Addition of castor oil as a booster in colon capsule regimens significantly improves completion rates and polyp detection

Abstract

BACKGROUND Incomplete excretion rates are problematic for colon capsule endoscopy (CCE). Widely available booster regimens are suboptimal. Recently published data on one day preparation CCE protocol using castor oil appeared effective. AIM To assess the impact of adding castor oil to a standard split-dose (2-d) preparation in an unselected Western patient cohort. METHODS All patients aged 18 or more referred to our unit for a CCE over a 5-mo period were prospectively recruited. Controls were retrospectively identified from our CCE database. All patients received split bowel preparation with Moviprep ® [polyethylene glycol (PEG)-3350, sodium sulphate, sodium chloride, potassium chloride, sodium ascorbate and ascorbic acid for oral solution; Norgine B. V, United States], a PEG-based solution used predominantly in our colonoscopy practice. Control booster regimen included Moviprep ® with 750 mL of water (booster 1) on reaching the small bowel. A further dose of Moviprep ® with 250 mL of water was given 3 h later and a bisacodyl suppository (Dulcolax ® ) 10 mg after 8 h, if the capsule was not excreted. In addition to our standard booster regimen, cases received an additional 15 mL of castor oil given at the time of booster 1. A nested case control design with 2:1 ratio (control:case) was employed. Basic demographics, completion rates, image quality, colonic transit time, diagnostic yield and polyp detection were compared between groups, using a student t or chi-square tests as appropriate. RESULTS One hundred and eighty-six CCEs [mean age 60 years (18-97), 56% females, n = 104], including 62 cases have been analysed. Indication breakdown included 96 polyp surveillance (51.6%), 42 lower gastrointestinal symptoms (22.6%), 28 due to incomplete colonoscopy (15%), 18 anaemia (9.7%) and 2 inflammatory bowel disease surveillance (1.1%). Overall, CCE completion was 77% (144/186), image quality was adequate/diagnostic in 91% (170/186), mean colonic transit time was 3.5 h (0.25-13), and the polyp detection rate was 57% (106/186). Completion rates were significantly higher with castor oil, 87% cases (54/62) vs 73% controls (90/124), P = 0.01. The number needed to treat with castor oil to result in an additional complete CCE study was 7, absolute risk reduction = 14.52%, 95% confidence interval (CI): 3.06- 25.97. This effect of castor oil on excretion rates was more significant in the over 60 s, P < 0.03, and in females, P < 0.025. Similarly, polyp detection rates were higher in cases 82% (51/62) vs controls 44% (55/124), P = 0.0001, odds ratio 5.8, 95%CI: 2.77-12.21. Colonic transit times were similar, 3.2...

Castor Oil in Bowel Preparation Regimens for Colon Capsule Endoscopy: A Systematic Review with Meta-Analysis

“…Thorough snowballing yielded two articles for screening abstracts, of which both were considered eligible for full-text reading and were finally included in the study ( Figure 1 ). In total, six articles were included in this meta-analysis [ 12 , 14 , 15 , 23 , 24 , 25 ].…”

“…In all studies, PEG-based laxatives were used for bowel preparation before capsule ingestion; in two studies, the split dose regimen was employed. Prokinetics were used in all six studies; in four metoclopramide [ 12 , 14 , 15 , 24 ], in one mosapride citrate [ 25 ], and in another, a combination of metoclopramide and mosapride citrate as well as suppository [ 23 ]. The details of the bowel preparation regimens are presented in Table 3 .…”

“…Male participants ranged from 30% to 75%, and the median age ranged from 40 to 67 years. The populations varied between studies and included screening patients [ 14 , 25 ], patients with symptoms [ 12 , 14 , 15 , 25 ], ulcerative colitis [ 24 ], patients for colonic surveillance [ 12 , 23 ], or after incomplete colonoscopy [ 12 , 15 ], as well as dialysis and kidney transplant patients [ 23 ]. None of the studies reported significant adverse events, but in one study [ 24 ], two individuals with minor events (nausea and discomfort) were noted.…”

“…The pooled PP of acceptable bowel preparation was not significantly different between CCE using castor oil (80%, CI 95%; 65–92) and the control groups (87%, CI 95%; 83–91) ( Figure 3 ). The three studies reporting the proportion of individuals with acceptable bowel preparation used the Leighton–Rex scale [ 14 ], the Boston Bowel Preparation Scale [ 12 ], and the Aronchick Global Assessment Scale [ 15 ], respectively. The two studies reporting bowel preparation per segment had acceptable bowel preparation in 44% and 86% of investigated segments [ 24 , 25 ].…”

“…Sodium Phosphate (NaP) boosters have been the most commonly used but have not been associated with higher CRs or adenoma detection rates [ 10 ]. Castor oil is a safe laxative derived from the castor bean that is widely available and commonly used in the general population [ 11 , 12 ]. Adding castor oil to a polyethylene glycol (PEG)-based bowel preparation regimen before colonoscopy has decreased the required volume of bowel preparation solution [ 13 ].…”