Now I have the pleasure of welcoming back Dr. Tiara Levin to address optimizing bowel preparation in your endoscopy unit. Tiara, welcome back and looking forward to learning from you again. Thanks. We're kind of going from the sublime to the ridiculous now with the transition from telehealth to optimizing bowel prep. One is very virtual and one is very much real life, IRL. Let me see if I can advance the slides. So we're going to review some barriers to adequate bowel prep, describe approaches to optimizing bowel prep, and then review different ways to score the quality of your bowel prep. Just remember, Eden would not be satisfied unless I didn't remind you it's not enough to score the preps. You got to have a plan to hit the target of 90% plus adequate preps. So what's a bowel prep? Bowel prep is the purgative, the medication and the timing of use. It's the whatever dietary changes you recommend for your patients. Managing medications like insulin or anticoagulants, mental and physical preparation, really preparing patients to be able to take their prep to help let them know what to expect. You use Vaseline or Desitin to reduce irritation, logistical preparation, make sure they get a driver, make sure they know who to call. If any of these break down, the bowel prep will likely not be adequate. We don't have a good bowel prep, we're going to have longer procedures, we're going to decrease the important cecal intubation rate, we're going to need to repeat the procedures. This makes the whole thing less cost effective. It's additionally risky to patients, and it will decrease their patient experience and certainly make your providers unhappy as well. And it will reduce your adenoma detection. I think it goes without saying, if you have a better prep, and this goes back almost 20 years, better preps lead to more neoplasia detection. Risk factors for poor prep, older age, male sex, higher body mass index. We tend to see poorer preps in our inpatients. Patients on multiple medications, including tricyclics or narcotics, those with diabetes. Conditions that impair mobility, and prior GI surgical resections, including gastric or even colonic can affect the quality of the bowel prep. There's lots of options for patient education, standardization, booklets, videos. There are different vendors that can help you with this. Text messages, there are vendors for this as well. Smartphone apps and robocalls to remind people to take their prep and when to do it. There's lots of options with regard to preps. There's the full-volume, kind of traditional go lightly or co-lite, 4-liter polyethylene glycol electrolyte lavage solution, so-called PEG-ELS. There are isoosmotic low-volume preps, such as movie prep, usually have 2 liters. Hyperosmotic low-volume preps, like sodium sulfate, potassium sulfate, magnesium sulfate, the SUPREP, sodium picosulfate, magnesium sulfate, magnesium oxide, and with citric acid, the PREPOPIC or CLINPIC, sodium sulfate, magnesium sulfate, KCL, SUTAB, or the sodium biphosphate, sodium phosphate, OsmoPREP. Then many practices like to use the OTC products, MagCitrate and Miralax, for kind of an improved patient experience as well. It's important to kind of personalize the regimen to improve satisfaction and adherence. So people are complaining of nausea, antiemetics might play a role, either Zofran, Ondansetron, or metoclopramide. For improving the taste, Miralax plus Gatorade or some of the smaller-volume preps. You can use lower-volume preps to address some of the concerns about volume and bloating, particularly in bariatric patients, that can be important. There's mental barriers. And then people who are unable to take a day off prior to the colonoscopy in order to take their prep, or people who work at night, there's an option for same-day preps. Just things to be aware of in special populations, advanced age, you should avoid sodium phosphate. People after bariatric surgery would do better with a low-volume prep or giving them more time to drink their prep. People with renal insufficiency, cirrhosis or heart failure, you need to use more of the isoosmotic preps as opposed to the sodium phosphate or magnesium citrate. Spinal cord injury patients might need a special regimen, and cystic fibrosis patients may also have some difficulty. And I do want to give a shout out to my colleague, Audrey Calderwood, who helped me with a couple of these slides. She's really the expert on preps. So here's our first poll, which of the following is the most common type of prep used in your practice? The isoosmotic full-volume, so-called go lightly, the isoosmotic low-volume prep, the hyperosmotic low-volume prep, or OTC preps. And I'll wait for Eden to collect the votes, and then we'll take a look. They are coming in. Okay, let's get a few more in. Got to keep people awake. Yep, exactly. We're not even to lunch. Okay, and we'll get the final votes in, and I will, or selections in, I should say. And we will share the results. So it looks like large-volume preps are still kind of leading the league, and a lot of fairly significant use of the OTC products with Megxitrate and Miralax combination. So that's helpful. I think a lot of that's driven by reimbursement. The other preps are often not covered by insurance, and people have to pay out of pocket. And that is also not popular with patients as well. One thing that can be helpful is to have patients report the effluent color to help predict the