Colonoscopy preps: what's best?
1996; Elsevier BV; Volume: 43; Issue: 5 Linguagem: Inglês
10.1016/s0016-5107(96)70302-4
ISSN1097-6779
Autores Tópico(s)Colorectal Cancer Screening and Detection
ResumoIn this issue of Gastrointestinal Endoscopy, two reports provide further information regarding potential adverse events from the use of oral sodium phosphate (NaP) for colon preparation.1Lieberman DA Ghormley J Flora K. Effect of oral sodium phosphate colon preparation on serum electrolytes in patients with normal serum creatinine.Gastrointest Endosc. 1996; 43: 467-469Abstract Full Text Full Text PDF PubMed Google Scholar, 2Zwas F Cirillo N El-Serag HB Eisen RN. Colonic mucosal abnormalities associated with oral sodium phosphate solution.Gastrointest Endosc. 1996; 43: 463-466Abstract Full Text Full Text PDF PubMed Scopus (116) Google Scholar In one study of patients with presumed normal renal function (based on a serum creatinine level of <1.5 mg/dL), significant increases in serum phosphate and sodium along with decreases in serum calcium and potassium were observed without concomitant clinical manifestations.1Lieberman DA Ghormley J Flora K. Effect of oral sodium phosphate colon preparation on serum electrolytes in patients with normal serum creatinine.Gastrointest Endosc. 1996; 43: 467-469Abstract Full Text Full Text PDF PubMed Google Scholar The second study provides confirmation of a previous report3Hixson LJ. Colorectal ulcers associated with sodium phosphate catharsis.Gastrointest Endosc. 1995; 42 ([letter]): 101-102Abstract Full Text Full Text PDF PubMed Scopus (55) Google Scholar of the development of aphthoid-like lesions associated with the use of NaP for colon preparation and further characterizes that this side effect, which affected nearly 25% of patients, was located predominantly in the left colon and was manifested by nonspecific biopsy findings without features that might cause confusion with Crohn's disease.2Zwas F Cirillo N El-Serag HB Eisen RN. Colonic mucosal abnormalities associated with oral sodium phosphate solution.Gastrointest Endosc. 1996; 43: 463-466Abstract Full Text Full Text PDF PubMed Scopus (116) Google Scholar These two studies identify potential problems with NaP bowel preparation and raise the question, “What is the best colonoscopy preparation?” At the outset, it should be stated that the “best bowel preparation” for colonoscopy may not be identifiable because of the large variation in patients and colons.4Cotton PB Williams CB. Practical gastrointestinal endoscopy.in: 3rd edition. Blackwell Scientific Publications, Oxford, London1990: 160-168Google Scholar, 5Williams CB Waye JD. Colonoscopy and flexible sigmoidoscopy.in: Textbook of gastroenterology. J.B. Lippincott, New York1991: 2249-2265Google Scholar While a specific bowel preparation may be comfortable for one patient, it may induce nausea, vomiting, or severe abdominal cramps in the next patient. In addition, special circumstances such as inflammatory bowel disease, lower gastrointestinal bleeding, youth, or old age may dictate modification of the usual preparation. Conversely, one can postulate ideal attributes of a bowel preparation such as short period of dietary restrictions, pleasant taste, reasonable volume, simple packaging and instructions, and avoidance of systemic or local side effects such as electrolyte abnormalities, nausea, vomiting, excessive abdominal cramps, and colonic mucosal lesions. This editorial review will compare the standard oral lavage regimens with the newer oral NaP preparations for colonoscopy. Compliance with bowel preparations is facilitated by standardized, clearly written instructions. Certain changes in diet and medications are required prior to colonoscopy. Oral iron medications should be stopped 4 to 5 days before colonoscopy, since organic tannates make the colonic contents black, viscous, and difficult to clear. Constipating agents, such as codeine or loperamide, should be stopped 12 to 36 hours prior to colonoscopy. Aspirin, nonsteroidal