CONCISE REVIEW FOR CLINICIANS

Optimizing Bowel Cleansing for Colonoscopy

Seth Sweetser, MD, and Todd H. Baron, MD

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Abstract

Adequate bowel cleansing is essential for complete examination of the colon mucosa during colonoscopy.
Suboptimal bowel preparation has potential adverse consequences, such as missed pathologic abnormal-
ities, the need for repeated procedures, and increased procedure-related complications. Several factors can
predict individuals at increased risk for inadequate bowel preparation. If predictors of inadequate bowel
preparation are identified, then education should be intensified and a more aggressive bowel regimen
recommended. On completion of this article, you should be able to (1) define the frequency of inadequate
colon preparations, (2) identify predictors of poor bowel preparation, and (3) use a more aggressive bowel
regimen when clinically indicated.
ª 2015 Mayo Foundation for Medical Education and Research n Mayo Clin Proc. 2015;90(4):520-526

C
olonoscopy is most often performed colonic preparation are highlighted, and steps
for colorectal cancer screening. For to optimize bowel preparation are outlined.
From the Division of Gastro- optimal performance and visualization
enterology and Hepatology,
Mayo Clinic College of Medi-
of mucosal lesions and details, adequate bowel TYPES OF COLONIC PURGATIVES
cine, Rochester, MN (S.S.); preparation is essential. The degree of bowel The ideal bowel preparation should effectively
and the Division of Gastro- cleansing is a critical factor in diagnostic colonos- clear the colon of stool and provide maximal
enterology and Hepatology,
University of North Carolina
copy. However, bowel preparation is inadequate visualization of mucosa, preserve the gross and
School of Medicine, Chapel in up to 30% of cases1 and decreases diagnostic microscopic integrity of the colon, and be easily
Hill (T.H.B.). accuracy, prolongs the procedure time, de- administered, well tolerated, and safe. The ideal
creases surveillance intervals, increases cost, colonic purgative does not exist. Available colo-
and potentially results in procedure-related com- noscopy preparations are of 2 broad categories:
plications. In this article, the available bowel polyethylene glycol (PEG) based and hyperos-
preparations are reviewed, considerations for motic. Both types of preparations can produce

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www.mayoclinicproceedings.org n ª 2015 Mayo Foundation for Medical Education and Research
OPTIMIZING BOWEL CLEANSING FOR COLONOSCOPY

adequate bowel cleansing but with variability in which is an option in patients without congestive
tolerance, preparation-induced mucosal changes, heart failure, liver disease with ascites, or chronic
and adverse events. kidney disease.

