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Colonoscopy: Pre-procedure Considerations July, 2013

Colonoscopy: Pre-procedure Considerations July, 2013. Paul C. Schroy III, MD, MPH David Lichtenstein MD, and Brian Jacobson MD, MPH Boston Medical Center Boston MA. Bowel Preparation. Quality of Bowel Prep: Why Does It Matter?.

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Colonoscopy: Pre-procedure Considerations July, 2013

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  1. Colonoscopy:Pre-procedure ConsiderationsJuly, 2013 Paul C. Schroy III, MD, MPH David Lichtenstein MD, and Brian Jacobson MD, MPH Boston Medical Center Boston MA

  2. Bowel Preparation

  3. Quality of Bowel Prep:Why Does It Matter? • Bowel preparation is inadequate in up to 25% of patients undergoing colonoscopy • Consequences of inadequate prep: - Increased difficulty of colonoscopy - Prolonged procedure time - Reduced cecal intubation rates - Repeat procedures and shorter surveillance intervals - Reduced Adenoma Detection Rates - Exposure to higher malpractice risk Nelson DB, et al. GastrointestEndosc 2002;55:307-14 Rex DK, et al. Am J Gastroenterol 2002;97:1696-700 Froehlich F, et al. GastrointestEndosc 2005;61:378-84 Harewood GC et al. GastrointestEndosc 2003;58:76-9

  4. Negative Consequences of Inadequate Colonoscopy Repeat procedures mean: • Additional expenditure by client, insurance, government, and/or program • Time lost by client from work and related consequences, for example, lost wages • Additional risk of possible negative side effects from: • repeated bowel preparation (electrolyte imbalance, etc.); or • repeated procedure (bowel perforation, complications from anesthesia, etc.) Prevention and Health Promotion Administration Center for Cancer Prevention and Control Cigarette Restitution Fund Program http://phpa.dhmh.maryland.govJuly 2013

  5. Types of Bowel Preps • Isosmotic full volume • Isosmotic low volume • Hyper Osmotic

  6. Isosmotic Full Volume Preps

  7. Isosmotic Low Volume Preps

  8. Hyper Osmotic Preps * Black box warning

  9. Split Dose Preps

  10. Split Dose Preps • Part (usually ½) of laxative taken the evening prior and remainder a.m. of procedure • Colonoscopy should be performed within 8 hours of the last dosing • More effective and better tolerated than full dose p.m. • Demonstrated superiority • PEG • High volume (3L/1L or 2L/2L) • Low volume (1L/1L) • Osmotics-NaP, Mg citrate, Na sulfate • Recommended in ACG guidelines for CRC screening Rex DK, et al. Am J Gastroenterol. 2009;104:739-750.

  11. PEG (4L) vs. PEG 3350 + Ascorbate (2L+1L H2O) Percentage of ALL SEGMENTS being rated Excellent-Good Preps Marmo R et al. Gastrointest Endosc 2010;72:313-20

  12. PEG Split-Dosing: Meta-analysis Split-dose PEG is superior to full-dose PEG with respect to… • Satisfactory colon cleansing (OR 3.70; 95% CI, 2.79-4.91;p<0.01) • Likelihood of discontinuing prep (OR 0.53; 95% CI, 0.28-0.98;p=0.04) • Willingness to repeat same prep (OR 1.76; 95% CI,1.06-2.91;p=0.03) • Side effects, e.g., nausea (OR 0.55; 95% CI, 0.38-0.79;p<0.01) Kilgore TW et al. Gastrointest Endosc. 2011;73:1240-45

  13. Timing

  14. Bowel Preps for Afternoon Colonoscopy:Timing is Everything • Patient driven factors (AM better tolerated) • Less interference with day prior work • Lower incidence of prep related symptoms • Superior sleep quality • Dietary restriction? • Prep Options • PM only-No! • Split Dosing (PM/AM) or AM only superior • Start: within 8 hrs. of colonoscopy • End: >2 hrs prior to colonoscopy

  15. Morning Only Prep for PM Colonoscopy % patients “Good” (Ottawa <2) prep Varughese S et al. Am J Gastroenterol 2010;105:2368-74

  16. PM/AM Split-Dosing: What are the Barriers? Patient acceptance of sleep disturbance? 85% surveyed willing to get up at night to take 2nd dose 78% complied Bowel activity in transit to procedure “pit stop”? No difference taken PM or SD PM/AM (5-15%) Non-compliance with preprocedure fasting guidelines (increased risk of aspiration)? ASA guideline: clears OK 2 hours prior Unger RZ, Rex DK, et al. Dig Dis Sci 2010;55:2030-34 Parra-Blanco A et al. World J Gastroenterol 2006;12:6161-6 Khan MA et al. Gastrointest Endosc 2008;67(suppl):AB246 American Society of Anesthesiologists Practice Guidelines for Preoperative Fasting and Pharmacologic Agents to Reduce the Risk of Pulmonary Aspiration. Anesthesiology 2011;114:495-511