anti-inflammatory drugs, or anticoagulants may require discontinuation 7 days prior to examination to reduce the risk of bleeding with the performance of polypectomy. Generally, a clear liquid diet is recommended for 24 hours prior to examination. Allowable clear liquids include water, strained fruit juices (apple, lemonade), clear broth or bouillon, coffee or tea (without milk), ices, gelatin, and a few hard candies. One thing that is forbidden is any red or purple juices, which can appear red in the colon and be mistaken for blood. When the procedure is scheduled for the morning, patients are typically placed NPO after midnight. For afternoon procedures, clear liquids are usually permitted up to 5 hours prior to the procedure. Prior to the early 1980s, purgatives with enemas were the most commonly used bowel preparation.4Cotton PB Williams CB. Practical gastrointestinal endoscopy.in: 3rd edition. Blackwell Scientific Publications, Oxford, London1990: 160-168Google Scholar, 5Williams CB Waye JD. Colonoscopy and flexible sigmoidoscopy.in: Textbook of gastroenterology. J.B. Lippincott, New York1991: 2249-2265Google Scholar The typical regimen included contact laxatives, such as castor oil, senna, or bisacodyl, given at 3:00 to 4:00 PM on the previous afternoon to allow evacuation of bowel contents prior to bedtime. Enemas were typically given 1 hour prior to the procedure to complement the laxative and remove any solid residue in the distal colon. The primary disadvantage of the purgative regimen was the significant abdominal cramping associated with this bowel preparation. A number of studies in the 1980s comparing a purgative regimen with an oral lavage with balanced electrolyte solution with polyethylene glycol (PEG) demonstrated that, in general, both patients and colonoscopists preferred the oral lavage regimen. Osmotic purges are an alternative to the above oral purgative regimen.4Cotton PB Williams CB. Practical gastrointestinal endoscopy.in: 3rd edition. Blackwell Scientific Publications, Oxford, London1990: 160-168Google Scholar, 5Williams CB Waye JD. Colonoscopy and flexible sigmoidoscopy.in: Textbook of gastroenterology. J.B. Lippincott, New York1991: 2249-2265Google Scholar The agents generally used are magnesium salts (citrate or sulfate) or a nonabsorbable carbohydrate such as mannitol. The citrus flavored magnesium citrate is generally preferred. Mannitol is a sugar for which the body has no absorptive enzymes. Five percent mannitol is isotonic, and generally 2 L are drunk over an hour or more. The solution is quite sweet, and cooling it may lessen the commonly associated nausea. This preparation may be associated with the production of hydrogen gas resulting from fermentation by intestinal bacteria, and thus there is a risk of explosion during electrosurgical procedures.6Bigard M-A Gaucher P Lassalle C. Fatal colonic explosion during colonoscopic polypectomy.Gastroenterology. 1979; 77: 1307-1310PubMed Scopus (158) Google Scholar This risk can be eliminated by insufflation of carbon dioxide during the procedure, or the exchange of colonic gas several times by aspiration and reinsufflation. This remote risk of explosion and necessity for carbon dioxide insufflation has generally made mannitol an unpopular preparation. Oral gastrointestinal lavage utilizing electrolyte-PEG lavage solutions has become the standard method for preparing the lower gastrointestinal tract prior to colonoscopy.7Davis GR Santa Ana CA Morawski SG Fordtran JS. Development of a lavage solution associated with minimal water and electrolyte absorption or secretion.Gastroenterology. 1980; 78: 991-995PubMed Scopus (463) Google Scholar, 8DiPalma JA Brady III, CE Stewart DL et al.Comparison of colon cleansing methods in preparation for colonoscopy.Gastroenterology. 1984; 86: 856-860PubMed Google Scholar, 9Pockros PJ Foroozan P. Golytely lavage versus a standard colonoscopy preparation. Effect on normal colonic mucosal histology.Gastroenterology. 