Post-colonoscopy Colorectal Cancer Research Articles

Artificial intelligence–assisted real-time monitoring of effective withdrawal time during colonoscopy: a novel quality marker of colonoscopy

Background and aimsThe importance of withdrawal time during colonoscopy cannot be overstated in mitigating the risk of missed lesions and post-colonoscopy colorectal cancer. We evaluated a novel colonoscopy quality metric called the effective withdrawal time (EWT), which is an artificial intelligence (AI) derived quantitative measure of quality withdrawal time and their association with various colonic lesions detection rates, as compared with standard withdrawal time (SWT). MethodsA total of 350 video recordings of colonoscopy withdrawal (from caecum to anus) were assessed by the new AI model. The primary outcome was adenoma detection rate (ADR) according to different quintiles of EWT. Multivariate logistic regression, adjusting for baseline covariates, was used to determine the adjusted odd ratios (OR) for EWT on lesion detection rates, with the lowest quintile as reference. The area under the receiver operating characteristic curve (AUC) of EWT was compared with SWT. ResultsThe crude ADR in different quintiles of EWT, from lowest to highest, was 10.0%, 31.4%, 33.3%, 53.5%, and 85.7%, respectively. The ORs of detecting adenoma and polyp were significantly higher in all top 4th quintiles when compared to the lowest quintile. Each minute increase in EWT was associated with a 49% increase in ADR (aOR, 1.49; 95% CI, 1.36 to 1.65). The AUC of EWT was also significantly higher than SWT on adenoma detection (0.80 [95%CI: 0.75 – 0.84] vs 0.70 [95%CI: 0.64-0.74], p <0.01). ConclusionsThe AI-derived EWT monitoring is a promising novel quality indicator for colonoscopy, which is more associated with ADR than SWT.

Interval post-colonoscopy colorectal cancer following a negative colonoscopy in a fecal immunochemical test-based screening program.

In the Dutch colorectal (CRC) screening program, fecal immunochemical test (FIT)-positive individuals are referred for colonoscopy. If no relevant findings are detected at colonoscopy, individuals are reinvited for FIT screening after 10 years. We aimed to assess CRC risk after a negative colonoscopy in FIT-positive individuals. In this cross-sectional cohort study, data were extracted from the Dutch national screening information system. Participants with a positive FIT followed by a negative colonoscopy between 2014 and 2018 were included. A negative colonoscopy was defined as a colonoscopy during which no more than one nonvillous, nonproximal adenoma < 10 mm or serrated polyp < 10 mm was found. The main outcome was interval post-colonoscopy CRC (iPCCRC) risk. iPCCRC risk was reviewed against the risk of interval CRC after a negative FIT (FIT IC) with a 2-year screening interval. 35 052 FIT-positive participants had a negative colonoscopy and 24 iPCCRCs were diagnosed, resulting in an iPCCRC risk of 6.85 (95 %CI 4.60-10.19) per 10 000 individuals after a median follow-up of 1.4 years. After 2.5 years of follow-up, age-adjusted iPCCRC risk was approximately equal to FIT IC risk at 2 years. Risk of iPCCRC within a FIT-based CRC screening program was low during the first years after colonos-copy but, after 2.5 years, was the same as the risk in FIT-negative individuals at 2 years, when they are reinvited for screening. Colonoscopy quality may therefore require further improvement and FIT screening interval may need to be reduced after negative colonoscopy.

S718 Adenoma Detection Rate After Positive Stool-Based Screening and Risk of Interval Post-Colonoscopy Colorectal Cancer

S718 Adenoma Detection Rate After Positive Stool-Based Screening and Risk of Interval Post-Colonoscopy Colorectal Cancer

Frequency of serrated polyposis syndrome recognition by community endoscopists.

Background and study aims Some data indicate serrated polyposis syndrome (SPS) is underdiagnosed. We determined the frequency of SPS diagnosis by community endoscopists prior to referral to a tertiary center. Patients and methods We performed a retrospective analysis of a prospectively collected database of SPS patients at a tertiary academic hospital. There were 212 patients who were referred to our center for resection of one or more lesions detected at a prior colonoscopy and who had records available that allowed determination of whether SPS was diagnosed before referral. Results Only 25 of 212 patients (11.8%) had a diagnosis or suspicion of a polyposis syndrome prior to referral, and only 12 patients (5.7%) had a specific SPS diagnosis made prior to referral. Among 187 patients diagnosed at our center, 39 had sufficient serrated lesions removed and documented in outside records to meet SPS criteria prior to referral, but the diagnosis was not made by the referring physician despite adequate numbers of lesions resected. The remaining cases required lesions removed at our center to meet SPS diagnostic criteria. Limitations were a single center, single expert endoscopist. Conclusions SPS is the most common colorectal polyposis syndrome, but it remains underdiagnosed by community endoscopists. Underdiagnosis may contribute to post-colonoscopy colorectal cancer in patients with SPS.

