Oral Polyethylene Glycol Research Articles

Bowel cleansing, dysbiosis, and postoperative infection: the dots are starting to connect.

When preparing the bowel for surgery using purgative cleansing of either oral polyethylene glycol versus 0.9% normal saline enemas, the degree of dysbiosis is the same and is temporary recovering toward normal by postoperative day 30. When examining all infections, independent of treatment group, it appears that many infections arise from among the gut microbiota

Effectiveness of Mechanical Bowel Preparation before Robot-Assisted Laparoscopic Gynecologic Surgery: A Randomized, Single-Blind, Controlled Trial

Objective: The objective of this randomized controlled trial was to compare the effect of bowel preparation using only oral polyethylene glycol electrolyte (PEG) solution versus oral PEG solution combined with mechanical sodium phosphate (NaP) enema on the surgical field visualization in patients undergoing robot-assisted laparoscopic gynecologic procedures. Methods: Participants were randomized to either a single oral PEG solution or an oral PEG solution combined by mechanical NaP enema. The intraoperative visualization of the surgical field, the ease of manipulation of the bowels, and overall difficulty level of the surgery were evaluated by the surgeon using a self-administered questionnaire. After the surgery, the patients completed a survey assessing postoperative gastrointestinal discomfort. Results: A total of 114 women were enrolled and randomized to oral PEG solution-only group (n = 48), and oral PEG plus mechanical NaP enema group (n = 66). Forty-two women in oral PEG-only group and 59 oral PEG plus NaP enema group completed the study. There was no difference in intraoperative visualization or overall difficulty of the operation between the two groups, and bowel manipulation was easier in the oral PEG-only group. Also, there was no difference in operating time between the groups. The patients’ level of gastrointestinal discomfort after the surgery was not significantly different between the two groups. Conclusion: Routine use of mechanical NaP enema before robot-assisted laparoscopic gynecologic surgery is not recommended, because it has no additional benefit regarding intraoperative visualization or the surgical level of difficulty over oral bowel preparation methods.

Oral sulfate solution versus polyethylene glycol for bowel preparation before colonoscopy, meta-analysis and trial sequential analysis of randomized clinical trials.

This study aimed to compare oral sulfate solution (OSS) with polyethylene glycol (PEG) for bowel preparation before colonoscopy. A literature search was performed on PubMed, Ovid, and Cochrane Databases for randomized clinical trials (RCT) comparing OSS with PEG for bowel preparation before colonoscopy. The last search was performed on 22 August 2023. The primary outcome was the quality of bowel preparation. The outcomes were compared by meta-analysis and trial sequential analysis (TSA). A total of 14 RCTs with 4526 patients were included. OSS was comparable with PEG regarding adequate bowel preparation [P = 0.16, odds ratio (OR) = 1.19, 95% confidence interval (CI) [0.93, 1.51], I2 = 0%]. However, OSS showed obvious priority in excellent bowel preparation (P < 0.001, OR = 1.62, 95% CI [1.27, 2.05], I2 = 0%) and total Boston bowel preparation scale (BBPS) [P = 0.02, weighted mean difference (WMD) = 0.27, 95% CI [0.05, 0.50], I2 = 84%]. Additionally, the detection rate of polyps (P = 0.001, OR = 1.44, 95% CI [1.15, 1.80], I2 = 0%) and adenoma (P = 0.007, OR = 1.22, 95% CI [1.06, 1.42], I2 = 0%) was significantly higher in the OSS group. The two groups showed comparable incidence of adverse events except for a higher incidence of dizziness (P = 0.02, OR = 1.74, 95% CI [1.08, 2.83], I2 = 11%) was indicated in the OSS group. Moreover, OSS was associated with a higher satisfaction score (P = 0.02, WMD = 0.62, 95% CI [0.09, 1.15], I2 = 70%). In the TSA, the cumulative Z-curve crossed both the conventional boundary and trial sequential monitoring boundary and the required information size has been reached for excellent bowel preparation and total BBPS. The current data demonstrated that OSS was associated with better quality of bowel preparation. More clinical trials are still needed to confirm other outcomes.