1985; 88: 545-548PubMed Google Scholar, 10Fortran JS Santa Ana CA Cleveland MB. A low-sodium solution for gastrointestinal lavage.Gastroenterology. 1990; 98: 11-16PubMed Google Scholar, 11DiPalma JA Marshall JB. Comparison of a new sulfate-free polyethylene glycol electrolyte lavage solution versus a standard solution for colonoscopy cleansing.Gastrointest Endosc. 1990; 36: 285-289Abstract Full Text PDF PubMed Scopus (98) Google Scholar, 12Saux MC Saint-Martin E Vergier JF et al.Acceptability and effectiveness of a low sodium PEG solution for colon cleansing before coloscopy.Gastroenterology. 1992; 102 ([abstract]): A24Google Scholar The standard commercial preparations utilized in the United States are Golytely, Nulytely, and Colyte, plain and flavored (Table 1). The original balanced electrolyte solution with PEG was developed by Davis and colleagues,7Davis GR Santa Ana CA Morawski SG Fordtran JS. Development of a lavage solution associated with minimal water and electrolyte absorption or secretion.Gastroenterology. 1980; 78: 991-995PubMed Scopus (463) Google Scholar who also coined the name “Golytely” in 1980. This solution was designed with sodium sulfate, which is associated with only trivial amounts of water and sodium absorption or secretion during total gut perfusion. A number of subsequent clinical studies comparing Golytely with the then-standard preparation for colonoscopy (purgatives and enemas) demonstrated that Golytely was preferred by colonoscopists because it allowed better visualization of the colonic mucosa, and by patients because it required a shorter preparation time and had fewer side effects.8DiPalma JA Brady III, CE Stewart DL et al.Comparison of colon cleansing methods in preparation for colonoscopy.Gastroenterology. 1984; 86: 856-860PubMed Google Scholar Moreover, biopsy studies demonstrated that the colon lavage preserved normal mucosal histology, whereas the previous standard colon preparation flattened the surface epithelial cells and depleted goblet cells as well as causing edema of the lamina propria.9Pockros PJ Foroozan P. Golytely lavage versus a standard colonoscopy preparation. Effect on normal colonic mucosal histology.Gastroenterology. 1985; 88: 545-548PubMed Google ScholarTable 1Composition of oral lavage solutionsGolytelyNulytelyColyteNa+ (mEg/L)12565125K+ (mEq/L)10510Cl- (mEq/L)355335HCO3 - (mEq/L)201720SO4 = (mEq/L)40080PEG* (gm/L)6010560Osmolality280288280*PEG 3350. Open table in a new tab The primary disadvantage of balanced electrolyte solutions is the necessity of ingesting a large volume of fluid (4 L) and the salty taste. It is generally recommended that no solid food be ingested 3 to 4 hours prior to the initiation of Golytely. The rate of administration of the lavage solution is 8 ounces every 10 minutes, with the first bowel movement usually occurring 1 hour later. The side effects of nausea or vomiting may be associated with poor compliance with ingestion of the full amount of fluid necessary to induce clear, watery stools and a clean colon. In some cases, an antiemetic such as prochlorperazine maleate (Compazine) may be required if the patient is experiencing nausea or vomiting. Oral lavage is contraindicated in any patient with ileus, gastric retention, documented or potential mechanical bowel obstruction, severe colitis, or neurologic impairment preventing safe swallowing. A nasogastric tube can be used to infuse the balanced electrolyte solution in patients unable to ingest the lavage solution. It is uncertain whether the entire 4 L of solution should be consumed by all patients. Some colonoscopists qualify their instructions by telling patients that they can taper off oral ingestion once watery diarrhea becomes clear, while other colonoscopists believe that ingestion of lesser amounts of solution is fraught with more frequent incidence of poorly prepared colons. The highly salty taste of Golytely led to the development of alternative balanced electrolyte solutions.10Fortran JS Santa Ana CA Cleveland MB. A low-sodium solution for gastrointestinal lavage.Gastroenterology. 