antidiuretic hormone suppression that occurs with selective serotonin reuptake inhibitor administration. Here, the authors first review the literature reporting hyponatremia with selective serotonin reuptake inhibitor use. The authors then present two cases of severe postoperative hyponatremia after plastic surgery operations. The authors propose that patients using selective serotonin reuptake inhibitors, especially elderly patients and those undergoing procedures with expected large fluid shifts, should be tested preoperatively and postoperatively for serum sodium levels so that a diagnosis of hyponatremia may be made early and treated before a catastrophic event. CLINICAL QUESTION/LEVEL OF EVIDENCE Therapeutic, V.
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Affiliation(s)
- Steven M Levine
- New York, N.Y.,From the Department of Plastic Surgery, Lenox Hill Hospital; the Hansjörg Wyss Department of Plastic Surgery, New York University Medical Center; and anesthesia private practice
| | - Sammy Sinno
- New York, N.Y.,From the Department of Plastic Surgery, Lenox Hill Hospital; the Hansjörg Wyss Department of Plastic Surgery, New York University Medical Center; and anesthesia private practice
| | - Dominick Cannavo
- New York, N.Y.,From the Department of Plastic Surgery, Lenox Hill Hospital; the Hansjörg Wyss Department of Plastic Surgery, New York University Medical Center; and anesthesia private practice
| | - Daniel C Baker
- New York, N.Y.,From the Department of Plastic Surgery, Lenox Hill Hospital; the Hansjörg Wyss Department of Plastic Surgery, New York University Medical Center; and anesthesia private practice
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17
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Windpessl M, Schwarz C, Wallner M. "Bowel prep hyponatremia" - a state of acute water intoxication facilitated by low dietary solute intake: case report and literature review. BMC Nephrol 2017; 18:54. [PMID: 28173768 PMCID: PMC5297160 DOI: 10.1186/s12882-017-0464-2] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2016] [Accepted: 01/26/2017] [Indexed: 12/29/2022] Open
Abstract
Background Symptomatic hyponatremia is considered a rare complication of oral bowel preparation for colonoscopy. The pathophysiology underlying this phenomenon has been widely regarded as a mere sequela of excessive arginine vasopressin (AVP) release. Case presentation This case describes a 61-year old woman who developed acute hyponatremic encephalopathy when preparing for elective outpatient lower endoscopy. She had had negligible oral solute intake for two days and ingested four liters of clear fluid within two hours. On admission, the patient was agitated and had slurred speech. Treatment with hypertonic saline lead to full recovery. A brisk aquaresis confirmed acute dilutional hyponatremia. Conclusion Apart from elevated AVP-levels, the amount and speed of fluid intake and concomitant low-solute intake constitute important risk factors in the development of clinically relevant hyponatremias in patients undergoing colonoscopies. Understanding that the cause of sodium imbalance in this scenario is multifactorial and complex is pivotal to recognizing and ideally preventing this complication, for which we propose the term “bowel prep hyponatremia”.
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Affiliation(s)
- Martin Windpessl
- Fourth Department of Medicine, Section of Nephrology, Klinikum Wels-Grieskirchen, Grieskirchnerstraße 42, 4600, Wels, Austria.
| | - Christoph Schwarz
- First Department of Medicine, Landeskrankenhaus Steyr, Steyr, Austria
| | - Manfred Wallner
- Fourth Department of Medicine, Section of Nephrology, Klinikum Wels-Grieskirchen, Grieskirchnerstraße 42, 4600, Wels, Austria
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18
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Kim HG, Huh KC, Koo HS, Kim SE, Kim JO, Kim TI, Kim HS, Myung SJ, Park DI, Shin JE, Yang DH, Lee SH, Lee JS, Lee CK, Chang DK, Joo YE, Cha JM, Hong SP, Kim HJ. Sodium Picosulfate with Magnesium Citrate (SPMC) Plus Laxative Is a Good Alternative to Conventional Large Volume Polyethylene Glycol in Bowel Preparation: A Multicenter Randomized Single-Blinded Trial. Gut Liver 2016; 9:494-501. [PMID: 25287163 PMCID: PMC4477993 DOI: 10.5009/gnl14010] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/02/2023] Open
Abstract
Background/Aims We investigated whether sodium picosulfate with magnesium citrate (SPMC) plus bisacodyl compares favorably with conventional polyethylene glycol (PEG) with respect to bowel cleansing adequacy, compliance, and safety. Methods We performed a multicenter, prospective, single-blinded study in outpatients undergoing daytime colonoscopies. Patients were randomized into a split preparation SPMC/bisacodyl group and a conventional split PEG group. We compared preparation adequacy using the Boston bowel preparation scale (BBPS), ease of use using a modified Likert scale (LS), compliance/satisfaction level using a visual analogue scale (VAS), and safety by monitoring adverse events during the colonoscopy between the two groups. Results A total of 365 patients were evaluated by intention to treat (ITT) analysis, and 319 were evaluated by per protocol (PP) population analysis (153 for SPMC/bisacodyl, 166 for PEG). The mean total BBPS score was not different between the two groups in both the ITT and PP analyses (p>0.05). The mean VAS score for satisfaction and LS score for the ease of use were higher in the SPMC/bisacodyl group (p<0.001). The adverse event rate was lower in the SPMC/bisacodyl group than in the PEG group (p<0.05). Conclusions The SPMC/bisacodyl treatment was comparable to conventional PEG with respect to bowel preparation adequacy and superior with respect to compliance, satisfaction, and safety.
