So we're back now we're moving down to the lower GI tract and I wanted to talk about bowel preparation before colonoscopy. So I have no disclosures. And the objectives of this presentation we're going to be going over the timing of the preparation regimens for colonic cleansing prior to the colonoscopy adjunctive measures that can be used. Diet during the bowel cleansing and selection of the bowel preparation in specific populations. Now anyone who's experienced in gastroenterology, this is probably the number one question that our patients ask us is, has the preparation changed? So I hope that this is going to arm you with some additional information you can take back to your clinic. So polling question number one, which colon preparation would you avoid in the elderly in renal disease? Great. That is the correct answer. So the magnesium citrate can cause difficulties in elderly patients and renal disease. Okay, next polling question, which of the following is not a common side effect from colon preparations? Number one, bloating, number two, diarrhea, number three, nausea, number four, excessive laughter. 100%. Oh, some people think that there's laughter. Okay. So excessive laughter is not one of the common side effects from the preparation. Thank you. All right. So the timing of the preparation is important to go over with your patients. And I'm not sure how your practices are set up, but the preparations are ordered by you as a provider or by the gastroenterologist. And then usually that task is handed off to your medical assistant to go over the details of the preparation. The amount of time that our staff spends with patients going over this preparation is going to ensure success. And that's the key outcome for the patient's understanding of this preparation is because you want to make sure the bowel is clean. So timing of the preparation, there's split dose preparation is preferred regimen. And this probably recently transitioned, I want to say, over the last five to seven years. And there really was a lot of great data to show if you give half the preparation the evening before and then the other half the preparation earlier in the morning, you get a better cleaning of the bowel. And you don't not only do you not have the solid matter or solid or liquid stool, but also the volume of the stool is defecated from the colon. You get a higher quality preparation, as I mentioned, improve patient tolerance and the day before in the morning of the procedure. So the timing of that preparation that day before your first dose is 1700 to 1800 in the afternoon. And what I tell patients is because they always want to know if they can work the day before the procedure. So you as the clinician should be familiar with the preparation schedule so you can give them that additional guidance before you're handing them off. So the day two or the day of the procedure, the second dose is going to be three to eight hours prior to procedure. No difference in that residual gastric fluid between your split dose and the single dose the day before too. And what's interesting is that now that we've opened up our schedule, we're seeing more patients in the afternoon. This is this type of preparation, the timing has worked out really well because you can have that staggered time of the three to eight hours before the procedure. So timing of your preparation, you have hospitalized patients will prefer for the split prep and patients undergoing afternoon colonoscopy bowel preps. You can administer it almost entirely the morning of the examination, which from someone who's experienced at first. You know, you really question this methodology, but it's worked out so well for patients because that's where you see you get a lot of the side effects is from the volume of the fluid that the patients we've been asking patients to take over the years at that one time. That's where you get the side effects of the nausea and vomiting. So the regiments for the bowel cleansing before the colonoscopy, we can break it down into three agents and then a combination agent. So there's iso-osmotic agents, the hyper-osmotic agents, hyper-osmotic agents and the combination agents. And I'll go ahead and go over some of the combination side effects and the brand names. So your iso-osmotic agents is the good old fashioned PEG or polyethylene glycol, which would come in your four liter drug. And patients would be asked to drink that, you know, within a relatively short period of time. It's good safety profile, but the problem is you'd have your side effects of more nausea, vomiting, bloating and abdominal cramping. Now, sometimes what would be combined with that would be a prokinetic agent, which would help stimulate the bowel to help propulse the liquid, which is your bisacodyl and fleece enema. And what you see a lot of times, most of the time is that bisacodyl that is triggering the nausea and vomiting that our patients are calling about. So iso-osmotic agents is high volume, go lightly, new lightly. Low volume is the movie prep or plan view. Much more tolerable preparation, but similar efficacy. The hypo-osmotic agents are the low volume PEG preps. So you're looking at a Miralax prep, requires the addition of a commercially available sports drink. So our organization, we actually recommend Gatorade, not FDA approved for prep, not equivalent to other low volume preps, but it's widely used. In fact, our department, we have seven practicing gastroenterologist seeing patients. And there was a point in time that we had seven different preparations in our organization. And some of them were very designer based, very personal preference. So it was an act of Congress in our department to actually transition all of our practicing providers into one preparation. So our medical assistants are certainly ecstatic that we have now one preparation that we use. Of course, in special circumstances, if a patient has problems with chronic constipation or we need to give them an additional day, then it's usually clear liquids the day before and maybe additional laxatives that day before. So the hyper-osmotic agents, the oral sodium sulfate, no significant electrolyte shift, well tolerated, compares well to other low volume preps. And this is under the brand name of Suprep. The hyper-osmotic agents or magnesium citrate, it's not FDA approved, but this was one that we were using for the longest time. In fact, we would have bottles of magnesium citrate in our office and really the verbiage to our patients were that we're going to give them a goodie bag before they go home. In fact, we have an open access system in our organization. So in the front office, we have bags with magnesium citrate sitting out. And one of my patients I had seen for a different reason actually picked up a bottle and took it on the way home because she thought they were extra drinks. She told me about it later and fortunately she didn't start drinking it until she read the label. So this ingredient, one study did find that the magnesium citrate is superior to other low volume preps excreted via kidneys. And again, this is one of the polling questions you want to avoid in patients with renal disease or elderly patients with cardiac disease. The hyper-osmotic agents or the sodium phosphate, significant side effects, low volume prep, no longer available. So patients that you see repeatedly in your five-year, 10-year mark would come in to say, I want that prep that I had, that