The Burden of Bowel Preparation on Patients’ Quality of Life: The Elephant in the Colonoscopy Room!

Abstract

Introduction: An adequate bowel preparation is essential for optimal colonoscopy, yet colon preparations are generally poorly tolerated. Although traditionally described in terms of solution administered, many additional elements are involved in the preparation. These include various dietary modifications and specific time allocation leading to important adjustments in social or work schedule and impacting the immediate pre-procedural quality of life (QoL), which often goes unregistered in clinical trials. We aimed to study the effect of bowel preparations on pre-procedural QoL by examining 7 specific variables (hunger, taste, volume, sleep, social, work, and adverse events). Methods: Patients scheduled for elective ambulatory colonoscopy were asked to complete a questionnaire regarding their experience with the prescribed bowel preparation. Diet liberation was allowed with split-dose PEG (4L PEG or 2L Moviprep®) while full-dose PEG consumers had to adhere to a clear fluid diet after breakfast. Sodium picosulfate recipients had to follow 2 days of low-fiber diet and 1 day of clear fluids prior to examination. The questionnaire was administered by 2 research assistants. The 7 aforementioned variables were graded using a visual scale of 0-10 (best to worst). A score ≥7 was considered to indicate a significant negative impact and was used as primary outcome. Patients were also asked to grade in descending order what they perceived as the worst aspect of the preparation. Results: Two hundred sixteen patients completed the survey. Preparations consisted of split-dose sodium picosulfate (SPS; n=49), 4L split-dose PEG±menthol (n=49), full-dose PEG (n=68), and 2L split-dose Moviprep® (M; n=50). With the exception of work and adverse effects, all other variables were considered to have a negative impact by >20% of patients (range: 20.4-34.2). SPS was superior to the PEG regimens in taste (4.1% vs. 35.9%) and volume (0% vs. 44.9%; p<0.05 for both) but was inferior for hunger (30.6% vs. 19.2%; p=0.09). The addition of menthol to PEG resulted in a significant improvement of taste perception (22.4% vs. 41.5%; p=0.02). Sleep disturbances were most common with SPS and least with split-dose PEG (30.6% vs. 17.4%; p<0.05). Overall, patients ranked volume, taste, and hunger as most burdensome. Conclusion: The burden of bowel preparation is substantial with greater than 20% of patients reporting considerable disturbance in pre-procedural QoL. Taste and volume aversions are conspicuously absent with low-volume sodium picosulfate but are important limitations of PEG preparations. Compared to split-dose PEG regimens, low-volume sodium picosulfate is significantly limited by hunger levied by dietary restriction and by disturbed sleep.