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Affiliation(s)
- Hyun Gun Kim
- Institute for Digestive Research, Department of Internal Medicine, Soonchunhyang University College of Medicine, Seoul, Korea
| | - Kyu Chan Huh
- Division of Gastroenterology, Department of Internal Medicine, Konyang University College of Medicine, Daejeon, Korea
| | - Hoon Sup Koo
- Division of Gastroenterology, Department of Internal Medicine, Konyang University College of Medicine, Daejeon, Korea
| | - Seong-Eun Kim
- Division of Gastroenterology, Department of Internal Medicine, Ewha Womans University School of Medicine, Seoul, Korea
| | - Jin-Oh Kim
- Institute for Digestive Research, Department of Internal Medicine, Soonchunhyang University College of Medicine, Seoul, Korea
| | - Tae Il Kim
- Division of Gastroenterology, Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Korea
| | - Hyun-Soo Kim
- Division of Gastroenterology, Department of Internal Medicine, Yonsei University Wonju College of Medicine, Wonju, Korea
| | - Seung-Jae Myung
- Department of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Dong Il Park
- Department of Internal Medicine, Kangbuk Samsung Hospital, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Jeong Eun Shin
- Division of Gastroenterology, Department of Internal Medicine, Dankook University College of Medicine, Cheonan, Korea
| | - Dong-Hoon Yang
- Department of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Suck-Ho Lee
- Institute for Digestive Research, Department of Internal Medicine, Soonchunhyang University College of Medicine, Seoul, Korea
| | - Ji Sung Lee
- Biostatistical Consulting Unit, Soonchunhynag University College of Medicine, Seoul, Korea
| | - Chang Kyun Lee
- Biostatistical Consulting Unit, Soonchunhynag University College of Medicine, Seoul, Korea
| | - Dong Kyung Chang
- Division of Gastroenterology, Department of Internal Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Young-Eun Joo
- Division of Gastroenterology, Department of Internal Medicine, Chonnam National University Medical School, Gwangju, Korea
| | - Jae Myung Cha
- Biostatistical Consulting Unit, Soonchunhynag University College of Medicine, Seoul, Korea
| | - Sung Pil Hong
- Division of Gastroenterology, Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Korea
| | - Hyo Jong Kim
- Division of Gastroenterology, Department of Internal Medicine, Kyung Hee University School of Medicine, Seoul, Korea
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19
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Nardone R, Brigo F, Trinka E. Acute Symptomatic Seizures Caused by Electrolyte Disturbances. J Clin Neurol 2016; 12:21-33. [PMID: 26754778 PMCID: PMC4712283 DOI: 10.3988/jcn.2016.12.1.21] [Citation(s) in RCA: 114] [Impact Index Per Article: 12.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2015] [Revised: 09/01/2015] [Accepted: 09/03/2015] [Indexed: 01/10/2023] Open
Abstract
In this narrative review we focus on acute symptomatic seizures occurring in subjects with electrolyte disturbances. Quite surprisingly, despite its clinical relevance, this issue has received very little attention in the scientific literature. Electrolyte abnormalities are commonly encountered in clinical daily practice, and their diagnosis relies on routine laboratory findings. Acute and severe electrolyte imbalances can manifest with seizures, which may be the sole presenting symptom. Seizures are more frequently observed in patients with sodium disorders (especially hyponatremia), hypocalcemia, and hypomagnesemia. They do not entail a diagnosis of epilepsy, but are classified as acute symptomatic seizures. EEG has little specificity in differentiating between various electrolyte disturbances. The prominent EEG feature is slowing of the normal background activity, although other EEG findings, including various epileptiform abnormalities may occur. An accurate and prompt diagnosis should be established for a successful management of seizures, as rapid identification and correction of the underlying electrolyte disturbance (rather than an antiepileptic treatment) are of crucial importance in the control of seizures and prevention of permanent brain damage.
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Affiliation(s)
- Raffaele Nardone
- Department of Neurology, Paracelsus Medical University Salzburg, and Christian Doppler Medical Centre, Salzburg, Austria.,Department of Neurology, Franz Tappeiner Hospital, Merano, Italy
| | - Francesco Brigo
- Department of Neurological and Movement Sciences, University of Verona, Verona, Italy
| | - Eugen Trinka
- Department of Neurology, Paracelsus Medical University Salzburg, and Christian Doppler Medical Centre, Salzburg, Austria.,Centre for Cognitive Neurosciences Salzburg, Salzburg, Austria.,University for Medical Informatics and Health Technology, UMIT, Hall in Tirol, Austria.
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20
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Bhat AH, Parray FQ, Chowdri NA, Wani RA, Thakur N, Nazki S, Wani I. Mechanical bowel preparation versus no preparation in elective colorectal surgery: A prospective randomized study. INTERNATIONAL JOURNAL OF SURGERY OPEN 2016. [DOI: 10.1016/j.ijso.2016.02.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
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21
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Wadsworth P, Blackburne H, Dixon L, Dobbs B, Eglinton T, Ing A, Mulder R, Porter RJ, Wakeman C, Frizelle FA. Does Bowel Preparation for Colonoscopy Affect Cognitive Function? Medicine (Baltimore) 2015; 94:e1823. [PMID: 26554781 PMCID: PMC4915882 DOI: 10.1097/md.0000000000001823] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
Abstract
Colonoscopy is a common procedure used in the diagnosis and treatment of a range of bowel disorders. Prior preparation involving potent laxatives is a necessary stage to ensure adequate visualization of the bowel wall. It is known that the sedatives given to most patients during the colonoscopy cause a temporary impairment in cognitive function; however, the potential for bowel preparation to affect cognitive function has not previously been investigated. To assess the effect of bowel preparation for colonoscopy on cognitive function. This was a prospective, nonrandomized controlled study of cognitive function in patients who had bowel preparation for colonoscopy compared with those having gastroscopy and therefore no bowel preparation. Cognitive function was assessed using the Modified Mini Mental State Examination (MMMSE) and selected tests from the Cambridge Neuropsychological Test Automated Battery. Individual test scores and changes between initial and subsequent tests were compared between the groups. Age, gender, and weight were also compared. Forty-three colonoscopy and 25 gastroscopy patients were recruited. The 2 groups were similar for age and gender; however, patients having gastroscopy were heavier. MMMSE scores for colonoscopy and gastroscopy groups, respectively, were 28.6 and 29.5 (P = 0.24) at baseline, 28.7 and 29.8 (P = 0.32) at test 2, 28.1 and 28.5 (P = 0.76) at test 3. Motor screening scores for colonoscopy and gastroscopy groups, respectively, were 349.3 and 354.1 (P = 0.97) at baseline, 307.5 and 199.7 (P = 0.06) at test 2, 212.0 and 183.2 (P = 0.33) at test 3. Spatial working memory scores for colonoscopy and gastroscopy groups, respectively, were 14.4 and 6.7 (P = 0.29) at baseline, 9.7 and 4.3 (P = 0.27) at test 2, 10 and 4.5 (P = 0.33) at test 3. Digit Symbol Substitution Test scores for colonoscopy and gastroscopy groups, respectively, were 36.3 and 37.8 (P = 0.84) at baseline, 36.4 and 40.0 (P = 0.59) at test 2, 38.6 and 40.8 (P = 0.76) at test 3.This study did not find evidence of cognitive impairment resulting from administration of bowel preparation before colonoscopy.
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Affiliation(s)
- P Wadsworth
- From the Colorectal Unit, Department of Surgery, Christchurch Hospital, Christchurch, New Zealand (PW, HB, LD, BD, TE, AI, RM, RJP, CW, FAF) and Department of Psychological Medicine, University of Otago, Christchurch (RM and RP)
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22
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Chi AC, McGuire BB, Nadler RB. Modern Guidelines for Bowel Preparation and Antimicrobial Prophylaxis for Open and Laparoscopic Urologic Surgery. Urol Clin North Am 2015; 42:429-40. [PMID: 26475940 DOI: 10.1016/j.ucl.2015.05.007] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
Mechanical bowel preparation (MBP) and antibiotics (oral and/or intravenous) have historically been used to decrease infectious complications in surgeries that involve manipulation of bowel or potential risk of injury. The use of MBP has recently been challenged in the colorectal surgery literature, thus inspiring similar critical evaluation of our practices in urology. This review gives a brief overview of the history of mechanical and oral antibiotic bowel preparation, as well as the evolution of the practice trends in colorectal surgery and urology. We also examine contemporary guidelines in skin preparation as well as antimicrobial prophylaxis before surgery.
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Affiliation(s)
- Amanda C Chi
- Department of Urology, Northwestern University Feinberg School of Medicine, Chicago, IL 60611, USA
| | - Barry B McGuire
- Department of Urology, Northwestern University Feinberg School of Medicine, Chicago, IL 60611, USA
| | - Robert B Nadler
- Department of Urology, Northwestern University Feinberg School of Medicine, Chicago, IL 60611, USA.