1990; 98: 11-16PubMed Google Scholar Nulytely is a solution that was developed by removing sodium sulfate, increasing the concentration of PEG, and making minor adjustments in the concentration of other salts (Table 1). It was postulated that the less salty taste of Nulytely would make it less difficult to drink and therefore enhance patient compliance. Some11DiPalma JA Marshall JB. Comparison of a new sulfate-free polyethylene glycol electrolyte lavage solution versus a standard solution for colonoscopy cleansing.Gastrointest Endosc. 1990; 36: 285-289Abstract Full Text PDF PubMed Scopus (98) Google Scholar, 12Saux MC Saint-Martin E Vergier JF et al.Acceptability and effectiveness of a low sodium PEG solution for colon cleansing before coloscopy.Gastroenterology. 1992; 102 ([abstract]): A24Google Scholar but not all13Froehlich F Fried M Schnegg JF Gonvers JJ. Palatability of a new solution compared with standard polyethylene glycol solution for gastrointestinal lavage.Gastrointest Endosc. 1991; 37: 325-328Abstract Full Text PDF PubMed Scopus (25) Google Scholar, 14Lémann M Halphen M Flourié B et al.Controlled trial of palatability of a new low-sodium PEG lavage solution.Gastroenterology. 1993; 104 ([abstract]): A16Google Scholar studies comparing Golytely and Nulytely confirm the taste preference for the solution with sodium sulfate removed. Another commercial balanced electrolyte solution, Colyte, was revised with added flavor ingredients and is marketed as Colyte-Flavored. In a tasting survey by normal subjects consuming small volumes (60 mL) of various flavored balanced electrolyte solutions, patients overall preferred lemon-flavored Colyte versus lemon/lime-flavored Colyte or Nulytely.15Matter SE Rice PS Campbell DR. Colonic lavage solutions: plain versus flavored.Am J Gastroenterol. 1993; 88: 49-52PubMed Google Scholar In another study, one packet of Crystalite or two packages of Kool-Aid added to 4 L of Colyte did not increase osmolality above the range considered safe for colonic lavage and were found to be significantly more palatable than unflavored Colyte.16Gruber M Fay D Pudhurodsky T Lance P. Artificial flavoring significantly improves palatability of colonic lavage solution.Gastrointest Endosc. 1991; 37 ([abstract]): 233Google Scholar A number of adjunctive measures have been evaluated in combination with ingestion of oral balanced electrolyte solutions, including simethicone, bisacodyl, metaclopramide, and cisapride. Although some earlier studies had demonstrated that the addition of simethicone resulted in fewer bubbles or colonic foam, this measure has not gained popularity. Similarly, metaclopramide and cisapride have not consistently improved either the quality or tolerance of colonic lavage and thus are not used on a widespread basis. The results of some recent studies have resulted in renewed interest in the use of the laxative, oral NaP (Fleet Phospho-Soda), for preparing the colon for colonoscopy.17Vanner SJ MacDonald PH Paterson WG et al.A randomized prospective trial comparing oral sodium phosphate with standard polyethylene glycol-based lavage solution (Golytely) in the preparation of patients for colonoscopy.Am J Gastroenterol. 1990; 85: 422-427PubMed Google Scholar, 18Kolts BE Lyles WE Achem SR Burton L Geller AJ MacMath T. A comparison of the effectiveness and patient tolerance of oral sodium phosphate, caster oil, and standard electrolyte lavage for colonoscopy or sigmoidoscopy preparation.Am J Gastroenterol. 1993; 88: 1218-1223PubMed Google Scholar, 19Cohen SM Wexner SD Binderow SR et al.Prospective, randomized, endoscopic-blinded trial comparing precolonoscopy cleansing methods.Dis Colon Rectum. 1994; 37: 689-696Crossref PubMed Scopus (264) Google Scholar, 20Henderson JM Barnett JL Turgeon DK et al.Single-day, divided-dose oral sodium phosphate laxative versus intestinal lavage as preparation for colonoscopy: efficacy and patient tolerance.Gastrointest Endosc. 