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Around 14 Million colonoscopies are performed every year in the United States (1). It is the most effective test for the detection and prevention of colorectal cancer, the second leading cause of cancer death in the United States (2). Aside from detection and prevention of colorectal cancer, colonoscopy is also performed for the detection and treatment of lower gastrointestinal tract diseases. All colonoscopies require bowel preparation to clean the colon wall, improve insertion of the colonoscope and allow thorough inspection during withdrawal. Two of the most important quality indicators in colonoscopy, adenoma detection rate and cecal intubation rate are influenced by the quality of the bowel preparation (3, 4, 5, 6). Inadequate bowel preparation is a risk factor for colon gas explosion during therapeutic colonoscopy (7, 8), fecal peritonitis (9), and post-polypectomy bleeding (10).
Inadequate bowel prep also represents a huge cost to the healthcare system. In one study, inadequate bowel preparation increased the direct cost of colonoscopy by 12%-22% depending on the practice setting (11). This cost is attributable to increased duration of the examination and the need for repeated procedures. This study did not include several costs including the indirect costs of inadequate bowel preparation for colonoscopy.
Despite the importance of good bowel preparation, up to 25% of all bowel preparations are considered inadequate (6). The recommended level of adequate bowel preparation is greater than 85% (12).
The Cost to the Individual
Inadequate bowel prep can be costly to the patients. Poor bowel preparation lowers the detection of colon polyps and colorectal cancers thereby increasing the risk of developing colorectal cancer especially if the patient fails to repeat the procedure in a timely fashion. The need for repeated procedures increases the risk of complications and its attendant costs. Often the cost of the purgative is borne by the patient. The cost of transportation is also borne by the patient. Patients are usually required to be accompanied by an adult. The wages of the patient and the accompanying adult is often lost for that day especially for low income hourly-paid workers.
The Cost to the Healthcare System
Inadequate bowel prep increases the time it takes to complete a colonoscopy due to time spent cleaning and suctioning the colon wall (11). This may lead to increased time spent by providers (gastroenterologists, nurses, technicians, anesthesiologists) on a procedure thereby reducing the overall number of colonoscopies performed during the work hours. This may also lead to increased need for medications used in sedation and their attendant costs.
The Cost to the Society
The societal cost of inadequate bowel prep is enormous. Inadequate bowel preparation can lead to increased morbidity and mortality from colorectal cancer as a result of aborted procedures, failure to reschedule, missed lesion and interval cancer. Repeat procedures increase the cost of colonoscopy. There is lost productivity associated with attendance at colonoscopy for the patient and the accompanying adult. Costs associated with inadequate bowel preparation represent opportunity cost for other essential healthcare needs and non-healthcare societal needs.
A radical solution is to eliminate the need for bowel preparation for colonoscopy. Indeed, a technology is currently being developed to test this strategy (13). This technology is far from being available and even if developed, cannot provide the therapeutic capabilities of colonoscopy. The most effective solution to the problem of inadequate bowel preparation will likely involve multiple strategies. Since the risk factors for inadequate bowel preparation are known, solutions should be developed to mitigate these risk factors. Poor bowel preparation has been attributed to factors such as chronic constipation, use of constipating medications especially opioids and tricyclic antidepressants, diabetes mellitus, obesity, prior resection of the colon, prior inadequate prep for colonoscopy, Medicaid insurance status, lower educational level, English as a secondary language status, longer wait times, and low health literacy (14, 15, 16, 17, 18, 19, 20, 21,22, 23). Specific therapies can address these risk factors (Table 2).
Solutions to inadequate bowel prep can be approached from three perspectives: the purgative, the patient and the provider (3 P’s, Table 3). Improvements are needed in the agents used for bowel preparation. The purgative has to be effective, affordable and easy to use. The split dosing strategy has become an effective strategy to improve compliance especially when large volume purgatives are used.
The provider should be able to identify patients at risk for inadequate bowel prep. Clinical decision tool to identify at risk population and recommend intensive bowel preparation regimen should be developed. The additional therapy may be in form of educational instructions or medication. The clinical decision tool may be embedded in the electronic medical records for easier use.
The patient should be able to follow simple instructions regarding bowel preparation. Comprehension of a written colonoscopy preparation leaflet is low especially among patients with low health literacy (22). Bowel preparation instructions should be available in the primary language of the patient. If possible, the instructions should be available in written and video formats. Educational booklet, especially with cartoon visual aid as well as video has been shown to improve the quality of bowel preparation (24, 25, 26). A telephone reminder a day before the procedure has been shown to improve adequacy of bowel preparation (27). To assure adequate bowel preparation before a patient shows up for colonoscopy, there must be a way for the patient to check their level of preparedness at home. Rectal effluent may predict adequacy of bowel preparation and may be used to guide further bowel preparation (28). Hydrogen breath test can also predict the quality of colonic preparation for colonoscopy though it is currently not being used in clinical practice (29, 30). The information from this bowel preparedness level must be actionable. Patients must be able to use this information to continue or escalate their bowel preparation.
Finally, in the event that inadequate bowel preparation is only identified during colonoscopy, salvage therapies should be available to improve bowel preparation if possible. Water flushes, enemas and additional use of purgative may be used.
