La preparazione per la colonscopia. Marco Bertini

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1 La preparazione per la colonscopia Marco Bertini Sezione Dipartimentale Servizio di Endoscopia Digestiva Dipartimento di Gastroenterologia e Malattie Infettive

2 The ESGE recommends a low-fiber diet on the day preceding colonoscopy (weak recommendation, moderate quality evidence). Studio retrospettivo 789 pazienti Wu K-L, Rayner CK, Chuah S-K et al. Impact of low-residue diet on bowel preparation for colonoscopy. Dis Colon Rectum 2011; 54: Sezione Dipartimentale Servizio Endoscopico

3 The ESGE does not make any recommendations regarding the use of low-fiber diet for more than 24 hours prior to the examination (insufficient evidence to make a recommendation). The ESGE recommends against the routine use of enemas in addition to oral bowel preparation (strong recommendation, moderate quality evidence). The ESGE does not recommend the routine use of prokinetic agents as adjuncts to bowel preparation (weak recommendation, moderate quality )evidence)). The ESGE suggests adding simethicone to standard bowel preparation (weak recommendation, high quality evidence). Dieta a basso residuo nelle 24 ore precedenti No Clismi No Procinetici Si Simeticone (metanalisi Wu L.Et al.2011) Sezione Dipartimentale Servizio Endoscopico

4 The ESGE recommends a split regimen of 4 L PEG solution (or a sameday regimen in the case of afternoon colonoscopy) for routine bowel preparation. A split regimen (or same-day regimen in the case of afternoon colonoscopy) of 2 L PEG plus ascorbate or of sodium picosulphate plus magnesium citrate may be valid alternatives, in particular for elective outpatient colonoscopy (strong recommendation,high quality evidence). In patients with renal failure, PEG is the only recommended bowel preparation. The delay between the last dose of bowel preparation and colonoscopy should be minimized and no longer than 4 hours (strong recommendation, moderate quality evidence) Sezione Dipartimentale Servizio Endoscopico

5 PEG 4 Litri somministrazione Split PEG 2 litri + ascorbato o Sodio picosolfato+mg citrato Ma attenzione(!) In caso di insufficienza renale Ä indicato solo l'uso di PEG Non deve intercorrere un intervallo superiore a 4 ore fra la fine della preparazione e l'esecuzione della colonscopia Sezione Dipartimentale Servizio Endoscopico

6 The ESGE advises against the routine use of oral sodium phosphate for bowel preparation because of safety concerns (strong recommendation, low quality evidence). The ESGE suggests that oral sodium phosphate can only be advised in selected cases of specific needs that cannot be met by alternative products (e. g., patient unable to tolerate other agents) and only in individuals assessed by physicians to be at low risk of oral sodium phosphate-related side-effects. An evaluation of the kidney function should be available before prescribing oral sodium phosphate (weak recommendation, low quality evidence). If oral sodium phosphate is used for bowel preparation, 90 ml (solution) or 32 tablets each containing 1.5 g sodium phosphate (48g total), both in a split-dose regimen is recommended (strong recommendation, high quality evidence) Sezione Dipartimentale Servizio Endoscopico

7 Polyethylene glycol (PEG) vs. oral sodium phosphate (OSP) : 6 metanalisi di cui 4 a favore di OSP e due inconclusive ma ragioni di sicurezza non consentono di indicare OSP come preparazione di riferimento Magnesium citrate with stimulant laxative Una metanalisi che dimostra come OSP>Mg Citrato (OR 3.82, 95%CI ) Low-volume PEG Vari studi hanno confrontato 2 vs 4 l (totale 1997 pts).risultati: Non vi sono significative differenze in termini di preparazione per il colon al completo mentre se si valuta la preparazione del colon dx 4 litri risultano superiori a 2 l. Sezione Dipartimentale Servizio Endoscopico

8 Split-dose regimen La dose frazionata in due tempi risulta migliore della dose assunta in unica soluzione il giorno precedente Per : QualitÅ della preparazione intestinale QuantitÅ di lesioni piatte rilevate Kilgore TW, Abdinoor AA, Szary NM et al. Bowel preparation with split-dose polyethylene glycol before colonoscopy: a metaanalysis of randomized controlled trials. Gastrointest Endosc 2011 Parra-Blanco A, Nicolas-Perez D, Gimeno-Garcia A et al. The timing of bowel preparation before colonoscopy determines the quality of cleansing, and is a significant factor contributing to the detection of flat lesions.world J Gastroenterol 2006

9 Same-day regimen La dose di 4 litri di PEG assunta lo stesso giorno migliora la pulizia intestinale La dose di 2 litri di PEG Ascorbato Å tollerata in modo migliore se assunta nello stesso giorno Non si sono rilevate differenze nella preparazione globale Church JM. Effectiveness of polyethylene glycol antegrade gut lavage bowel preparation for colonoscopy timing is the key! Dis Colon Rectum 1998; 41: Varughese S, Kumar AR, George A et al. Morning-only one-gallon polyethylene glycol improves bowel cleansing for afternoon colonoscopies: a randomized endoscopist-blinded prospective study. AmJ Gastroenterol 2010; 105: Matro R, Shnitser A, Spodik M et al. Efficacy of morning-only compared with split-dose polyethylene glycol electrolyte solution for afternoon colonoscopy: a randomized controlled single-blind study. Am J Gastroenterol 2010; 105:

10 Timing of colonoscopy Intervallo intercorrente fra la fine della preparazione e l'esame 4 ore(?) ogni ora in piu' diminuisce le possibilita' di avere il colon dx visibile Siddiqui AA, Yang K, Spechler SJ et al. Duration of the interval between the completion of bowel preparation and the start of colonoscopy predicts bowel-preparation quality. Gastrointest Endosc 2009; 69: Rischio di incontinenza durante il viaggio (5-16% ns) Rischio di broncoaspirazione per la sedazione profonda: 2 ore Committee on Standards and Practice Parameters, American Society of Anesthesiologists. Practice guidelines for preoperative fasting and the use of pharmacologic agents to reduce the risk of pulmonary aspiration: application to healthy patients undergoing elective procedures: An updated report by the American Society of Anesthesiologists Committee on Standards and Practice Parameters. Anesthesiology 2011; 114:

11 The ESGE advises against the routine use of oral sodium phosphate for bowel preparation because of safety concerns (strong recommendation, low quality evidence). The ESGE suggests that oral sodium phosphate can only be advised in selected cases of specific needs that cannot be met by alternative products (e. g., patient unable to tolerate other agents) and only in individuals assessed by physicians to be at low risk of oral sodium phosphate-related side-effects. An evaluation of the kidney function should be available before prescribing oral sodium phosphate (weak recommendation, low quality evidence). If oral sodium phosphate is used for bowel preparation, 90 ml (solution) or 32 tablets each containing 1.5 g sodium phosphate (48g total), both in a split-dose regimen is recommended (strong recommendation, high quality evidence).

12 Casi Particolari The ESGE found insufficient evidence to determine for or against the use of specific regimens in pregnant/breastfeeding women. However, if total colonoscopy is strongly indicated, PEG regimens may be considered, with tapwater enemas preferred in the case of sigmoidoscopy (insufficient evidence to determine net benefits or risks) The ESGE suggests the use of PEG for bowel preparation in patients affected by or at risk of inflammatory bowel disease. Other agents may cause mucosal abnormalities that mimic inflammatory bowel disease (weak recommendation, moderate quality evidence). The ESGE recommends PEG for bowel preparation if urgent colonoscopyis scheduled for lower gastrointestinal bleeding (strong recommendation,moderate quality evidence).

13 Grazie per l attenzione

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