A Randomized Controlled Trial Comparing Polyethylene Glycol with Sodium Phosphate for Gut Preparation in children undergoing Proctoscopy

Background: The outcome of diagnostic and therapeutic procedures such as proctoscopy, colonoscopy, and endoscopy relies on thorough bowel preparation, ensuring a complete view of the colonic mucosa. Aim: To compare polyethylene glycol with sodium phosphate for gut preparation in children undergoing proctoscopy. Methods: We conducted a study on pediatric patients aged 3 to 14 years who underwent elective proctoscopy. The study took place in the pediatric surgical ward of Mayo Hospital, Lahore, following approval from the hospital's Ethical Committee. We educated the parents or guardians of patients preoperatively about the use of bowl preparatory agents, their effectiveness, outcomes, side effects, complications, and informed consent. We divided the children into two groups to determine the method of bowl preparation. Patients in Group 'A' underwent bowl preparation using polyethylene glycol. Results: There were 60 patients, with 30 in each group. Patients in Group 'A' were given bowl preparation with polyethylene glycol. Before the proctoscopy, the patients underwent a 1-day PEG 3350 bowel preparation regimen. While group B had bowel preparation with sodium phosphate enema, the patients' mean ages were 4.46 years. In group A, there were 16 males and 14 females, while in group B, there were 19 males and 11 females. In group A, 11 patients demonstrated excellent compliance, 12 showed partial compliance, and 7 showed poor compliance with polyethylene glycol. While in group B, 22 patients showed excellent compliance, and 8 patients showed good compliance. Practical Implication: The study suggests that both polyethylene glycol (PEG) and sodium phosphate enema are suitable for pediatric patients undergoing proctoscopy. However, compliance rates vary between the two methods. Patients in group A showed varying levels of compliance, while those in group B showed higher compliance. Therefore, healthcare providers should consider sodium phosphate enema for improved patient adherence and procedural outcomes. This highlights the importance of assessing compliance rates for informed decision-making. Conclusion: In our experience, sodium phosphate enema was superior to oral polyethylene glycol in terms of compliance and adequacy of gut preparation. There were also fewer side effects with the sodium phosphate enema. Keywords: Polyethylene glycol, proctoscopy, gut preparation

Polyethylene glycol compared to lactulose for constipation in pregnancy: A randomized controlled trial.

To compare polyethylene glycol 4000 versus lactulose in chronic constipation during pregnancy. Women at 28-32 weeks' gestation attending antenatal clinic for routine care were screened using the Rome IV chronic constipation criterion. Eligible women were approached and consented. Participants were randomized to oral polyethylene glycol (10 g/day) or lactulose (10 g/day) for 4 weeks. A bowel movement diary was kept and outcomes using the Patient Assessment of Constipation Symptoms questionnaire (PAC-SYM), Patient Assessment of Constipation Quality of Life questionnaire (PAC-QoL) and Bristol Stool Form Scale (BSFS), which were evaluated at the start and end of the four-week period. Relative risks (RR) were determined for the coprimary outcomes of complete spontaneous bowel movement (CSBM) and PAC-SYM mean score improvement (decrease in score of >1 from the baseline). A total of 4323 women underwent screening, of which 780 fulfilled the Rome IV criterion, and 360 consented to participate (180 randomized to PEG and lactulose, respectively). Data from 247 women who completed the study were analyzed. CSBM was achieved in 107/124 (86.3%) versus 102/123 (82.9%) (RR 1.04, 95% CI: 0.93-1.16, P = 0.464) for PEG and lactulose trial arms, respectively. PAC-SYM mean score improvement was 62/118 (52.5%) in the PEG arm versus 44/118 (37.3%) in the lactulose arm (RR 1.40, 95% CI: 1.05-1.88). Of secondary outcomes, a significant difference was found in favor of PEG, with respect to PAC-SYM abdominal symptoms subscale, normal stool versus loose stool consistency and side effects of vomiting and diarrhea. After controlling for parity, baseline PAC-SYM, PAC-QoL scores, characteristics different at baseline, only diarrhea and loose stools remained significant. Both PEG 4000 and lactulose are effective laxatives in pregnancy with similar performance after adjusted analysis. Diarrhea and loose stools are less frequently reported with PEG.

Efficacy and safety of oral sulfate tablet vs. polyethylene glycol and ascorbate for bowel preparation in children.

