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Seong, Yoo, Lee, Park, Kim, Kim, and Kim: Formulation and Management of Poor Bowel Preparation: A Survey Study
Original Article

Korean J Gastroenterol 2016;68(2):70-76.

Published online: 4 October 2016

DOI: https://doi.org/10.4166/kjg.2016.68.2.70

Formulation and Management of Poor Bowel Preparation: A Survey Study

Jae Ho Seong, Jin Sae Yoo, Kyong Joo Lee, Hong Jun Park, Hee Man Kim, Jae Woo Kim, Hyun-Soo Kim

Division of Gastroenterology and Hepatology, Department of Internal Medicine, Yonsei University Wonju College of Medicine, Wonju, Korea

Correspondence to: Hyun-Soo Kim, Division of Gastroenterology and Hepatology, Department of Internal Medicine, Yonsei University Wonju College of Medicine, 20, Ilsan-ro, Wonju 26426, Korea. Tel: +82-33-741-1229, Fax: +82-33-741-1228, E-mail: hyskim@yonsei.ac.kr

Received 13 June 2016       Revised 14 July 2016       Accepted 19 July 2016

Copyright © 2016 Korean Ophthalmological Society

This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/4.0/) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

Abstract

Background/Aims

There are no established guidelines for bowel preparation formulation for bowel cleansing, nor is there an optimal method of dealing with inadequate bowel cleansing. This study investigated bowel preparation formulation preferences and responses to bowel preparation situations using surveys.

Methods

The study surveyed 221 Korean lower gastrointestinal endoscopists from January to March 2015 and assessed their responses.

Results

The analysis indicated that 2-L polyethylene glycol (PEG) plus ascorbic acid (Asc) was the preferred method (76.5%) and most responders expressed satisfaction with the formulation in both potency and safety. To address poor bowel preparation on the day of colonoscopy, the majority of physicians chose to order ingestion of additional preparations and proceed with the colonoscopy as scheduled (56.6%). In addition, concerns about renal safety and electrolyte stability were raised regarding oral sodium phosphate.

Conclusions

This study found that 2-L PEG+Asc was preferred for potency and safety, and that Korean endoscopists preferred to proceed with colonoscopy in poor bowel preparation situations rather than choose an alternate diagnostic modality.

