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Gow-Lee B, Gaumnitz J, Alsadhan M, Garg G, Amoafo L, Zhang Y, Fang J, Rodriguez E. Cirrhosis and Portal Hypertension Worsen Bowel Preparation for Screening Colonoscopy. J Clin Gastroenterol 2025; 59:82-89. [PMID: 38567898 DOI: 10.1097/mcg.0000000000001990] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/09/2023] [Accepted: 02/12/2024] [Indexed: 12/13/2024]
Abstract
BACKGROUND Colonoscopy is a diagnostic and therapeutic procedure that reduces colorectal cancer incidence and mortality but requires adequate bowel cleansing for high-quality examination. Past studies have suggested cirrhosis as a risk factor for worse bowel preparation. METHODS We carried out a match-controlled retrospective study evaluating patients with and without cirrhosis who underwent outpatient screening colonoscopies to assess the effect of cirrhosis and portal hypertension complications on preparation quality and endoscopic measures. We also did a subgroup analysis excluding patients with obesity. RESULTS We examined 1464 patients with cirrhosis and matched controls. Cirrhotic patients had lower mean Boston Bowel Preparation Scale (BBPS) scores and slower cecal intubation times. We found a single point increase in the Model for End-stage Liver Disease (MELD) score, as well as ascites, hepatic encephalopathy, and variceal hemorrhage were all associated with a longer cecal intubation time. Subgroup analysis excluding patients with obesity again found a significantly lower BBPS score and longer cecal intubation time while also finding a 24% drop in polyp detection. CONCLUSIONS Patients with cirrhosis have worse BBPS scores and longer cecal intubation times. Nonobese cirrhotic patients additionally have a lower polyp detection rate. Portal hypertension complications were associated with worsened preparation quality and longer cecal intubation times. Each incremental increase in MELD score lengthened cecal intubation time. These findings support a more aggressive bowel preparation strategy for patients with cirrhosis, especially patients with severe disease or portal hypertension complications.
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Affiliation(s)
- Benjamin Gow-Lee
- Department of Internal Medicine, Spencer Fox Eccles School of Medicine
| | - John Gaumnitz
- Department of Internal Medicine, Spencer Fox Eccles School of Medicine
| | | | - Gauri Garg
- College of Social and Behavioral Sciences
| | - Linda Amoafo
- Division of Biostatistics, Department of Population Health Science, Spencer Fox Eccles School of Medicine
| | - Yue Zhang
- Division of Epidemiology, Department of Internal Medicine, Spencer Fox Eccles School of Medicine
| | - John Fang
- Division of Gastroenterology, Hepatology, and Nutrition, Department of Internal Medicine, Spencer Fox Eccles School of Medicine, University of Utah, Salt Lake City, UT
| | - Eduardo Rodriguez
- Division of Gastroenterology, Hepatology, and Nutrition, Department of Internal Medicine, Spencer Fox Eccles School of Medicine, University of Utah, Salt Lake City, UT
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Gimeno-García AZ, Sacramento-Luis D, Ashok-Bhagchandani R, Nicolás-Pérez D, Hernández-Guerra M. Interventions to improve bowel cleansing in colonoscopy. Expert Rev Gastroenterol Hepatol 2025; 19:39-51. [PMID: 39758033 DOI: 10.1080/17474124.2025.2450699] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/31/2024] [Revised: 12/07/2024] [Accepted: 01/04/2025] [Indexed: 01/07/2025]
Abstract
INTRODUCTION Suboptimal bowel preparation adversely affects colonoscopy quality, increases healthcare costs, and prolongs waiting time. The primary contributing factors include poor tolerance to the preparation solutions, noncompliance with prescribed instructions, and suboptimal efficacy of the bowel cleansing solution itself. AREAS COVERED This review examined the predictive factors associated with suboptimal bowel preparation and discussed interventions aimed at improving bowel cleansing. It also provides evidence-based practical algorithms supplemented by insights from our own clinical experience. Relevant topics were reviewed using resources from the PubMed database. EXPERT OPINION Although current bowel preparation protocols are effective for the majority of patients, a significant proportion still present challenges for optimal preparation. These patients may benefit from personalized strategies tailored to the specific causes of preparation failure. Conducting a thorough interview is crucial for identifying the reasons for failure, particularly in patients who have previously experienced suboptimal preparation during colonoscopy. In colonoscopy-naïve patients, it is essential to assess the risk of suboptimal preparation. In both cases, interventions should be customized to either address the identified causes in the former group or employ preventive strategies to reduce the likelihood of failure in the latter.