Higher Serrated Polyp Detection Rates Are Associated With Lower Risk of Postcolonoscopy Colorectal Cancer: Data From the New Hampshire Colonoscopy Registry.

We used New Hampshire Colonoscopy Registry data to examine the association between postcolonoscopy colorectal cancer (PCCRC) and sessile serrated detection rates (SSLDRs). We included patients with either a colonoscopy or a CRC diagnosis in the NH State Cancer Registry. PCCRC was any CRC diagnosed ≥ 6 months after index examination. Of 26,901 patients, 162 were diagnosed with PCCRC. The hazard ratio for PCCRC was lowest for patients whose endoscopists had the highest SSLDR quintile (≥6%) (hazard ratio 0.29; 95% confidence interval 0.16-0.50). Endoscopists with higher SSLDRs had lower risks of PCCRC. These data validate SSLDR as a clinically relevant quality measure.

Identifying the need for a UK colorectal cancer screening programme for patients with cystic fibrosis (CF): 10-year retrospective review of colonoscopy and colorectal cancer outcomes at a single CF centre

ObjectivePatients with cystic fibrosis (pwCF) have a high incidence of early colorectal cancer (CRC). In the absence of a UK CRC screening programme for pwCF, we evaluated the utility and...

Postcolonoscopy colorectal cancer: Prevalence, categorization and root-cause analysis based on the World Endoscopic Organization system

AimsThe World Endoscopy Organization (WEO) recommends that endoscopy units implement a process to identify postcolonoscopy colorectal cancer (PCCRC). The aims of this study were to assess the 3-year PCCRC rate and to perform root-cause analyses and categorization in accordance with the WEO recommendations. Patients and methodsCases of colorectal cancers (CRCs) in a tertiary care center were retrospectively included from January 2018 to December 2019. The 3-year and 4-year PCCRC rates were calculated. A root-cause analysis and categorization of PCCRCs (interval and type A, B, C noninterval PCCRCs) were performed. The level of agreement between two expert endoscopists was assessed. ResultsA total of 530 cases of CRC were included. A total of 33 were deemed PCCRCs (age 75.8±9.5 years; 51.5% women). The 3-year and 4-year PCCRC rates were 3.4% and 4.7%, respectively. The level of agreement between the two endoscopists was acceptable either for the root-cause analysis (k=0.958) or for the categorization (k=0.76).The most plausible explanations of the PCCRCs were 8 “likely new PCCRCs”, 1 (4%) “detected, not resected”, 3 (12%) “detected, incomplete resection”, 8 (32%) “missed lesion, inadequate examination”, and 13 (52%) “missed lesion, adequate examination”. Most PCCRCs were deemed noninterval Type C PCCRCs (N=17, 51.5%). ConclusionWEO recommendations for root-cause analysis and categorization are useful to detect areas for improvement. Most PCCRCs were avoidable and were likely due to missed lesions during an otherwise adequate examination.

A retrospective analysis of the histology of resected polyps and colonoscopy quality parameters in Belgium.

adenoma detection rate is a well known quality parameter for colonoscopy. However recently other quality parameters have emerged. We wanted to evaluate the histology of the resected polyps, different quality indicators of colonoscopy and post colonoscopy colorectal cancer (PCCRC) in Belgium and analyzed data about colonoscopies performed between 2008-2015. Reimbursement data on colorectal related medical procedures from the Intermutualistic Agency were linked with data on clinical and pathological staging of colorectal cancer and with histologic data of resected polyps available at the Belgian Cancer Registry over a period covering 8 years (2008-2015). 298,246 polyps were resected in 294,923 colonoscopies, of which 275,182 were adenomas (92 %) and 13,616 were SSLs (4%). There was a significant but small correlation between the different quality parameters and PCCRC. Post colonoscopy colorectal cancer rate after 3 years was 7.29 %. There were marked geographic differences in Belgium concerning adenoma detection rate, sessile adenoma detection rate and post colonoscopy colorectal cancer. Most resected polyps were adenomas, only a small percentage involved sessile serrated lesions. There was a significant correlation between adenoma detection rate and other quality parameters, and a small but significant correlation between PCCRC and the different quality parameters. The lowest post colonoscopy colorectal cancer rate was reached with an ADR of 31.4 % and a SSL-DR of 1.2 %.

