Poor Bowel Preparation Research Articles

S0337 Increased Risk of Left-Sided Advanced Colorectal Neoplasia but Not Serrated Polyps in Adults Less Than 50 Years Who Present With Bleeding: Data From the New Hampshire Colonoscopy Registry

INTRODUCTION: Data regarding advanced neoplasia and serrated polyps (SPs) in adults <50 years of age who present with bleeding are vital for screening and diagnosing CRC in adults <50. We used data from the New Hampshire Colonoscopy Registry (NHCR) to compare the anatomical location of advanced neoplasia and SPs in average risk patients to those who present with bleeding. METHODS: An average risk screening equivalent cohort was created for the analysis. Since many adults <50 have diagnostic exams, we formed an “average risk” sample by selecting diagnostic exams with indications that are associated with a low risk for advanced neoplasia such as change in bowel habits (e.g., constipation) and abdominal pain (Cha et al GIE 2015) and combining these with screening exams. We excluded higher risk indications from this cohort (e.g., anemia or bleeding) as well as surveillance, family history of first degree relative with CRC, IBD, incomplete exams, and poor bowel prep. We compared outcomes for the average risk equivalent group to our group of interest, i.e., exams with bleeding indications. Outcomes were advanced neoplasia (adenomas >1 cm, with villous elements, HGD, and CRC) and clinically important SPs ((HP > 1 cm), any sessile serrated polyp and traditional serrated adenomas) as stratified by anatomical location, left sided (distal to splenic flexure) and right sided (proximal to descending colon). We present absolute and adjusted risks for advanced neoplasia and SPs. Covariates were age, sex, smoking and BMI. RESULTS: There were 5855 NHCR average risk patients <50 years (avg age 38.5 yrs) and 2814 with bleeding (37.6 yrs). The absolute and adjusted risks for left sided advanced neoplasia were significantly higher for patients with bleeding than those in the average risk equivalent group (OR = 1.73 95% CI: 1.28–2.34) (Table 1). The increased risk was especially high for left sided CRC (OR = 4.82 95% CI 1.47–15.81). Conversely there was no increased risk for right sided advanced neoplasia, CRC or proximal or distal SPs. CONCLUSION: Young patients with bleeding had an increased risk for left sided advanced neoplasia. These data support current recommendations that patients <50 with bleeding should undergo evaluation for colorectal neoplasia, especially of the left side of the colon. However, there was no increased risk for SPs or right sided neoplasia or CRC in young individuals with bleeding, highlighting a clinically relevant difference in outcomes that may affect choice of testing options for this group.Table 1.: As compared to the average risk screening equivalent group, there was an increased risk for left sided neoplasia including CRC but not for right sided neoplasia or serrated polyps at any location

S0270 Repeat Endoscopies in Patients With Suboptimal Bowel Prep in a Safety Net Setting

INTRODUCTION: Colorectal cancer is the 3rd leading cause of death in the US. Colonoscopy is the most commonly used diagnostic tool in our arsenal and more than 15 million are performed annually in the US. In 2012, The US Multi-Society Task Force on Colorectal Cancer guidelines for the first time mentioned poor preparation and recommended repeat examination within 1 year in most cases of poor bowel preparation. METHODS: We performed a retrospective review of inpatient and outpatient electronic health records at Dell Seton Medical Center and CommUnityCare (CUC), a large safety net health care system in Austin, Texas to describe rates of inadequate bowel preparation. We identified 1709 eligible patients between ages 50 and 75 within the safety net system who had evidence of colonoscopy within the past 10 years. 204 of 1709 (12%) patients had suboptimal bowel prep, identified as fair or poor. Each chart was reviewed to determine what the recommended interval was for repeat testing was, whether it was performed, and whether any further intervention was necessary. RESULTS: Of the 204 patient who had suboptimal prep, 109 (53%) were deemed to be in need of a colonoscopy or fecal immunochemical test (FIT) as no follow-up was done.Those patients were classified into increased risk (personal or family history of CRC, adenomatous polyps or polyps with dysplasia or FIT positive) or average risk (no risk factors). Average risk patients were sent FIT test kits, while increased risk patients were contacted and scheduled for colonoscopies. Of the 109, 67 (61%) were deemed to need FIT testing, 24 (22%) were in need of colonoscopies now, 9 (8%) were in need of colonoscopies in the future, 6 (5%) patients were out of CUC system, and 3 (3%) were >75 years old and over age of recommended screening. Of the 41 patients overdue for colonoscopy that we were able to contact, 4 (0.1%) of those patients were found with cancer or high-grade dysplasia. CONCLUSION: Healthcare providers must be aware of patients with poor bowel prep, particularly in a safety net setting. Poorly prepared colons result in a longer cecal intubation time, a lower cecal intubation rate, higher adenoma miss rate (AMR), as well as increase in total costs to healthcare system. Therefore, gastroenterologists should develop a call back or a reminder system and should educate patients about need for repeat colonoscopies in those poor prep.Figure 1.: Schematic Representation of Follow-up for Patients with History of Poor Prep Colonoscopy.

S0276 Can iFOBT (Immunochemical Faecal Occult Blood Test) for Bowel Cancer Screening Be Safely Deferred for Five Years After a Colonoscopy?