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Affiliation(s)
- Antonio Z Gimeno-García
- Gastroenterology Department, Hospital Universitario de Canarias, La Laguna, Tenerife, Spain
- Instituto Universitario de Tecnologías Biomédicas (ITB) & Centro de Investigación Biomédica de Canarias (CIBICAN), Internal Medicine Department, Universidad de La Laguna, Tenerife, Spain
| | | | | | - David Nicolás-Pérez
- Gastroenterology Department, Hospital Universitario de Canarias, La Laguna, Tenerife, Spain
| | - Manuel Hernández-Guerra
- Gastroenterology Department, Hospital Universitario de Canarias, La Laguna, Tenerife, Spain
- Instituto Universitario de Tecnologías Biomédicas (ITB) & Centro de Investigación Biomédica de Canarias (CIBICAN), Internal Medicine Department, Universidad de La Laguna, Tenerife, Spain
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Shahini E, Sinagra E, Vitello A, Ranaldo R, Contaldo A, Facciorusso A, Maida M. Factors affecting the quality of bowel preparation for colonoscopy in hard-to-prepare patients: Evidence from the literature. World J Gastroenterol 2023; 29:1685-1707. [PMID: 37077514 PMCID: PMC10107216 DOI: 10.3748/wjg.v29.i11.1685] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/01/2022] [Revised: 02/02/2023] [Accepted: 03/07/2023] [Indexed: 03/17/2023] Open
Abstract
Adequate bowel cleansing is critical for a high-quality colonoscopy because it affects diagnostic accuracy and adenoma detection. Nevertheless, almost a quarter of procedures are still carried out with suboptimal preparation, resulting in longer procedure times, higher risk of complications, and higher likelihood of missing lesions. Current guidelines recommend high-volume or low-volume polyethylene glycol (PEG)/non-PEG-based split-dose regimens. In patients who have had insufficient bowel cleansing, the colonoscopy should be repeated the same day or the next day with additional bowel cleansing as a salvage option. A strategy that includes a prolonged low-fiber diet, a split preparation regimen, and a colonoscopy within 5 h of the end of preparation may increase cleansing success rates in the elderly. Furthermore, even though no specific product is specifically recommended in the other cases for difficult-to-prepare patients, clinical evidence suggests that 1-L PEG plus ascorbic acid preparation are associated with higher cleansing success in hospitalized and inflammatory bowel disease patients. Patients with severe renal insufficiency (creatinine clearance < 30 mL/min) should be prepared with isotonic high volume PEG solutions. Few data on cirrhotic patients are currently available, and no trials have been conducted in this population. An accurate characterization of procedural and patient variables may lead to a more personalized approach to bowel preparation, especially in patients undergoing resection of left colon lesions, where intestinal preparation has a poor outcome. The purpose of this review was to summarize the evidence on the risk factors influencing the quality of bowel cleansing in difficult-to-prepare patients, as well as strategies to improve colonoscopy preparation in these patients.