Polyp characteristics at screening colonoscopy and post-colonoscopy colorectal cancer mortality: a retrospective cohort study.

Polyp size and high-grade dysplasia in polyps at screening colonoscopy are considered risk factors for post-colonoscopy colorectal cancer (PCCRC) development and death, which might be averted by surveillance colonoscopy. However, robust evidence backing these risk factors is lacking. We aimed to investigate whether polyp size or dysplasia grade is associated with PCCRC mortality. This was a retrospective study including individuals of the Austrian Quality Certificate for Screening Colonoscopy who underwent a colonoscopy between January 2007 and December 2020. We investigated the association of polyp size and dysplasia in polyps with PCCRC mortality according to Cox regression analysis. In addition, whether patients with certain polyp characteristics had similar risk for CRC death compared with the Austrian population was assessed by calculating standardized mortality ratios (SMRs). A total of 316,001 individuals were included. After a median follow-up time of 5.27 years (95% confidence interval [CI], 5.25-5.29), a significant association of polyps 10 to 20mm (hazard ratio, 4.00; 95% CI, 2.46-6.50; P< .001) as well as high-grade dysplasia (hazard ratio, 6.61; 95% CI, 3.31-13.2; P< .001) with PCCRC death was observed. PCCRC mortality was significantly lower than the expected CRC mortality in the general population in patients with polyps<10mm and without high-grade dysplasia (SMR, .27; 95% CI, .21-.33; P< .001), which was not observed for patients with polyps≥10mm or with high-grade dysplasia (SMR, 2.05; 95% CI, 1.64-2.57; P< .001). Polyp size≥10mm and high-grade dysplasia are associated with PCCRC mortality in screening patients. The data suggest that these patients might benefit most from surveillance colonoscopy.

Revisiting bowel preparation: The quest for the optimal low‐residue diet duration

Revisiting bowel preparation: The quest for the optimal <scp>low‐residue</scp> diet duration

Computer-aided detection in real-world colonoscopy: enhancing detection or offering false hope?

Colorectal cancer stands as the second leading cause of cancer-related deaths worldwide, posing an important global health challenge. Screening colonoscopy with removal of neoplastic lesions has been recognised as one of the most effective methods of preventing colorectal cancer. 1 Zauber AG Winawer SJ O'Brien MJ et al. Colonoscopic polypectomy and long-term prevention of colorectal-cancer deaths. N Engl J Med. 2012; 366: 687-696 Crossref PubMed Scopus (2095) Google Scholar Adenoma detection rate (ADR) serves as a crucial quality indicator in colonoscopy, as it is inversely associated with post-colonoscopy (interval) colorectal cancer. 2 Kaminski MF Regula J Kraszewska E et al. Quality indicators for colonoscopy and the risk of interval cancer. N Engl J Med. 2010; 362: 1795-1803 Crossref PubMed Scopus (1431) Google Scholar However, it is estimated that around a quarter of colorectal neoplasms are missed during a single colonoscopy procedure. 3 van Rijn JC Reitsma JB Stoker J Bossuyt PM van Deventer SJ Dekker E Polyp miss rate determined by tandem colonoscopy: a systematic review. Am J Gastroenterol. 2006; 101: 343-350 Crossref PubMed Scopus (1056) Google Scholar To address this issue, computer-aided detection (CADe) systems using artificial intelligence (AI) have emerged as promising tools that allow increased detection of colorectal neoplastic lesions, thus enhancing the overall effectiveness of colonoscopy. 4 Misawa M Kudo SE Mori Y et al. Current status and future perspective on artificial intelligence for lower endoscopy. Dig Endosc. 2021; 33: 273-284 Crossref PubMed Scopus (16) Google Scholar Effect of real-time computer-aided detection of colorectal adenoma in routine colonoscopy (COLO-GENIUS): a single-centre randomised controlled trialOur findings support the benefits of CADe, even in a non-academic centre. Systematic use of CADe in routine colonoscopy should be considered. Full-Text PDF

Incomplete resection rates of 4- to 20-mm non-pedunculated colorectal polyps when using wide-field cold snare resection with routine submucosal injection

