Editorial: A Light Breakfast, a Jug of Salt Water and Bowel

Abstract

Successful colonoscopy is predicated on achieving adequate colon cleansing. An ideal bowel preparation would be low in volume, acceptable to patients, reliable in cleansing effi cacy, and safe. The study by Di Palma et al. in this issue shows that a novel, low-volume (960 ml) preparation of mixed sulfate salts can achieve excellent bowel cleansing with acceptable tolerability and minimal electrolyte shifts. A split-dosing strategy, with a proportion of the preparation administered on the day of colonoscopy, achieved a 97.2 % preparation success rate vs. 82.4 % using a regimen provided entirely the day before colonoscopy. These results were comparable with control groups using a commercially available polyethylene glycol solution. Endoscopists and patients alike should be encouraged by the trend toward lower-dose bowel cleansing regimens that achieve equivalent effi cacy compared with large-volume preparations. Am J Gastroenterol 2009; 104:2285-2287 doi: 10.1038/ajg.2009 It could be argued that there is no medication more commonly prescribed by a busy endoscopist than a bowel preparation. Yet, the volume of scientifi c literature on the pharmacokinetics, efficacy, and side eff ects of bowel cleansing agents used for colonoscopy and other medical procedures is scant when compared with other agents used for digestive health. Th e importance of bowel preparation before colonoscopy cannot be understated. Inadequate colon cleansing is associated with lower endoscopic yield for adenomas (1,2) , decreased fi nd rates for fl at lesions (3), and longer examinations (2) . Unfortunately, bowel preparation is oft en inadequate to permit complete examination of the colon (1) , necessitating shorter screening and surveillance intervals. Perhaps most importantly, patients report that the bowel preparation is both the leading deterrent to undergoing screening colonoscopy (4) and the most diffi cult part of the examination (5) .In this issue of the American Journal of Gastroenterology , Di Palma et al . report the results of a randomized, multicenter, industry-sponsored, endoscopist-blinded trial of a novel oral sulfate solution for pre-colonoscopic bowel preparation (6) . Study subjects were randomized to one of two therapeutic dosing strategies: same-day (PM before examination) vs. split-dose (PM / AM) preparation. Case subjects used two 480-ml doses of a solution comprised of sodium, potassium, and magnesium sulfate salts. Controls used two 1-L doses of a commercially available polyethylene glycol solution with electrolytes and ascorbic acid (PEG-EA, MoviPrep, Salix Pharmaceuticals, Morrisville, NC). Th e primary endpoint was bowel preparation success defi ned as a score of " excellent " or " good " using a previously published scale (7,8) . Tolerability was assessed using a questionnaire administered on the date of the examination.Th e intention-to-treat analysis included 387 subjects randomized to the same-day dosing strategy (194 sulfate, and 364 subjects in the split-dose strategy (181 sulfate, 183 PEG-EA). Bowel preparati...