quality of the prep. So your staff, when they're admitting the patient, can ask the patient just basically, you know, what's coming out when you went to the bathroom last time before you came in. And that can give you an idea of what you're in for with your colonoscopy. If it's, you know, what we're aiming for is sort of that clear yellow, and they see the bottom of the toilet bowl kind of thing, and the darker and more quality of the material gets, the less good your prep is going to be. So some practices, especially if it's early in your day, you could have your patient take an additional purgative, such as two liters of an additional prep, or drink some of the over-the-counter Miralax, or potentially take some tap water enemas. These are potential options. Not every place has the availability of the bathroom that they could dedicate to helping patients continue to take their prep during the day of the procedure. This is direct, I'll just direct you to this ASGE document on listing all the commonly available bowel preps and some of the issues to be concerned about with them. This is really the time of the talk where we really emphasize split dosing. The longer people wait between completing their prep and when the time of their colonoscopy occurs, the less likely you're going to have a good bowel prep. The small intestine is kind of continually producing kind of a mucus and bile stained material that even when people aren't eating, can really cloud the appearance of your, particularly your proximal colon and make it hard to find those elusive sessile serrated lesions. So this is just to gauge the audience, how often are you guys using split-dose preps in your practice? Never less than a third, one-third to two-thirds of the time, nearly 90% or more than 90% of the time. Wow, this will be interesting. We'll keep this open just for a second more, again, no wrong answers. Maybe some are a little more right than others, but, and we will share the results. That's good. Three quarters of you are using split doses most of the time, and that's the right answer. So we can kind of fly through my slides where I'm kind of going to be trying to sell you on the split-dose preps. This is really the, this is the insight that we want you to take away from this talk. It's split-dose preps are superior to, based on any type of prep that you might be using. And essentially it means part of the purgative is taken the evening prior. Second dose ideally starts four to six hours before the colonoscopy, and people should complete the last dose at least two hours before the procedure time. If you're working with anesthesiologists, they might wish you to say three hours before the procedure time. This is supported by meta-analyses demonstrating satisfactory colon cleansing with split-dose compared to full-dose PEG the night before, less likely to discontinue the prep, more willing to repeat the prep, and also reduction in nausea. Adenoma detection rates are improved with split-dose prep as opposed to taking the whole prep the day before. The low-volume equivalent, low-volume preps are equivalent to high-volume split-dose bell preps. So either the low or the high-volume preps, whichever your patients can get or will tolerate, that's kind of the most important thing, and this has been studied multiple times and needs to hold up. So some people have barriers to doing this kind of an evening before and morning of the procedure preps. Certainly many gastroenterologists are worried, will patients accept getting up early? If you start your unit at 7 or 8 a.m. in the morning, that means people are getting up at 3, 4 o'clock in the morning to take their second dose, but most people are willing to get up early or in the middle of the night, so to speak, to take that second dose, and nearly 80% actually comply, especially when you communicate the reasons. Many people don't realize how important it is to find those elusive cest-ulcerated lesions, and you really need a clean right colon in order to be able to do that. People are worried about having to stop on the way to the procedure area to have a bowel movement, essentially, and this can be a concern if you're drinking the prep the morning of the procedure, but there's really no difference in the need to stop for a bowel movement whether you take a morning, take a split dose, or you take an evening on the prep, and people are worried about pre-procedure fasting guidelines, you know, having an empty stomach when you come in for the procedure, but if you have two to three hours gap between the last oral ingestion and when you start the procedure, the risk of aspiration is really pretty low. Just looking at the residual gastric volume after a same-day prep, if people had clear liquids, the minimum fasting period is two hours. Not too many of our patients are having breast milk, most of those are pediatric patients. Late meal recommendation is six hours before doing any kind of sedation, and there's no association between the interval from last fluid ingestion and residual gastric volume when you look at the split-dose prep versus the evening-only bowel prep. The afternoon or late morning offers an opportunity for same-day preps, which seem to be very effective and particularly attractive for people who can't take time off the day before for that clear liquid diet, for that, take that prep in the afternoon of the day before. And this way, people are less likely to lose sleep or have