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23
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Saltzman JR, Cash BD, Pasha SF, Early DS, Muthusamy VR, Khashab MA, Chathadi KV, Fanelli RD, Chandrasekhara V, Lightdale JR, Fonkalsrud L, Shergill AK, Hwang JH, Decker GA, Jue TL, Sharaf R, Fisher DA, Evans JA, Foley K, Shaukat A, Eloubeidi MA, Faulx AL, Wang A, Acosta RD. Bowel preparation before colonoscopy. Gastrointest Endosc 2015; 81:781-94. [PMID: 25595062 DOI: 10.1016/j.gie.2014.09.048] [Citation(s) in RCA: 292] [Impact Index Per Article: 29.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/18/2014] [Accepted: 09/18/2014] [Indexed: 01/10/2023]
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24
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Lee JY, Jang BI, Nam YJ, Song J, Kim MC, Chung SM, Jang JG, Cho JH. Severe hyponatremia and seizures after bowel preparation with low-volume polyethylene glycol plus ascorbic acid solution. Yeungnam Univ J Med 2015. [DOI: 10.12701/yujm.2015.32.1.55] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Affiliation(s)
- Jae Young Lee
- Department of Internal Medicine, Yeungnam University College of Medicine, Daegu, Korea
| | - Byung Ik Jang
- Department of Internal Medicine, Yeungnam University College of Medicine, Daegu, Korea
| | - Yoon Jeong Nam
- Department of Internal Medicine, Yeungnam University College of Medicine, Daegu, Korea
| | - Jay Song
- Department of Internal Medicine, Yeungnam University College of Medicine, Daegu, Korea
| | - Min Cheol Kim
- Department of Internal Medicine, Yeungnam University College of Medicine, Daegu, Korea
| | - Seung Min Chung
- Department of Internal Medicine, Yeungnam University College of Medicine, Daegu, Korea
| | - Jong Geol Jang
- Department of Internal Medicine, Yeungnam University College of Medicine, Daegu, Korea
| | - Jae Ho Cho
- Department of Internal Medicine, Yeungnam University College of Medicine, Daegu, Korea
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25
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Cho YS, Nam KM, Park JH, Byun SH, Ryu JS, Kim HJ. Acute hyponatremia with seizure and mental change after oral sodium picosulfate/magnesium citrate bowel preparation. Ann Coloproctol 2014; 30:290-3. [PMID: 25580417 PMCID: PMC4286777 DOI: 10.3393/ac.2014.30.6.290] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/22/2014] [Accepted: 09/12/2014] [Indexed: 12/22/2022] Open
Abstract
Sodium picosulfate/magnesium citrate (Picolight Powder), which is used as a bowel preparation for the colon and the rectum, can cause a severe electrolyte imbalance like hyponatremia. When hyponatremia gets severe or occurs rapidly, it can lead to death due to associated complications. We have experienced a case of hyponatremia associated with seizure and loss of consciousness in a 76-year-old woman, who took sodium picosulfate/magnesium citrate as a bowel preparation for colonoscopy. She was taking thiazide and synthroid for the treatment of hypertension and hypothyroidism, respectively, and she had other underlying medical conditions such as a history of seizure and dementia. Following the diagnosis of hyponatremia, we used an intravenous injection of 3% NaCl to normalize the sodium level in her serum, and her associated symptoms soon disappeared.
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Affiliation(s)
- Young Sun Cho
- Department of Internal Medicine, Wallace Memorial Baptist Hospital, Busan, Korea
| | - Kyung Min Nam
- Department of Internal Medicine, Wallace Memorial Baptist Hospital, Busan, Korea
| | - Jang Ho Park
- Department of Internal Medicine, Wallace Memorial Baptist Hospital, Busan, Korea
| | - Sang Hwan Byun
- Department of Internal Medicine, Wallace Memorial Baptist Hospital, Busan, Korea
| | - Jin Suck Ryu
- Department of Internal Medicine, Wallace Memorial Baptist Hospital, Busan, Korea
| | - Hyun Ju Kim
- Department of Internal Medicine, Wallace Memorial Baptist Hospital, Busan, Korea
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26
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Parra-Blanco A, Ruiz A, Alvarez-Lobos M, Amorós A, Gana JC, Ibáñez P, Ono A, Fujii T. Achieving the best bowel preparation for colonoscopy. World J Gastroenterol 2014; 20:17709-17726. [PMID: 25548470 PMCID: PMC4273122 DOI: 10.3748/wjg.v20.i47.17709] [Citation(s) in RCA: 56] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/25/2013] [Revised: 07/20/2014] [Accepted: 11/08/2014] [Indexed: 02/06/2023] Open
Abstract
Bowel preparation is a core issue in colonoscopy, as it is closely related to the quality of the procedure. Patients often find that bowel preparation is the most unpleasant part of the examination. It is widely accepted that the quality of cleansing must be excellent to facilitate detecting neoplastic lesions. In spite of its importance and potential implications, until recently, bowel preparation has not been the subject of much study. The most commonly used agents are high-volume polyethylene glycol (PEG) electrolyte solution and sodium phosphate. There has been some confusion, even in published meta-analyses, regarding which of the two agents provides better cleansing. It is clear now that both PEG and sodium phosphate are effective when administered with proper timing. Consequently, the timing of administration is recognized as one of the central factors to the quality of cleansing. The bowel preparation agent should be administered, at least in part, a few hours in advance of the colonoscopy. Several low volume agents are available, and either new or modified schedules with PEG that usually improve tolerance. Certain adjuvants can also be used to reduce the volume of PEG, or to improve the efficacy of other agents. Other factors apart from the choice of agent can improve the quality of bowel cleansing. For instance, the effect of diet before colonoscopy has not been completely clarified, but an exclusively liquid diet is probably not required, and a low-fiber diet may be preferable because it improves patient satisfaction and the quality of the procedure. Some patients, such as diabetics and persons with heart or kidney disease, require modified procedures and certain precautions. Bowel preparation for pediatric patients is also reviewed here. In such cases, PEG remains the most commonly used agent. As detecting neoplasia is not the main objective with these patients, less intensive preparation may suffice. Special considerations must be made for patients with inflammatory bowel disease, including safety and diagnostic issues, so that the most adequate agent is chosen. Identifying neoplasia is one of the main objectives of colonoscopy with these patients, and the target lesions are often almost invisible with white light endoscopy. Therefore excellent quality preparation is required to find these lesions and to apply advanced methods such as chromoendoscopy. Bowel preparation for patients with lower gastrointestinal bleeding represents a challenge, and the strategies available are also reviewed here.
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27
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Rivero-Sánchez L, Pellisé M. [Bowel preparation for colonoscopy. Any significant progress on the horizon?]. GASTROENTEROLOGIA Y HEPATOLOGIA 2014; 38:287-300. [PMID: 25499609 DOI: 10.1016/j.gastrohep.2014.10.008] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/21/2014] [Revised: 10/21/2014] [Accepted: 10/27/2014] [Indexed: 02/07/2023]
Abstract
Colonoscopy is the method of choice for colorectal cancer screening. To be effective, screening colonoscopy must have high quality standards. The key element is the quality of the preparation. However, up to 20% of patients are inadequately prepared and, at present, anterograde washing is the least tolerated part of the procedure. In the choice of preparation, safety is a prerequisite and efficacy is a priority. Tolerance is a secondary but nevertheless influential factor in the quality of preparation and has consequently been the primary focus of many recent studies. In the last few years, a rapidly increasing number of studies have evaluated new drugs, dosages and adjuvant therapies to improve efficacy and tolerability. These studies have collaterally shown that inadequate preparation and lack of adherence to the prescribed regimen can be partially predicted, making it essential to identify this patient subgroup and invest the necessary effort in their instruction. New individualized and flexible approaches are expected for the different clinical scenarios. The search for the ideal colonoscopy preparation, which would be tolerable, safe and above all effective, remains open.