Polyethylene Glycol Hyperosmotic Preparations

The PEG-electrolyte regimens are the most Hyperosmotic preparations contain poorly
commonly administered preparations. A variety absorbed multivalent cations or anions with
of PEG-based formulations are available, and osmotic effects and increase intraluminal water,
they differ with respect to volume of solution, causing bowel distension and evacuation. The
electrolyte content, requirement for adjunctive available hyperosmotic agents include sodium
laxative, presence of artificial sweeteners, and effi- phosphate (NaP), sodium picosulfate, and mag-
cacy. In general, PEG-based formulations include nesium citrate.
standard 4-L and reduced-volume 2-L prepara- The NaP preparations are effective and may
tions. The 2-L, low-volume PEG preparation is be better tolerated than PEG-based preparations
said to provide comparable colonic cleansing as because of lower volume. A meta-analysis found
4-L formulations.2,3 However, note that clinical NaP to be more effective in bowel cleansing
trials of colonoscopy purgatives are often designed than standard PEG-electrolytes and comparable
as noninferiority studies and are not powered to in terms of adverse events.8 However, most
demonstrate equivalence. In addition, patients studies compared NaP with standard 4-L PEG-
with chronic constipation are often excluded electrolytes. When both are administered in
from studies. Therefore, low-volume PEG formu- split-dose regimens, no difference in efficacy
lations are not sufficient in all patient populations. was seen, but split-dose PEG-electrolytes were
In a recent meta-analysis, 4-L, split-dose PEG- better tolerated, with less nausea and vomiting.9
electrolytes were found to be superior.4 Therefore, when administered in split fashion,
Overall, PEG-based preparations are safe and PEG formulations seem to be better tolerated
well tolerated. The most common adverse events than NaP, with equal cleansing efficacy.
are nausea, abdominal pain, and bloating. Not Potential adverse effects of NaP preparations
surprisingly, the reduced volume regimens include fluid shifts, hyperphosphatemia, electro-
decrease nausea and abdominal bloating and lyte abnormalities, tonic-clonic seizures, mucosal
may be better tolerated. The PEG preparations damage, and acute renal failure (acute phosphate
are iso-osmotic and are preferred in patients nephropathy). Acute phosphate nephropathy is
less likely to tolerate fluid shifts, such as those characterized by precipitation of calcium phos-
with renal insufficiency, congestive heart failure, phate crystals in the renal tubules, which may
or advanced liver disease. Because of their excel- cause chronic irreversible kidney injury even in
lent safety profile, PEG-based agents are the most patients with previously normal renal function.
commonly used bowel colonoscopy purgatives. Previous renal insufficiency and medications
that impact renal function, such as diuretics,
Over-the-Counter PEG Product angiotensin-converting enzyme inhibitors, and
MiraLAX (PEG 3350; Braintree Laboratories angiotensin receptor blockers, predispose to com-
Inc) is an over-the-counter product for the treat- plications of NaP.10 Although the incidence of
ment of constipation. As a colonoscopy bowel- acute phosphate nephropathy is low, the Food
cleansing regimen, 1 bottle (8.3 oz; 238 g) is and Drug Administration issued a black box
mixed with 64 oz of Gatorade (PepsiCo) to create warning for acute phosphate nephropathy in
a nonosmotically balanced 2-L PEG formulation. those with advanced age, preexisting renal dis-
Bisacodyl tablets or magnesium citrate are used in ease, decreased intravascular volume, and use of
conjunction with the PEG 3350 powder. How- medications that affect renal perfusion or func-
ever, 4-L, split-dose PEG-electrolyte preparations tion. Because of these concerns, routine use of
seem to be more effective.5,6 In contrast, tolera- NaP as a bowel preparation is not recommen-
bility (taste and overall experience) is better ded.11 Despite this statement, a recent large, retro-
with MiraLAX/Gatorade than with 4-L PEG- spective cohort study found no increased risk of
electrolytes.6,7 Despite MiraLAX/Gatorade being acute kidney injury with the use of oral NaP
a hypotonic solution, hyponatremia is rare with compared with PEG even in high-risk clinical
the use of this over-the-counter formulation, subgroups.12 This finding suggests that serious

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 MAYO CLINIC PROCEEDINGS

TABLE 1. Commonly Used Bowel Preparations

Type Products Comments on use
Polyethylene glycol
4-L PEG-ELS GoLYTELY and Colyte 4 L is the gold standard for efficacy
4-L SF PEG NuLYTELY and TriLyte 4 L is the gold standard for efficacy
2-L PEG-ELS and bisacodyl HalfLytely Preferable option if history of poor tolerability of the 4-L
PEG preparation and medical/patient predictors of poor
preparation are absent
2-L PEG with ascorbate MoviPrep Alternative to 4-L PEG if no medical/patient predictors of
poor preparation
MiraLAX and Gatorade OTC Inferior to PEG in preparation quality and may precipitate
severe hyponatremia because not osmotically balanced
Sodium phosphate tablet OsmoPrep Avoid in individuals with cardiac, renal, or liver disease
Sodium picosulfate Prepopik Better tolerated than PEG preparations; avoid in
individuals with cardiac, renal, or liver disease
Sodium sulfate Suprep Similar efficacy and tolerability as PEG formulation; avoid
in individuals with cardiac, renal, or liver disease
ELS ¼ electrolyte lavage solution; OTC ¼ over the counter; PEG ¼ polyethylene glycol; SF ¼ sulfate free.