Bowel preparation for pediatric colonoscopy presents several challenges. However, no bowel preparation regimen is universally preferred for children. We aimed to investigate the efficacy and safety of oral sulfate tablet (OST) in pediatric bowel preparation. This study retrospectively analyzed data from children who received 2l of polyethylene glycol and ascorbate (PEG/Asc) or OST for bowel preparation between 2021 and 2023. A comparative analysis was conducted between the two groups. A total of 146 patients were included (2l PEG/Asc: 115, 73.0% vs. OST: 31). No significant difference was observed in the total BBPS score (median 8.0 vs. 8.0, P = 0.152) and the total OBPS score (median 5.0 vs. 3.0, P = 0.152) between the two groups. No significant difference was noted in the ratio of a bubble score of 0 (73.0% vs. 93.5%, P = 0.132). The incidence of abdominal pain was significantly lower in the OST group (32.2% vs. 3.2%, P = 0.002). The VAS score for overall satisfaction was significantly higher in the OST group (4.0 vs. 7.0, P < 0.001). For the next colonoscopy bowel preparation, a higher proportion of patients in the OST group showed a willingness to use the same preparation regimen (33.9% vs. 83.9%, P < 0.001). OST was as efficacious and safe as 2 L of PEG/Asc for pediatric bowel preparation. The satisfaction level was higher with OST than with 2 L of PEG/Asc. OST may be considered a good alternative for children with poor compliance during bowel preparation.

Abstract IA019: Clinical trials of GUCY2C (GCC) agonists for colorectal cancer prevention

Abstract Guanylyl cyclase C (GUCY2C), expressed on intestinal epithelial cells, is the receptor for heat-stable enterotoxins (STs) produced by diarrheagenic bacteria. Fluid secretion reflects ST activation of GUCY2C, which produces cyclic (c)GMP activating ion channels. Beyond toxins, GUCY2C binds uroguanylin in small intestine and guanylin in colorectum, which also stimulate secretion. This mechanism is the basis for the oral agonists linaclotide (ST analog) and plecanatide (uroguanylin analog) to treat constipation. Guanylin is the most commonly lost gene product, while GUCY2C expression is retained, in colorectal tumors. Eliminating GUCY2C promotes tumor formation, while oral GUCY2C agonists or transgenic guanylin reduce intestinal tumors, in mice. These data support a hypothesis in which loss of guanylin silencing GUCY2C is a key step in intestinal transformation which can be prevented by oral GUCY2C agonists. However, GUCY2C agonists are formulated for duodenal activity, without bioavailability in the colorectum. Here, we explored whether this pharmacokinetic (PK) barrier could be abrogated with high doses (HD) of linaclotide. Indeed, HD linaclotide induced a cGMP response in mucosal biopsies obtained by colonoscopy following oral polyethylene glycol (PEG) preparation. This cGMP response was validated by VASP phosphorylation and suppression of crypt proliferation. Similarly, HD linaclotide induced cGMP in colon biopsies obtained by sigmoidoscopy following oral PEG. However, HD linaclotide failed to induce cGMP in colon biopsies obtained by sigmoidoscopy i n the absence of oral PEG . Thus, oral PEG abrogated the PK barrier, delivering linaclotide to the colorectum. Unfortunately, dolcanatide, a proteolysis-resistant analog of plecanatide, also failed to overcome the colorectal PK barrier, although it produced duodenal secretion and diarrhea. Thus, guanylin loss silencing GUCY2C appears to be a key step in intestinal transformation. Preclinical models suggest that oral GUCY2C agonists stimulate GUCY2C signaling, opposing tumorigenesis. However, translation of these observations appears to be constrained by a PK barrier, reflecting agonists formulated for duodenal activity, without colorectal bioavailability. Exploiting GUCY2C for chemoprevention awaits agonists formulated for the colorectum. We are exploring the ability of GUCY2C agonists to activate cGMP in duodenum (within the PK barrier), as a prelude to trials in patients with FAP at risk for duodenal tumors. Citation Format: Scott A. Waldman. Clinical trials of GUCY2C (GCC) agonists for colorectal cancer prevention [abstract]. In: Proceedings of the Second Biennial NCI Meeting: Translational Advances in Cancer Prevention Agent Development (TACPAD); 2022 Sep 7-9. Philadelphia (PA): AACR; Can Prev Res 2022;15(12 Suppl_2): Abstract nr IA019.

Comparison of the efficacy and safety between oral sulfate tablet and polyethylene glycol for bowel preparation before colonoscopy according to age.