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Affiliation(s)
- Liseth Rivero-Sánchez
- Unidad de Endoscopia, Servicio de Gastroenterología, Institut Clínic de Malalties Digestives i Metabòliques, Hospital Clínic, Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, España
| | - María Pellisé
- Unidad de Endoscopia, Servicio de Gastroenterología, Institut Clínic de Malalties Digestives i Metabòliques, Hospital Clínic, Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, España.
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28
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Ell C, Fischbach W, Layer P, Halphen M. Randomized, controlled trial of 2 L polyethylene glycol plus ascorbate components versus sodium phosphate for bowel cleansing prior to colonoscopy for cancer screening. Curr Med Res Opin 2014; 30:2493-503. [PMID: 25180609 DOI: 10.1185/03007995.2014.960513] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
BACKGROUND Colonoscopy requires effective bowel preparation for adequate mucosal visualization. Safety and acceptability of bowel preparation are key components in colorectal cancer screening (CRC) populations. OBJECTIVE To compare the efficacy, safety and acceptability of bowel preparation with polyethylene glycol (PEG), ascorbic acid, sodium ascorbate (ascorbate components), sodium sulfate and electrolytes (PEG+Asc) or sodium phosphate (NaP). METHODS Consenting adults undergoing elective out-patient colonoscopy for CRC were randomized to take 2 L PEG+Asc or 90 mL NaP (control) following manufacturer's instructions. PEG+Asc was taken the evening before and morning of the colonoscopy; NaP was taken the morning and evening before colonoscopy. Participants followed a restricted diet specific to each preparation. Primary endpoint was bowel cleansing success (100% colon mucosa visible) rated by an independent expert panel (all experienced endoscopists) unaware of treatment allocations. Subject reported outcomes about the preparations were elicited. Adverse events were recorded. CLINICAL TRIAL REGISTRATION Clinicaltrials.gov: NCT00427089. RESULTS Successful bowel cleansing rate was significantly higher in the PEG+Asc (N = 242) than the NaP (N = 114) group (PEG+Asc 93.4% [95% CI 89.5-96.2] versus NaP 22.8% [15.5-31.6%], p < 0.0001). Subject reported outcomes on acceptability of the two different preparations were not significantly different (p = 0.238). However, taste ratings for PEG+Asc were significantly better versus NaP (mean VAS: 31.2 and 38.1 respectively, p = 0.0111). The proportion of patients prepared to receive the same preparation again was significantly higher in the PEG+Asc group (88.4% vs. 78.1%, p < 0.0001). CONCLUSIONS PEG+Asc provided superior bowel cleansing to NaP and was well tolerated. Findings for PEG+Asc are aligned with previous similar studies; however, differences observed in NaP cleansing results, especially for the proximal colon segments, may be due to factors including: differences in demographics and population types and the use of the validated Harefield Cleansing Scale as an assessment tool combined with expert reviews, which may have resulted in conservative cleansing assessments.
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Affiliation(s)
- C Ell
- Dr Horst Schmidt Kliniken GmbH, Klinik für Innere Medizin II , Wiesbaden , Germany
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29
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Florentin M, Liamis G, Elisaf MS. Colonoscopy preparation-induced disorders in renal function and electrolytes. World J Gastrointest Pharmacol Ther 2014; 5:50-54. [PMID: 24868484 PMCID: PMC4023323 DOI: 10.4292/wjgpt.v5.i2.50] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/15/2013] [Accepted: 04/16/2014] [Indexed: 02/06/2023] Open
Abstract
Colonoscopy and flexible sigmoidoscopy are commonly used mainly for colon cancer screening and detection, but also in several other situations such as inflammatory bowel disease (for diagnosis and follow up) and gastrointestinal hemorrhage. Bowel cleansing preparations mainly include polyethylene glycol and oral sodium phosphate solutions, with the later being most frequently used due to better toleration from patients. Despite their favourable safety profile these agents have been associated with renal function deterioration and electrolyte disorders, some of which were serious or even fatal. The present paper discusses the complications associated with colonoscopy preparation agents.
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Weir MA, Fleet JL, Vinden C, Shariff SZ, Liu K, Song H, Jain AK, Gandhi S, Clark WF, Garg AX. Hyponatremia and sodium picosulfate bowel preparations in older adults. Am J Gastroenterol 2014; 109:686-94. [PMID: 24589671 DOI: 10.1038/ajg.2014.20] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/26/2013] [Accepted: 01/14/2014] [Indexed: 12/11/2022]
Abstract
OBJECTIVES Bowel preparations are commonly prescribed drugs. Case reports and our clinical experience suggest that sodium picosulfate bowel preparations can precipitate severe hyponatremia in some older adults. At present, this risk is poorly quantified. We investigated the association between sodium picosulfate use and the risk of hyponatremia in older adults. METHODS We conducted a population-based retrospective cohort study using six linked administrative databases in Ontario, Canada. All Ontario residents over the age of 65 years who filled an outpatient bowel preparation prescription before colonoscopy were eligible. We enrolled new users of either sodium picosulfate (n=99,237) or polyethylene glycol (n=48,595). The primary outcome was hospitalization with hyponatremia within 30 days of the bowel preparation assessed by database codes. The secondary outcomes were hospitalization with urgent head computed tomography (CT) (a proxy for acute central nervous system disturbance) and all-cause mortality. RESULTS The baseline characteristics of the two groups, including patient demographics, comorbid conditions, and concomitant medications, were nearly identical. Compared with polyethylene glycol, sodium picosulfate was associated with a higher risk of hospitalization with hyponatremia (absolute risk increase: 0.05%, 95% confidence interval (CI): 0.04-0.06%, relative risk (RR): 2.4, 95% CI: 1.5-3.9), but not hospitalization with urgent CT head (RR: 1.1, 95% CI: 0.7-1.4) or mortality (RR: 0.9, 95% CI: 0.7-1.3). CONCLUSIONS Sodium picosulfate bowel preparations lead to more hyponatremia than polyethylene glycol. There was no evidence of increased risk of acute neurologic symptoms or mortality. The absolute increase in risk of hospitalization with hyponatremia remains low but may be avoidable through appropriate fluid intake or preferential use of polyethylene glycol in some older adults.