INTRODUCTION: Australian and international guidelines suggest that immunochemical faecal occult blood test (iFOBT) for colorectal cancer (CRC) screening may be deferred for 5–10 years after a negative colonoscopy. The aim of this retrospective multicentre observational study was to evaluate the outcomes of patients who had a repeat colonoscopy for iFOBT positivity within five years of a previous colonoscopy showing low risk or normal findings, to assess the risk of interval CRC and advanced colorectal neoplasia (ACRN). We sought to determine if having a prior colonoscopy with normal or low risk findings within the last five years would predict for negative findings on a repeat colonoscopy in asymptomatic patients who were iFOBT positive. METHODS: We retrospectively identified patients who underwent a repeat colonoscopy for iFOBT positivity within five years of a previous colonoscopy showing normal or low risk findings from November 2016 to November 2018. Patients identified from Provation, Auscare and the Viewer databases were included from four sites, including The Prince Charles Hospital in Brisbane, Cairns Base Hospital, Innisfail Hospital and Atherton District Hospital in Northern Queensland. We excluded patients with a past history of CRC, patients with a familial malignancy syndrome, patients with poor bowel preparation and patients who were symptomatic. RESULTS: Among 3,795 patients who underwent colonoscopy for a positive iFOBT in the study period, 239 had a previous colonoscopy in the five-year window that met inclusion criteria. Of these, 4 (1.7%) patients had locally advanced CRC at two regional sites, and 19 (7.9%) patients had ACRN. 42 (17.6%) patients had high risk adenoma, 21 (8.8%) patients had sessile serrated adenoma and 87 (36.4%) patients had adenoma of various sizes. Inadequate bowel preparation in the previous colonoscopy was associated with the findings of subsequent high-risk adenomas and CRC. CONCLUSION: Our study observed that a substantial portion of patients have interval ACRN associated with a positive iFOBT performed outside of guidelines. These finding were not uniform between the study sites and may reflect local differences, highlighting the importance of interpretation of guidelines, the ability of the clinician to override guidelines if clinically indicated, the need for colonoscopy care standards and teamwork that may facilitate excellence in practice.

S0294 Smaller Sized Sessile Serrated Lesions in Asians Suggest the Need for a More Careful Examination of the Proximal Colon in This Population

INTRODUCTION: Sessile serrated lesions (SSLs) are premalignant colonic lesions suspected to be a major cause of de-novo, colorectal cancers (CRCs) developing between screening colonoscopies. Studies have suggested an overall lower incidence of CRCs but a higher rate of de-novo CRCs in Asians, raising suspicion that SSLs may have a significant role in this population. However, prevalence and characteristics of SSLs in Asians undergoing CRC screening are seldom reported. METHODS: We conducted a retrospective review of index colonoscopy cases spanning 2017–2019 for patients age 50–59 years undergoing average-risk CRC screening at our urban tertiary care center. Data was collected for baseline patient characteristics, as well assize, location and histology of colonic lesions. Patients with personal or first-degree family history of CRC or premalignant lesions, hereditary CRC syndromes, inflammatory bowel disease, or poor bowel preparations were excluded. Statistical comparisons were performed using Student’s t-test, Chi-square test, and Fisher’s test. Logistic regression was performed to analyze the association between the development of SSLs and clinical variables. RESULTS: A total of 1100 patients consisting of Asians (N = 322, 29.3%) and non-Asians (N = 778, 70.7%) were included in the analysis Asians had lower prevalence of obesity, tobacco smoking, alcohol use, HIV infection, and distant family history of CRC when compared to non-Asians (Table 1). The overall prevalence of SSLs (8.1%) was similar to prior studies, and between Asians and non-Asians (6.8% and 8.6% respectively, P = 0.33). The mean SSL size was significantly smaller in Asians (4.7 ± 2.4 mm vs. 7.3 ± 5.7 mm, P = 0.001). Most SSLs were located proximal to the splenic flexure in both groups (75.0% in Asians and 84.1% in non-Asians, P = 0.35). Only tobacco smoking was independently associated with the development of SSLs (Table 2). CONCLUSION: We found that SSLs are as prevalent and smaller in size on index screening colonoscopy among average-risk Asians compared to the general population. Due to their flat appearance and proximal location, SSLs are more difficult to identify endoscopically. In addition, smaller lesions are more likely to be missed on routine screening colonoscopy. This suggests the need for more thorough inspection of the proximal colon during index screening of this population, along with more frequent screening, mirroring some of the recently evolving guidelines for other specific patient populations.Table 1.: Baseline characteristics of the patient populationTable 2.: Univariate and multivariate models demonstrating the association between the outcome of sessile serrated lesions and clinical variables in the entire cohort (N = 1,100)