Background:Recently, a novel oral sulfate tablet (OST) has been introduced for bowel preparation before colonoscopy. However, whether elderly patients can take OST is not yet clear, as OST consists of 28 tablets. We aimed to compare the efficacy and safety of OST and polyethylene glycol (PEG) for bowel preparation for colonoscopy according to age.Methods:We randomly divided subjects into an OST group and a PEG group and compared Boston Bowel Preparation Score (BBPS), bubble score, patient compliance and satisfaction, and safety between the 2 groups according to age (under 65 years of age vs 65 years of age and older).Results:Among the 179 participants, 61 were 65 years of age and older. The BBPS and bubble score of the OST group were better than that of the PEG group, regardless of age. The satisfaction of the OST group was better than that of the PEG group, regardless of age. The compliance was not different between the 2 groups; however, the OST group under 65 years of age had a higher rate of completing the dose within 2 hours compared with the PEG group under 65 years of age. Adverse events including abdominal distension, abdominal pain, nausea, or vomiting were not different between the 2 groups.Conclusion:The use of OST for bowel preparation before colonoscopy is as effective and safe as PEG, and these results were consistent in elderly people 65 years of age and older.

Comparative evaluation of enema alone and in combination with oral polyethylene glycol for bowel preparation before transvaginal pelvic floor reconstruction in elderly patients: a retrospective cohort study

The aim of this retrospective study was to assess the value of using an enema alone for mechanical bowel preparation (MBP) before transvaginal pelvic floor reconstruction (TPFR) in patients ≥65 years old. In total, 190 patients were included [81 in the enema group vs. 109 in the enema + polyethylene glycol (PEG) group]. The levels of serum potassium (p = .004) and calcium (p = .005) were higher in the enema group after surgery. The decrease in serum calcium was more significant in the enema + PEG group (p = .027). More patients in the enema + PEG group developed hypokalaemia (p = .035) or hypocalcaemia (p = .008) after surgery. The incidence of thrombus and surgical site infection was similar and earlier bowel movement was evident in the enema group (p = .000). Overall, the enema group used more laxatives (p = .026). Using enema alone before TPFR reduces the incidence of electrolyte disturbances with no increase in surgical complications in elderly patients. IMPACT STATEMENT What is already known on this subject? TPFR is an effective treatment for pelvic organ prolapse (POP) in elderly women. Bowel preparation performed before gynecological surgery can reduce surgical site infection, but increase discomfort and electrolyte disturbance. What do the results of this study add? The levels of serum potassium and calcium were lower in the enema + PEG group than in the enema group after surgery and more patients developed hypokalaemia or hypocalcaemia in the enema + PEG group. The incidence of thrombus and surgical site infection was similar between the two groups. Bowel movement was earlier in the enema group. What are the implications of these findings for clinical practice and/or future research? Using enema alone before TPFR reduces the incidence of electrolyte disturbance and does not increase surgical complications. This conclusion needs to be confirmed by random controlled trial studies in the future.

PREVALENCE OF HYPOKALEMIA AFTER BOWEL PREPARATION IN PATIENTS UNDERGOING COLORECTAL INTERVENTIONS

INTRODUCTION:-Bowel preparation is usually done before colonoscopy and other colorectal interventions. It mostly contain oral sodium phosphate or polyethylene glycol solutions.. Bowel preparation results in electrolyte shifts, requiring special precautions especially in high risk patients. It causes abdominal distension ( ileus), muscle cramps , arrhythmia, hypokalemia.This study is undertaken to determine the electrolyte imbalances and clinical outcome of the patient who underwent bowel preparation and colorectal intervention. MATERIAL AND METHODS:- We conducted our study in Department of General Surgery, Dr. B. R. A. M. Hospital Raipur C.G. over a period of 1 year.Written and informed consent was taken from all the patients. This study is hospital based,cross sectional observational study.Patient was given two liters polyethylene glycol based solution which contain polyethylene glycol,sodium chloride,potassium chloride,sodium bicarbonate,and anhydrous sodium sulfate for bowel cleansing and asked to drink the solution in 2 hrs and to feed on only clear fluids. We compared serum potassium levels before and after bowel preparation and evaluated the development of hypokalemia after bowel preparation. RESULTS:- The study was done among 71 patients who underwent bowel preparation before colorectal intervention at Dr.B.R.A.M. hospital Raipur (C.G.) in one year. 36.6% of the participants developed mild hypokalemia after bowel preparation. Most of the patients belong to age group of 41-50 years(26.8%). The duration of passage of first flatus and first feces after intervention was longer in patient with hypokalemia (1.73 and 3.30) as compared to patient with normokalemia (0.87 and 1.26). CONCLUSION :-On the basis of our study it is evident that hypokalemia can develop after bowel preparation in patients who underwent colorectal interventions.