adverse renal effects from oral NaP preparations than 5 mm throughout the colorectum.15 This
are rare. If considered for use, oral NaP prepara- operational definition allows the detection of clin-
tions are best for otherwise healthy patients, ically significant lesions and is accompanied by
who should be instructed on how to maintain the expectation that screening and surveillance
adequate hydration during preparation and af- intervals available in established guidelines are fol-
ter the procedure. lowed. Inadequate preparations result in exami-
Sodium sulfate is an alternative osmotic nations being repeated sooner, which increases
bowel purgative with similar effectiveness and the cost and potential risks of colonoscopy. Liter-
tolerance as PEG formulations. Sodium sulfate ature has emerged defining patients who are at
solutions do not cause significant electrolyte or risk for inadequate bowel cleansing (Table 2).
fluid shifts in individuals without cardiac, renal, There are 2 sets of predictors of inadequate prep-
or liver disease.2 Sodium sulfateebased prepara- aration: medical factors and patient factors.16
tions have not been tested in patients at risk for Medical predictors include previous failed
electrolyte abnormalities or intravascular volume bowel preparation, chronic constipation, use
shifts; therefore, they are not recommended for of constipating medications, diabetes mellitus,
use in such patients. obesity, and previous colonic resection. Medi-
A newer dual-action hyperosmotic prepara- cal predictors of inadequate preparation can be
tion contains sodium picosulfate and magnesium. easily identified by providers. Patient factors
Sodium picosulfate acts as a stimulant laxative, associated with inadequate bowel preparation
and magnesium acts as an osmotic agent. Sodium relate to predictors of not following preparation
picosulfate is better tolerated than and produces a instructions and include Medicaid insurance, En-
similar degree of cleansing as NaP13 and PEG3 glish not being the patient’s first language, lower
preparations. However, sodium picosulfate prep- educational level, low health literacy, low patient
arations can precipitate severe hyponatremia in activation (how engaged a patient is in his or her
older adults.14 health care), and a longer waiting time between
Commonly used bowel preparations and the date the procedure is scheduled and the day
comments on their use are summarized in of the procedure.16 Patient factors are difficult to
Table 1. assess in clinical practice. Two useful surrogates
for not following bowel preparation instructions
GENERAL PREPARATION are Medicaid insurance and English not being
CONSIDERATIONS the patient’s first language. It is important to iden-
An adequate preparation is defined as one that al- tify medical and patient predictors so that mea-
lows endoscopic visualization of polyps larger sures can be taken to overcome them.
n n
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OPTIMIZING BOWEL CLEANSING FOR COLONOSCOPY

ADDITIONAL FACTORS INFLUENCING

TABLE 2. Medical and Patient Predictors of Inadequate Bowel Preparation
CLEANSING
Additional factors that may influence the quality Medical predictors Predictors of not following instructions
of bowel preparation include split-dose admin- Previous failed preparation Medicaid insurance
istration, timing, dietary factors, and use of Chronic constipation English not being the patient’s first language
adjunctive agents. Traditionally, a large volume Use of constipating medications Lower educational level
(eg, opioids, tricyclics)
of iso-osmotic PEG-electrolyte solution was
Diabetes mellitus Low health literacy
given 1 day before colonoscopy. The main dis-
Obesity Low patient activation
advantages of this preparation are large volume Previous colonic resection Longer waiting time between date procedure
and poor palatability. Poor adherence prompted scheduled and day of procedure
refinements such as split-dose administration.
Dose splitting consists of taking half the prepara-
tion the evening before and the remainder the
morning of the examination. Meta-analyses4,17 of bowel preparation. Refraining from seeds and
show that split-dosing regimens are more effec- corn is recommended for several days before
tive, irrespective of the type of bowel preparation colonoscopy, and only clear fluids are permitted
used, which is due to improved tolerance and on the day preceding the procedure. Consump-
adherence to preparation regimens, with sub- tion of solid, low-residue food before colonos-
sequent improvement in quality of bowel copy does not affect the efficacy of colon
cleansing.18 Because split-dose preparation cleansing and can enhance tolerance compared
regimens are associated with better colonic with a clear liquid diet.23 In addition to being
cleansing (particularly in the right colon), better tolerated, a low-residue diet results in
increased patient satisfaction, and improved more adequate bowel cleanliness than a clear
polyp detection rates,17,19 it is considered liquid diet on the day preceding colonoscopy.24
the standard for patients undergoing colonos- The importance of adherence to a low-residue
copy.20 Time between bowel preparation and diet was highlighted in a large retrospective
the start of colonoscopy is also important in cohort study,25 and ingestion of a prescribed
determining bowel preparation quality. A low-residue diet for 2 days preceding colonos-
shorter interval between the last dose of bowel copy was an independent predictor of adequate
preparation and the colonoscopy procedure is bowel preparation.
associated with improved bowel preparation
quality.21 To maximize preparation quality, ADJUNCTS TO COLON CLEANSING
colonoscopy should be performed within 3 Adjunctive agents, such as enemas, prokinetics,
to 5 hours of the last dose of preparation. and simethicone, are variably used to improve
Every hour by which the interval is extended bowel preparation, but routine use of such
is associated with a 10% decrease in adequate adjuncts is not necessary and does not improve
bowel preparation.21 An interval of more than bowel preparation. Adjunctive enema decreases
5 hours from the last purgative dose allows patient acceptability. Prokinetic agents, such as
new small intestinal effluent to coat the right metoclopramide, have not shown improvement
colonic mucosa, which impairs mucosal visu- in tolerability or quality of bowel cleansing and
alization.22 Sessile serrated polyps are more are not recommended.11 Bubbles and foam
commonly located in the right colon and are encountered during colonoscopy can decrease
likely even more vulnerable to underdetection mucosal visualization. Simethicone reduces the
than adenomas in persons with suboptimal surface tension of air bubbles and is inexpensive;
preparations. Consideration should be given however, its addition to oral lavage preparations
to not performing colonoscopies with a does not improve colon cleanliness.26
preparation-to-colonoscopy interval greater
than 7 hours because of significant worsening SELECTING A BOWEL PREPARATION
in bowel preparation quality. Many providers prescribe the same bowel prepa-
In addition to an active cleansing agent, ration for all procedures, irrespective of patient
bowel preparation typically consists of a restric- characteristics. Given the high rate of inadequate
tive diet. However, there is a paucity of data cleansing, identifying patients at higher risk for
regarding the role of dietary factors in the quality poor bowel cleansing is important. Inadequate