S2121 Overt Small Bowel Bleeding From a Jejunal GIST

INTRODUCTION: Gastrointestinal stromal tumors (GISTs) are rare causes of gastrointestinal malignancies. Herein we describe a cause of upper GI bleeding from a jejunal GIST. CASE DESCRIPTION/METHODS: A 58-year-old male with history of chronic hepatitis B, hypertension and hyperlipidemia presented to the hospital with melena and lightheadedness. The patient was hemodynamically stable with an elevated BUN/creatinine ratio and initial hemoglobin of 11.5 g/dL. His repeat CBC twelve hours later revealed down trend of hemoglobin to 8.5 g/dL. Review of the patient’s past admission and outpatient history revealed the patient was admitted two years prior for GI bleed requiring multiple blood transfusions. At that time, upper endoscopy, colonoscopy and CT scan of the abdomen/pelvis were unrevealing as was a 99 Technetium bleeding scan. He was discharged and scheduled for outpatient small bowel video capsule but was lost to follow up. He returned to the clinic one year later and repeat upper endoscopy and colonoscopy were performed. Upper endoscopy revealed mild gastritis and colonoscopy revealed medium sized hemorrhoids but he had a poor colon bowel prep. Small bowel video capsule endoscopy revealed AVM's in the proximal small bowel but the study was also poor due to bile obscuring most of the small bowel mucosa. Due to concern for possible small bowel AVM bleed, we opted to perform upper endoscopy with push enteroscopy. A large ulcerated friable nodular mass with stigamata of recent bleeding was identified in the proximal jejunum. Bite on bite biopsies were obtained to evaluate the mass and a tattoo was placed for identification purposes. Despite the deep biopsies, pathology later returned as normal small bowel mucosa. A CT enterography was obtained revealing a 3.5 × 3.6 × 3.5 cm hyperenhancing mass arising from the proximal jejunum with adjacent wall thickening. Surgical consultation was obtained and the patient underwent laparoscopic resection of the mass. Pathology demonstrated low grade spindle-cell type gastrointestinal stromal tumor. DISCUSSION: Although an uncommon cause for GI bleeding overall, GISTs are a common cause of small bowel bleeding. Obtaining a thorough history and evaluation of the patient’s prior outpatient records proved useful in identifying the cause of bleeding in this case even though it was different from what was suspected.Figure 1Figure 2

S3440 A Rare but Serious Complication of Colonoscopy

INTRODUCTION: Reading View. Press Alt Shift A for accessibility help. Colonoscopy is the most widely used procedure for many colonic diseases. Hemorrhage and perforation are the most common complications. Splenic injury after colonoscopy is a very rare yet serious complication. Here we present a case followed by the review of literature. CASE DESCRIPTION/METHODS: Reading View. Press Alt Shift A for accessibility help. A 71-year-old woman presented with left lower abdominal pain after undergoing routine colonoscopy three days prior. She had history of right hemicolectomy for colonic carcinoma. Her exam showed tenderness in the left lower quadrant and epigastric area. Labs were significant for hemoglobin 10.7 g/dL (baseline 11 g/dL). CT abdomen revealed a 6.2 × 2.3 × 5.1 cm hematoma surrounding the lower pole of the spleen (Figure 1). She was managed conservatively with fluid resuscitation. CT angiography showed no active bleeding. Her hemoglobin remained stable and she did not require any surgical intervention. DISCUSSION: Reading View. Press Alt Shift A for accessibility help. Splenic injury is an under-reported complication of colonoscopy, with only 103 cases reported until 2012. The first ever case of splenic injury was reported in 1974 by Wherry and Zehner with the incidence of around 0.00005-0.017% and a mortality rate of 5%. Risk factors for splenic injury post-colonoscopy are previous surgical adhesions, as in our patient, IBD, difficult colonoscopy, rushing during the procedure and insufficient visualization due to poor bowel preparation. Splenic capsular avulsions and lacerations are caused either by direct injury during manipulation through the splenic flexure or during a difficult colonoscopy owing to transcolic pressure or looping of the instrument. Technical maneuvers during colonoscopy such as the alpha maneuver, straightening of the sigmoid loop, external pressure on the left hypochondrium also increase the risk. The most common symptom is left upper quadrant pain, with referred pain to the left shoulder known as the Kehr sign. Symptoms usually present within 24 hours. CT abdomen is the best imaging modality. Splenic injury post colonoscopy is treated either conservatively or through surgical intervention depending upon the hemodynamic status of patient and size of hematoma. Conservative management includes fluid resuscitation or blood product replacement. Surgical intervention is recommended for hemodynamic instability or Grades IV-V splenic lacerations.Figure 1.: CT scan abdomen and pelvis with intravenous contrast (Coronal view – right panel & Transverse view – left panel) showing spleen (blue arrows) and a 6.2 × 2.3 × 5.1 cm hematoma (green arrows).Figure 2.: CT scan abdomen and pelvis with intravenous contrast (Coronal view – right panel & Transverse view – left panel) showing spleen (blue arrows) and a 6.2 × 2.3 × 5.1 cm hematoma (green arrows).

