July 16, 2010 — For colonoscopies performed in the afternoon, having patients drink the full gallon of a polyethylene glycol (PEG) bowel prep solution in the morning rather than the evening before results in better bowel cleansing, physicians in the U.S. report.
In their study, the right, middle, and left colon in the morning group were 3, 8 and 3 times more likely, respectively, to have a "good prep" than the evening group.
Patients also found the morning regimen easier to tolerate, with less bloating and better sleep quality.
"So doing the bowel prep on the morning of the procedure worked well for both the colonoscopists and for the patients," senior author Dr. Fernando J. Castro, from Cleveland Clinic Florida in Weston, told Reuters Health.
In 2009, the American College of Gastroenterology endorsed "split-PEG" as the optimal bowel prep regimen, with two liters taken the evening before and two liters the morning of the procedure.
Earlier this year, researchers in Philadelphia found that morning-dosing was clinically equivalent to the split-PEG schedule for afternoon colonoscopies, while a team in Korea reported "excellent" results with a split-dose regimen for morning procedures. (See Reuters Health stories of May 12 and June 24, 2010.)
The current study, published online July 6th in the American Journal of Gastroenterology, included 136 patients, mean age 52 years. Fifty-four percent were undergoing screening colonoscopy; the rest had altered bowel habits, abdominal pain or rectal bleeding. Dr. Castro's team excluded patients with a history of colon resection or suspicion of bowel obstruction.
They randomly assigned 68 patients to drink the solution between 5 and 9 PM the evening before colonoscopy, with nothing else but clear fluids that day. The other 68 were to drink the solution between 6 and 10 AM the same day of the procedure; they were allowed to eat breakfast the day before, followed by clear liquids for the rest of the day.
The eight endoscopists, unaware of the patient's protocol, assessed bowel cleansing using the Ottawa scale, which assigns a score of 0 (no liquid) to 4 (solid stool, not washable) to each part of the colon — right, middle, and left — as well as 0 to 2 points for overall quantity of fluid.
The mean total Ottawa scale score was 7.10 in the evening group and 4.73 in the morning group, and scores for each colon segment were consistently lower in the morning group (p < 0.01 for each comparison). In addition, patients in the morning group were twice as likely to receive the lowest (i.e., the best) score for overall fluid quantity in the colon.
One reason why the morning bowel prep results in better cleansing, Dr. Castro said, is that "as the patient finishes drinking the solution, bile starts to accumulate in the colon, staining the bowel so the colonoscopist can see less. The closer the colonoscopy to the time of the prep, the better the visibility is."
The number of patients with polyps and adenomas were similar for the two protocols. Likewise, withdrawal time, time to reach the cecum, and total duration of colonoscopy did not differ significantly between groups.
Patient questionnaires showed that those in the morning group were 58% less likely to lose sleep (p = 0.038) and 55% less likely to have bloating (p = 0.027) compared with the evening group.
Dr. Castro recommends either the split-dose strategy or using the whole gallon of solution on the morning preceding afternoon colonoscopies.
As to whether patients could cut the dose of the prep solution — which many find unpleasant — that will require head-to-head trials, he added.
Am J Gastroenterol. Published online July 6, 2010.
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