bloating compared to the evening or split-dose prep and less interference of their work schedule. Essentially, this study demonstrates that taking it all in the morning can actually work very well for the percent of patients with a quote-unquote good bowel prep. Adenoma detection for same-day versus split-dose bowel preps, no difference. So this is also validated as an approach. Dietary restriction, this is one of those things that are kind of like beliefs among gastroenterologists. We all learned in training what sort of diet to recommend to our patients, and we're kind of reluctant. We have been reluctant to let go of that clear liquid diet on the day before, but if you allow a low-residue diet for breakfast and lunch and in some studies, dinner on the day prior to the procedure, that often yields no difference in prep quality when compared to clear liquid diet. It is really the high-fiber diet, the nuts and seeds, those are the ones that could cause problems and you definitely want people to be kind of off of those. It does improve tolerability and greater willingness to repeat the prep. If using a split-dose, you can allow a low-residue diet or full liquids up until the evening prior to the endoscopy. This is based on the most recent U.S. Multi-Society Task Force guideline on bowel preps, which the bowel prep guideline is actually under revision, so keep an eye out for a new bowel prep guideline coming soon. All right, so what are people actually doing in practice? Are you telling your patients clear liquids only, full liquids until the evening prior to the colonoscopy, the low-residue diet, or I don't think anyone's doing this, but no dietary restrictions? Yeah, we'd have to give that person a talking to if somebody checked that, right? Well, I'd be very curious about their prep quality and maybe we should be doing a study. We certainly would have higher patient satisfaction scores. What are they doing for salvage? Yeah. Okay, I will share the results. So yeah, 100%, 16 out of 16 clear liquids only. I think this is something we do in our practice as well. A lot of people wonder or are concerned about the ability of patients to really interpret what a full-liquid diet is or a low-residue diet. I think that is kind of one of the things holding folks back. Inevitably, there'll be the patient who comes in and the nurses will be doing the intake when they're getting them ready for the procedure and they'll say, oh yeah, I was eating such and such up until the midday or I had breakfast or lunch. And the nurses may, depending on how they're instructed, they may want to cancel the procedure. But I think it's important to ask what is actually coming out in the toilet bowl, that picture that I showed earlier, and that can give you a guidance on whether to go forward. So clear liquid diet does not seem to be required. But remember that bowel prep quality adequacy is a recommended quality metric. So the URP target is 90% or better, and this is defined as the frequency with which bowel preparation is adequate to allow the use of recommended surveillance or screening intervals. So that was the, you know, can detect everything short of lesions that are smaller than 5 millimeters. And so you want to have that 90% or better. So what does that mean? That would degrade the bowel prep. So we should be assessing the bowel prep after all the efforts to clear the debris have been completed and routinely measure the rate of adequate preps and adequate preps should be achieved in greater than 85% or in our case, 90% of all exams on a per physician basis. This is from, this is now eight years old and being updated. This is the multi-society task force guideline. Accurate equals a recommendation of an appropriate screening or surveillance interval. And so it's no longer confidence that polyps greater than 5 millimeters were not obscured, but you want to feel confident that you saw 95% or more of the mucosa. If the benchmark of 85% is not reached, an improvement initiative should be undertaken. The two preferred ways of measuring bowel prep are either the Boston bowel prep scale or the Orangic scale. And we'll kind of go over those a little bit. So the Boston bowel prep scale involves looking at multiple sections of the colon. And the score ranges from zero to three. Three is where in that segment of the colon, it was completely clear a score of two. Most of the mucosa could be seen. There was a minor amount of residual staining, small fragments of stool or opaque liquid. Something like you see in that upper right corner is something you could probably clear with some washing and suctioning. The scores of one or zero, there's no hope of really clearing that through the scope. So there are three segments, and then you add up your, with a potential of three on each segment. So you could get nine if it was completely clean. You kind of add up the score on each segment. And there is a training video available for people to see. So if the Boston bowel prep score can, will correspond with, will correlate with endoscopist behavior regarding follow-up intervals for colonoscopy. Only segment scores of two or three should lead to a 10-year follow-up. And segment scores of two or three going up 5% misrated abnormals greater than five millimeter would go to segments where one. So you want to aim for at least a segment score of two and hopefully three on your bowel preps. The uronchic is a little more straightforward, requires