S0275 Multimedia-Based Education on Bowel Preparation Improves Adenoma Detection Rate - A Systematic Review &amp; Meta-Analysis of Randomized Controlled Trials

INTRODUCTION: Colorectal cancer (CRC) is the third most common cause of cancer worldwide and the third leading cause of cancer deaths in western countries. Studies have shown a strong association between screening colonoscopy and a reduced risk of death from colorectal cancers. The incidence of poor bowel preparation has been reported in up to 25% cases. We conducted a systematic review and comprehensive meta-analysis to evaluate the effect of patient education using multimedia education on adenoma detection rate and adequacy of bowel preparation. METHODS: Multiple databases were searched through May 2020 for studies that reported the efficacy of multimedia education (smartphone app and audio-visual aids) in improving quality of bowel preparation and its effect on adenoma detection rate (ADR). Meta-analysis was performed to determine whether multimedia based patient education (MM) helps improve ADR and bowel preparation quality as compared to controls (CT). RESULTS: We included 13 randomized controlled trials with a total of 3754 patients. Overall ADR was higher in patients receiving multimedia based education (26%) as compared to CT (20.1%) (OR 1.4 CI 1.01–1.85; I2 = 57; P = 0.04) (Figure 1). In particular, for patients over 50 years of age, ADR was better in MM cohort as compared to controls (OR 1.8 CI 1.1–2.9; I2 = 0; P = 0.03) (Figure 2). Finally, a higher proportion of patients receiving multimedia based education achieved optimal bowel preparation. CONCLUSION: Pre-colonoscopy patient education using multimedia based platforms seems to improve ADR by improving the adequacy of bowel preparation for colonoscopy.Figure 1.: Overall ADR.Figure 2.: ADR by mean age.

Colonoscopy Outcomes in Average-Risk Screening Equivalent Young Adults: Data From the New Hampshire Colonoscopy Registry.

Data are needed to further inform the American Cancer Society recommendation to begin colorectal cancer (CRC) screening at age 45. We used the New Hampshire Colonoscopy Registry to compare the prevalence of advanced neoplasia (AN) in an "average-risk screening equivalent" group aged 45-49 years with patients aged 50-54 years and older receiving screening colonoscopy. Colonoscopies in adults older than 50 years of age usually have diagnostic indications of varying clinical significance. We combined patients older than 50 years with diagnostic indications (abdominal pain and constipation) expected to yield AN prevalence similar to screening low AN risk and those with a screening indication to form an "average-risk screening equivalent" group. We excluded high-risk indications (e.g., bleeding and anemia), surveillance examinations, and patients with a first-degree family history of CRC, incomplete examinations, and poor bowel preparation. We calculated prevalence/adjusted risks for AN (≥1 cm, villous, high-grade dysplasia, and CRC) and clinically significant serrated polyps (large [≥1 cm] hyperplastic polyps, sessile serrated polyp, traditional serrated adenomas, and proximal hyperplastic polyp ≥ 5 mm). In our sample (n = 40,812), AN prevalence was as follows: <40 years (1.1%), 40-44 years (3.0%), 45-49 years (3.7%), 50-54 years (3.6%), 55-59 years (5.1%), and 60+ years (6.7%) (P < 0.0001 across all groups). The prevalence of both AN and clinically significant serrated polyp was similar in the 45-49 and 50-54 years' age groups. Furthermore, the prevalence of AN increased significantly in the 40-44 group as compared to that in the <40 years group. Adjusted analyses confirmed these results. The diagnostic indications considered to have low risk were not predictive of AN. New Hampshire Colonoscopy Registry data, demonstrating an increase in AN risk starting at age 40 and a similar prevalence for individuals aged 45-49 and those ages 50-54, provide clinically useful evidence for optimization of prevention and the age to start screening. However, this is a complex issue involving additional considerations that will need to be addressed.

Heterogeneity in colorectal cancer incidence among people recommended 3-yearly surveillance post-polypectomy: a validation study.

Background Colonoscopy surveillance is recommended for patients at increased risk of colorectal cancer (CRC) following adenoma removal. Low-, intermediate-, and high-risk groups are defined by baseline adenoma characteristics. We previously examined intermediate-risk patients from hospital data and identified a higher-risk subgroup who benefited from surveillance and a lower-risk subgroup who may not require surveillance. This study explored whether these findings apply in individuals undergoing CRC screening. Methods This retrospective study used data from the UK Flexible Sigmoidoscopy Screening Trial (UKFSST), English CRC screening pilot (ECP), and US Kaiser Permanente CRC prevention program (KPCP). Screening participants (50 – 74 years) classified as intermediate-risk at baseline colonoscopy were included. CRC data were available through 2006 (KPCP) or 2014 (UKFSST, ECP). Lower- and higher-risk subgroups were defined using our previously identified baseline risk factors: higher-risk participants had incomplete colonoscopies, poor bowel preparation, adenomas ≥ 20 mm or with high-grade dysplasia, or proximal polyps. We compared CRC incidence in these subgroups and in the presence vs. absence of surveillance using Cox regression. Results Of 2291 intermediate-risk participants, 45 % were classified as higher risk. Median follow-up was 11.8 years. CRC incidence was higher in the higher-risk than lower-risk subgroup (hazard ratio [HR] 2.08, 95 % confidence interval [CI] 1.07 – 4.06). Surveillance reduced CRC incidence in higher-risk participants (HR 0.35, 95 %CI 0.14 – 0.86) but not statistically significantly so in lower-risk participants (HR 0.41, 95 %CI 0.12 – 1.38). Conclusion As previously demonstrated for hospital patients, screening participants classified as intermediate risk comprised two risk subgroups. Surveillance clearly benefited the higher-risk subgroup.

