1. Colon Prep Update: 2015 Let’s be clear
Harish K Gagneja, MD, AGAF, FACG, FASGE
President, TSGE
President, Austin Gastroenterology, P.A.

2. “The colonoscopy was a great experience except for the horrible bowel prep. There has to be an easier way to get cleaned out, doc!!”

3. A cleanly prepped colon
is a
critical component
of a
successful colonoscopy

4. Colon Prep

5. Oh no……..

6. Risk Factors for Poor Prep
Male
Elderly
Higher BMI
Unmarried
Co-morbities
Dementia
Sedentary life style
Diabetes
Opioids use
Prior inadequate bowel prep
Inpatient status

7. Bowel Prep is Important!!
Inadequate prep leads to
Longer procedure time
Lower ADR
Increased complications
Need for repeat examination – cost
Over 20 million colonoscopies are performed in US

8. Focus on Quality Bowel Prep
The success of a colonoscopy is closely linked to good bowel preparation, with poor bowel prep often resulting in missed precancerous lesions
40% miss rate for all polyps
27% miss rate large polyps

9. Focus on Quality Bowel Prep
Poor bowel cleansing can result in increased costs related to early repeat procedures. (1% rule: for each 1% of preparations that are inadequate the cost of delivering colonoscopy increases by 1%)

10. Focus on Quality Bowel Prep
The discomfort and inconvenience of bowel preparation affects participation in colonoscopy screening programs
The quality of bowel cleansing affects:
Cecal intubation rate
polyp detection rate
Flat polyps detection rate
Patients lost to follow up

11. Focus on Quality Bowel Prep
Bowel Prep added to Key Quality measures to be reported
Bowel Prep (New)
Detection
Documentation of cecal intubation
Screening & surveillance intervals
Up to 20 to 25 percent of all colonoscopies are reported to have an inadequate bowel preparation – target to reduce to less than 15%. (Adequate preparation should be achieved in ≥90% of exams (my opinion)

12. Ideal Bowel Prep for Colonoscopy
Should be
Safe
Tolerable by the patient
Effective to clean the colon and hence improve adenoma detection

13. Which one is the ideal bowel prep for the colonoscopy?

14. NONE!!

15. Preps for Colonoscopy – FDA approved
GoLYTELY/NuLYTELY/TriLyte/colyte
4-L PEG 3350 ES
HalfLytely - 2L PEG 3350ES/Bisacodyl
MoviPrep – 2L PEG 3350 ES/Ascorbic acid
SUPREP – Oral sulfate solution
Osmoprep – Sodium Phosphate tablets
Prepopik – Picosulfate solution

16. Preps for Colonoscopy – Non-FDA approved
MiraLAX and Gatorade mixture
MagCitrate combined with Bisacodyl (LoSoPrep)
MagCitrate and MiraLAX
MiraLAX/Gatorade combined with Bisacodyl
Any combination of the above – Really!!

17. New Considerations in Prep
Low pressure intra-colonic water infusion system aka “HyGIeacare”

18. 4-L PEG Solutions PROS - safe, effective especially with split dose
CONS – large volume, caution with elderly, nausea, cramps, fullness, bloating and palatability issues for some patients,
C/I – GI obstruction, gastric retention, bowel perforation, toxic colitis and toxic maegacolon

19. HalfLytely PROS – safe, better tolerated than 4L solutions
CONS – Less effective than 4L solutions, similar side-effects as with 4L solutions, concerns about Ischemic colitis changes with Bisacodyl use
C/I – GI obstruction, gastric retention, bowel perforation, toxic colitis and toxic maegacolon

20. MoviPrep
PROS – safe, better tolerated than 4L solutions (overall volume is 2L prep and 1L clear liquids), effective
CONS – Taste, may cause malaise, nausea, abdominal pain and vomiting, serious AEs may occur as a result of electrolyte abnormalities, use with caution in patients with renal dysfunction

21. SUPREP PROS – Well tolerated due to small volume, effective
CONS – Taste, may cause discomfort, abdominal distension, pain, nausea and vomiting, may cause temporary elevations in uric acid, caution in renal disease, expensive with variable insurance coverage

22. OSMOPREP – “pills”
PROS - Well tolerated, effective, better tolerated than the PEG solutions
CONS – May cause bloating, abdominal pain, nausea and vomiting, rare reports of phosphate nephrotoxicity (black box warning from the FDA)
C/I – Renal disease, cirrhosis, CHF, concomitant use of medications that can affect renal function such as ACEI, diuretics, elderly are at risk for complications