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 MAYO CLINIC PROCEEDINGS

Hospitalized Individuals
TABLE 3. Steps to Optimizing Bowel Preparation
Hospitalized patients spend most of their time
1. Provide both verbal and written instructions in bed, with limited ambulation. Most of the
2. Use a split-dosing strategy
approved bowel preparations were studied in
3. Ensure a preparation-to-colonoscopy interval of <5 h
ambulatory outpatients, where upright posture
4. Intensify the bowel-cleansing regimen if medical predictors of inadequate
preparation exist
and walking promote gastrointestinal motility
5. Individualize the cleansing regimen and increase education in previous failed and facilitate laxation. Hospitalized patients
preparations should receive the gold standard of a 4-L PEG-
6. Recommend adequate hydration during purgative ingestion electrolyte solution in split dosing to ensure
7. Instruct patient to avoid consuming raw vegetables, seeds, nuts, and corn for 3 d adequate colon cleansing.
before colonoscopy
Elderly Patients
Advanced age (>65 years) is a predictor of inad-
bowel preparation is often predictable based on 2 equate bowel preparation.28 There are no specific
categories of factors: medical predictors and other bowel preparation regimens for elderly persons.
patient issues, such as socioeconomic status, However, NaP preparations should be avoided
educational level, insurance type, and health in this population15 for concern of nephrotoxi-
literacy. If any of these predictive factors of inad- city. In addition, sodium picosulfate preparations
equate preparation are present, a more individu- can precipitate severe hyponatremia in older
alized and aggressive preparation regimen should adults.14 Because age is a predictor of inadequate
be instituted. bowel preparation, the gold standard of a 4-L
An evidence-based strategy for how to PEG-electrolyte solution should be used instead
respond to medical predictors of inadequate of low-volume PEG-electrolyte preparations to
preparation is not available. Common strategies ensure adequate colon cleansing.
in clinical practice include using a standard
4-L preparation “plus” or a “2-day” prepara-
Suspected Inflammatory Bowel Disease
tion. The standard preparation plus strategy
The use of NaP-containing preparations can
is used in individuals with medical factors pre-
induce endoscopic mucosal abnormalities that
dictive of inadequate preparation. The standard
mimic Crohn disease. Nonspecific aphthoid-like
4-L PEG formulation is prescribed in a split
mucosal lesions occur in approximately 25% of
dose with the addition of a stimulant laxative
patients. These superficial mucosal changes can
(3-12 tablets of low-dose senna or 10 mg of bisa-
lead to diagnostic confusion. Thus, NaP prepara-
codyl) to increase the cleansing effect. The 2-day
tions should not be used in patients with unex-
preparation is used after a previous failed prepara-
plained diarrhea and when the diagnosis of
tion and consists of repeating the standard PEG-
inflammatory bowel disease is suspected.
electrolyte preparation by taking 8 L over 2
days. In 1 study, repeating colonoscopy the next
day reduced the risk of repeated failure.27 When Previous Bariatric Surgery
a predictor of not following preparation instruc- No specific preparation regimens are recommen-
tions is present (eg, Medicaid insurance and ded in persons with a history of bariatric surgery.
English not being the patient’s first language), Patients who have undergone restrictive gastric
increased educational efforts should be instituted, surgery may better tolerate low-volume prepara-
including a preprocedural visit incorporating in- tions. In addition, sugar-free drinks and foods
structions in the patient’s primary language. A should be consumed to avoid symptoms related
general stepwise approach to optimizing bowel to dumping from the high sugar content.29
preparation is outlined in Table 3.
CONCLUSION
SPECIAL PATIENT POPULATIONS The goal of bowel preparation for colonoscopy is
Specific populations, such as inpatients, the to clean the colon for effective examination in a
elderly, those suspected of having inflammatory safe and tolerable manner. With this goal in
bowel disease, and individuals with previous bar- mind, several steps can be taken to optimize
iatric surgery, may benefit from a tailored bowel bowel preparation (Table 3). First, all patients
preparation. should be provided with simple and convenient
n n
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OPTIMIZING BOWEL CLEANSING FOR COLONOSCOPY