Keywords: Colonoscopy, Cathartics

References

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Table 1.
Questionnaire Results
Questionnaire Tertiary (n=109) P Private/secondary (n=112) Total (n=221) p-value
1. What is the most important factor in choosing bowel preparation formulation?
 1. Bowel preparation potency 78 (71.6) 71 (63.4) 149 (67.4) 0.1953
 2. Possible complications (safety) 15 (13.8) 28 (25.0) 43 (19.5) 0.0349
 3. Patient compliance 16 (14.7) 15 (13.4) 31 (14.0) 0.7831
2. Which bowel preparation formulation do you prefer?
 1. 4-L PEG 35 (32.1) 18 (16.1) 53 (24.0) 0.0052
 2. 2-L PEG+Asc 76 (69.7) 93 (83.0) 169 (76.5) 0.0197
 3. Magnesium citrate combined with sodium picosulfate 4 (3.7) 5 (4.5) 9 (4.1) 0.7651
 4. Oral sodium phosphate 1 (0.9) 2 (1.8) 3 (1.4) 0.5771
 5. I don't have a preferred formula. 1 (0.9) 1 (0.9) 2 (0.9) 0.9846
3. Do you prescribe laxatives such as bisacodyl in conjunction with bowel preparation formula? If so, for which patients?
 1. No, I do not prescribe additional laxatives. 56 (51.4) 61 (54.5) 117 (52.9) 0.6456
 2. Yes, but only to those expected to show poor bowel cleansing (severe constipation, elderly patients, etc.). 47 (43.1) 35 (31.3) 82 (37.1) 0.0678
 3. Yes, to all patients, to improve the degree of bowel preparation. 6 (5.5) 16 (14.3) 22 (10.0) 0.0293
4. Which additional bowel preparation method do you employ in patients with severe constipation?
 1. I order the bowel preparation formulas to be taken in divided doses. 22 (20.2) 35 (31.3) 57 (25.8) 0.0601
 2. I prescribe laxatives (such as bisacodyl) in addition to bowel preparation formulas. 60 (55.0) 48 (42.9) 108 (48.9) 0.0699
 3. I increase the dose of bowel preparation formula. 42 (38.5) 37 (33.0) 79 (35.7) 0.394
 4. I extend the duration of diet control prior to colonoscopy. 62 (56.9) 47 (42.0) 109 (49.3) 0.0266
 5. I don't find additional methods to be necessary. 4 (3.7) 6 (5.4) 10 (4.5) 0.5462
5. How do you respond to poor bowel preparation status (solid feces remaining) on the day of colonoscopy?
 1. Order additional ingestion of the same formula and perform colonoscopy as scheduled 60 (55.0) 65 (58.0) 125 (56.6) 0.6539
 2. Order additional ingestion of a different formula and perform colonoscopy as scheduled 6 (5.5) 12 (10.7) 18 (8.1) 0.1569
 3. Reschedule colonoscopy and prescribe a different formula 10 (9.2) 5 (4.5) 15 (6.8) 0.164
 4. Reschedule colonoscopy, prescribe the same formula, add bisacodyl laxatives, and order tighter diet control 37 (33.9) 26 (23.2) 63 (28.5) 0.0773
 5. Administer additional formula through colonoscopy and perform colonoscopy as scheduled 0 (0.0) 6 (5.4) 6 (2.7) 0.0143
 6. Perform additional enema and proceed with colonoscopy as scheduled 4 (3.7) 7 (6.3) 11 (5.0) 0.3779
 7. Choose alternate diagnostic modality (double barium contrast or CT colonography) 0 (0.0) 1 (0.9) 1 (0.5) 0.3228
 8. Do not perform colonoscopy at all. 0 (0.0) 0 (0.0) 0 (0.0)  
 9. Others 2 (1.8) 3 (2.7) 5 (2.3) 0.0673
6. What is the most frequent cause of poor bowel preparation, based on your experience?
 1. Poor compliance with bowel preparation formulation (Failure to ingest full dose of formula) 42 (38.5) 43 (38.4) 85 (38.5) 0.9830
 2. Failure to follow the instructions on formula ingestion (incorrect preparation of formula, etc.) 32 (29.4) 31 (27.7) 63 (28.5) 0.7822
 3. Underlying comorbidities of the examinee (old age, severe constipation, chronic diseases, etc.) 33 (30.3) 26 (23.2) 59 (26.7) 0.2355
 4. Inadequate potency of the prescribed bowel preparation formula 2 (1.8) 6 (5.4) 8 (3.6) 0.1611
 5. Poor diet control prior to colonoscopy 13 (11.9) 8 (7.1) 21 (9.5) 0.2253
 6. Others 1 (0.9) 3 (2.7) 4 (1.8) 0.3262
7. Have you experienced electrolyte imbalance following the use of bowel preparation agents?
 1. No 80 (73.4) 86 (76.8) 166 (75.1) 0.5599
 2. Yes 27 (24.8) 26 (23.2) 53 (24.0) 0.7865