1995; 42: 238-243Abstract Full Text Full Text PDF PubMed Scopus (103) Google Scholar Fleet Phospho-Soda is a buffered oral saline laxative containing 2.4 gm monobasic sodium phosphate and 0.9 gm dibasic sodium phosphate in a stable, buffered aqueous solution and is sold as a nonprescription item at any pharmacy in a ginger-lemon flavored or unflavored formulation. Typically, the 1 ½-ounce size is used for bowel preparation, although a 3-ounce preparation is also available. For colonoscopy, 1 ½ ounce of Fleet Phospho-Soda is added to 4 ounces of water the evening before colonoscopy followed by three 8-ounce portions of clear liquids. On the morning of the procedure, an additional 1 ½ ounces of Fleet Phospho-Soda added to 4 ounces of water is ingested. It is recommended that the preparation be completed at least 3 hours prior to colonoscopy. Oral NaP should not be used in patients with impaired renal function, congestive heart failure, or cirrhosis with ascites because absorption of sodium and/or phosphate may have deleterious effects. Transient hyperphosphatemia (mean increase, 4.1 mg/dL) was documented in a recent experience with this bowel preparation, but there was no hypocalcemia or clinical adverse events.17Vanner SJ MacDonald PH Paterson WG et al.A randomized prospective trial comparing oral sodium phosphate with standard polyethylene glycol-based lavage solution (Golytely) in the preparation of patients for colonoscopy.Am J Gastroenterol. 1990; 85: 422-427PubMed Google Scholar Other studies have also demonstrated changes in electrolytes, including a rise in serum phosphate and sodium and fall in serum calcium and potassium, which are typically reversible within hours and not associated with symptoms.1Lieberman DA Ghormley J Flora K. Effect of oral sodium phosphate colon preparation on serum electrolytes in patients with normal serum creatinine.Gastrointest Endosc. 1996; 43: 467-469Abstract Full Text Full Text PDF PubMed Google Scholar, 18Kolts BE Lyles WE Achem SR Burton L Geller AJ MacMath T. A comparison of the effectiveness and patient tolerance of oral sodium phosphate, caster oil, and standard electrolyte lavage for colonoscopy or sigmoidoscopy preparation.Am J Gastroenterol. 1993; 88: 1218-1223PubMed Google Scholar, 19Cohen SM Wexner SD Binderow SR et al.Prospective, randomized, endoscopic-blinded trial comparing precolonoscopy cleansing methods.Dis Colon Rectum. 1994; 37: 689-696Crossref PubMed Scopus (264) Google Scholar, 20Henderson JM Barnett JL Turgeon DK et al.Single-day, divided-dose oral sodium phosphate laxative versus intestinal lavage as preparation for colonoscopy: efficacy and patient tolerance.Gastrointest Endosc. 1995; 42: 238-243Abstract Full Text Full Text PDF PubMed Scopus (103) Google Scholar, 21Huynh T Vanner S Paterson W. Safety profile of 5-hour oral sodium phosphate regimen for colonoscopy cleansing: lack of clinically significant hypocalcemia or hypovolemia.Am J Gastroenterol. 1995; 90: 104-107PubMed Google Scholar, 22Clarkston WK Dies DF Bjerregaard P Schratz L Rebholz A Kotar S. A single blind comparison of serum electrolytes, serum phosphorus, serum calcium, and ventricular arrhythmias in outpatients receiving Nulytely verus Fleet Phospho-Soda preparation for colonoscopy: preliminary results.Gastrointest Endosc. 1994; ([abstract]): 92PubMed Google Scholar However, one fatality associated with the use of Fleet Phospho-Soda and electrolyte imbalance has been reported.23Fass R Do S Hixson LJ. Fatal hyperphosphatemia following Fleet Phospho-Soda in a patient with colonic ileus.Am J Gastroenterol. 1993; 88: 929-932PubMed Google Scholar In a randomized study comparing Golytely to Fleet Phospho-Soda, sodium phosphate was safe, better tolerated, and more effective than Golytely.17Vanner SJ MacDonald PH Paterson WG et al.A randomized prospective trial comparing oral sodium phosphate with standard polyethylene glycol-based lavage solution (Golytely) in the preparation of patients for colonoscopy.Am J Gastroenterol. 