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Affiliation(s)
- Matthew A Weir
- 1] Division of Nephrology, Department of Medicine, Western University, London, Ontario, Canada [2] Kidney Clinical Research Unit, Western University, London, Ontario, Canada
| | - Jamie L Fleet
- Kidney Clinical Research Unit, Western University, London, Ontario, Canada
| | - Chris Vinden
- Division of General Surgery, Department of Surgery, Western University, London, Ontario, Canada
| | - Salimah Z Shariff
- 1] Kidney Clinical Research Unit, Western University, London, Ontario, Canada [2] Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada
| | - Kuan Liu
- 1] Kidney Clinical Research Unit, Western University, London, Ontario, Canada [2] Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada
| | - Haoyuan Song
- Schulich School of Medicine and Dentistry, Western University, London, Ontario, Canada
| | - Arsh K Jain
- 1] Division of Nephrology, Department of Medicine, Western University, London, Ontario, Canada [2] Kidney Clinical Research Unit, Western University, London, Ontario, Canada [3] Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada
| | | | - William F Clark
- 1] Division of Nephrology, Department of Medicine, Western University, London, Ontario, Canada [2] Kidney Clinical Research Unit, Western University, London, Ontario, Canada
| | - Amit X Garg
- 1] Division of Nephrology, Department of Medicine, Western University, London, Ontario, Canada [2] Kidney Clinical Research Unit, Western University, London, Ontario, Canada [3] Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada [4] Department of Epidemiology and Biostatistics, Western University, London, Ontario, Canada
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Abstract
Adequate bowel preparation is essential for optimal colonoscopy. Suboptimal bowel preparation occurs in 25% to 40% of cases and is associated with canceled procedures, prolonged procedure time, incomplete examination, increased cost, and missed pathology. There are several effective formulations for colon cleansing with a good safety profile. Split dosing should be implemented whenever possible in an effort to enhance tolerance and adherence, and improve mucosal visibility and overall quality of the examination. In this review, modern bowel preparations are discussed including their mechanism of action, mode of use, safety, and how to optimize outcomes.
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Affiliation(s)
- Ala I Sharara
- Division of Gastroenterology, Department of Internal Medicine, American University of Beirut Medical Center, Beirut, Lebanon.
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High- versus low-volume polyethylene glycol plus laxative versus sennosides for colonoscopy preparation in children. J Pediatr Gastroenterol Nutr 2013; 57:230-5. [PMID: 23568049 DOI: 10.1097/mpg.0b013e3182950ef5] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Abstract
OBJECTIVE Many protocols of bowel preparation are available for use in children; however, none of them is commonly accepted. The aim of the study was to evaluate the efficacy and acceptability of high-volume polyethylene glycol (PEG) versus low-volume PEG combined with bisacodyl (BPEG) versus sennosides for colonoscopy preparation in children. METHODS Participants ages 10 to 18 years were randomly assigned to receive either PEG 60 or PEG 30 mL kg⁻¹ day⁻¹ plus oral bisacodyl 10 to 15 mg/day or sennosides 2 mg kg⁻¹ day⁻¹ for 2 days. A blinded assessment of bowel cleansing was made by the endoscopist according to the Aronchick and Ottawa scales. Patient acceptability was evaluated with the visual-analog scale. Analysis was done on an available case analysis basis. RESULTS Of 240 patients enrolled in the study 234 patients were available for analysis of the efficacy of colon cleansing. There were no significant differences found among the 3 groups for the proportions of participants with excellent/good (PEG: 35/79, BPEG: 26/79, sennosides 25/76) and poor/inadequate (PEG: 20/79, BPEG: 28/79, sennosides 28/76) bowel preparation evaluated with the Aronchick scale and for the mean Ottawa total score (PEG: 5.47 ± 3.63, BPEG: 6.22 ± 3.3, sennosides: 6.18 ± 3.53). Acceptability of bowel cleansing protocol was similar in all of the groups (P = 0.8). CONCLUSIONS All 3 cleansing methods showed similar efficacy and tolerability; however, none of them was satisfactory.
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Otchy DP, Crosby ME, Trickey AW. Colectomy without mechanical bowel preparation in the private practice setting. Tech Coloproctol 2013; 18:45-51. [PMID: 23467770 DOI: 10.1007/s10151-013-0990-2] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/18/2012] [Accepted: 02/11/2013] [Indexed: 12/30/2022]
Abstract
BACKGROUND Despite randomized trials and meta-analyses demonstrating the safety of omitting mechanical bowel preparation (MBP) before colorectal surgery, private practice surgeons may hesitate to eliminate MBP for fear of being outside community standards. This study evaluated the safety of eliminating MBP before colectomy in a private practice setting. METHODS This prospective observational study included elective abdominal colorectal operations from one surgeon's practice from October 2008 to June 2011. MBP was not routinely utilized after November 2009. Postoperative 30-day complication rates and length of hospital stay were compared in patients with and without MBP. Multivariable regression models were developed to compare outcomes among study groups, adjusting for demographics, diagnoses, procedures, and year. RESULTS A total of 165 patients were analyzed. Demographics were similar between groups. Laparoscopic procedures were more common in patients without MBP due to increased laparoscopy over time (43 vs. 61 %, p = 0.03). As regards complications, infection rates were similar between groups (MBP 10.5 % vs. no MBP(NMBP) 11.4 %, adj p = 0.57). Patients without MBP had a shorter length of hospital stay (median: 6 vs. 5 days, p = 0.01), but those differences were not statistically significant after adjustment (p = 0.14). CONCLUSIONS Private practice surgeons should embrace evidence-based practice changes and make efforts to quantitatively evaluate the safety of those changes. Omission of MBP for most elective colectomy procedures appears to be safe with no significant increase in complications or length of hospital stay. Because MBP has substantial drawbacks, there is little justification for its routine use in the majority of elective abdominal colorectal procedures.
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Affiliation(s)
- D P Otchy
- Fairfax Colon and Rectal Surgery P.C., 2710 Prosperity Ave., Suite #200, Fairfax, VA, 22031, USA,
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Cao F, Li J, Li F. Mechanical bowel preparation for elective colorectal surgery: updated systematic review and meta-analysis. Int J Colorectal Dis 2012; 27:803-10. [PMID: 22108902 DOI: 10.1007/s00384-011-1361-y] [Citation(s) in RCA: 92] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/10/2011] [Indexed: 02/06/2023]
Abstract
PURPOSE Mechanical bowel preparation (MBP) for elective colorectal surgery has been practiced as a clinical routine for many decades. However, earlier randomized clinical trials (RCTs) and meta-analyses suggest that MBP should be abandoned before colorectal surgery because of the futility in reducing postoperative complications and motility. The new published results from three RCTs comparing MBP with no MBP in colorectal surgery in 2010 make the updating of systemic review and meta-analysis necessary. The aim of this study was to estimate efficacy of MBP in prevention of postoperative complications for elective colorectal surgery. METHOD A literature search was performed mainly in electronic database including Cochrane Library, EMBASE, and MEDLINE. The inclusion criteria were randomized clinical trials comparing MBP with no MBP before colorectal surgery. Septic complications, reoperation, and death were recorded as primary and secondary outcomes. The meta-analysis was conducted according to the QUOROM statement. RESULTS Fourteen RCTs were included in our analysis with a total number of 5,373 patients: 2,682 with MBP and 2,691 without. Comparing with no MBP for elective colorectal surgery, our study showed that MBP had not reduce any postoperative complications when concerning anastomotic leak [odds ratio (OR) 95% confidence interval (CI), 1.08 (0.82-1.43); P = 0.56]; overall SSI [OR 95% CI, 1.26 (0.94-1.68); P = 0.12]; extra-abdominal septic complications [OR 95% CI, 0.98 (0.81-1.18); P = 0.81]; wound infections [OR 95% CI, 1.21 (1.00-1.46); P = 0.05]; reoperation or second intervention rate [OR 95% CI, 1.11 (0.86-1.45); P = 0.42]; and death [OR 95% CI, 0.97(0.63-1.48); P = 0.88]. CONCLUSION No evidence was noted supporting the use of MBP in patients undergoing elective colorectal surgery. MBP should be omitted in routine clinical practice.
