The Evolution of Bowel Preparation and New Developments

Jeong Bae Park; Yong Kook Lee; Chang Heon Yang

doi:10.4166/kjg.2014.63.5.268

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Park, Lee, and Yang: The Evolution of Bowel Preparation and New Developments

Review Article

Korean J Gastroenterol 2014;63(5):268-275.

Published online: 4 October 2014

DOI: https://doi.org/10.4166/kjg.2014.63.5.268

The Evolution of Bowel Preparation and New Developments

Jeong Bae Park, Yong Kook Lee, Chang Heon Yang

Department of Internal Medicine, Dongguk University College of Medicine, Gyeongju, Korea

Correspondence to: Chang Heon Yang, Division of Gastroenterology and Hepatology, Department of Internal Medicine, Dongguk University College of Medicine, 87 Dongdae-ro, Gyeongju 780-350, Korea. Tel: +82-54-770-8206, Fax: +82-54-770-8378, E-mail: chhyang@dongguk.ac.kr

This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/3.0/) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

Abstract

Bowel preparation is essential for successful colonoscopy examination, and the most important factor is the bowel preparation agent used. However, selection of a bowel preparation agent invariably involves compromise. Originally, bowel preparation was performed for radiologic and surgical purposes, when the process involved dietary limitations, cathartics, and enemas, which had many side effects. Development of polyethylene glycol (PEG) solution led to substantive advancement of bowel preparation; however, despite its effectiveness and safety, the large volume involved, and its salty taste and unpleasant odor reduce compliance. Accordingly, modified PEG solutions requiring consumption of lower volumes and sulfate-free solutions were developed. Aqueous sodium phosphate is more effective and better tolerated than PEG solutions; however, fatal complications have occurred due to water and electrolyte shifts. Therefore, aqueous sodium phosphate was withdrawn by the US Food and Drug Administration, and currently, only sodium phosphate tablets remain available. In addition, oral sulfate solution and sodium picosulfate/magnesium citrate are also available, and various studies have reported on adjunctive preparations, such as hyperosmolar or stimulant laxatives, antiemetics, and prokinetics, which are now in various stages of development.

Keywords: Bowel preparation, Colonoscopy, Polyethylene glycols, Sodium phosphate, Picosulfate sodium

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Table 1.

The US Food and Drug Administration (FDA)-approved Bowel Preparation Agents for Colonoscopy

Bowel preparation agents	Characteristics	Advantages	Disadvantages	Cautions
4-Liter PEG	Not approved by the FDA for split dosing	Safe and effective	High-volume, may cause nausea, abdominal fullness, and bloating salty taste and unpleasant smell	Contraindicated in patients with ileus, gastrointestinal obstruction, gastric retention, bowel perforation, toxic colitis or toxic megacolon, hypersensitivity to components of it
4-Liter sulfate-free PEG	Not approved by the FDA for split dosing	Safe and effective Less salty and more tolerable (palatable)	High-volume may cause nausea, abdominal fullness, and bloating	Same as 4-liter PEG
2-Liter PEG with bisacodyl	Not approved by the FDA for split dosing	Low-volume Effective and tolerable	May cause discomfort, abdominal fullness, cramping, nausea, and vomiting	Contraindicated in patients with gastrointestinal obstruction, bowel perforation, toxic colitis and toxic megacolon, gastric retention, ileus Fluid and electrolyte disturbances can lead to serious adverse events such as cardiac arrhythmias, seizures and renal impairment
2-Liter PEG with ascorbic acid	Approved by the FDA for split dosing	Low-volume Ascorbic acid acts as a flavoring	May cause malaise, nausea, vomiting, abdominal pain, dyspepsia	Same as 2-liter PEG with bisacodyl
Sodium phosphate tablets	Avoid in patient with renal disease, congestive heart failure, or concomitant medications that can affect renal function	Low-volume Effective and tolerable	May cause bloating, nausea, abdominal pain, and vomiting	Contraindicated in patients with acute phosphate nephropathy, gastrointestinal obstruction, gastric bypass or stapling surgery, bowel perforation, toxic colitis and toxic megacolon, allergy to components of it Fluid and electrolyte disturbances can lead to cardiac arrhythmias, seizure, and renal impairment
Oral sulfate solution	Approved by the FDA for split dosing	Safe and effective	May cause discomfort, abdominal distension, abdominal pain, nausea, and vomiting May cause temporary elevation of uric acid	Same as 2-liter PEG with bisacodyl
Sodium picosulfate/ magnesium citrate	Approved by the FDA for split dosing	Low-volume Effective and tolerable (good taste, less nauseating)	May cause headache, nausea, proctalgia	Contraindicated in patients with allergic to components of it, gastric retention, ulcers, renal impairment, bowel perforation, congestive heart failure, inflammatory bowel disease, hypermagnesemia, gastrointestinal obstruction, ileus, toxic colitis and toxic megacolon

PEG, polyethylene glycol.

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