8. If so, choose all bowel preparation formula that have resulted in electrolyte imbalance.
 1. 4-L PEG 10 (9.2) 6 (5.4) 16 (7.2) 0.2736
 2. 2-L PEG＋ Asc 8 (7.3) 4 (3.6) 12 (5.4) 0.2165
 3. Magnesium citrate combined with sodium picosulfate 14 (12.8) 14 (12.5) 28 (12.7) 0.9387
 4. Oral sodium phosphate 11 (10.1) 14 (12.5) 25 (11.3) 0.5720
9. What is the safety issue of most concern when prescribing bowel preparation formula?
 1. Most complications are dismissable.I am concerned about nausea and vomiting, which prevents complete ingestion of formula. 62 (56.9) 69 (61.6) 131 (59.3) 0.4746
 2. I am concerened about the possibility of electrolyte imbalance. 37 (33.9) 43 (38.4) 80 (36.2) 0.4915
 3. I am concerned about bowel inflammation, which may mask colonic lesions. 13 (11.9) 0 (0.0) 13 (5.9) 0.0002
 4. Others 2 (1.8) 1 (0.9) 3 (1.4) 0.5452
10. Based on your experience, choose all the items that are relevanat with the use of 2-L PEG+Asc (Coolprep; Taejoon Pharmaceuticals).
 1. I have never prescribed it. 4 (3.7) 12 (10.7) 16 (7.2) 0.0433
 2. It is satisfactory in terms of bowel preparation potency. 69 (63.3) 80 (71.4) 149 (67.4) 0.1975
 3. It appears to be less potent than 4-L PEG. 28 (25.7) 15 (13.4) 43 (19.5) 0.0210
 4. It is a safe formula that can be recommended to patients with renal failure. 31 (28.4) 28 (25.0) 59 (26.7) 0.5633
 5. It is appropriate for elderly patients with various comorbidities (renal disease, heart disease, etc.). 39 (35.8) 40 (35.7) 79 (35.7) 0.9919
 6. It requires less amount of ingestion and provides better patient compliance compared to 4-L PEG. 63 (57.8) 54 (48.2) 117 (52.9) 0.1536
 7. Others 1 (0.9) 0 (0.0) 1 (0.5) 0.3096
11. Based on your experience, choose all the items that are relevant with the use of oral NaP (Clicolon; Korea Pharma).
 1. I have never prescribed it. 59 (54.1) 63 (56.3) 122 (55.2) 0.7512
 2. It is satisfactory in terms of bowel preparation potency. 7 (6.4) 11 (9.8) 18 (8.1) 0.3556
 3. It appears to be less potent than 4-L PEG. 20 (18.3) 13 (11.6) 33 (14.9) 0.1598
 4. It can be used safely in patients with renal failure despite the risk of electrolyte imbalance. 3 (2.8) 1 (0.9) 4 (1.8) 0.2999
 5. It should be used only in healthy adults due to the risk of electrolyte imbalance. 30 (27.5) 34 (30.4) 64 (29.0) 0.6423
 6. I avoid the use of oral NaP becauses of concerns with nephropathy. 26 (23.9) 27 (24.1) 53 (24.0) 0.9647
 7. I avoid the use of oral NaP becauses of concerns with bowel inflammation. 7 (6.4) 5 (4.5) 12 (5.4) 0.5208
 8. Others 2 (1.8) 3 (2.7) 5 (2.3) 0.6732
12. Based on your experience, choose all the items that are relevant with the use of PSMC (Picolyte; Pharmbio Korea).
 1. I have never prescribed it. 43 (39.4) 44 (39.3) 87 (39.4) 0.9801
 2. It is satisfactory in terms of bowel preparation potency. 10 (9.2) 13 (11.6) 23 (10.4) 0.5537
 3. It appears to be less potent than 4-L PEG. 41 (37.6) 45 (40.2) 86 (38.9) 0.6959
 4. When used cautiously, it is a safe formula that can be recommended to patients with renal failure. 12 (11.0) 8 (7.1) 20 (9.0) 0.3165
 5. It can be used safely in patients with renal failure despite the risk of electrolyte imbalance. 6 (5.5) 9 (8.0) 15 (6.8) 0.4545
 6. It should be used only in healthy adults due to the risk of electrolyte imbalance. 38 (34.9) 24 (21.4) 62 (28.1) 0.0263
 7. I avoid the use of PSMC becauses of concerns with bowel inflammation. 6 (5.5) 4 (3.6) 10 (4.5) 0.4894
 8. Others 1 (0.9) 1 (0.9) 149 (67.4) 0.9846

Values are presented as n (%).

A 12-item questionnaire on formulation preference and management of poor bowel preparation was distributed to 221 South Korean endoscopists. Multiple answers were allowed. Null hypotheses of no difference were rejected if p-values were less than 0.05.

PEG, polyethylene glycol; ASc, ascorbic acid; NaP, sodium phosphate; PSMC, sodium picosulfate magnesium oxide citric acid.

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