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Affiliation(s)
- F Cao
- Department of General Surgery, Xuanwu Hospital, Capital Medical University, 100053, Beijing, China
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Melnyk M, Casey RG, Black P, Koupparis AJ. Enhanced recovery after surgery (ERAS) protocols: Time to change practice? Can Urol Assoc J 2011; 5:342-8. [PMID: 22031616 DOI: 10.5489/cuaj.11002] [Citation(s) in RCA: 131] [Impact Index Per Article: 9.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Radical cystectomy with pelvic lymph node dissection remains the standard treatment for patients with muscle invasive bladder cancer. Despite improvements in surgical technique, anesthesia and perioperative care, radical cystectomy is still associated with greater morbidity and prolonged in-patient stay after surgery than other urological procedures. Enhanced recovery after surgery (ERAS) protocols are multimodal perioperative care pathways designed to achieve early recovery after surgical procedures by maintaining preoperative organ function and reducing the profound stress response following surgery. The key elements of ERAS protocols include preoperative counselling, optimization of nutrition, standardized analgesic and anesthetic regimens and early mobilization. Despite the significant body of evidence indicating that ERAS protocols lead to improved outcomes, they challenge traditional surgical doctrine, and as a result their implementation has been slow.The present article discusses particular aspects of ERAS protocols which represent fundamental shifts in surgical practice, including perioperative nutrition, management of postoperative ileus and the use of mechanical bowel preparation.
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Affiliation(s)
- Megan Melnyk
- Department of Urological Sciences, University of British Columbia, Gordon & Leslie Diamond Health Care Centre, Vancouver, BC
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Keedy AW, Yee J, Aslam R, Weinstein S, Landeras LA, Shah JN, McQuaid KR, Yeh BM. Reduced cathartic bowel preparation for CT colonography: prospective comparison of 2-L polyethylene glycol and magnesium citrate. Radiology 2011; 261:156-64. [PMID: 21873253 DOI: 10.1148/radiol.11110217] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
PURPOSE To prospectively compare adequacy of colonic cleansing, adequacy of solid stool and fluid tagging, and patient acceptance by using reduced-volume, 2-L polyethylene glycol (PEG) versus magnesium citrate bowel preparations for CT colonography. MATERIALS AND METHODS This study was approved by the institutional Committee on Human Research and was compliant with HIPAA; all patients provided written consent. In this randomized, investigator-blinded study, 50 patients underwent oral preparation with either a 2-L PEG or a magnesium citrate solution, tagging with oral contrast agents, and subsequent CT colonography and segmentally unblinded colonoscopy. The residual stool (score 0 [best] to 3 [worst]) and fluid (score 0 [best] to 4 [worst]) burden and tagging adequacy were qualitatively assessed. Residual fluid attenuation was recorded as a quantitative measure of tagging adequacy. Patients completed a tolerance questionnaire within 2 weeks of scanning. Preparations were compared for residual stool and fluid by using generalized estimating equations; the Mann-Whitney test was used to compare the qualitative tagging score, mean residual fluid attenuation, and adverse effects assessed on the patient experience questionnaire. RESULTS The mean residual stool (0.90 of three) and fluid burden (1.05 of four) scores for PEG were similar to those for magnesium citrate (0.96 [P = .58] and 0.98 [P = .48], respectively). However, the mean fecal and fluid tagging scores were significantly better for PEG (0.48 and 0.28, respectively) than for magnesium citrate (1.52 [P < .01] and 1.28 [P < .01], respectively). Mean residual fluid attenuation was higher for PEG (765 HU) than for magnesium citrate (443 HU, P = .01), and mean interpretation time was shorter for PEG (14.8 minutes) than for magnesium citrate (18.0 minutes, P = .04). Tolerance ratings were not significantly different between preparations. CONCLUSION Reduced-volume PEG and magnesium citrate bowel preparations demonstrated adequate cleansing effectiveness for CT colonography, with better tagging and shorter interpretation time observed in the PEG group. Adequate polyp detection was maintained but requires further validation because of the small number of clinically important polyps.
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Affiliation(s)
- Alexander W Keedy
- Department of Radiology, University of California, San Francisco, San Francisco Veterans Affairs Medical Center, VAMC, San Francisco, CA 94143, USA
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Adamcewicz M, Bearelly D, Porat G, Friedenberg FK. Mechanism of action and toxicities of purgatives used for colonoscopy preparation. Expert Opin Drug Metab Toxicol 2011; 7:89-101. [PMID: 21162694 DOI: 10.1517/17425255.2011.542411] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
IMPORTANCE OF THE FIELD In developed countries, colonoscopy volume has increased dramatically over the past 15 years and is the principle method used to screen for colon cancer. Preparations used for colon cleaning have evolved over the past 30 years. Some preparations have been shown to be unsafe and are now used on a limited basis. There has been progress on limiting the volume required and on taste improvement. AREAS COVERED IN THIS REVIEW This review provides an account of preparations used from 1980 when PEG-based preparations became widely available, until the present day. The review highlights their mechanism of action and principle toxicities. The handling of solutes and solute-free fluid by the colon is also reviewed. WHAT THE READER WILL GAIN The reader will gain a perspective on the factors considered in developing colonic purgatives and the rationale for choosing selected preparations based on patient factors such as age, co-morbidities and concomitant medications. TAKE HOME MESSAGE Although generally safe and effective, colonic purgatives have both acute and permanent toxicities. The safest preparations utilize PEG combined with a balanced electrolyte solution. Limitations of this preparation center on the volume required and poor taste. Alternative formulations are now available; however, those using sodium phosphate have fallen out of favor due to a risk of renal toxicity.
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Affiliation(s)
- Margaret Adamcewicz
- Temple University School of Medicine, Department of Medicine, Section of Gastroenterology, Philadelphia, PA 19140, USA
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38
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Hasan AG, Brown WR. Colonic cleansing for colonoscopy: a risk to be taken seriously. Gastrointest Endosc 2011; 73:616-8. [PMID: 21353860 DOI: 10.1016/j.gie.2010.11.050] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/13/2010] [Accepted: 11/29/2010] [Indexed: 02/08/2023]
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Roig JV, García-Fadrique A, Salvador A, Villalba FL, Tormos B, Lorenzo-Liñán MÁ, García-Armengol J. [Selective intestinal preparation in a multimodal rehabilitation program. Influence on preoperative comfort and the results after colorectal surgery]. Cir Esp 2011; 89:167-74. [PMID: 21333970 DOI: 10.1016/j.ciresp.2010.12.003] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2010] [Revised: 11/15/2010] [Accepted: 12/01/2010] [Indexed: 12/28/2022]
Abstract
INTRODUCTION Despite there being no evidence of the advantages of its use, mechanical bowel preparation (MBP) continues to be routine in colorectal surgery. Our objective is to analyse the impact of its selective use, as regards patient comfort and results, comparing a perioperative multimodal rehabilitation program (MMRH) with conventional care (CC). MATERIAL AND METHODS A prospective study of 108 patients proposed for elective surgery, assigned consecutively 2:1 to an MMRH protocol which only included MBP in rectal surgery with low anastomosis, or to CC in whom MBP was used except in right colon surgery. We also studied two Groups (A and B) with and without the use of MBP. Their tolerance, results and postoperative recovery variables were analysed. RESULTS Thirty-nine patients were included in Group A, and 69 in Group B. A MMRH protocol was used in another 69 patients. The Group A patients had more abdominal pain, anal discomfort, nausea and thirst, but there were no differences as regards, death, overall or local complications, whilst there was less complications, suture failures and death in the MMRH when compared with CC Group (P<.05). There were no advantages observed in the use of MBP as regards the start of bowel movements, tolerance to diet or hospital stay, but these parameters were favourable to the MMRH when compared with CC Group. CONCLUSIONS The restriction of MBP is safe, and associated with an MMRH program, contributes to a faster and more comfortable recovery, without increasing complications.