Predictors and Management of Failed Fecal Microbiota Transplantation for Recurrent Clostridioides difficile Infection.

Clostridioides difficile infection (CDI) recurs in 10% to 15% after fecal microbiota transplantation (FMT). We identify predictors, and describe management and outcome of patients with recurrent CDI after FMT in a predominantly outpatient cohort. A nested case-control study of patients undergoing FMT for recurrent CDI from August 2012 to January 2017 was performed. FMT failure was defined as recurrent diarrhea with positive C. difficile stool test during follow-up (≥2 mo). Controls (patients without FMT failures) were matched to cases 1:1 for sex and timing of FMT±1 month. Overall, 522 patients underwent FMT; 70 [13.4%; median age 53.8 years (range, 18 to 89 y), 54.3% females] recurred within a median 5.6 months (range, 0.2 to 34.9 mo). Number of prior CDI episodes, prior CDI treatment, and prior CDI-related hospitalizations were similar in cases and controls. Systemic antibiotics after FMT (54.3% vs. 21.4%, P<0.0001), inflammatory bowel disease (IBD) (34.3% vs. 15.7%, P=0.01), pseudomembranes at FMT (4.3% vs. 0%, P=0.03), and poor bowel preparation (68.5% vs. 31.4%, P=0.01) were associated with FMT failure. On multivariate analysis, IBD [odds ratio (OR) 4.34; 95% confidence interval (CI), 1.24-15.15], systemic antibiotics (OR 7.39; 95% CI, 3.02-18.07), and poor bowel preparation (OR 3.84; 95% CI, 1.59-9.28) predicted FMT failure with an area under the curve of 0.78. Among FMT failures, 37 (52.8%) were managed with antibiotics, 32 (45.7%) with repeat FMT after antibiotics and 1 with colectomy. Use of systemic antibiotics, IBD, and poor bowel preparation predict FMT failure. Patients with FMT failure can be managed with antibiotics and/or repeat FMT.

Effect of bowel preparation volume in inpatient colonoscopy. Results of a prospective, randomized, comparative pilot study

BackgroundInpatient status has been shown to be a predictor of poor bowel preparation for colonoscopy; however, the optimal bowel preparation regimen for hospitalized patients is unknown. Our aim was to compare the efficacy of bowel preparation volume size in hospitalized patients undergoing inpatient colonoscopy.MethodsThis prospective, single blinded (endoscopist), randomized controlled trial was conducted as a pilot study at a tertiary referral medical center. Hospitalized patients undergoing inpatient colonoscopy were assigned randomly to receive a high, medium, or low-volume preparation. Data collection included colon preparation quality, based on the Boston Bowel Preparation Scale, and a questionnaire given to all subjects evaluating the ability to completely finish bowel preparation and adverse effects (unpleasant taste, nausea, and vomiting).ResultsTwenty-five colonoscopies were performed in 25 subjects. Patients who received low-volume preparation averaged a higher mean total BBPS (7.4, SD 1.62), in comparison to patients who received high-volume (7.0, SD 1.41) and medium-volume prep (6.9, SD 1.55), P = 0.77. When evaluating taste a higher score meant worse taste. The low-volume group scored unpleasant taste as 0.6 (0.74), while the high-volume group gave unpleasant taste a score of 2.2 (0.97) and the medium-volume group gave a score of 2.1 (1.36), P < 0.01.ConclusionIn this pilot study we found that low-volume colon preparation may be preferred in the inpatient setting due its better rate of tolerability and comparable bowel cleanliness when compared to larger volume preparation, although we cannot overreach any definitive conclusion. Further more robust studies are required to confirm these findings.Trial registrationThe Affect of Low-Volume Bowel Preparation for Hospitalized Patients Colonoscopies. Trial registration: NCT01978509 (terminated). Retrospectively registered on November 07, 2013.

Tu1170 RISK FACTOR ANALYSIS OF CECAL INTUBATION RATES AND QUALITY OF BOWEL PREPARATION IN THE ELDERLY: A TERTIARY HEALTH NETWORK STUDY