Table 1. Cost of Inadequate Bowel Preparation
|Lower detection of polyps|
Lower detection of colon cancer
Need to repeat procedure
Increased exposure to risk of complications
Loss to follow-up before re-evaluation
Increased cost (co-pay, purgative, transportation,
Lost productivity (for patient and accompanying adult)
|Longer time to achieve cecal intubation|
Longer time to complete withdrawal
Increased use of resources (medication, personnel, equipment, materials)
|Increased morbidity and mortality from colorectal cancer
Increased healthcare cost
Table 2. Risk Factors for Inadequate Bowel Preparation and Solutions
|Type of risk factors||List of risk factors||Solutions|
Table 3. The 3 P’S of Bowel Preparation
|The Purgative||The Patient||The Provider|
(Low volume, acceptable taste)
|Able to follow simple prep instructions||Identify patients at risk for inadequate poor prep.|
|Effective by itself without an additional agent||Have instructions in primary language of the patient. If possible, the instructions should be available in written and video formats||Provide additional therapies (educational or additional prep agents) depending on risk stratification|
|Affordable||Review instructions on bowel prep a day before procedure||Provide telephone reminder a day before the procedure|
|Safe||Check level of preparedness and escalate prep if necessary||Have salvage therapies available if necessary|
Don’t be a poor prep
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- Froehlich F, Wietlisbach V, Gonvers JJ et al. Impact of colonic cleansing on quality and diagnostic yield of colonoscopy: the European panel of appropriateness of gastrointestinal endoscopy European multicenter study. Gastrointest Endosc 2005; 61: 378-384
- Lebwohl B, Kastrinos F, Glick M, et al. The impact of suboptimal bowel preparation on adenoma miss rate and the factors associated with early repeat colonoscopy. Gastrointest Endosc 2011; 73: 1207-1214
- Chokshi RV, Hovis CE, Hollander T, et al. Prevalence of missed adenomas in patients with inadequate bowel preparation on screening colonoscopy. Gastrointest Endosc 2012; 75: 1197-1203.
- Harewood GC, Sharma VK, de Garmo P. Impact of colonoscopy preparation quality on detection of suspected colonic neoplasia. Gastrointest Endosc 2003; 58: 76-79
- Manner H, Plum N, Pech O, Ell C, Enderle MD. Colon explosion during argon plasma coagulation. Gastrointest Endosc 2008; 67: 1123-1127
- Lades SD, Karamanolis G, Ben-Soussan E. Colonic gas explosion during therapeutic colonoscopy with electrocautery. World J Gastroenterol 2007; 13: 5295-5298
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- Kim HS, Kim TI, Kim WH, et al. Risk factors for immediate post-polypectomy bleeding of the colon: A multicenter study. Am J Gastroenterol 2006;101: 1333-1341
- Rex DK, Imperiale TF, Latinovich DR, Bratcher LL. Impact of bowel preparation on efficiency and cost of colonoscopy. Am J Gastroenterol 2002; 97: 1696-1700
- Johnson DA, Barkun AN, Cohen LB, et al. Optimizing adequacy of bowel cleansing for colonoscopy: Recommendations from the U.S Multi Society Task Force on Colorectal Cancer. Am J Gastroenterol 2014;109: 1528-1545
- Chatrath H, Rex DK. Potential screening benefit of a colorectal imaging capsule that does not require bowel preparation. J Clin Gastroenterol 2014; 48: 52-54
- Ness RM, Manam R, Hoen H, et al. Predictors of inadequate bowel preparation for colonoscopy. Am J Gastroenterol 2001; 96:1797–802
- Serper M, Gawron AJ, Smith SG, et al. Patient factors that affect quality of colonoscopy preparation. Clin Gastroenterol Hepatol 2014; 12:451–7
- Chan WK, Saravanan A, Manikam J, et al. Appointment waiting times and education level influence the quality of bowel preparation in adult patients undergoing colonoscopy. BMC Gastroenterol 2011; 11:86.
- Fatima H, Johnson CS, Rex DK. Patients’ description of rectal effluent and quality of bowel preparation at colonoscopy. Gastrointest Endosc 2010; 71:1244–1252
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- Hassan C, Fuccio L, Bruno M, et al. A predictive model identifies patients most likely to have inadequate bowel preparation for colonoscopy. Clin Gastroenterol Hepatol 2012; 10:501–6
- Spiegel BMR, Talley J, Shekelle P, et al. Development and validation of a novel patient educational booklet to enhance colonoscopy preparation. Am J Gastroenterol 2011; 106: 875-883
- Tae JW, Lee JC, Hong SJ, et al. Impact of patient education with cartoon visual aids on the quality of bowel preparation for colonoscopy. Gastrointest Endosc 2012;76: 804-11
- Prakesh SR, Verma S, McGowan J, et al. Improving the quality of colonoscopy bowel preparation using an educational video. Can J Gastroenterol 2013; 27: 696-700
- Liu X, Luo H, Zhang L, et al. Telephone-based re-education on the day before colonoscopy improves the quality of bowel preparation and the polyp detection rate: a prospective, colonoscopist-blinded, randomized, controlled study. Gut 2014; 63: 125-130
- Hoonsub So, Sun-Jin Boo, Hyungil Seo et al. Patient descriptions of rectal effluents may help to predict the quality of bowel preparation with photographic examples. Intes Res 2015; 13(2): 153-159
- Urita Y, Hike K, Torii N, et al. Hydrogen breath test as an indicator of the quality of colonic preparation for colonoscopy. Gastrointest Endosc 2003; 57: 174-177.
- Altomare DF, Bonfrate L, Krawczyk M, et al. The inulin hydrogen breath test predicts the quality of colonic preparation. Surg Endosc 2014; 28: 1579-87