1990; 85: 422-427PubMed Google Scholar In this Canadian study, oral NaP was approximately eight times less expensive than Golytely. Moreover, the concern regarding histologic alterations of the bowel, based on reported changes induced by sodium phosphate enemas, was not confirmed in this study using oral NaP; biopsy specimens from patients prepared with either NaP or Golytely were comparable.17Vanner SJ MacDonald PH Paterson WG et al.A randomized prospective trial comparing oral sodium phosphate with standard polyethylene glycol-based lavage solution (Golytely) in the preparation of patients for colonoscopy.Am J Gastroenterol. 1990; 85: 422-427PubMed Google Scholar In another study comparing Golytely, lemon flavored castor oil, and oral NaP, the quality of the preparation was better with NaP than the other two agents and patient acceptance was similar for each.18Kolts BE Lyles WE Achem SR Burton L Geller AJ MacMath T. A comparison of the effectiveness and patient tolerance of oral sodium phosphate, caster oil, and standard electrolyte lavage for colonoscopy or sigmoidoscopy preparation.Am J Gastroenterol. 1993; 88: 1218-1223PubMed Google Scholar It was estimated that patient savings with oral NaP would be $5000 per 100 colonoscopies. Other studies have also shown that colon preparation with oral NaP is preferred to oral lavage.19Cohen SM Wexner SD Binderow SR et al.Prospective, randomized, endoscopic-blinded trial comparing precolonoscopy cleansing methods.Dis Colon Rectum. 1994; 37: 689-696Crossref PubMed Scopus (264) Google Scholar, 20Henderson JM Barnett JL Turgeon DK et al.Single-day, divided-dose oral sodium phosphate laxative versus intestinal lavage as preparation for colonoscopy: efficacy and patient tolerance.Gastrointest Endosc. 1995; 42: 238-243Abstract Full Text Full Text PDF PubMed Scopus (103) Google Scholar A study comparing oral NaP with Colyte concluded that NaP was a well-tolerated and safe colon cleansing agent in older patients and confirmed the lower cost.24Haroon N Iber FL. A randomized clinical trial comparing oral sodium phosphate (NaP) with standard polyethylene glycol-based lavage solution (Colyte) in the preparation of patients for colonoscopy.Gastroenterology. 1992; 102 ([abstract]): A13Google Scholar Another study comparing oral NaP with Colyte concluded that both preparations resulted in satisfactory colon cleansing in approximately 90% of patients and there was little overall difference in the quality of preparation or side effects.25Marshall J Pineda J Barthel J King P. Prospective, randomized trial comparing sodium phosphate (SP) solution (Fleet Phospho-Soda) with PEG electrolyte lavage solution (Colyte) for the preparation of patients undergoing colonoscopy.Gastrointest Endosc. 1993; 39 ([abstract]): 268Google Scholar There currently are six Fleet prep kits marketed for bowel cleansing regimens in preparation for barium enema, abdominal surgery, or colonoscopy. These kits contain various combinations of either NaP or flavored castor oil as a laxative, four laxative tablets of bisacodyl, and either a suppository or an enema. A similar product used in other countries is X-Prep, which combines a senna preparation with an enema. One study has demonstrated that 4 L of Golytely and X-Prep had equivalent colon cleansing efficacy, but that patients judged X-Prep to be less unpleasant.26Handgartner PJ Mödunch R Meier J Ammann R Bühler H. Comparison of three colon cleansing methods: evaluation of a randomized clinical trial with 300 ambulatory patients.Endoscopy. 1989; 21: 272-275Crossref PubMed Scopus (39) Google Scholar The utility of the various Fleet prep kits has not been widely studied as preparation for colonoscopy; however, they duplicate the former preparation in vogue prior to the advent of balanced electrolyte solutions in the early 1980s. It is generally stated that if a patient is fit for colonoscopy, the patient is also fit for a standard full bowel preparation. There is some concern that over-vigorous bowel preparations may precipitate relapses in inflammatory bowel disease. Patients with severe colitis are unlikely to need or safely undergo colonoscopy. Zwas and colleagues2Zwas F Cirillo N El-Serag HB Eisen RN. Colonic mucosal abnormalities associated with oral sodium phosphate solution.Gastrointest Endosc. 