Colonoscopy is an important tool in the diagnosis and management of colonic disorders. Adequate bowel preparation (BP) and completion of the colonoscopy, as measured by cecal intubation (CI) rates, are imperative for successful colonoscopy. Elderly patients generally have lower functional ability, higher co-morbidity and decreased colonic motility which may negatively impact CI and BP. Currently, there is limited data about CI and BP in the elderly population. We hope to determine the impact of various factors that can affect CI and BP in patients 75 years of age and above. (582) We conducted a retrospective chart review to identify patients who underwent colonoscopy between 2012 and 2019 within our health network. We collected data on patient characteristics, quality of bowel preparation and cecal intubation rates. All statistical analyses were conducted in IBM SPSS for Windows Version 26 to compute means and frequencies of patient characteristics and colonoscopy outcomes. Chi –Square tests were done to test differences between various categorical variables, and odds ratios were evaluated to test for associations between potential risk factors and BP and CI rates. A total of 387 patients were included with median age of 79 years, 44.4% males and 88.9% Caucasian. Most of the of colonoscopies (71.3%) were performed for a diagnostic indications. 51.2% were on Aspirin and 29.7% were obese. We found that 91.8% of patients had a good bowel preparation, and cecal intubation was achieved in 94.1% of colonoscopies. Table 1 includes a complete list of patient characteristics. Subgroup analysis showed larger proportion of patients with obesity, impaired fasting glucose, metabolic syndrome, fatty liver, constipation, ASA score 3 or more, and current smokers in the younger (75-84 years) age group, while older (85-95 years) patients had more coronary artery disease, aortic stenosis, intake of Aspirin and opioids and poor BP. Statistically significant risk factors for poor bowel preparation include being a current smoker (OR 2.79, 95% CI 0.98-7.94). Chronic obstructive pulmonary disease (COPD) (OR 2.67, 95% CI 0.92-7.71)and use of NSAIDs (OR 2.83, 95% CI 1.05-7.68) or opioid medications (OR 3.76, 95% CI 1.37-10.3) were associated with failure of CI. Table 2 includes additional risk factors assess for poor CI rates and inadequate BP. Ethnicity, increased age, and use of Aspirin had no adverse impact on CI or BP. Colonoscopy in the elderly was found to have high CI and BP rates. Our study found certain risk factors were associated with adverse impact on both parameters, while a lower BMI is associated with improved outcomes. Our study is limited by retrospective nature and lack of ethnic diversity.View Large Image Figure ViewerDownload Hi-res image Download (PPT)

Mo1747 ONE WEEK POLYETHYLENE GYCOL (PEG) 3350 FOLLOWED BY SPLIT DOSE PEG ELECTOLYTE SOLUTION WITH OR WITHOUT ASCORBIC ACID IMPROVED COLONOSCOPY BOWEL PREPARATION IN PATIENTS WITH CONSTIPATION: A QUALITY IMPROVEMENT PROJECT AT A LARGE VETERANS AFFAIRS HOSPITAL

High quality bowel preparation is crucial for an effective examination of the colon during colonoscopy. Diabetes, chronic constipation, spinal cord injury, and the use of medications such as narcotics and tricyclic antidepressants are well known predictors of inadequate bowel preparation. The 2014 US Multi-Society Task Force guidelines do not recommend the use of a specific bowel regimen in high risk patients, and limits its statement to the favorable use of additional purgatives in this group of patients (weak recommendation, low quality evidence). We aimed to identify the rate of inadequate bowel preparation in high risk patients and to compare the efficacy of different types of bowel preparations in this population. We identified colonoscopies (n=3651) performed at our institution between January 2019 until November 2019. Patients at high risk for inadequate preparation were identified by specific ICD-10 codes for constipation, diabetes or spinal cord injury or by review of outpatient pharmacy orders for narcotics, antidepressants or laxatives. Bowel preparation adequacy was reported according to the 4- point Boston Bowel Preparation Scale. Mid-P Exact test was used to compare the rates of poor bowel preparation in constipated patients according to the bowel preparation received. The majority of patients were male (92.3%) with a mean age of 64.2+10.4. Approximately 65% of patients received a split dose PEG electrolyte solution with ascorbic acid (Moviprep), 25% received 1 week of PEG 3350 (Miralax) prior to a split dose Moviprep or PEG electrolyte solution (Golytely), and 9.5% prepped with Golytely. Overall, 680 colonoscopies (18.6%) had inadequate bowel preparation of which 235 (6.4%) were deemed poor. A total of 2166 colonoscopies (59.3%) were performed on high risk patients (table). Among high risk patients, the rate of inadequate bowel preparation was 24.5% (figure). In a subgroup analysis on patients with constipation who were prescribed laxatives (n=984), the rate of poor bowel preparation was significantly reduced in patients who received 1 week of Miralax followed by split dose Moviprep or Golytely (13.9%) compared to Split dose Moviprep or Golytely alone (19.9%) OR= 0.65( 95% CI: 0.46-0.91, p=0.006). High risk patients have an increased rate of inadequate bowel preparation. One week of Miralax followed by split dose Moviprep or Golytely reduced the rate of poor bowel preparation in constipated patients on laxatives. If proven beneficial in large randomized controlled trials, this method of preparation will reduce repeated colonoscopies and wasted capacity in endoscopy unit.View Large Image Figure ViewerDownload Hi-res image Download (PPT)

Low-residue diet for colonoscopy in veterans: Risk factors for inadequate bowel preparation and patient satisfaction and compliance.

Bowel preparation with low-residue diet (LRD) has resulted in higher patient satisfaction and similar polyp detection rates compared to conventional clear liquid diet. However, there is limited experience with LRD in veterans, in whom conditions associated with poor bowel preparation are more prevalent than the general population. To examine risk factors associated with inadequate bowel preparation, we conducted a chart review of outpatient colonoscopies at the Manhattan VA Medical Center from February 2017 to April 2018. To examine patient satisfaction and compliance, we administered an anonymous questionnaire to patients undergoing outpatient colonoscopy from March to August 2018. Patients assessed by chart review (n = 660) were 92% male with a mean age of 64 years. An adequate Boston Bowel Preparation Scale score ≥2 in each colonic segment was achieved in 94% of procedures. Higher BMI, diabetes, prior inadequate bowel preparation, bowel preparation duration of two days, and opioid use were associated with inadequate bowel preparation on univariable analysis. On multiple logistic regression, only higher BMI remained a predictor, with every one-unit increase associated with a 6% increased odds of poor bowel preparation. Questionnaire responses showed 84% of patients were willing to repeat LRD bowel preparation, 85% found the process easy or acceptable, and 78% reported full adherence to LRD. These findings demonstrate that bowel preparation quality, patient satisfaction, and compliance were all high among veterans using LRD.

