New guidelines for optimizing bowel preparation in colonoscopy procedures

Updated consensus recommendations by the U.S. Multi-Society Task Force on Colorectal Cancer (MSTFCRC) address optimizing the quality of bowel preparation for colonoscopy. The document presents clinical strategies to improve bowel preparation as they apply before, during, and after colonoscopy. 

The MSTFCRC offers evidence-based recommendations and key concepts on topics including patient education and navigation, dietary restrictions, choice of preparation agent, the timing and volume of doses, routine use of irrigation pumps to assist with bowel cleansing during colonoscopy, and same-day salvage maneuvers for inadequate preps. In recognizing bowel preparation adequacy rate as a quality measure, the authors recommend a "reasonable benchmark" of greater than or equal to 90% at both the level of individual endoscopists and at the level of the endoscopy unit. The majority of the MSTFCRC recommendations focus on outpatients at low risk for inadequate bowel cleansing, but statements addressing those at risk for inadequate bowel prep quality are also provided. 

The MSTFCRC includes representatives from the three U.S. GI societies, the American College of Gastroenterology (ACG), the American Gastroenterological Association (AGA), and the American Society for Gastrointestinal Endoscopy (ASGE). This consensus document is published online today in the three societies' respective scientific journals. 

"Colorectal cancer remains the second most common cause of cancer death in the United States, and colonoscopy is considered the gold standard for evaluating the colon, including assessing causes of colon-related signs or symptoms and the detection of precancerous lesions. It is well recognized that the adequacy of bowel preparation is essential for optimal colonoscopy performance," write the MSTFCRC authors. 

Our guidance, which is an update of the 2014 recommendations, aims to help all gastroenterologists achieve a benchmark of 90% of exams with adequate bowel preparation. Highlights include the use of low volume bowel preparation and the adjunctive use of simethicone."

Joseph C. Anderson, MD, FACG, one of the co-lead authors of the MSTFCRC recommendations

"Bowel preparation is a vital part of colonoscopy. If the colon is not adequately cleaned, the person performing the colonoscopy may miss important findings such as small polyps. Many cases end up cancelled when the bowel preparation is inadequate, and that creates tremendous frustration for patients and inefficient use of resources," added Brian C. Jacobson, MD, MPH, FACG, AGAF, FASGE, also a co-lead author. 

Select recommendations and key concepts 

Choice of prep, dosing and timing, and dietary restrictions 

• According to MSTFCRC, the choice of bowel preparation regimen, including the purgative, should take into consideration patient preference, comorbidities, safety, associated additional costs to the patient for both prescription and over-the-counter purgatives and adjuncts, and ease for the patient in obtaining and consuming any purgatives or adjuncts. 

• The authors recommend the selection of a bowel preparation regimen that considers the individual's medical history, medications, and, when available, the adequacy of bowel preparation reported from prior colonoscopies. 

• Timing of the doses of bowel preparation agents has implications for the adequacy of bowel cleansing depending upon time of day for the colonoscopy. The authors write that "splitting the doses of bowel preparation agents the night before and morning of colonoscopy and using a 2-liter regimen is sufficient for a morning colonoscopy, while a same-day regimen is an acceptable alternative for outpatients at low risk for inadequate bowel prep undergoing afternoon colonoscopy. A same-day regimen is recommended as an acceptable alternative for individuals undergoing afternoon colonoscopy, but we suggest that a same-day regimen is an inferior alternative for individuals undergoing morning colonoscopy." 

• The authors recommend that individuals using a split-dose regimen begin consuming the second portion of the bowel prep agent 4 to 6 hours before the time of the colonoscopy and complete the prep at least 2 hours before the procedure start. 

• Recommendations regarding dietary modifications depend upon the patient's risk for inadequate bowel prep. For ambulatory patients at low risk for inadequate bowel prep, the authors recommend limiting dietary restrictions to the day before a colonoscopy, relying on either clear liquids or low-fiber/low-residue diets for the early and midday meals. The authors provide a table of low-residue foods and sample meals reported in the scientific literature.

• While the authors do not find one bowel preparation purgative as superior to others, the document includes a table of characteristics of commonly used prep regimens including their side effects and contraindications.

Assessing bowel preparation 

• The MSTFCRC addresses documentation of bowel prep quality in the endoscopy report and recommends that quality be assessed after all washing and suctioning have been completed using reliably understood descriptors that communicate the adequacy of the preparation. 

• The authors recommend that the term "adequate bowel preparation" be used to indicate that standard screening or surveillance intervals can be assigned based on the findings of the colonoscopy. 

Postcolonoscopy: Prep adequacy rate as a quality measure 

• The MSTFCRC recommends routine tracking of the rate of adequate bowel preparations at the level of individual endoscopists and at the level of the endoscopy unit at a target of greater than or equal to 90% for both rates. 

Source: U.S. Multi-Society Task Force on Colorectal Cancer, Optimizing Bowel Preparation Quality for Colonoscopy: Consensus Recommendations by the US Multi-Society Task Force on Colorectal Cancer 

Brian C. Jacobson, MD, MPH, FACG, AGAF, FASGE; Joseph C. Anderson, MD, FACG; Carol A. Burke, MD, MACG, AGAF, FASGE; Jason A. Dominitz, MD, MHS, FACG, AGAF, MASGE; Seth A. Gross, MD, FACG, AGAF, FASGE; Folasade P. May, MD, PhD, MPhil, AGAF; Swati G. Patel, MD, MS; Aasma Shaukat, MD, MPH, FACG, AGAF, FASGE; and Douglas J. Robertson, MD, MPH, AGAF.