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Affiliation(s)
- José Vicente Roig
- Unidad de Coloproctología, Servicio de Cirugía General y del Aparato Digestivo, Consorcio Hospital General Universitario de Valencia, Valencia, Spain.
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Preoperative bowel preparation for patients undergoing elective colorectal surgery: a clinical practice guideline endorsed by the Canadian Society of Colon and Rectal Surgeons. Burns 2010; 36:1320-1; author reply 1318-20. [PMID: 21092431 DOI: 10.1016/j.burns.2010.03.019] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2010] [Accepted: 03/03/2010] [Indexed: 12/18/2022]
Abstract
BACKGROUND Despite evidence that mechanical bowel preparation (MBP) does not reduce the rate of postoperative complications, many surgeons still use MBP before surgery. We sought to appraise and synthesize the available evidence regarding preoperative bowel preparation in patients undergoing elective colorectal surgery. METHODS We searched MEDLINE, EMBASE and Cochrane Databases to identify randomized controlled trials (RCTs) comparing patients who received a bowel preparation with those who did not. Two authors reviewed the abstracts to identify articles for critical appraisal. We used the methods of the United States Preventive Services Task Force to grade study quality and level of evidence, as well as formulate the final recommendations. Outcomes assessed included postoperative infectious complications, such as anastomotic dehiscence and superficial surgical site infections. RESULTS Our review identified 14 RCTs and 8 meta-analyses. Based on the quality and content of these original manuscripts, we formulated 6 recommendations for various aspects of bowel preparation in patients undergoing elective colorectal surgery. CONCLUSION Taking into account the lack of difference in postoperative infectious complication rates when MBP is omitted and the adverse effects of MBP, we believe that, based on the literature, MBP before surgery should be omitted.
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Abstract
Efficient cleansing of the colon before a colonoscopy or a radiological examination is essential. The osmotically acting cathartics (those given the Anatomical Therapeutic Chemical code A06AD) currently used for this purpose comprise products based on three main substances: sodium phosphate, combinations of polyethylene glycol and electrolyte lavage solutions (PEG-ELS), and magnesium citrate. All these preparations give adequate cleansing results and have similar profiles in terms of the frequency and type of mild to moderate adverse effects. However, serious adverse events, such as severe hyperphosphatemia and irreversible kidney damage owing to acute phosphate nephropathy, have been reported after use of sodium-phosphate-based products. The aim of this Review is to provide an update on the potential safety issues related to the use of osmotically acting cathartics, especially disturbances of renal function and water and electrolyte balance. The available evidence indicates that PEG-ELS-based products are the safest option. Magnesium-citrate-based, hypertonic products should be administered with caution to elderly individuals and patients who are prone to develop disturbances in water and electrolyte balance. Sodium-phosphate-based products can occasionally cause irreversible kidney damage and should not be routinely used in bowel-cleansing procedures.
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Abstract
Colonoscopy is a routinely performed procedure in children and adolescents. Proper visualization of the intestinal mucosa, completion of the procedure, including examination of the terminal ileum, detection of pathological lesions, and therapeutic maneuvers, all are highly dependent on the quality of the bowel preparation. A significant proportion of patients, in some reports up to one third, are inadequately prepared for the examination, which leads to extended procedure time, incomplete examination, or need for repeat procedure. Aside from efficacy and safety, the most important aspects of colon preparation in pediatrics are ease of administration, palatability, dietary restriction, and minimization of disruption of daily routine. An ideal preparation does not exist and a wide variety of regimens are being used. Several of these have been investigated in pediatric clinical trials. This article reviews the published literature with an emphasis on the most commonly used agents, their mechanism of action, efficacy and ease of use, and safety.
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Chappell D, Jacob M. Influence of non-ventilatory options on postoperative outcome. Best Pract Res Clin Anaesthesiol 2010; 24:267-81. [PMID: 20608562 DOI: 10.1016/j.bpa.2010.02.004] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
Perioperative patient handling should urgently be updated according to current evidence and, if none is available, at least according to physiological knowledge. To prevent pulmonary aspiration, preoperative fasting for 2 h (clear fluids) and 6 h (solid food) and abdication of 20 min for smoking is sufficient. Beta-blockage requires an indication. Bowel preparation should be abandoned and minimal invasive surgery as well as local and regional anaesthesia should be used where possible. Fluid therapy should be rational and requirement-adapted, and hypothermia, postoperative nausea and vomiting, unnecessary drains, tubes and catheters avoided. A multi-modal opioid-sparing pain therapy, sufficient oxygenation as well as early nutrition and mobilisation all play an important role for patient outcome. Recent studies have postulated that combining single-modality evidence-based care principles into a multi-modal effort to enhance postoperative recovery has improved patient outcome. Henrik Kehlet termed such a principle the 'fast-track concept', comprehending the entire perioperative phase starting with preoperative preparation, over atraumatic surgical and anaesthesiological techniques reducing the neuroendocrine stress response and also comprising the postoperative treatment. This strategy has been shown to positively influence organ function, homeostasis, morbidity, need for hospitalisation and convalescence and, therefore, to reduce costs. Despite these promising results, general implementation of evidence-based measures leaves a lot to be desired. Further development of surgical minimally invasive techniques and ongoing evaluation of procedure-specific strategies is urgently warranted.
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Affiliation(s)
- Daniel Chappell
- Clinic of Anesthesiology, Ludwig-Maximilians-University, Nussbaumstrasse 20, 80336 Munich, Germany.
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Haris Á, Demeter P, Tóth I, Polner K. Severe hyponatremia and comatose state during colonoscopy preparation. Orv Hetil 2010; 151:828-31. [DOI: 10.1556/oh.2010.28855] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
A szerzők egy 83 éves nőbeteg esetét ismertetik, akinél kolonoszkópiás előkészítés során, de a nátrium-foszfát ozmotikus hashajtó bevételét megelőzően, hirtelen eszméletvesztés és epileptiform görcsök jelentkeztek. A laboratóriumi vizsgálat súlyos hyponatraemiát igazolt. Hypertoniás sóinfúzió hatására az elektrolitzavar rendeződött, az eszméletzavar lassan oldódott, és a beteg mentális állapota fokozatosan javulni kezdett. A hyponatraemia hátterében az előkészítéstől és a vizsgálattól való félelem, stressz indukálta ADH-szekréció és a beteg által „félreértett”, túlzott folyadékbevitel állt. Az esetismertetés célja, hogy felhívja a figyelmet a kolonoszkópiás vizsgálati előkészítés veszélyére, ami az orvos utasítását „túlzottan” betartó beteget fenyegeti, továbbá, hogy bemutassa az akut hyponatraemia ellátását.