Impact of Inadequate Bowel Cleansing on Colonoscopic Findings in Routine Screening Practice.

INTRODUCTION:Colonoscopy is an imperfect gold standard for detecting colorectal neoplasms because some proportion of adenomas may be missed, mainly small lesions. This proportion is expected to be higher in case of inadequate bowel cleansing, which is frequently seen in routine practice. We estimated the proportions of neoplasms that are in principle detectable by colonoscopy but might be missed in case of incomplete bowel preparation.METHODS:For 8,193 participants of screening colonoscopy in South-Western Germany, recruited between 2005 and 2016, the prevalence and numbers of different findings were extracted from colonoscopy reports and compared according to the reported bowel preparation quality.RESULTS:Bowel preparation quality was reported as good, poor, or was unspecified in 30.3%, 11.1%, and 58.6% of colonoscopy records. Reported prevalences of nonadvanced adenomas (NAAs) were similar among participants with poor and unspecified bowel preparation quality but substantially lower than among participants with good bowel preparation (adjusted prevalence rate ratio [RR] 0.86, 95% confidence interval [CI]: 0.77–0.96). The differences were observed for proximal but not for distal NAAs (RRs 0.82, 95% CI: 0.71–0.95 and 0.95, 95% CI: 0.82–1.10).DISCUSSION:Our study suggests that a significant proportion of NAAs located in the proximal colon might be missed during colonoscopy if bowel cleansing is not adequate. Major efforts should be made to further facilitate and enhance high-quality bowel preparation in routine screening practice.

Poor Bowel Preparation in Crohn’s Disease

Question: An elderly man with known penetrating Crohn’s disease presents for routine colonoscopy to assess disease activity. He was in clinical remission on a combination of infliximab with mercaptopurine. A colonoscopy 6 months ago was aborted owing to poor bowel preparation in the sigmoid and transverse colon although it was noted that he had a possible narrowing in the sigmoid colon (Figure A). The patient was adamant that he took the preparation as requested. A computed tomography (CT) colonography, CT enteroclysis and repeat colonoscopy with extended bowel preparation were performed.

Impact of Colonoscopy Bowel Preparation Quality on Follow-up Interval Recommendations for Average-risk Patients With Normal Screening Colonoscopies: Data From the New Hampshire Colonoscopy Registry.

National guidelines for colonoscopy screening and surveillance assume adequate bowel preparation. We used New Hampshire Colonoscopy Registry (NHCR) data to investigate the influence of bowel preparation quality on endoscopist recommendations for follow-up intervals in average-risk patients following normal screening colonoscopies. The analysis included 9170 normal screening colonoscopies performed on average risk individuals aged 50 and above between February 2005 and September 2013. The NHCR Procedure Form instructs endoscopists to score based on the worst prepped segment after clearing all colon segments, using the following categories: excellent (essentially 100% visualization), good (very unlikely to impair visualization), fair (possibly impairing visualization), and poor (definitely impairing visualization). We categorized examinations into 3 preparation groups: optimal (excellent/good) (n=8453), fair (n=598), and poor (n=119). Recommendations other than 10 years for examinations with optimal preparation, and >1 year for examinations with poor preparation, were considered nonadherent. Of all examinations, 6.2% overall received nonadherent recommendations, including 5% of examinations with optimal preparation and 89.9% of examinations with poor preparation. Of normal examinations with fair preparation, 20.7% of recommendations were for an interval <10 years. Among those examinations with fair preparation, shorter-interval recommendations were associated with female sex, former/nonsmokers, and endoscopists with adenoma detection rate ≥20%. In 8453 colonoscopies with optimal preparations, most recommendations (95%) were guideline-adherent. No guideline recommendation currently exists for fair preparation, but in this investigation into community practice, the majority of the fair preparation group received 10-year follow-up recommendations. A strikingly high proportion of examinations with poor preparation received a follow-up recommendation greater than the 1-year guideline recommendation. Provider education is needed to ensure that patients with poor bowel preparation are followed appropriately to reduce the risk of missing important lesions.

Personal instruction for patients before colonoscopies could improve bowel preparation quality and increase detection of colorectal adenomas.