Background and study aims Incomplete resection of 4- to 20-mm colorectal polyps occur frequently (> 10 %), putting patients at risk for post-colonoscopy colorectal cancer. We hypothesized that routine use of wide-field cold snare resection with submucosal injection (CSP-SI) might reduce incomplete resection rates (IRRs). Patients and methods Patients aged 45 to 80 years undergoing elective colonoscopies were enrolled in a prospective clinical study. All 4- to 20-mm non-pedunculated polyps were resected using CSP-SI. Post-polypectomy margin biopsies were obtained to determine IRRs through histopathology assessment. The primary outcome was IRR, defined as remnant polyp tissue found on margin biopsies. Secondary outcomes included technical success and complication rates. Results A total of 429 patients (median age 65 years, 47.1 % female, adenoma detection rate 40 %) with 204 non-pedunculated colorectal polyps 4 to 20 mm removed using CSP-SI were included in the final analysis. CSP-SI was technical successful in 97.5 % (199/204) of cases (5 conversion to hot snare polypectomy). IRR for CSP-SI was 3.8 % (7/183) (95 % confidence interval [CI] 2.7 %-5.5 %). IRR was 1.6 % (2/129), 16 % (4/25), and 3.4 % (1/29) for adenomas, serrated lesions, and hyperplastic polyps respectively. IRR was 2.3 % (2/87), 6.3 % (4/64), 4.0 % (6/151), and 3.1 % (1/32) for polyps 4 to 5 mm, 6 to 9 mm, < 10 mm, and 10 to 20 mm, respectively. There were no CSP-SI-related serious adverse events. Conclusions Use of CSP-SI results in lower IRRs compared to what has previously been reported in the literature for hot or cold snare polypectomy when not using wide-field cold snare resection with submucosal injection. CSP-SI showed an excellent safety and efficacy profile, however comparative studies to CSP without SI are required to confirm these results.

Editorial: Optimizing the success of cold snare polypectomy in colonoscopy practice

Editorial: Optimizing the success of cold snare polypectomy in colonoscopy practice

Colorectal cancer and advanced adenoma incidence during post-polypectomy surveillance: a national cohort study in the English Bowel Cancer Screening Programme.

Improved colonoscopy quality has led to debate about whether all post-polypectomy surveillance is justified. We evaluated surveillance within the English Bowel Cancer Screening Programme (BCSP) to determine the yield of surveillance and identify predictive factors for surveillance outcome. We performed a retrospective cohort study of individuals undergoing post-polypectomy surveillance between July 2006 and January 2017. BCSP records were linked to the National Cancer Registration Database to identify interval-type post-colonoscopy colorectal cancers (CRCs). Advanced adenoma and CRC at surveillance were documented. CRC incidence was compared with the general population using standardized incidence ratios (SIRs). Predictors of advanced adenomas at first surveillance (S1), and CRC during follow-up, were identified. 44 151 individuals (23 078 intermediate risk; 21 073 high risk) underwent 64 544 surveillance episodes. Advanced adenoma and CRC yields were, respectively, 10.0 % and 0.5 % at S1, 8.5 % and 0.4 % at S2, and 10.8 % and 0.4 % at S3. S1 yield was lowest in those with one index adenoma ≥ 10 mm (advanced adenoma 6.1 %; CRC 0.3 %). The SIR was 0.76 (95 %CI 0.66-0.88), accounted for by the intermediate risk group (intermediate risk SIR 0.61, 95 %CI 0.49-0.75; high risk SIR 0.95, 95 %CI 0.79-1.15). Adenoma multiplicity, presence of a large nonpedunculated adenoma, and greater villous component were associated with advanced adenoma at S1. Older age and multiplicity were significantly associated with CRC risk. This large, national analysis found low levels of CRC in those undergoing surveillance and low advanced adenoma yield in most subgroups. Less intensive surveillance in some subgroups is warranted, and surveillance may be avoided in those with a single large adenoma.