Influence of oral contrast type and volume on patient experience and quality of luminal distension at MR Enterography in Crohn’s disease: an observational study of patients recruited to the METRIC trial

ObjectivesTo compare the distention quality and patient experience of oral mannitol and polyethylene glycol (PEG) for MRE.MethodsThis study is a retrospective, observational study of a subset of patients enrolled in a multicentre, prospective trial evaluating the diagnostic accuracy of MRE for small bowel Crohn’s. Overall and segmental MRE small bowel distention, from 105 patients (64 F, mean age 37) was scored from 0 = poor to 4 = excellent by two experienced observers (68 [65%] mannitol and 37 [35%] PEG). Additionally, 130 patients (77 F, mean age 34) completed a questionnaire rating tolerability of various symptoms immediately and 2 days after MRE (85 [65%] receiving mannitol 45 [35%] receiving PEG). Distension was compared between agents and between those ingesting ≤ 1 L or > 1 L of mannitol using the test of proportions. Tolerability grades were collapsed into “very tolerable,” “moderately tolerable,” and “not tolerable.”ResultsPer patient distension quality was similar between agents (“excellent” or “good” in 54% [37/68] versus 46% [17/37]) with mannitol and PEG respectively. Jejunal distension was significantly better with mannitol compared to PEG (40% [27/68] versus 14% [5/37] rated as excellent or good respectively). There was no significant difference according to the volume of mannitol ingested. Symptom tolerability was comparable between agents, although fullness following MRE was graded as “very tolerable” in 27% (12/45) of patients ingesting PEG, verses 44% (37/84) ingesting mannitol, difference 17% (95% CI 0.6 to 34%).ConclusionMannitol-based solutions and PEG generally achieve comparable distension quality and side effect profiles, although jejunal distension is better quality with mannitol. Neither distension quality nor side-effect profile is altered by ingestion of more than 1 L of mannitol.Key Points• Mannitol-based and PEG-based oral preparation agents generally achieve comparable distension quality for MRE with the exception of the jejunum which is better distended with mannitol.• Mannitol-based and PEG-based oral preparation agents used for MRE have similar side effect profiles.• Neither distension quality nor side-effect profile is altered by ingestion of more than 1 L of mannitol.

Saudi Experts Consensus on Diagnosis and Management of Pediatric Functional Constipation.

Although functional gastrointestinal disorders (FGIDs) are very common in pediatric patients, there is a scarcity of published epidemiologic data, characteristics, and management patterns from Saudi Arabia, which is the 2nd largest Arabic country in terms of area and the 6th largest Arabic country in terms of population, with 10% of its population aged <5 years. Functional constipation (FC) is an FGID that has shown a rising prevalence among Saudi infants and children in the last few years, which urges us to update our clinical practices. Nine pediatric consultants attended two advisory board meetings to discuss and address current challenges, provide solutions, and reach a Saudi national consensus for the management of pediatric constipation. The pediatric consultants agreed that pediatricians should pay attention to any alarming signs (red flags) found during history taking or physical examinations. They also agreed that the Rome IV criteria are the gold standard for the diagnosis of pediatric FC. Different therapeutic options are available for pediatric patients with FC. Dietary treatment is recommended for infants with constipation for up to six months of age. When non-pharmacological interventions fail to improve FC symptoms, pharmacological treatment with laxatives is indicated. First, the treatment is aimed at disimpaction to remove fecal masses. This is achieved by administering a high dose of oral polyethylene glycol (PEG) or lactulose for a few days. Subsequently, maintenance therapy with PEG should be initiated to prevent the re-accumulation of feces. In addition to PEG, several other options may be used, such as Mg-rich formulas or stimulant laxatives. However, rectal enemas and suppositories are usually reserved for cases that require acute pain relief. In contrast, infant formulas that contain prebiotics or probiotics have not been shown to be effective in infant constipation, while the use of partially hydrolyzed formula is inconclusive. These clinical practice recommendations are intended to be adopted by pediatricians and primary care physicians across Saudi Arabia.

Promelaxin Microenemas Are Non-inferior to Oral Polyethylene Glycol for the Treatment of Functional Constipation in Young Children: A Randomized Clinical Trial.