23. MiraLAX Prep
PEG-3350 solution without added electrolytes – not balanced
Not FDA approved
Pros – Low volume prep (2L), tolerated well (although study comparing the 4L golytely and MiraLAX prep showed no difference in tolerability)*
Cons – Electrolyte disturbances especially hyponatremia has been reported, inferior to 4L PEG solution when used as split dose. **
*Enestvedt BK, et al. Aliment Pharmacol Ther. 2011;33(1):33-40
**Hjelkrem M, et al. Clin Gastroenterol Hepatol. 2011;9(4):

24. Comparison of Different Preps
Purgative
Number of Trials
ITT Patients
OR (95% CI)
PEG split HD
PEG split LD 6
1,305
1.89 ( )
PEG split vs NaP split 1
218
0.35 ( )
PEG split vs PICO split 89
6.32 ( )
PEG split vs OSS split
379
1.07 ( )
NaP split vs PICO split
372
1.15 ( )
Menard et al, GIE, 2014

25. Miralax/Gatorade Prep
Patients like this
Physicians use it frequently
Siddiqui et al 2014, 5 trials,
Adequate prep ( )
ADR NS
Side effects NS
Willingness to repeat ( )
Multiple case reports of hyponatremia, not FDA approved

26. Timing of Prep
Day before
Split dose
Same day prep

27. Split Dose Prep : Efficacy
Author
Timeframe
No. of Trials
Efficacy/OR
Kilgore 2011 5
3.7 ( )
Enestvedt 2012 9
3.5 ( )
Bucci 2014 29
85% vs 63%
Martel 2015 47
2.5 ( )

28. Split Dose Prep – Patient Considerations
Well accepted
Increased compliance (94% vs 84%)
Willingness to repeat (OR )

29. The Split-Dose Difference

30. Split Dose Prep: ADR Martel et al 2015, meta-analysis 47 trials
OR 1.5 ( )

31. Split Dose Prep is the
standard of care in
2015

32. Same Day Prep for PM cases
Author
No. of Patients
Comparison
Adequacy of Prep
P-value
Church 1998
317
AM vs PM
90% vs 73%
<0.01
Varughesa 2010
136
4.7 vs 7.1
Ottawa scale
Matro 2010
116
AM vs PM/AM
92% vs 94%
0.01*
*non-inferior
Longcroft 2012
227
98% vs 90%

33. Low Pressure Intra-colonic water infusion system

34. Low Pressure Intra-colonic water infusion system
Prep Tech introduces lubricated, sterile disposable nozzle into the rectum.
Gentle stream of temperature controlled gravity-flow water loosens stool and induces peristalsis for natural evacuation of the colon.
Patient evacuates bowel and urinates freely and naturally throughout the procedure.
Prep is complete when clear water exits the body and the trained practitioner determines that patient has completed all phases of cleansing (usually less than one hour).

35. Low Pressure Intra-colonic water infusion system – Safety Features
Stringent validated disinfection protocol
Rectal nozzle is gently arched and ergonomic, with a diameter of less than 1 cm.
Water flows through both a sediment and UV filter.
Temperature of the water is steadily maintained in the safe range between 37-39° C as set by the operator.
Water automatically stops flowing to the patient should the temperature go above 39° C.
Water pressure is maintained at approximately 1 psi (well below the 2 psi limit the large intestine can safely tolerate

36. Low Pressure Intra-colonic water infusion system - AG Experience

37. ADR: AG vs National Average
25%
18%
6 minutes
Austin Gastro
39%
27%
9 minutes
ADR-Male
ADR-Female
W/D Time

38. Low Residue Diet and Prep
Clear liquids versus low residue diet
Gut activity, stimulated by food
DDW 2015, abstract, Nguyen et al
5 studies, meta-analysis
OR 3.2 ( )

39. Adjuncts to Preparation
Simethicone
Bisacodyl
Lubiprostone
Prokinetics
Lopermide
Probiotics
Olive oil

40. Patient Education Patient must be engaged
Written instructions +/- visual aids - works
Educational booklet – better prep
YouTube videos – increased ADR
Smartphone Apps – not widely used

41. Conclusions Split the dose Consider low residue diet Patient education
Shoot for 4 hr runway time
Consider low residue diet
Non-inferior cleaning
Increased tolerability
Patient education

42. Thank You