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Affiliation(s)
- Endrit Shahini
- Gastroenterology Unit, National Institute of Gastroenterology-IRCCS “Saverio de Bellis”, Castellana Grotte, Bari 70013, Italy
| | - Emanuele Sinagra
- Gastroenterology and Endoscopy Unit, Fondazione Istituto G. Giglio, Cefalù 90015, Italy
| | - Alessandro Vitello
- Gastroenterology and Endoscopy Unit, S.Elia-Raimondi Hospital, Caltanissetta 93100, Italy
| | - Rocco Ranaldo
- Department of Internal Medicine, “Mazzolani-Vandini” Hospital, Digestive Endoscopy, Ferrara 744011, Italy
| | - Antonella Contaldo
- Gastroenterology Unit, National Institute of Gastroenterology “S de Bellis” Research Hospital, Bari 70013, Italy
| | - Antonio Facciorusso
- Department of Medical Sciences, University of Foggia, Section of Gastroenterology, Foggia 71122, Italy
| | - Marcello Maida
- Gastroenterology and Endoscopy Unit, S.Elia-Raimondi Hospital, Caltanissetta 93100, Italy
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Grassi G, Lenci I, Signorello A, Milana M, Baiocchi L. Gastrointestinal endoscopy in cirrhotic patient: Issues on the table. World J Gastrointest Endosc 2021; 13:210-220. [PMID: 34326942 PMCID: PMC8311468 DOI: 10.4253/wjge.v13.i7.210] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/29/2021] [Revised: 06/22/2021] [Accepted: 06/28/2021] [Indexed: 02/06/2023] Open
Abstract
Patients with liver cirrhosis are fragile and present specific clinical hallmarks. When undergoing to gastrointestinal (GI) endoscopy, these subjects require an individual pre evaluation, taking into account: Level of haemostasis impairment, the individual risk of infection, the impact of sedation on hepatic encephalopathy and other factors. The overall assessment of liver function, employing common scoring systems, should be also assessed in the preprocedural phase. Beside some common general problems, regarding GI endoscopy in cirrhotic subjects, also specific issues are present for some frequent indications or procedures. For instance, despite an increased incidence of adenomas in cirrhosis, colon cancer screening remains suboptimal in subjects with this disease. Several studies in fact demonstrated liver cirrhosis as a negative factor for an adequate colon cleansing before colonoscopy. On the other hand, also the routine assessment of gastroesophageal varices during upper GI endoscopy presents some concern, since important inter-observer variability or incomplete description of endoscopic findings has been reported in some studies. In this review we discussed in details the most relevant issues that may be considered while performing general GI endoscopic practice, in patient with cirrhosis. For most of these issues there are no guidelines or clear indications. Moreover until now, few studies focused on these aspects. We believe that targeting these issues with corrective measures may be helpful to develop a tailored endoscopic approach for cirrhosis, in the future.
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Affiliation(s)
- Giuseppe Grassi
- Hepatology Unit, University of Tor Vergata, Rome 00100, Italy
| | - Ilaria Lenci
- Hepatology Unit, University of Tor Vergata, Rome 00100, Italy
| | | | - Martina Milana
- Hepatology Unit, University of Tor Vergata, Rome 00100, Italy
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Martel M, Ménard C, Restellini S, Kherad O, Almadi M, Bouchard M, Barkun AN. Which Patient-Related Factors Determine Optimal Bowel Preparation? ACTA ACUST UNITED AC 2018; 16:406-416. [PMID: 30390208 DOI: 10.1007/s11938-018-0208-9] [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] [Indexed: 02/07/2023]
Abstract
PURPOSE OF REVIEW Adequate bowel cleansing before colonoscopy is a simple concept but the high rate of inadequate or incomplete bowel cleanliness and its consequences have been the subject of many studies, guidelines, and meta-analysis. The complexity resides in all the factors surrounding preparation intake such as type and regimen of bowel preparation, diets, compliance, and also patient-related factors that all influence quality of the bowel preparation. The purpose of this review is to focus specifically on patient-related factors and their challenges. Patients with lower GI bleeding are excluded from this review. RECENT FINDINGS Patient factors that may be associated with a poor bowel preparation were searched for in the literature. With regard to patient's characteristics, higher age, male gender, and socio-economic status (lower income, Medicaid, and lower education) were all associated with higher rates of inadequate bowel preparation. Comorbidities such as inflammatory bowel disease (IBD), in-patients, body mass index (BMI), cirrhosis, constipation, and neurological condition as well as some pharmacotherapy were also associated with inadequate bowel preparation. Studies identifying predictive patient factors as well as those studying these patients in particular showed variability in the strength of the patient factor associations. Patients taking tricyclic antidepressant, narcotics, and those with neurological conditions were identified to have a stronger association with worse bowel cleanliness. Those can be implemented with the current recommendations of split-dosing. Identifying individual factors that can impact the quality of bowel cleanliness can be challenging. Some have been well-studied in the literature such as age, in-patient status, or constipation and others such as male gender or higher BMI have required more studies to clearly conclude on any possible association. In many studies, simple recommendations like walking 30 min during the preparation, and additional instructions or support have also been added to instructions to improve motility and compliance.