1996; 43: 463-466Abstract Full Text Full Text PDF PubMed Scopus (116) Google Scholar recommend that NaP not be used as a colonoscopy preparation in patients with inflammatory bowel disease because of the potential of misinterpretation of aphthoid lesions induced by the preparation. Colonoscopy had initially been used for the evaluation of acute lower gastrointestinal bleeding by attempted examination of the unprepared colon, but the procedure was technically difficult and success was limited. After the widespread availability of balanced electrolyte solutions, several studies demonstrated that whole gut lavage followed by colonoscopy allowed the frequent identification of the bleeding lesions and facilitated endoscopic therapy. A colon clean of feces is equally critical in the complete examination of the colon in children.27Barrish JO Gilger MA. Colon cleanout preparations in children and adolescents.Gastroenterol Nurs. 1993;December; : 106-109Crossref PubMed Scopus (21) Google Scholar, 28Bines JE Winter HS. Lower endoscopy.in: Pediatric gastrointestinal disease. Decker, Philadelphia: B.C1991: 1257-1271Google Scholar Colonic lavage solutions are often used to prepare bowels in children, but the volume is modified according to body weight. A study comparing various preparations in children concluded that Golytely yielded the best results with the fewest side effects.27Barrish JO Gilger MA. Colon cleanout preparations in children and adolescents.Gastroenterol Nurs. 1993;December; : 106-109Crossref PubMed Scopus (21) Google Scholar A higher rate of poor colon preparations may be seen in elderly patients. In a study of subjects older than age 65 years compared with younger patients, a poor bowel preparation was found in 13% of the elderly population as compared with 8% of the younger controls.29Wilson JAP. Adequacy of preparation for colonoscopy in elderly patients.Gastroenterology. 1993; 104 ([abstract]): A653Google Scholar In another study, older patients were found to have better tolerance for a balanced electrolyte solution with fewer cramps than subjects of younger age. Overall, age did not influence the adequacy of preparation for gut lavage.30DiPalma JA Brady III, CE Pierson WP. Colon cleansing: acceptance by older patients.Am J Gastroenterol. 1986; 81: 652-655PubMed Google Scholar The charges to patients or their insurance carriers is approximately sevenfold less for Fleet Phospho-Soda versus the commercial balanced electrolytes-PEG solutions (Table 2). An added convenience for Fleet Phospho-Soda is that is can be purchased without a prescription.Table 2Costs of colonoscopy preparations*Pharmacy #1 ($)Pharmacy #2 ($)Golytely18.5031.80Nulytely18.4031.80Colyte20.1531.80‡Colyte-Flavored18.4033.80‡Fleet Phospho-Soda (45 mL)†0.901.50Fleet Prep Kits‡2.61→5.155.23→7.33*Costs represent retail charge in dollars to patient or insurance carrier. †Nonprescription. ‡A generic preparation (Go-Evac) is available for $14.13. Open table in a new tab What is the best colonoscopy prep? A balanced electrolyte solution and oral NaP provide comparable colonic cleansing, although many patients prefer NaP. Colonoscopy preparation with NaP is significantly less expensive. Since all patients and colons are different, it might not be unreasonable to take a few minutes to describe the advantages and disadvantages of both preparations to patients scheduled for colonoscopy and solicit their preference. Specific disorders such as renal insufficiency, congestive heart failure, ascites, and possibly inflammatory bowel disease favor the use of a balanced electrolyte solution. On the other hand, previous difficulty with consuming a gallon of fluid or associated nausea and vomiting would tip the scales in favor of oral NaP.
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