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Affiliation(s)
- Ágnes Haris
- 1 Fővárosi Önkormányzat Szent János Kórháza és Észak-budai Egyesített Kórházai, Szent Margit Kórház Nefrológia Osztály Budapest Bécsi út 132. 1032
| | - Pál Demeter
- 2 Fővárosi Önkormányzat Szent János Kórháza és Észak-budai Egyesített Kórházai, Szent Margit Kórház Gasztroenterológia Osztály Budapest
| | - Ignác Tóth
- 3 Fővárosi Önkormányzat Szent János Kórháza és Észak-budai Egyesített Kórházai, Szent Margit Kórház Neurológiai Rehabilitációs Osztály Budapest
| | - Kálmán Polner
- 1 Fővárosi Önkormányzat Szent János Kórháza és Észak-budai Egyesített Kórházai, Szent Margit Kórház Nefrológia Osztály Budapest Bécsi út 132. 1032
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Xu R, Zhao X, Zhong Z, Zhang L. No advantage is gained by preoperative bowel preparation in radical cystectomy and ileal conduit: a randomized controlled trial of 86 patients. Int Urol Nephrol 2010; 42:947-50. [DOI: 10.1007/s11255-010-9732-9] [Citation(s) in RCA: 45] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2010] [Accepted: 03/20/2010] [Indexed: 10/19/2022]
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Syndrome of inappropriate secretion of antidiuretic hormone after endoscopic submucosal dissection for early gastric cancer. Clin J Gastroenterol 2009; 2:262-265. [PMID: 26192421 DOI: 10.1007/s12328-009-0085-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/16/2009] [Accepted: 03/31/2009] [Indexed: 10/20/2022]
Abstract
We report the first case of syndrome of inappropriate secretion of antidiuretic hormone (SIADH) after endoscopic submucosal dissection (ESD) for early gastric cancer. A 64-year-old man with early gastric cancer was admitted to our hospital for ESD. Baseline laboratory tests showed a serum sodium concentration of 132 mEq l(-1). We performed an ESD for the gastric cancer, which was 9 mm in diameter and located in the posterior wall of the mid-gastric body. The patient experienced nausea and lethargy the second day after ESD. His serum sodium level was low (118 mEq l(-1)), and he fulfilled the criteria for SIADH. Fluid restriction, infusion of normal saline, and administration of diuretics gradually increased his serum sodium level, and his symptoms disappeared. Endoscopists should recognize that SIADH is a potential complication of endoscopic procedures such as ESD, especially among patients with low baseline sodium concentrations.
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Dillon CE, Laher MS. The rapid development of hyponatraemia and seizures in an elderly patient following sodium picosulfate/magnesium citrate (Picolax). Age Ageing 2009; 38:487. [PMID: 19406975 DOI: 10.1093/ageing/afp054] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
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Abstract
PURPOSE The mechanisms of action, clinical efficacy, tolerability, and safety of two major classes of bowel purgatives, poly-ethylene glycol- electrolyte lavage solutions (PEG-ELSs) and sodium phosphate preparations, are reviewed. SUMMARY PEG-ELSs are osmotically balanced preparations that promote bowel cleansing through the ingestion of nonabsorbable fluid. Sodium phosphate preparations are hyperosmotic purgatives that promote bowel cleansing by osmotically drawing fluid into the bowel lumen for evacuation. Studies suggest that 2-L PEG-ELS regimens are generally as effective as and more tolerable than full-volume PEG-ELS preparations. Studies have also found that sodium phosphate tablets may provide a more tolerable alternative to PEG-ELS regimens and traditional sodium phosphate products without compromising bowel cleansing efficacy. Proper renal function plays a particularly important role in avoiding potential safety issues related to sodium phosphate-induced shifts in the fluid and electrolyte balance. Preventing dehydration in patients undergoing bowel preparation can prevent severe adverse events, regardless of the purgative administered. Optimizing the process of bowel preparation involves administering proper purgative choices in appropriate patient populations. Moreover, patient education and compliance with preparation instructions, including correct dosing and adequate hydration, may reduce the risk of adverse events and serious complications. CONCLUSION Although next-generation PEG-ELS and sodium phosphate products are well tolerated and preferred by patients over traditional bowel preparation regimens, safety issues remain a concern for both purgative classes. Sodium phosphate preparations are generally more effective and better tolerated than PEG-ELS formulations but should be administered with caution in patients with preexisting or at an increased risk for electrolyte disturbances.
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Affiliation(s)
- Gary Lichtenstein
- Division of Gastroenterology, Department of Medicine, Hospital of the University of Pennsylvania, 3400 Spruce Street, Philadelphia, PA 19104, USA.
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Updated systematic review and meta-analysis of randomized clinical trials on the role of mechanical bowel preparation before colorectal surgery. Ann Surg 2009; 249:203-9. [PMID: 19212171 DOI: 10.1097/sla.0b013e318193425a] [Citation(s) in RCA: 213] [Impact Index Per Article: 13.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
BACKGROUND Earlier meta-analyses of small randomized trials suggested that mechanical bowel preparation (MBP) should be omitted before colorectal surgery because it does not affect complication rates 0 mortality and may be even harmful; however, more recent large randomized trials suggested an increased occurrence of pelvic abscesses in the absence of MBP. Therefore, an updated large meta-analysis was conducted to re-evaluate the role of MBP in colorectal surgery. Furthermore, the influence of different kind of MBP regimes on infectious outcomes was examined. METHODS The meta-analysis was conducted according to the QUOROM statement; the inclusion criteria were randomized clinical trials comparing MBP with no MBP before colorectal surgery. The primary outcome was anastomotic leakage; secondary outcomes were other septic complications. RESULTS Fourteen trials were included with a total number of 4859 patients: 2452 in the MBP group and 2407 in the no MBP group. We found no statistical difference between the groups for anastomotic leakage [OR = 1.12 (0.82-1.53), P = 0.46], pelvic or abdominal abscess (P = 0.75), and wound sepsis (P = 0.11). When all surgical site infections were considered, the meta-analysis favored no MBP [OR = 1.40 (1.05-1.87), P = 0.02].Sensitivity analyses showed similar results for all subgroups but when poor or small trials were excluded, there was a slightly higher risk of deep abdominal abscesses with no MBP, however, the number needed to harm was as high as 333 patients, suggesting this difference to be not clinically relevant. The use of different MBP regimes did not influence primary and secondary outcomes. The main limitation concerned rectal surgery for which the limited data preclude any interpretation. CONCLUSION Although it did not confirm the harmful effect of mechanical bowel preparation (suggested by previous meta-analyses), this meta-analysis including almost 5000 patients, demonstrates with a high level of evidence that any kind of mechanical bowel preparation should be omitted before colonic surgery.
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