Background: Polyethylene glycol (PEG) is recommended as first-line treatment of pediatric functional constipation. However, the oral route of administration is often poorly feasible in children mostly due to poor palatability. Promelaxin microenemas exert a topical evacuative action and may offer a valuable option in pediatric FC.Aim: To assess whether Promelaxin microenemas would be non-inferior to PEG 4000 in young children with FC.Methods: This is a randomized, open-label, multi-centric, non-inferiority trial enrolling infants and young children aged 6–48 months, with FC according to Rome III criteria. After 1 week of run in, children were randomized to 2 weeks of Promelaxin or PEG, followed by a 6-week on-demand treatment period. Primary endpoint was response rate to randomized treatment, with “response” defined as at least 3 evacuations per week and an average increase of at least one evacuation per week as compared to baseline. Safety, stool consistency and the analysis of fecal microbiota were secondary endpoints.Results: Out of the 158 patients who entered the trial, 153 patients were treated (77 and 76, PEG and Promelaxin arm, respectively). In the primary analysis, the 95% confidence interval (CI) for the treatment's effect lay entirely above the non-inferiority margin in both Full Set (FAS) and Per Protocol (PP) analyses, providing evidence of the non-inferiority of Promelaxin vs. PEG 4000 [response rate difference: 16.5% (CI 1.55–31.49%) and 11.03% (CI −5.58 to 27.64%), FAS and PP analyses, respectively]. Mean compliance to the randomized treatment was >80% in both arms. Secondary endpoints did not significantly differ between the two arms, except for the average number of total days of on-demand treatment that was significantly lower in the Promelaxin arm [14.6 (12.7) vs. 9.8 (9.1), mean (SD); primary endpoint responders in PEG and Promelaxin arm, respectively; p = 0.027]. Microbiota evenness significantly increased in the PEG 4000 arm at V4 as compared to the Promelaxin arm (p < 0.05). In addition, at V5, patients treated with PEG showed a significantly decreased microbiota density as compared to patients treated with Promelaxin (p = 0.036).Conclusions: Promelaxin microenemas are non-inferior to oral PEG in children with FC.Clinical Trial Registration: www.ClinicalTrials.gov, identifier: NCT02751411.

Allergic reactions to coronavirus disease 2019 vaccines and addressing vaccine hesitancy: Northwell Health experience

BackgroundAllergic and nonallergic adverse reactions have been reported with global coronavirus disease 2019 (COVID-19) vaccination. It was previously hypothesized that polyethylene glycol (PEG) may be responsible for anaphylactic reactions to messenger RNA (mRNA) COVID-19 vaccines. ObjectiveTo report the workflow established at our institution, types, and frequency of adverse reactions to mRNA COVID-19 vaccines in patients presenting for allergy evaluation. MethodsA COVID-19 vaccine adverse reaction registry was established. We used PEG prick skin testing, followed by PEG challenges in selected cases, to ensure PEG tolerance and encourage completion of COVID-19 vaccination series. ResultsA total of 113 patients were included. Most vaccine reactions (86.7%) occurred in women. Anaphylaxis occurred only in women, all of which had a history of allergic disease and two-thirds had asthma. Anaphylaxis rate was 40.6 cases per million. None of the anaphylactic cases developed hypotension, required intubation, or required hospital admission. Systemic allergic symptoms, not fulfilling anaphylaxis criteria, were significantly more common in Pfizer-BioNTech than Moderna-vaccinated patients (P = .02). We observed a higher incidence of dermatologic nonurticarial reactions in men (P = .004). Among first-dose reactors, 86.7% received and tolerated the second dose. We observed a high rate of false-positive intradermal skin test results and frequent subjective symptoms with oral PEG challenge. ConclusionIntradermal PEG testing has limited utility in evaluating anaphylaxis to mRNA vaccines. Most severe postvaccination allergic symptoms are not caused by hypersensitivity to PEG. Most people with reaction to the initial mRNA vaccine can be safely revaccinated. Patients with anaphylaxis to COVID-19 vaccines benefit from physician-observed vaccination.

Intestinal Decontamination Therapy for Dyskinesia and Motor Fluctuations in Parkinson's Disease

