kjg The Korean Journal of Gastroenterology Korean J Gastroenterol 1598-9992 2233-6869 The Korean Journal of Gastroenterology 10.4166/kjg.2010.56.5.299 kjg-56-299 Original Article Comparison between Conventional 4 L Polyethylene Glycol and Combination of 2 L Polyethylene Glycol and Sodium Phosphate Solution as Colonoscopy Preparation LeeJung WonM.D. ∗ † KimNayoungM.D. ∗ † ChaByung HyoM.D. ∗ LeeByoung HwanM.D. ∗ HwangTae JunM.D. ∗ JeongYu JeongM.D. ∗ ChoiTae HyuckM.D. ∗ KimHee-SupM.D. ∗ MyungHyung-JoonM.D. ∗ KimJangeonM.D. ∗ JangJe-HyuckM.D. ∗ KimYeo MyeongM.D. ∗ KimJong YeopM.D. ∗ ParkSang WookM.D. ∗ ParkHyun KyungM.D. ∗ SuhSeungchulM.D. ∗ SeoPyoung JuM.D. ∗ SongJoon ChangM.D. ∗ ShinCheol MinM.D. ∗ † EumYoung OokM.D. ∗ KwonJung HeeM.D. ∗ † KimJin JooM.D. ∗ † SongByeong JunM.D. ∗ † ParkYoung SooM.D. ∗ † LeeDong HoM.D. ∗ † Department of Internal Medicine, Seoul National University Bundang Hospital, Seoungnam, Korea Department of Internal Medicine, Seoul National University College of Medicine and Liver Research Institute, Seoul, Korea Correspondence to: Nayoung Kim, M.D. Department of Internal Medicine, Seoul National University Bundang Hospital, 300, Gumi-dong, Bundang-gu, Sungnam 463-707, Korea Tel: +82-31-787-7008, Fax: +82-31-787-4051 E-mail: nayoungkim49@empal.com 22010 2122010 565 299306 01072010 02082010 Copyright © 2010 The Korean Journal of Gastroenterology 2010 Abstract Background/Aims

Effective bowel preparation is essential for accurate diagnosis of colon disease. We investigated efficacy and safety of 2 L polyethylene glycol (PEG) solution with 90 mL sodium phosphate (NaP) solution compared with 4 L PEG method.

 Methods

Between August 2009 and April 2010, 526 patients were enrolled who visited Seoul National University Bundang Hospital for colonoscopy. We allocated 249 patients to PEG 4 L group and 277 patients to PEG 2 L with NaP 90 mL group. Detailed questionnaires were performed to investigate compliance, satisfaction and preference of each method. Bowel preparation quality and segmental quality were evaluated. Success was defined as cecal intubation time less than 20 minutes without any help of supervisors.

 Results

Both groups revealed almost the same baseline characteristics except the experience of operation. PEG 4 L group's compliance was lower than PEG 2 L with NaP 90 mL group. Success rate and cecal intubation time was not different between two groups. Overall bowel preparation quality of PEG 2 L with NaP 90 mL group was better than PEG 4 L group. Segmental bowel preparation quality of PEG 2 L with NaP 90 mL group was also better than PEG 4 L group in all segments, especially right side colon. Occurrence of hy-perphosphatemia was higher in PEG 2 L with NaP 90 mL group than PEG 4 L group. However, significant adverse event was not reported.

 Conclusions

PEG 2 L with NaP 90 mL method seems to be more effective bowel preparation than PEG 4 L method.

 Colonoscopy Bowel preparation Polyethylene glycol Sodium phosphate REFERENCES Tan JJ Tjandra JJ Which is the optimal bowel preparation for colonoscopy - a metaanalysis Colorectal Dis 2006 8 247258 DiPalma JA Brady CE 3rd Colon cleansing for diagnostic and surgical procedures: polyethylene glycol-electrolyte lavage solution Am J Gastroenterol 1989 84 10081016 Huppertz-Hauss G Bretthauer M Sauar J Polyethylene glycol versus sodium phosphate in bowel cleansing for colonoscopy: a randomized trial Endoscopy 2005 37 537541 Kastenberg D Chasen R Choudhary C Efficacy and safety of sodium phosphate tablets compared with PEG solution in colon cleansing: two identically designed, randomized, controlled, parallel group, multicenter phase III trials Gastrointest Endosc 2001 54 705713 Cohen SM Wexner SD Binderow SR Prospective, randomized, endoscopic-blinded trial comparing precolonoscopy bowel cleansing methods Dis Colon Rectum 1994 37 689696 Vanner SJ MacDonald PH Paterson WG Prentice RS Da Costa LR Beck IT A randomized prospective trial comparing oral sodium phosphate with standard polyethylene gly-col-based lavage solution (Golytely) in the preparation of patients for colonoscopy Am J Gastroenterol 1990 85 422427 Ell C Fischbach W Keller R A randomized, blinded, prospective trial to compare the safety and efficacy of three bowel-cleansing solutions for colonoscopy (HSG-01*) Endoscopy 2003 35 300304 Martinek J Hess J Delarive J Cisapride does not improve precolonoscopy bowel preparation with either sodium phosphate or polyethylene glycol electrolyte lavage Gastrointest Endosc 2001 54 180185 DiPalma JA Marshall JB Comparison of a new sulfate-free polyethylene glycol electrolyte lavage solution versus a standard solution for colonoscopy cleansing Gastrointest Endosc 1990 36 285289 Curran MP Plosker GL Oral sodium phosphate solution: a review of its use as a colorectal cleanser Drugs 2004 64 16971714 Chung JI Kim N Um MS Learning curves for colonoscopy: a prospective evaluation of gastroenterology fellows at a single center Gut Liver 2010 4 3135 Orrom WJ Wong WD Rothenberger DA Jensen LL Evaluation of an air-filled microballoon and mini-transducer in the clinical practice of anorectal manometry. Preliminary communication Dis Colon Rectum 1990 33 594597 Harewood GC Sharma VK de Garmo P Impact of colonoscopy preparation quality on detection of suspected colonic neoplasia Gastrointest Endosc 2003 58 7679 Bressler B Paszat LF Vinden C Li C He J Rabeneck L Colonoscopic miss rates for right-sided colon cancer: a population-based analysis Gastroenterology 2004 127 452456 Bernstein C Thorn M Monsees K Spell R O'Connor JB A prospective study of factors that determine cecal intubation time at colonoscopy Gastrointest Endosc 2005 61 7275 Shah HA Paszat LF Saskin R Stukel TA Rabeneck L Factors associated with incomplete colonoscopy: a population based study Gastroenterology 2007 132 22972303 Aronchick CA Lipshutz WH Wright SH Dufrayne F Bergman G A novel tableted purgative for colonoscopic preparation: efficacy and safety comparisons with Colyte and Fleet Phospho-Soda Gastrointest Endosc 2000 52 346352 Lieberman DA Ghormley J Flora K Effect of oral sodium phosphate colon preparation on serum electrolytes in patients with normal serum creatinine Gastrointest Endosc 1996 43 467469 Heher EC Thier SO Rennke H Humphreys BD Adverse renal and metabolic effects associated with oral sodium phosphate bowel preparation Clin J Am Soc Nephrol 2008 3 14941503 Hurst FP Abbott KC Acute phosphate nephropathy Curr Opin Nephrol Hypertens 2009 18 513518 Figures and Tables