verbal and written instructions on bowel prepara- tolerability in bowel preparation for colonoscopy. Aliment Phar-
macol Ther. 2011;33(1):33-40.
tion. These instructions should include the use of 6. Hjelkrem M, Stengel J, Liu M, Jones DP, Harrison SA. MiraLAX
a split-dosing regimen, with completion of the is not as effective as GoLytely in bowel cleansing before
preparation less than 5 hours before colonoscopy. screening colonoscopies. Clin Gastroenterol Hepatol. 2011;
9(4):326-332.
A PEG electrolyte preparation is indicated for 7. Samarasena JB, Muthusamy VR, Jamal MM. Split-dosed Mira-
patients at risk for electrolyte abnormalities LAX/Gatorade is an effective, safe, and tolerable option for
or intravascular volume shifts (eg, congestive bowel preparation in low-risk patients: a randomized controlled
study. Am J Gastroenterol. 2012;107(7):1036-1042.
heart failure, liver disease with ascites, or chronic 8. Tan JJ, Tjandra JJ. Which is the optimal bowel preparation for
kidney disease). If medical predictors of inade- colonoscopy: a meta-analysis. Colorectal Dis. 2006;8(4):247-258.
quate preparation exist, then a more aggressive 9. Seo EH, Kim TO, Kim TG, et al. Efficacy and tolerability of split-
dose PEG compared to split-dose aqueous sodium phosphate
preparation, such as 4-L PEG-electrolytes or a for outpatient colonoscopy: a randomized controlled trial. Dig
low-volume preparation plus magnesium citrate, Dis Sci. 2011;56(10):2963-2971.
should be provided. When patient predictors of 10. Rex DK. Dosing considerations in the use of sodium phosphate
bowel preparations for colonoscopy. Ann Pharmacother. 2007;
suboptimal preparation are identified, education 41(9):1466-1475.
should be intensified, with emphasis on ensuring 11. Hassan C, Bretthauer M, Kaminski MF, et al. Bowel preparation
understanding of the preparation process and the for colonoscopy: European Society of Gastrointestinal Endos-
copy (ESGE) Guideline. Endoscopy. 2013;45(2):142-150.
need for adherence. If no medical or patient fac- 12. Layton JB, Klemmer PJ, Christiansen CF, et al. Sodium phos-
tors predictive of inadequate preparation are pre- phate does not increase risk for acute kidney injury after
sent, then a high-quality colon cleansing can routine colonoscopy, compared with polyethylene glycol. Clin
Gastroenterol Hepatol. 2014;12(9):1514-1521.
usually be achieved with a low-volume PEG prep- 13. Renaut AJ, Raniga S, Frizelle FA, Perry RE, Guilford L.
aration. Finally, all patients should be advised to A randomized controlled trial comparing the efficacy and
avoid consuming raw vegetables, seeds, nuts, acceptability of phospo-soda buffered saline (Fleet) with sodium
picosulphate/magnesium citrate (Picoprep) in the preparation of
and corn for 3 days before colonoscopy and to patients for colonoscopy. Colorectal Dis. 2008;10(5):503-505.
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to minimize adverse effects of volume depletion picosulfate bowel preparations in older adults. Am J Gastroen-
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16. Rex DK. Bowel preparation for colonoscopy: entering an era of
Abbreviations and Acronyms: ELS = electrolyte lavage increased expectations for efficacy. Clin Gastroenterol Hepatol.
solution; NaP = sodium phosphate; OTC = over the 2014;12(3):458-462.
counter; PEG = polyethylene glycol; SF = sulfate free 17. Kilgore TW, Abdinoor AA, Szary NM, et al. Bowel preparation
with split-dose polyethylene glycol before colonoscopy: a
Correspondence: Address to Seth Sweetser, MD, Mayo meta-analysis of randomized controlled trials. Gastrointest
Clinic, 200 First St SW. Rochester, MN 55905 (sweetser. Endosc. 2011;73(6):1240-1245.
18. Aoun E, Abdul-Baki H, Azar C, et al. A randomized single-blind
[email protected]).
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striction compared with whole dose PEG-electrolyte solution
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