Optimizing Adequacy of Bowel Cleansing for Colonoscopy
Optimizing Adequacy of Bowel Cleansing for Colonoscopy
Recommendations
Reporting the quality of the bowel preparation is a required element of the colonoscopy report In clinical trials cleansing quality often is estimated using scales that downgrade quality for retained fluid. In clinical practice, however, retained fluid and much of the semisolid debris in the colon can be removed by intraprocedural cleansing. Because the capacity to conduct effective mucosal inspection is established after intraprocedural cleansing, the preparation quality in clinical practice should be assessed only after appropriate intraprocedural washing and suctioning has been completed. For this reason, the use of a validated bowel preparation scale that includes scoring retained fluid (eg, Aronchick, Ottawa) is not recommended. The US Multi-Society Task Force (USMSTF) considers the operational definition of an adequate preparation is one in which the colonoscopist can and does recommend a follow-up screening or surveillance interval for the next colonoscopy that is appropriate for the examination findings. Unfortunately, the scores in validated scales that correspond to the point at which the preparation meets the USMSTF operational definition of an adequate preparation (ability to follow the recommended screening or surveillance interval) generally are uncertain. In clinical practice clinicians often use an imprecisely defined 4-point scale of excellent, good, fair, and poor. In this scheme, excellent and good are widely viewed as adequate, but some research indicates that many fair preparations in clinical practice also are adequate The USMSTF previously recommended that clinicians could consider the preparation adequate if after suctioning and washing the mucosa during the procedure it was deemed adequate for the detection of lesions greater than 5 mm in size This concept is not part of a validated bowel preparation scale but it does reflect current concepts about the sizes of colorectal lesions that are clinically most important to detect Additional research is needed to develop validated scales for scoring bowel cleansing that do not consider retained fluid and include defined points that correspond to adequate preparation. Currently, the Boston Bowel Preparation scale comes closest to meeting these criteria because it does not consider retained fluid and a Boston Bowel Preparation Scale score of 5 or higher was associated with only a 2% rate of recommending shortened follow-up intervals A detailed review of bowel preparation scales is shown in Appendix B.
Whichever scale is used in practice, we recommend that the method for defining an adequate preparation should include whether the colonoscopist recommends the expected screening or surveillance intervals based on the colonoscopy findings, and that the ability to detect lesions greater than 5 mm in size throughout the colon is a clinically relevant test of adequacy and appropriateness to follow screening and surveillance intervals. Furthermore, endoscopists are encouraged to submit procedure reports into a data registry that benchmarks performance and quality measures against minimally accepted national thresholds and mean levels of performance among peers. If the rate of adequate bowel preparation for an endoscopist is below the USMSTF recommended benchmark of 85%, an improvement initiative should be undertaken. High rates of inadequate preparations can reflect low patient compliance, failure to adjust preparation regimens for medical predictors of inadequate preparation, or signal that processes and policies of the endoscopy unit need revision.
Rating the Quality of Bowel Preparation During Colonoscopy
Recommendations
Adequacy of bowel preparation should be assessed after all appropriate efforts to clear residual debris have been completed ( Strong recommendation, low-quality evidence ).
Measurement of the rate of adequate colon cleansing should be conducted routinely ( Strong recommendation, moderate-quality evidence ).
Adequate preparation, defined as cleansing that allows a recommendation of a screening or surveillance interval appropriate to the findings of the examination, should be achieved in 85% or more of all examinations on a per-physician basis ( Strong recommendation, low-quality evidence ).
Reporting the quality of the bowel preparation is a required element of the colonoscopy report In clinical trials cleansing quality often is estimated using scales that downgrade quality for retained fluid. In clinical practice, however, retained fluid and much of the semisolid debris in the colon can be removed by intraprocedural cleansing. Because the capacity to conduct effective mucosal inspection is established after intraprocedural cleansing, the preparation quality in clinical practice should be assessed only after appropriate intraprocedural washing and suctioning has been completed. For this reason, the use of a validated bowel preparation scale that includes scoring retained fluid (eg, Aronchick, Ottawa) is not recommended. The US Multi-Society Task Force (USMSTF) considers the operational definition of an adequate preparation is one in which the colonoscopist can and does recommend a follow-up screening or surveillance interval for the next colonoscopy that is appropriate for the examination findings. Unfortunately, the scores in validated scales that correspond to the point at which the preparation meets the USMSTF operational definition of an adequate preparation (ability to follow the recommended screening or surveillance interval) generally are uncertain. In clinical practice clinicians often use an imprecisely defined 4-point scale of excellent, good, fair, and poor. In this scheme, excellent and good are widely viewed as adequate, but some research indicates that many fair preparations in clinical practice also are adequate The USMSTF previously recommended that clinicians could consider the preparation adequate if after suctioning and washing the mucosa during the procedure it was deemed adequate for the detection of lesions greater than 5 mm in size This concept is not part of a validated bowel preparation scale but it does reflect current concepts about the sizes of colorectal lesions that are clinically most important to detect Additional research is needed to develop validated scales for scoring bowel cleansing that do not consider retained fluid and include defined points that correspond to adequate preparation. Currently, the Boston Bowel Preparation scale comes closest to meeting these criteria because it does not consider retained fluid and a Boston Bowel Preparation Scale score of 5 or higher was associated with only a 2% rate of recommending shortened follow-up intervals A detailed review of bowel preparation scales is shown in Appendix B.
Whichever scale is used in practice, we recommend that the method for defining an adequate preparation should include whether the colonoscopist recommends the expected screening or surveillance intervals based on the colonoscopy findings, and that the ability to detect lesions greater than 5 mm in size throughout the colon is a clinically relevant test of adequacy and appropriateness to follow screening and surveillance intervals. Furthermore, endoscopists are encouraged to submit procedure reports into a data registry that benchmarks performance and quality measures against minimally accepted national thresholds and mean levels of performance among peers. If the rate of adequate bowel preparation for an endoscopist is below the USMSTF recommended benchmark of 85%, an improvement initiative should be undertaken. High rates of inadequate preparations can reflect low patient compliance, failure to adjust preparation regimens for medical predictors of inadequate preparation, or signal that processes and policies of the endoscopy unit need revision.