Overall quality of bowel cleansing between conventional 4 L polyethylene glycol and combination of 2 L polyethylene glycol and sodium phosphate solution group in total (A), morning colonoscopy (B) and afternoon colonoscopy (C). PEG, polyethylene; NaP, sodium phosphate.

Segmental quality of bowel cleansing between conventional 4 L polyethylene glycol and combination of 2 L polyethylene glycol and sodium phosphate solution group in total (A), morning colonoscopy (B) and afternoon colonoscopy (C).

Patient Demographics

PEG 4 L PEG 2 L＋ NaP 90 mL p-value
Number 249 277
Mean age± SD (years) 60.0±12.5 54.4±12.7 ＜0.001
Male/Female 134/115 140/137 0.45
Height 162.7±8.7 163.7±8.1 0.20
Weight 62.0±10.5 63.7±11.8 0.94
BMI 23.3±2.8 23.7±3.2 0.23
Experience of colonoscopy 167 (75.9%) 166 (66.9%) 0.03
Experience of abdominal operation 103 (45.2%) 70 (28.2%) ＜0.001
PEG, polyethylene; NaP, sodium phosphate; SD, standard deviation; BMI, body mass index.

Bold style means statistical significance.

Procedure Result

PEG 4 L PEG 2 L＋ NaP 90 mL p-value
Explanation of procedure 0.10
  Not explained 16 (6.6%) 8 (2.9%)
  Not easily understood 2 (0.8%) 1 (0.4%)
Easily understood 226 (92.6%) 264 (96.7%)
Fulfillment of procedure 0.02
  Well performed 221 (90.2%) 263 (95.6%)
  Not well performed 24 (9.8%) 12 (4.4%)
Success rate (%) 88.1% 89.1% 0.72
Insertion time (min± SD) 8.7±8.0 9.5±7.8 0.08

PEG, polyethylene; NaP, sodium phosphate; SD, standard deviation.

Bold style means statistical significance.

Satisfaction and Preference of Preperation Method in the PEG 2 L＋ NaP 90 mL Group

Experience of previous PEG 4 L 139/277 (50.0%)
Satisfaction of PEG 2 L＋ NaP 90 mL
  Very good 12/139 (8.6%)
  Good 64/139 (46.0%)
  Same 41/139 (29.5%)
  Bad 22/139 (15.8%)
  Very bad 0/139 (0.0%)
Preference of PEG 2 L＋ NaP 90 mL 114/139 (82.0%)

PEG, polyethylene; NaP, sodium phosphate.

Mean Insertion Time according to Bowel Preparation Method and Experience of Endoscopist

Experience Bowel preparation method N Insertion time (min) p-value
Expert (≥200 cases) PEG 4 L 202 7.7±6.7 0.35
PEG 2 L＋ NaP 90 mL 214 7.9±6.5
Beginner (＜200 cases) PEG 4 L 20 18.4±12.3 0.87
PEG 2 L＋ NaP 90 mL 40 17.9±9.3

Post-Colonoscopy Laborlatory Result

Reference range PEG 4 L PEG 2 L + NaP 90 mL p-value
Calcium (mg/dL) 8.8-10.5 9.0±0.5 8.6±0.6 ＜0.001
Phosphate (mg/dL) 2.5-4.5 3.8±1.2 5.9±1.7 ＜0.001
Sodium (mg/dL) 135-145 141.74±1.9 141.0±2.7 0.75
Potassium (mg/dL) 3.5-5.5 　4.0±0.4 4.2±0.5 0.21
Chloride (mg/dL) 98-110 105.3±3.3 102.2±2.6 0.01
Bicarbonate (mg/dL) 24-31 24.0±4.0 27.8±3.0 0.02
Blood urea nitrogen (mg/dL) 10-26 13.6±4.7 13.9±4.3 0.71
Creatinine (mg/dL) 0.7-1.4 0.9±0.2 0.8±0.2 0.36

Bold style means statistical significance.