Same-Day Bowel Preparation Works for Afternoon Colonoscopies

From Gastro-Hep News: Same-Day Bowel Preparation Ideal for Afternoon Colonoscopies

An excerpt:

Same-day bowel preparation provides better cleansing and is preferred over a split-dose regimen for patients scheduled for an afternoon colonoscopy, according to results of a randomized, controlled study presented in abstract form by Dr Isabel Manzanillo-DeVore on October 9, 2018 at the American College of Gastroenterology (ACG) 2018 Annual Scientific Meeting in Philadelphia, Pennsylvania (Oral abstract 42)…

Patients in both groups were instructed to drink only clear liquids … beginning at noon the day before the colonoscopy…. In the same-day group, patients began bowel preparation at 5:30 am the day of the procedure and were told to finish a polyethylene glycol–electrolyte solution (PEG-ES; 4 L) at least 4 hours before their appointment.

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Low Fiber Diet During Bowel Prep

A recent prospective, randomized trial (A Mytyk et al. JPGN 2018; 66: 720-24) compared a low fiber diet with a clear liquid diet during a polyethyylene glycol prep prior to colonoscopy. N=184, Median age 15 yrs (range 6-18 yrs).

Low fiber diet included milk, dairy products, some soups, bread and rolls, sandwiches, meat, fish, eggs, pasta, and honey.

Children in both groups were asked to fast for a minimum of 6 hours prior to colonoscopy and their bowel prep was assessed with the Boston Bowel Preparation Scale (BBPS). Bowel prep consisted of PEG 4000 with electrolytes dosed at 66 mL/kg to max of 4 liters.

Key findings:

  • There was no significant difference in BBPS between the two groups
  • Overall, 95.4% of patients had good bowel cleanness (BBPS ≥5)

My take: This study indicates that with a good volume of bowel prep, a less-rigorous diet change may be effective for a cleanout.

Disclaimer: These blog posts are for educational purposes only. Specific dosing of medications/diets (along with potential adverse effects) should be confirmed by prescribing physician/nutritionist.  This content is not a substitute for medical advice, diagnosis or treatment provided by a qualified healthcare provider. Always seek the advice of your physician or other qualified health provider with any questions you may have regarding a condition.

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NASPGHAN “Best Practices Cleanout Regimens”

The authors of a recent report (JPGN 2014; 59: 409-16) acknowledge that “bowel regimens vary significantly” and “few clinical studies in pediatrics have evaluated the use of various bowel preparation regimens.” Furthermore, “pediatric studies did not have a common efficacy measure.”

Nevertheless, they provide a “NASPGHAN best practices cleanout regimens.”  According to Table 7:

  • Option 1: PEG-3350 (eg. Miralax) -1-day cleanout:  If less than 50 kg, then 4 g/kg/day + bisacodyl 5 mg.  If >50 kg, then 238 g in 1.5 L sports drink + bisacodyl 10 mg.   PEG-3350 administered over 4-6 hours.
  • Option 2: PEG-3350 -2-day cleanout: If <50 kg, then 2 g/kg/day + bisacodyl 5 mg; if >50 kg, then 2 g/kg/day + bisacodyl 10 mg.
  • Option 3: NG cleanout: PEG-ELS (eg. Nulytely) 25 mL/kg/h (max 450 mL/h).  NG cleanouts mainly in those with history of failed preps or other adherence problems (eg. vomiting).
  • Option 4: non-PEG cleanout: Magnesium citrate 4-6 mL/kg/day + bisacodyl 5-10 mg.

My personal opinion is that Table 7 could drop the words “best practices” since the report states “alternative dosing regimens may be entirely reasonable” and the data are quite limited.