little small bottle, that was the best. And there's a lot of education you have to provide to patients explaining that, well, that's not a prep that's now offered, it's not commercially available. And discussing with patients the importance of colon preparations and the previous effects they had is so key to patient's compliance. And you have to really revisit what they had before. And it's almost as if you are a cheerleader as you're in that exam room because you're encouraging them that this is a different preparation this year, you can do this. You can do it, you're going to be okay. It's going to have a different tolerability. Just make sure that you stay well hydrated and you're getting in enough electrolytes. So the combination preparation, the sodium phosphate and the magnesium citrate or the pre-POPIC prep. Stimulant laxative with the osmotic laxative compares well to other low volume preps. Again, well tolerated, but you're going to have some side effects of abdominal cramping. You're going to have some side effects of abdominal cramping, nausea, and vomiting can occur. So that combination preparation that I talked about, the osmotic laxative day one, you're going to have 12 tablets, 48 ounces of water over 80 minutes. And then day two, five to eight hours prior to the colonoscopy, you'll repeat day one. Now, the interesting part about the tablets is that patients will come in and say, I want the tablets. I heard about there's a tablet and I don't have to drink all that fluid. What patients don't realize is that they still have a large volume of fluid that they still need to ingest. And then some of our gastroenterologists have personally found that it will leave a white residue in the colon if they don't drink enough liquid to make sure that they're completing the preparation properly. So that's not a preparation that we recommend unless patients will, unless it's a, it's a deal breaker and they'll say, absolutely, we'll not do it. And then we'll give them an extra day of clear liquids prior to that. Sodium and sulfate and PEG prep. This is the Suclair prep. Low volume compares well to other low volumes, but again, side effects of nausea and vomiting. So adjunctive measures, laxatives. So sometimes if there's been a more difficult prep before, then we'll give laxatives like a Fleet's Phospha, like a Fleet's Enema the morning of the procedure. You know, adjunctive measures, some of the preparations will come with flavoring, but it's important to listen to your patients or listen to what other patients have experienced. Sometimes the flavoring can make them nauseated. If you're having a patient that is hospitalized, sometimes that the preparations are going to be administered via NG tube. Sometimes I'll see orders that metoclopramide or Regulin is used to help stimulate the gut to help make it more tolerable so the preparation can then stay down and not have any nausea or vomiting. And then simethicone, which is coming much more widely used before procedures to make sure that you're not having the bubbles in the colon after the preparation. So dieting during the bowel cleansing, very, very important to be on a clear liquid diet that day before. If you're doing one or two days before the preparation starts, depending on the patient's tolerability or experience, and sometimes we'll recommend a full liquid diet. And definitely a low residue diet. Having performed procedures, there's nothing more discouraging and or frustrating than to have stool in your way and not be able to get a clear look because you want to be able to provide that patient with the best information. So there's a high incidence of missed colon lesions, so it's important that the bowel preparation is clear. Special considerations, advanced age, comorbid conditions, inflammatory bowel disease, no specific recommendations, and bariatric surgery, no specific recommendations. You want to consider a low volume preparation. I know most of my patients that have had gastric bypass surgery, they assume that if they're having two to three bowel movements per day and they've had a gastric bypass, then they don't feel that, you know, they need additional fluid than someone else who hasn't had any gastric surgery. So salvage options for inadequate preparation. It says there's insufficient evidence to really recommend one single salvage strategy. I think a lot of gastroenterologists have come up with their own strategies or techniques, especially the day of the procedure. So enemas or through the scope enemas or same day or next day, additional bowel preps. For someone as myself in a practice where I perform flexible sigmoidoscopies, my patients come in having prepped just two fleets enemas the morning of the procedure. I have the luxury though, they're not sedated. And if I insert the instrument and I'm looking at, I really need to look at the rectum and do a retroflexion because there was a PET scan that was done. It looked like there was some rectal wall thickening. Then I can give the patient, or my staff can give a patient the fleece enema right then and there in the office. They can go to the bathroom. I can see my next patient and I can come back in again. When you have a patient that's sedated, that's on your table, you don't have that type of luxury. That's why it's so important to have that bowel preparation. So failed or previous preparations and constipation. Insufficient evidence was recommended for that single salvage strategy. Again, much more intensive bowel preparation, initial low residue diet, followed by clear liquid diet, and then up to 72 hours of total preparation. So the pearls are split dose is your best choice. Preparation of choice, consider the low residue diet before and considerations if you do have an elderly patient or cardiac patient. One thing I wanted to remember is the importance of documenting the bowel preparation. Previously, there was a four point scale that was gastroenterologist would recommend would document excellent, good, fair or poor. But now the majority of the trend is to document the Boston bowel preparation scale which is a nine point scale. The nine point scale is it actually will categorize the different three sections of the colon, the right colon, the transverse colon, the left colon, and they'll do a four point scale of how clean each of those sections is out. And I think with the rising incidence of colorectal cancer, and the known misleasuring that there is between interval cancers that can occur between colonoscopies. It's important that a standardized bowel scale is used and I know in our facility. We currently don't have a standardization for the bowel preparation documentation. I know we have EMR system probation, and it's a hard stop that they have to that our gastroenterologist have to document, whether it's excellent, good, fair, or poor, but it's personal preference, if they've adopted it to do the Boston bowel preparation and you usually find that our younger gastroenterologists that have recently graduated, they're using the Boston bowel preparation. And there's an article I want to bring to your attention in GIE that the ASGE published in 2014 that goes over that nicely so I'll include that reference in our in our summary material. That'll be good to go over. Let's see here. And that just two slides to go over the preparation, and thank you.

bowel preparation

colonoscopy

split dose preparation

Boston bowel preparation scale

patient compliance