  17. A.M. versus P.M. Procedures Adenoma Detection Rate (ADR) has been reported higher for morning compared to afternoon colonoscopy ADR 29.3% in morning vs. 25.3% in afternoon By multivariate analysis OR 1.2 (95% CI 1.06-1.4,p=0.008) Afternoon colonoscopies have higher failure rates than morning procedures Incomplete procedure (6.5% vs. 4.1%, OR 1.64, CI 1.11-2.44;p=0.01) Inadequate prep (15.4% AM vs. 19.7% PM, OR 1.35, CI 1.08-1.69;p=0.01) Sanaka MR et al. Am J Gastroenterol 2006;101:2726-30; Sanaka MR et al. Am J Gastroenterol 2009;104:1659-64

  18. Fatigue? Confounders? Lee A, et al. Am J Gastroenterol 2011;106:1457-65; Gurudu SR, et al. Am J Gastroenterol 2011;106:1466-71; Do A, et al. DDW 2012 Queue position (i.e. absolute numbers of cases prior) inversely associated with ADR When accounting for full-day vs. half-day blocks, full-day blocks have lower ADRs Adjustment for confounders (e.g. endoscopist, withdrawal time) may account for these observations Regardless, this is measurable and modifiable

  19. Diet

  20. Is Dietary Restriction Necessary? Meta-analysis of Split-dosing Take Home Message: Optimal preprocedure diet with split-dose regimen not well-defined. Most would consider a clear liquid diet as standard of care. Kilgore TW et al. Gastrointest Endosc. 2011;73:1240-45

  21. High vs. Low Residue Diet • Prospective cohort study in Taiwan asked about diet 2 days prior to colonoscopy • Low residue = well-cooked meats, eggs, white bread, white rice, pasta, no skins • Higher-residue diets were associated with worse bowel preparations • Only 44% adhered to low-residue diet Wu et al. Dis Colon Rectum 2011;54:107-12

  22. How To Predict a Bad Prep: Patient Characteristics • Inpatient vs. outpatient (Froehlich et al) • Elderly (Froehlich et al) • Obesity • Lower education • History of constipation • Use of antidepressants • Noncompliance

  23. How To Deal with a Bad Prep • No studies to provide evidence-based guidance • Navigator and patient education • Extend period of diet modification from 24 to 48h • Increase total volume of PEG ( 2 to 4 L, or 4 to 6L) • Split dosing • Adequate hydration • Add Magnesium citrate • Add oral bisacodyl or senna

  24. Bowel Prep is a Quality Indicator • High-quality practice should monitor prep quality as a quality indicator • Target: < 10% preps inadequate to detect lesions > 5 mm. • Consider practice level interventions if > 10% preps inadequate (e.g., patient education, use of split-dose regimens) Lieberman et al. Gastrointest Endoscopy 2007;65:757-66

  25. Medications

  26. Preprocedure: Anticoagulation

  27. Preprocedure: Diabetic medications Sifri R, et al. Ca Cancer J Clin 2010;60:40-49.

  28. Preprocedure: Antibiotic prophylaxis • Colonoscopy ± polypectomy = low risk procedure • Risk of bacteremia < routine daily activities • Revised AHA guideline (Wilson W, et al. Circulation 2007:116:1736-54). “Antibiotic prophylaxis to solely prevent infective endocarditis is not recommended for GU or GI procedures” • Not recommended for synthetic vascular grafts or orthopedic prostheses. (ASGE. Gastrointest Endosc 2008:67:791-8)

  29. Preprocedure: Miscellaneous Medications Sifri R, et al. Ca Cancer J Clin 2010;60:40-49.

  30. Preprocedure: Cardiac Devices • Determine the type of cardiac device, indication for the device, the patient’s underlying cardiac rhythm, and degree of pacemaker-dependence before endoscopy • Use continuous electrocardiographic rhythm monitoring in addition to pulse oximetry during the procedure. • Most patients with cardiac pacemakers may undergo routine uses of electrocautery (eg, polypectomy, hemostasis) with no alterations in management. • For patients who are pacemaker dependent and in whom prolonged electrocautery is anticipated consider reprogramming the pacemaker to an asynchronous mode via application of a magnet over the pulse generator during the use of electrocautery. • For patients with an implantable cardioverter-defibrillators (ICD) in whom the use of any electrocautery may be anticipated, consultation with a cardiologist or a heart-rhythm specialist is recommended. Deactivation of the ICD function by qualified personnel should be considered. GIE 2007;65;561-8

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