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Affiliation(s)
- Myriam Martel
- Division of Gastroenterology, McGill University Health Center, McGill University, Montreal, Canada
| | | | - Sophie Restellini
- Department of Specialties of Internal Medicine, Division of Gastroenterology, Geneva University Hospital, Geneva, Switzerland
| | - Omar Kherad
- Internal Medicine, La Tour Hospital, University of Geneva, Geneva, Switzerland
| | - Majid Almadi
- Division of Gastroenterology, King Khalid University Hospital, King Saud University, Riyadh, Saudi Arabia
| | - Maïté Bouchard
- Division of Gastroenterology, McGill University Health Center, McGill University, Montreal, Canada
| | - Alan N Barkun
- Division of Gastroenterology, McGill University Health Center, McGill University, Montreal, Canada.
- Epidemiology and Biostatistics and Occupational Health, McGill University Health Center, McGill University, 1650 Cedar Avenue, D7.346, Montréal, Québec, H3G1A4, Canada.
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Mandolesi D, Frazzoni L, Bazzoli F, Fuccio L. The management of 'hard-to-prepare' colonoscopy patients. Expert Rev Gastroenterol Hepatol 2017; 11:731-740. [PMID: 28594580 DOI: 10.1080/17474124.2017.1338947] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Effective bowel cleansing is crucial for high quality colonoscopy. A notable portion of patients still present with low quality bowel preparation prior to their colonoscopy, compromising the overall quality of their colonoscopy. Areas covered: This review focuses on the main strategies that can improve the cleansing quality with a special interest on those clinical conditions that have been associated with a poor bowel preparation quality, such as patients with chronic constipation, history of bowel resection, liver cirrhosis, diabetes mellitus and chronic kidney disease. The review provides a practical and evidence-based approach to help clinicians in the management of 'hard-to-prepare' patients. Expert commentary: In the past few years, the quality of colonoscopy has become a hot topic and bowel cleansing is a crucial part of it; however, the approach to patients with an increased risk of poor bowel preparation quality is still not always supported by high-quality evidence, since most of these patients are routinely excluded from the clinical studies. Trials focused on this subgroup of patients are recommended to provide tailored bowel preparation regimens and guarantee high-quality procedures.
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Affiliation(s)
- Daniele Mandolesi
- a Gastroenterology Unit, Department of Medical and Surgical Sciences , University of Bologna, S.Orsola-Malpighi Hospital , Bologna , Italy
| | - Leonardo Frazzoni
- a Gastroenterology Unit, Department of Medical and Surgical Sciences , University of Bologna, S.Orsola-Malpighi Hospital , Bologna , Italy
| | - Franco Bazzoli
- a Gastroenterology Unit, Department of Medical and Surgical Sciences , University of Bologna, S.Orsola-Malpighi Hospital , Bologna , Italy
| | - Lorenzo Fuccio
- a Gastroenterology Unit, Department of Medical and Surgical Sciences , University of Bologna, S.Orsola-Malpighi Hospital , Bologna , Italy
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