solutions to inadequate bowel preparation

Inadequate bowel preparation is costly. Inadequate bowel prep is predictable. Solutions to the problems of inadequate bowel prep are available.  Predictors of inadequate bowel prep can be categorized into 2 groups: medical and non-medical. Some of the predictors can be modified before colonoscopy so that inadequate bowel prep can be avoided.

Medical predictors of inadequate bowel preparation

  • Prior inadequate bowel prep
  • Chronic constipation
  • Use of constipating medications like narcotics
  • Diabetes mellitus
  • Obesity
  • Prior resection of the colon
  • Stroke
  • Dementia
  • Cirrhosis
  • Parkinson disease
  • Eight or more prescription medications
  • Prior abdominal surgeries like hysterectomy.

Non-medical predictors of inadequate bowel preparation

  • Age greater than 60 years
  • Male gender
  • Single or widowed status
  • English as a second language
  • Lower household income
  • Low patient activation
  • Low health literacy
  • Longer wait times from scheduling to actual colonoscopy
  • Medicaid insurance
  • In-patient status (hospitalized patients)
  • Afternoon colonoscopies
  • Lower educational level (less than 12th grade education)

Solutions to inadequate bowel preparation

  • Use of large volume PEG-based bowel cleansing agents.
  • Use of adjuncts (over the counter laxatives like bisacodyl) in addition to bowel cleansing agents.
  • Intense diet restrictions prior to colonoscopy.
  • Intense patient education.
  • Use of patient activation programs.
  • Use of simple and clear instructions.
  • Provision of instructions in patient’s language.
  • Use of multiple formats in the provision of instructions.
  • Use of patient engagement tools like telephone, text messages, apps.

 

The table below describes risk factors for inadequate bowel preparation and potential strategies to mitigate them.

Solutions to Inadequate Bowel Preparation

Type of risk factorsList of risk factorsSolutions
  • Medical

  • Prior inadequate bowel prep

  • Chronic constipation

  • Use of constipating medications like psychotropics, opioid narcotics

  • Diabetes Mellitus

  • Obesity

  • Prior resection of the colon

  • Stroke

  • Dementia

  • Cirrhosis

  • Parkinson disease

  • ≥8 active prescription medications

  • Prior abdominal surgeries like appendectomy, hysterectomy


  • Consider large volume agents alone OR

  • Consider use of large volume agents PLUS adjuncts like bisacodyl or magnesium citrate OR

  • Consider low volume agents PLUS adjuncts like bisacodyl or magnesium citrate

  • Consider intense diet restrictions prior to colonoscopy such as low fiber diet x 72hrs, clear liquid diet x 24hrs.

  • Consider intense educational and patient activation programs

  • Non-medical

  • Age > 60 years

  • Male gender

  • Single or widowed status

  • English as a 2nd language

  • Lower household income

  • Low patient activation

  • Low health literacy

  • Longer wait times

  • Medicaid insurance

  • In-patient status

  • Afternoon colonoscopies

  • Lower educational level, ≤ 12th grade education


  • Provide clear, understandable instructions.

  • Provide instructions in the patient’s language

  • Provide instructions in multiple formats (brochures, video).

  • Open communication channels.

  • Involve a family member or friend

  • Telephone re-education a day before colonoscopy.

  • Instruction reminders (stickers, alarm clocks, phone apps)