To analyze whether face-to-face education before colonoscopy improves the quality of bowel preparation and increases the detection of adenomas. A retrospective cross-sectional study of adult patients with colorectal polyps identified by colonoscopy as outpatients was performed. The patients underwent an added colonoscopy inpatient for resection of colorectal polyps. As outpatients, we gave the patients written bowel preparation instructions; however, when they were inpatients, we supplied face-to-face education. We analyzed the data from the two colonoscopies of the same group of patients out- and in-patients, including the quality of the intestinal preparation, the time to reach the ileocecal region, and the detection of adenomas. A total of 260 patients {age 63 [56, 68] years old, male/female (169/91)} were retrospectively included in our study. Two hundred fifty-two patients with a total of 685 adenomas were detected, 94 patients with 179 adenomas overlooked in the first colonoscopy. The BBPS Score during inpatient was higher than that during outpatient, {9 [8, 9] vs. 7 [6, 9]}, P<0.05, the Bubble Score during inpatient was lower than that during outpatient [0 (0.00, 0.00) vs. 0 (0.00, 1.00)], P<0.05. The time to reach the ileocecal region during inpatient is shorter than that during outpatient {6 [5, 9] vs. 7.5 [5, 11] min}, P<0.05. Poor bowel preparation, flat adenoma morphology, and adenoma diameter lower than 5mm were related adenoma misdiagnoses, P<0.05. Face-to-face patient education can improve the quality of bowel preparation, then shorten the time to reach the ileocecal region, and increase detection of colorectal adenomas.

A149 COMPARING THE REAL-WORLD EFFECTIVENESS OF 4L VERSUS 2L SPLIT COLONOSCOPY PREPARATIONS: PRELIMINARY DATA OF A SINGLE CENTRE EXPERIENCE THROUGH THE BRITISH COLUMBIA COLONOSCOPY SCREENING PROGRAM

Abstract Background The British Columbia Colon Screening Program (CSP) is a population-based program offering biennial fecal immunochemical test (FIT) to individuals age 50–74 years with follow-up colonoscopy for a positive FIT as well as individuals with a personal history of neoplastic polyps or a high risk family history of colorectal cancer. Over 20,000 colonoscopies are performed annually. In December 2018, program colonoscopists in Vancouver, Canada agreed to switch from a 2L polyethylene glycol (PEG) preparation to a 4L PEG preparation after studies suggested superiority of the higher volume preparation in achieving adequate bowel cleansing and improving adenoma detection rates (ADR). High quality bowel cleansing is critical to minimize repeat procedures and maximize neoplasia detection. Aims To compare the quality of bowel preparation and neoplasia detection rates using the 4L high volume split preparation (HVSP) versus the 2L low volume split preparation (LVSP) in patients undergoing colonoscopy in the BC CSP. Methods A retrospective review of consecutive patients undergoing colonoscopy through the CSP at St. Paul’s Hospital from Dec 2017-Apr 2018 and Dec 2018-Apr 2019 was conducted. Inclusion criteria included: age 50–74, patients undergoing colonoscopy for any reason through the BC CSP. Variables collected included: patient demographics, bowel preparation qualty and pathologic findings. ADR and sessile serrated polyp detection rate (SSDR) were analyzed. Results 462 colonoscopies were included, 280 in the LVSP group and 182 in the HVSP group. 8/280 (2.9%) had poor bowel preparation in the LVSP group, while 10/182 (5.5%) had poor bowel preparation in the HVSP group. The ADR and SSDR were 53.6% in LVSP vs. 50.0% in HVSP and 8.2% in LVSP vs. 8.8% in HVSP, respectively. Conclusions In this preliminary evaluation, the high volume PEG-based split preparation did not reduce the proportion of inadequate bowel preparations. Further evaluation of a larger number of colonoscopies is planned. Funding Agencies None

P010 FIRST SURVEILLANCE COLONOSCOPY FOR INFLAMMATORY BOWEL DISEASE – ARE WE GETTING IT RIGHT FROM THE START?

Abstract Background Surveillance for colorectal cancer (CRC) is necessary in patients with inflammatory bowel disease (IBD). Patients with ulcerative colitis (UC) have a similar CRC risk to those with Crohn’s colitis (CC). British Society of Gastroenterology (BSG) guidelines from 2010 outlined recommendations for screening including surveillance intervals and pancolonic dye spraying with targeted biopsies. We aimed to identify reasons why the first surveillance colonoscopy is not being performed as advised, including the role of poor bowel preparation and disease activity. Methods Retrospective study of all IBD colonoscopies over a 7 year period (2011–2018) across two sites at a tertiary London based hospital trust. 214 patients were identified and exclusion criterion was applied (not first surveillance/diagnosis prior to year 2000/PSC/inadequate data). 93 patients were included for analysis. Results 26 (28.0%) surveillance colonoscopies were performed prior to 10 years of diagnosis (ie. before BSG guideline recommendation). 22 (23.7%) surveillance colonoscopies performed after the recommended interval. Dye spray was performed in only 2 patients (2%). Reasons cited for not dying were only given in 4 (4.3%) cases, and included poor bowel prep or active disease. No reason was given in 87 (93%) cases. Targeted biopsies were performed in 24 (25.8%) patients, with random biopsies in 56 (60.2%) patients. Conclusion The first IBD surveillance colonoscopy is only being performed at the correct time interval in approximately 50% of cases with over a quarter being performed too soon and almost a quarter being performed too late. Pan-colonic dye spray is used in only 2% and targeted biopsies are taken in only 1 in 4 patients. Poor bowel preparation and disease activity do not appear to be limiting factors in the use of dye spray. We conclude that appropriate initial colitis surveillance is not being performed in the majority despite published guidelines. Organisational factors such as sufficient time allocated to dye spray colonoscopy, along with endoscopist skill, may be contributing factors.