Parkinson's disease is neurodegenerative disorder with an initial robust response to levodopa. As the disease progresses, patients frequently develop dyskinesia and motor fluctuations, which are sometimes resistant to pharmacological therapy. In recent years, abnormalities in gut microbiota have been identified in these patients with a possible role in motor manifestations. Dysbiosis may reduce levodopa absorption leading to delayed “On” or “no-On” states. Among 84 consecutive patients with PD, we selected 14 with levodopa-induced dyskinesia and motor fluctuations with a Movement Disorders Society Unified Parkinson's Disease Rating Scale (MDS-UPDRS) part IV ≥ 8 points following a trial of pharmacological adjustment 2–3 months prior to study enrollment or adjustments in deep brain stimulation therapy. Patients received treatment with sodium phosphate enema followed by oral rifaximin and polyethylene glycol for 7 and 10 days, respectively. Evaluations between 14 to 21 days after starting treatment showed improvement in MDS-UPDRS-IV (P = 0.001), including duration (P = 0.001) and severity of dyskinesia (P = 0.003); duration of medication “Off”-state (P = 0.004); functional impact of motor fluctuations (P = 0.047) and complexity of motor fluctuations (P = 0.031); no statistical improvement was observed in “Off” dystonia (P = 0.109) and total motor scores (P = 0.430). Marked to moderate improvement in dyskinesia was observed in 57% of cases with blinded evaluation of videos. About 80% of patients perceived moderate to robust improvement at follow-up. A therapeutic strategy aimed at decontamination of intestines showed benefit in motor fluctuations and dyskinesia. Further studies should confirm and clarify the mechanism of improvement observed in these patients.

Colonoscopic Instillation of Coca-Cola for Evacuation of Large Fecaloma: A Report of Two Cases and Review of Literature

Abstract Introduction Fecaloma is a large mass of organized hardened feces causing impaction, usually in rectum and sigmoid colon. Medical management usually entails digital evacuation, use of clearance enema, and oral laxatives. We report two patients managed successfully with colonoscopic instillation of Coca-Cola and review the literature. Case Report Patient 1: A 37-year-old male presented with firm, nontender, pitting mass over lower abdomen for 2 months and inability to pass stool for 1 month. Per-rectal examination and imaging confirmed presence of solid stool with gross distension of rectum and sigmoid colon. Attempts at clearance of stool with conventional methods were unsuccessful. At colonoscopy, 4 L of Coca-Cola was instilled into descending and sigmoid colon, leading to evacuation of 10 L of fragmented and liquid stool.Patient 2: A 72-year-old diabetic lady presented with constipation and tender, firm pelvic mass extending till mid-abdomen for 6 months. Per-rectal examination revealed presence of hard stool. Imaging confirmed large amount of fecal matter in dilated rectum, sigmoid, and descending colon. Attempts at evacuating stool with digital evacuation, sodium phosphate enema, and oral polyethylene glycol were unsuccessful. At colonoscopy, two sittings of instillation of 990 mL of Coca-Cola Light each were done into sigmoid colon over 2 days, resulting in clearance. Conclusion Colonoscopic instillation of Coca-Cola may be effective in evacuation of large fecaloma from rectum, sigmoid, and descending colon when refractory to use of conventional methods like digital disimpaction, rectal enema, and oral laxatives.

Oral Lactulose vs. Polyethylene Glycol for Bowel Preparation in Colonoscopy: A Randomized Controlled Study.

BackgroundColonoscopy is the method of choice to evaluate colonic mucosa and the distal ileum, allowing the diagnosis and treatment of many diseases. Appropriate bowel preparation necessitates the use of laxative medications, preferentially by oral administration. These include polyethylene glycol (PEG), sodium picosulfate, and sodium phosphate (NaP). Lactulose, a semi-synthetic derivative of lactose, undergoes fermentation, acidifying the gut environment, stimulates intestinal motility, and increases osmotic pressure within the lumen of the colon.MethodsIn this prospective randomized controlled study, we analyzed 40 patients who presented with symptomatic bleeding per rectum and underwent bowel preparation either with lactulose or polyethylene glycol for colonoscopy. The quality of bowel preparation and other variables like palatability, discomfort, and electrolyte levels were analyzed.ResultsThe majority of the patients (90%) were comfortable with the taste of lactulose solution, whereas the PEG group patients (55%) were equally divided on its palatability. On lactulose consumption, 40% of patients reported nausea/vomiting and around 10% of patients complained of abdominal discomfort. Serum sodium levels showed insignificant changes from 4.33 ± 0.07 mEq/L to 4.21 ± 0.18 mEq/L while potassium also remained similar from 4.26 ± 0.03 mEq/L to 4.22 ± 0.17 mEq/L. The mean Boston Bowel Preparation Score (BBPS) in patients who received lactulose solution was 6.25 ± 0.786 and in those who received PEG solution, it was 6.35 ± 0.813 (P-value = 0.59).ConclusionsLactulose is a significantly more palatable form of bowel preparation and causes minor discomfort. It has a good bowel cleansing action comparable to PEG without causing any hemodynamic changes. It can be considered a cheaper and safe alternative for bowel preparation in colonoscopy in low-resource settings.

