Optimizing Adequacy of Bowel Cleansing for Colonoscopy: Recommendations From the US Multi-Society Task Force on Colorectal Cancer

David A. Johnson,1 Alan N. Barkun,2 Larry B. Cohen,3 Jason A. Dominitz,4 Tonya Kaltenbach,5 Myriam Martel,2 Douglas J. Robertson,6,7 C. Richard Boland,8 Francis M. Giardiello,9 David A. Lieberman,10 Theodore R. Levin11 and Douglas K. Rex12

1Eastern VA Medical School, Norfolk, Virginia, USA; 2McGill University Health Center, McGill University, Montreal, Canada; 3Icahn School of Medicine at Mount Sinai, New York, New York, USA; 4VA Puget Sound Health Care System and University of Washington, Seattle, Washington, USA; 5Veterans Affairs Palo Alto, Stanford University School of Medicine, Palo Alto, California; 6VA Medical Center, USA; 7Geisel School of Medicine at Dartmouth, White River Junction, Vermont, USA; 8Baylor University Medical Center, Dallas, Texas, USA; 9Johns Hopkins University School of Medicine, Baltimore, Maryland, USA; 10Oregon Health and Science University, Portland, Oregon, USA; 11Kaiser Permanente Medical Center, Walnut Creek, California, USA; 12Indiana University School of Medicine,
Indianapolis, Indiana, USA.

Am J Gastroenterol advance online publication, 16 September 2014; doi: 10.1038/ajg.2014.272

Correspondence: David A. Johnson, Eastern VA Medical School, Norfolk, Virginia, USA . E-mail: dajevms@aol.com

Abstract

Colorectal cancer (CRC) is the second leading cause of cancer-related deaths in the United States. (1) Colonoscopy can prevent CRC by the detection and removal of precancerous lesions. In addition to CRC screening and surveillance, colonoscopy is used widely for the diagnostic evaluation of symptoms and other positive CRC screening tests. Regardless of indication, the success of colonoscopy is linked closely to the adequacy of preprocedure bowel cleansing.

Unfortunately, up to 20–25% of all colonoscopies are reported to have an inadequate bowel preparation. (2,3) The reasons for this range from patient-related variables such as compliance with preparation instructions and a variety of medical conditions that make bowel cleansing more difficult to unit-specific factors (eg, extended wait times after scheduling of colonoscopy). (4) Adverse consequences of ineffective bowel preparation include lower adenoma detection rates, longer procedural time, lower cecal intubation rates, increased electrocautery risk, and shorter intervals between examinations. (3,5,6,7)

Bowel preparation formulations intended for precolonoscopy cleansing are assessed based on their efficacy, safety, and tolerability. Lack of specific organ toxicity is considered to be a prerequisite for bowel preparations. Between cleansing efficacy and tolerability, however, the consequences of inadequate cleansing suggest that efficacy should be a higher priority than tolerability. Consequently, the choice of a bowel cleansing regimen should be based on cleansing efficacy first and patient tolerability second. However, efficacy and tolerability are closely interrelated. For example, a cleansing agent that is poorly tolerated and thus not fully ingested may not achieve an adequate cleansing.

The goals of this consensus document are to provide expert, evidence-based recommendations for clinicians to optimize colonoscopy preparation quality and patient safety. Recommendations are provided using the Grades of Recommendation Assessment, Development and Evaluation (GRADE) scoring system, which weighs the strength of the recommendation and the quality of the evidence. (8)

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