Colorectal Cancer _ ___________________________________________________________________________
Split-dose bowel cleansing is associated with greater willingness to repeat the regimen compared with day-before regimens. In addition, low-volume bowel cleansing agents are associated with greater compliance in repeat colonoscopies. There is insufficient evidence to recommend specific bowel preparation regimens for children, adolescents, and elderly persons, but sodium phosphate preparations should be avoided in the elderly, in children younger than 12 years of age, and in those with risk factors for complications from this medication, including known or suspected inflammatory bowel disease. Additional bowel purgatives should be considered in patients with risk factors for inadequate preparation. Low-volume preparations or extended time delivery for high-volume preparations are recommended for patients after bariatric surgery. Tap water enemas should be used to prepare the colon for sigmoidoscopy in pregnant women. There is insufficient evidence to recommend specific regimens for persons with a history of spinal cord injury; additional bowel purgatives should be considered. There is also insufficient evidence to recommend a single salvage strategy for patients whose poor preparation precludes effective colonoscopy completion. In these cases, large- volume enemas may be attempted in patients who present for colonoscopy and report brown effluent despite compliance with the colon-cleansing regimen. Through-the-scope enema with completion of colonoscopy the same day may also be considered, especially for patients receiving propofol sedation. Waking the patient from sedation and continuing with further oral ingestion of cathartic with same-day or next-day colonoscopy is associated with better outcomes than delayed colonoscopy. Quality Indicators for Colonoscopy Performance In 2015, an estimated 11 million outpatient colonoscopies were performed in the United States [141]. In addition to patient bowel preparation, optimal colonoscopy efficacy depends on operator performance. Inadequate colonoscopy performance demonstrably worsens the ability to prevent colorectal cancer diagnoses and deaths, and practice recommendations have been developed to better ensure quality colonoscopy performance [142]. Cecal Intubation . Cecal intubation involves advancing the colonoscope beyond the ileocecal valve, allowing the colonoscopist to visualize the medial wall of the cecum between the ileocecal valve and the appendiceal orifice. Cecal intubation is essential for optimal colonoscopy because many colorectal neoplasms are harbored in the proximal colon, including the cecum, and low cecal intubation rates are linked to higher rates of interval proximal colon cancer [143]. Colonoscopists should be able to intubate the cecum in ≥95% of screening colonoscopies in healthy adults. Photography of the cecum is mandated to verify intubation [142].
resection, spinal cord injury, Parkinson disease, and stroke, are generally more difficult to prepare adequately. Diabetes is associated with the highest prevalence of inadequate bowel preparation [137]. A preliminary assessment of preparation quality should be done in the recto-sigmoid colon. If the indication is screening or surveillance and the preparation is clearly inadequate for polyp detection greater than 5 mm, terminate and reschedule the procedure or attempt an additional bowel cleansing approach without canceling the procedure that day. If the colonoscopy is complete to cecum, and the preparation ultimately is deemed inadequate, the examination should be repeated, generally within one year; intervals shorter than one year are indicated when advanced neoplasia is detected and there is inadequate preparation. Adequacy of bowel preparation should be assessed after completing appropriate efforts to clear residual bowel debris. The rate of adequate preparation should be routinely recorded, and adequate patient preparation should be achieved in at least 85% of all examinations per physician [137]. Split-dose bowel-cleansing regimens are strongly recommended for screening colonoscopy. A same-day regimen is an acceptable alternative to split dosing, especially for patients undergoing afternoon examination. The second dose of split preparation should ideally begin four to six hours before the time of colonoscopy, with completion of the last dose at least two hours before the procedure time. With split-dose bowel-cleansing regimens, diet recommendations include low-residue or full liquids until evening on the day before colonoscopy. Healthcare professionals should give oral and written patient instructions for all components of colonoscopy preparation and emphasize the importance of compliance. The physician performing the colonoscopy should ensure that appropriate support and process measures are in place for patients to achieve adequate colonoscopy preparation quality. Selection of a bowel-cleansing regimen should consider patient’s medical history, medications, and, when available, previously reported bowel preparation adequacy. A split-dose regimen of a 4-L polyethylene glycol electrolyte lavage solution (PEG-ELS)-based cleansing agent provides high-quality bowel cleansing. In healthy, non-constipated individuals, a 4-L PEG-ELS formulation produces a bowel-cleansing quality comparable to lower-volume PEG formulations. Over-the-counter bowel cleansing agents have variable efficacy depending on the agent, dose, timing of administration, and whether used alone or in combination. Regardless of the agent, efficacy and tolerability are enhanced with a split-dose regimen. Although over-the-counter purgatives are generally safe, caution is required in certain populations, such as strictly avoiding magnesium-based preparations in patients with chronic kidney disease. Routine use of adjunctive agents for bowel cleansing before colonoscopy is not recommended.
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MDFL2626
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