With regard to split dosing preparations which are now recommended in adults, their role in pediatrics is a “potential area for future research.” For adults, the U.S. Multi-Society Task Force Consensus Statement on Adequate Bowel Cleansing for Colonoscopy (Johnson DA et al. Optimizing Adequacy of Bowel Cleansing for Colonoscopy: Recommendations from the US Multi-Society Task Force on Colorectal Cancer. Gastroenterology 2014; 147(4):903-924) recommends:

  • Use of a split-dose bowel cleansing regimen is strongly recommended for elective colonoscopy, meaning roughly half of the bowel cleansing dose is given the day of the colonoscopy.
  • The second dose of split preparation ideally should begin four to six hours before the time of colonoscopy with completion of the last dose at least two hours before the procedure time.
  • During a split-dose bowel cleansing regimen, diet recommendations can include either low-residue or full liquids until the evening on the day before colonoscopy. 

Take-home message: This NASPGHAN report summarizes the literature and provides recommendations for effective bowel preparations.

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Data Supporting Miralax

A summary of the effectiveness of polyethylene glycol for chronic constipation, fecal disimpaction, and as a bowel preparation are presented in a recent article (JPGN 2013; 57: 134-40).

The article provides information on the biochemistry and mechanism of action along with a good number of references –49.

From the summary:

“PEG is an osmotic laxative used in children in the last few years.  It is more effective than lactulose for the treatment of chronic constipation.  It is equally effective compared with milk of magnesia and mineral oil for the long-term treatment of constipation but has a much better acceptance rate…It is a safe medication without any significant adverse effects.  Because PEG can be mixed in a beverage of the patient’s choice, it has excellent long-term patient acceptance.”

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Three PEG Pediatric Cleanouts

Several articles highlight the use of polyethylene glycol (Miralax) as a bowel prep for children:

  1. JPGN 2013; 56: 215-19
  2. JPGN 2013; 56: 220-24
  3. JPGN 2013; 56: 225-28

These studies and the accompanying editorial (pg 115) show fairly good results with PEG cleanout regimens.

The first study compared PEG versus senna in a blinded, prospective randomized trial.  After enrolling 30 children (6-21 years of age) at a planned interim analysis, the study showed superiority of PEG (1.5 g/kg/day) when used for 2 days prior to colonoscopy.  In addition to laxatives, patients were instructed to consume full liquid diet for 2 days prior to procedure & clear liquid on day prior (up to 3 hours before procedure).  In the PEG group, good or excellent cleanout scores were noted in 88% compared with only 29% in the senna group. There were no significant adverse effects or electrolyte changes which are well-detailed in this study (Table 2).

The second study evaluated a 1-day regimen with 46 children in a prospective open-label study.  238 g of PEG was mixed with 1.9 L of gatorade and administered over several hours.  Patients (8-18 years) were instructed to take only clears after noon the day prior to procedure Only 37 (82%) were able to take the full preparation.  43 (93%) took at least 75% of the preparation.  Despite issues with tolerance and nausea/vomiting (noted in 60%), 77% were rated as having an effective cleanout.

The third study enrolled 45 children (5-21 years) in a prospective study of a 1-day bowel preparation. Patients <45 kg received 136 g of PEG solution with 32 ounces of Gatorade; patients >45 kg received 255 g in 64 ounces.  44 children completed study.  Patients were told to take PEG over 3 hours the evening prior to procedure and allowed clears until 3 hours prior to procedure.  In this group, nausea was noted in 34% and vomiting in 16%.  However, patients reported that preparation was easy in 61% and tolerable in 39%.  The quality of the preparation was considered excellent in 23%, good in 52%, fair in 23% and poor in 2%.  There were no significant electrolyte changes.

Take Home Message:

Numerous small studies show that PEG solutions can be used as a safe, effective bowel preparation in children.  Shorter duration preparations are more convenient and may result in nausea or vomiting.

In our institution, we frequently use PEG cleanouts.  However, typically our doses of PEG are lower (eg. 136-168 g) and often combined with an enema to complete cleanout process.  Unlike adult preparations, we have not instructed families in split-dose regimens mainly due to concerns about the ability of pediatric patients to adhere to these regimens.

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