Evaluating lubiprostone for effective bowel preparation before colonoscopy

BackgroundColon preparation is a fundamental step for performing a successful colonoscopy. We aimed to evaluate the effectiveness of administering lubiprostone (LB) added to a single dose of oral polyethylene glycol (PEG) solution in achieving satisfactory colon cleanliness and decreasing the side effects.ResultsOne-hundred percent of the control group patients reported that the experienced taste was worse than expected, while in the intervention group half of the patients (50%) said that the taste was natural and 48% experienced taste worse than expected (p<0.0001). Regarding Boston bowel preparation scale (BBPS), there was a significant difference in the overall Boston scale (p=0.02) with more efficacy in the intervention group as 66% of patients in the intervention group had good bowel preparation (5–7) and 24% excellent preparation (8–9). On the other hand, the overall Boston scale in the control group showed that 54% of patients were between 5 and 7, and only 16% of patients had overall Boston scale 8–9. In terms of the side effects of the preparation in both arms, the majority of cases in the intervention arm did not complain of any side effects (78%), while the majority of the complaints were vomiting in 16% of the intervention cases.ConclusionThe current evidence suggested that adding LB to the colon preparation significantly improved the tolerability and efficacy.

Mechanical bowel preparation before gynecologic laparoscopic procedures: Is it time to abandon this practice?

To examine the influence of mechanical bowel preparation on surgical field visualization and patients' quality of life during benign gynecologic laparoscopic procedures. A single blind, randomized, controlled trial was undertaken with laparoscopic gynecologic surgical patients to one of the following three groups: liquid diet on the preoperative day; mechanical bowel preparation with oral polyethylene glycol (PEG) solution; minimal residue diet for 3 days. Primary outcomes included assessment of the condition of small and large bowel and the overall quality of the surgical field. Additional measures included assessment of patients' preoperative symptoms, tolerance of the preparation method and compliance to the protocol, postoperative symptoms and bowel function. One hundred forty-four patients were randomized as follows: 49 to liquid diet, 47 to mechanical bowel preparation, and 48 to minimal residue diet. Most characteristics were similar across groups. The intraoperative surgical view and the condition of large and small bowel were equal or inferior at the patients who received mechanical bowel preparation compared with the other groups. The 4-point Likert scale scoring for small bowel (2.51 vs. 2.72 vs. 2.81, p = 0.04), large bowel (2.26 vs. 2.38 vs. 2.48, p = 0.32) and overall operative field quality (2.34 vs. 2.67 vs. 2.67, p = 0.03) demonstrated no advantage from the use of preoperative mechanical bowel preparation over liquid diet and minimal residue diet, respectively. Preoperative discomfort was significantly greater in the mechanical bowel preparation group. Mechanical bowel preparation before gynecologic laparoscopic operations for benign pathology could be safely abandoned. ISRCTN registry, https://doi.org/10.1186/ISRCTN59502124 (No 59502124).

Comparison of Oral Sulfate Solution and Polyethylene Glycol Plus Ascorbic Acid on the Efficacy of Bowel Preparation.

Background/AimsThe quality of bowel preparation is one of the quality indicators for colonoscopy. The aim of this study was to compare the efficacy of oral sulfate solution (OSS) and polyethylene glycol plus ascorbic acid (PEG-AA) for bowel preparation. MethodsThe study involved 167 patients who underwent diagnostic colonoscopies. Inadequate bowel preparation was defined as any score of ≤1 in each colon section based on the Boston Bowel Preparation Scale. Multivariate logistic regression was used to compare the efficacy of OSS and PEG-AA. Subgroup analyses were performed based on patient characteristics. ResultsOverall, 106 (63.5%) patients received OSS, and 61 (36.5%) patients received PEG-AA. The rate of inadequate bowel preparation was 12.3% in patients receiving OSS and 32.8% in patients receiving PEG-AA (p=0.001). OSS (odds ratio [OR] = 0.26; p=0.003) and morning examination (OR=0.11; p=0.038) were significantly associated with efficient bowel preparation. The efficacy of OSS compared with PEG-AA was only significant in patients ≥50 years of age vs. <50 years of age (OR=0.13; p=0.001 vs. OR=0.96; p=0.959) and female vs. male patients (OR=0.06; p=0.002 vs. OR=0.58; p=0.339). ConclusionsOSS was significantly more efficient for bowel preparation than PEG-AA, especially in patients ≥50 years of age and female patients. Morning examination led to a good quality of bowel preparation, irrespective of the preparation regimen.