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Dr. Johnson:
Hi, this is CME on ReachMD, and I’m Dr. Dave Johnson, and here with me today is Dr. Doug Rex.

Doug, can you talk about the inadequate bowel prep and its consequences?

Dr. Rex:
Yeah, Dave. Inadequate bowel preparation is a huge disappointment for the patient and the physician. This means that the procedure is going to have to be repeated. Our guidelines say it should be repeated within a year, and I mentioned earlier that we want the rate of inadequate preparations to be less than 10%. Ideally, 5% or less. If we have an inadequate preparation, the cost to the healthcare system and the disappointment for the patient, as well as the possibility that they’ll be lost to follow-up and not get their colonoscopy, are significant.

So are there factors that allow us to predict an inadequate preparation? Sort of 2 groups of things. One are predictors that the patient is less likely to follow the instructions. This includes people who don’t have English as their first language, patients with lower socioeconomic status, those with Medicaid insurance – this has been a surrogate for an increased risk of not following the instructions. For all patients, it’s critical that we talk to them, that we find a preparation that is right for them, that they’re going to be able to pay for, and that we can reach some agreement about what we’ll use. And then they need instructions that are both written and verbal, in every case. The other set of predictors are really medical ones. The most important is somebody who’s previously had an inadequate preparation, but also factors such as obesity, diabetes, patients who are on opioids or other drugs associated with constipation, very severe chronic constipation. When we see these medical factors, we may make an adjustment in how much preparation that we give, even giving the patient some extra preparation. So it’s important that whoever is talking to the patient then go to the physician performing the procedure and say, “Here’s a situation where we may have an increased risk of an inadequate prep. Should we modify? Should we add something to try to increase the chance we’ll be effective?” Then on the day the patient shows up, we want to right away assess the rectal effluent. We want that effluent to be yellow, with very minimal particulate material in it. If it’s still brown, we actually should consider giving the patient some additional oral preparation, moving them to later in the schedule, trying to retain them in the system if we can.

During the procedure, we’ve got some work to do. We have to clean up, and we can actually, in some cases, turn a fair preparation into an adequate preparation, a good preparation, a good preparation into an excellent preparation by intraprocedural cleanup, washing. And in fact, we want to assess the preparation after we’ve completed that intraprocedural cleansing. There are different scales for rating the preparation. The Boston Bowel Preparation Scale [BBPS] is an attractive one because it’s designed to be used after intraprocedural cleansing, and it’s been correlated with willingness to follow the guidelines. When the preparation is adequate by the BBPS scale, which means that on the 0-3 for each of the 3 segments of the colon we have a score of 2 or 3, then we know that the doctor is very likely to follow the recommendations for screening or surveillance.

So this a critical question. Inadequate preparation – lots of bad consequences. How can we predict who is likely to have an inadequate preparation, make adjustments in instructions or in the volume of preparation, work hard to try to salvage the situation if it doesn’t look good on the day of the procedure to minimize the need for repeating procedures.

Dr. Johnson:
Doug, thanks so much. It’s all about efficacy and tolerability. A couple points: inpatients are notorious for poor preps. GI surgeries, in particular, beware. And those are patients you’d think would clean quickly, but they don’t. And bariatric surgery patients don’t tolerate larger volume. Your points were well taken, and it’s certainly great guidance. Let’s do it right the first time. Predict and succeed.

Dr. Rex:
Great points, Dave. Thanks.

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