less math. And so for those of us who are math challenged and maybe used, I think a little bit more often, maybe slightly more traditional, but the key is to assess the adequacy of the prep after the bowel has been cleared. So excellent means more than 90% of the mucosa has been seen. It's mostly liquid stool and minimal suctioning. So if you had to do a fair amount of suctioning, but you still were able to achieve that 90% of the mucosa seen, and it's mostly liquid stool, then you would give it a good. If you did have to do a lot of suctioning and washing, but you were able to achieve that 90% of the mucosa, then you would achieve a score of fair, which would still be considered adequate, because you still saw the 90%. If it's poor, then it was less than 90% of the mucosa was seen and you basically couldn't clear it. So that's kind of the key to the uronchic scale. This is, you know, inadequate preps definitely affect your operation because what you're wanting to do is recommend that people come back for a short interval colonoscopy. But in reality, only a small number of patients from this study actually do make it back to do the follow-up procedure. Only 46% in this series of 20,000 screening and surveillance colonoscopies, actually 26% of those with inadequate prep actually returned, 46% of those with inadequate prep actually returned. 54% were kind of lost to follow-up and didn't make it back. And when they came back for their inadequate prep, they tried to do, many times they tried to do it on the next day, still 30% of those had an inadequate prep and 70% had an adequate prep. And if they did it not on the next day, they got a little bit better, 77% had an adequate prep, but still a significant number of people don't get, don't achieve an adequate prep. So this is kind of a challenge. This is a challenge in kind of most of our operations, what to do about the inadequate prep, how to get people back for their procedures. These are all kind of challenges. Okay. So how do people handle inadequate preps in their practice? Do you try and do the prep in the facility and do it on the same day, reschedule it for the next day, try and reschedule within a year using the same prep, or do you use a different prep, but also trying to use that one-year timeframe to get people back in? We're just surveying practice here. So no wrong answers. Let us know what you're doing. Maybe you don't have a plan and it's just, you kind of make it up each time with each patient, but. Okay. We will share those results. So people are definitely either trying to do the next day, sounds like when possible, or within a year kind of using a different prep, multi-day prep or adjunctive agents. All right. So that's helpful. So the post-procedure management is kind of the challenge. So it's timing. Do you try and rebook the next day or within one year? This is definitely a quality indicator. There's a lot of variables, you know, diet, how many preps, volume, how much time you take. And there's definitely adjunctive agents that you can use, 10 to 20 milligrams of bisacodyl. Oops. Seems to be moving, seems to have a mind of its own there for a minute. You can add magnesium citrate. You can do Miralax. You can do a larger volume, six liters. Some places are even using eight liters of PEG on two days, two days of clear liquids, three to seven days of a low residue diet. These are different things that you can do. Up with a low fiber diet times three days, liquid diet the day prior, bisacodyl, 10 milligrams and four liters PEG split dose, you can get a 90% adequate prep in this one series. And the other thing is some people are just really challenging to prep for all the reasons that I mentioned earlier. So you might consider alternative screening modalities, you know, in a pure screening situation, whether that's BIT or Cologuard, whether that is CT colonography with kind of labeling the stool. So you really can be sure that you really need to get in there with a colonoscopy to remove those polyps. So a couple of take home points, split dosing, same day, that's number one, low residue diet. There's some evidence supporting it, but I think it's challenging to implement in practice. Make sure you grade the bowel prep after cleaning for each colonoscopy, monitor adequacy on a per physician basis. If adequacy is less than 90% multifaceted quality improvement program, consider monitoring and continue to monitor after you implement the change to make sure that you see the improvements. There's some key references that I've listed here. Be on the lookout for a new document from the Multisociety Task Force that's in development right now. Best practices in the bowel prep, enhanced, make sure you have enhanced patient instructions. There's definitely try and compare with some experts that are out there. People are willing to share their guidelines. Use the standardized scoring system. Although it's stated there's no need for routine use of adjuncts, some practices have adopted routinely using adjuncts if your bowel prep effectiveness is definitely less than 90%. Split dose prepping, and definitely split dose would lead to a higher ADR. The four liters are not necessarily superior to lower volume PEG. Same day prep for afternoon cases and low residue diet also okay. And make sure you consider patient factors when prescribing the preps. I'll stop there and wait for the roundtable.

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