Impact of a scalable training program on the quality of colonoscopy performance and risk of postcolonoscopy colorectal cancer

Endoscopist adenoma detection rates (ADRs) vary widely and are associated with patients' risk of postcolonoscopy colorectal cancers (PCCRCs). However, few scalable physician-directed interventions demonstrably both improve ADR and reduce PCCRC risk. Among patients undergoing colonoscopy, we evaluated the influence of a scalable online training on individual-level ADRs and PCCRC risk. The intervention was a 30-minute, interactive, online training, developed using behavior change theory, to address factors that potentially impede detection of adenomas. Analyses included interrupted time series analyses for pretraining versus posttraining individual-physician ADR changes (adjusted for temporal trends) and Cox regression for associations between ADR changes and patients' PCCRC risk. Across 21 endoscopy centers and all 86 eligible endoscopists, ADRs increased immediately by an absolute 3.13% (95% confidence interval [CI], 1.31-4.94) in the 3-month quarter after training compared with .58% per quarter (95% CI, .40-.77) and 0.33% per quarter (95% CI, .16-.49) in the 3-year pretraining and posttraining periods, respectively. Posttraining ADR increases were higher among endoscopists with pretraining ADRs below the median. Among 146,786 posttraining colonoscopies (all indications), each 1% absolute increase in screening ADR posttraining was associated with a 4% decrease in their patients' PCCRC risk (hazard ratio, .96; 95% CI, .93-.99). An ADR increase of≥10% versus<1% was associated with a 55% reduced risk of PCCRC (hazard ratio, .45; 95% CI, .24-.82). A scalable, online behavior change training intervention focused on modifiable factors was associated with significant and sustained improvements in ADR, particularly among endoscopists with lower ADRs. These ADR changes were associated with substantial reductions in their patients' risk of PCCRC.

Root-cause Analysis of 762 Danish Post-colonoscopy Colorectal Cancer Patients

The term post-colonoscopy colorectal cancer (PCCRC) refers to colorectal cancer (CRC) diagnosed after a negative colonoscopy. Using the root-cause algorithm proposed by the World Endoscopy Organization, we aimed to investigate plausible explanations for PCCRCs and potential changes in plausible explanations for PCCRCs over time in a Danish Region. During 1995 to 2021, we used national health registries and electronic medical records in the Central Denmark Region to identify PCCRC cases, defined as CRCs recorded within 6 to 48 months after a colonoscopy. We then applied the World Endoscopy Organization algorithm to categorize explanations for PCCRC as follows: (A) possible missed lesion, prior examination adequate; (B) possible missed lesion, prior examination inadequate; (C) detected lesion, not resected; or (D) likely incomplete resection of previously identified lesion. PCCRCs were identified before (1995-2013) and after (2014-2021) implementation of nationwide fecal immunochemical test-based CRC screening and quality indicators for colonoscopy. We identified 762 PCCRCs, 53.5% among males and 57% among individuals ≥70 years. Forty-five percent were located in the proximal colon. We identified 616 (80.8%; 95% confidence interval [CI], 74.6%-87.5%) category A PCCRCs; 36 (4.7%; 95% CI, 3.3%-6.5%) category B PCCRCs; 26 (3.4%; 95% CI, 2.2%-4.9%) category C PCCRCs; and 84 (11%; 95% CI, 8.8%-13.6%) category D PCCRCs. Similar patterns were observed during the early (1995-2013) and late (2014-2021) study periods. Most PCCRCs originate from possible missed lesions and incompletely resected lesions during the complete study period. These findings indicate the importance of quality assurance of colonoscopy procedures and polypectomy techniques.

Artificial Intelligence Applied to Colonoscopy: Is It Time to Take a Step Forward?

Growing evidence indicates that artificial intelligence (AI) applied to medicine is here to stay. In gastroenterology, AI computer vision applications have been stated as a research priority. The two main AI system categories are computer-aided polyp detection (CADe) and computer-assisted diagnosis (CADx). However, other fields of expansion are those related to colonoscopy quality, such as methods to objectively assess colon cleansing during the colonoscopy, as well as devices to automatically predict and improve bowel cleansing before the examination, predict deep submucosal invasion, obtain a reliable measurement of colorectal polyps and accurately locate colorectal lesions in the colon. Although growing evidence indicates that AI systems could improve some of these quality metrics, there are concerns regarding cost-effectiveness, and large and multicentric randomized studies with strong outcomes, such as post-colonoscopy colorectal cancer incidence and mortality, are lacking. The integration of all these tasks into one quality-improvement device could facilitate the incorporation of AI systems in clinical practice. In this manuscript, the current status of the role of AI in colonoscopy is reviewed, as well as its current applications, drawbacks and areas for improvement.

Mortality After Postcolonoscopy Colorectal Cancer in the Veterans Affairs Health Care System

Postcolonoscopy colorectal cancer (PCCRC) refers to colorectal cancer (CRC) diagnosed after a colonoscopy in which no cancer was found and is reflective of colonoscopy quality at the individual and system levels. Colonoscopy is widely performed in the Veterans Affairs (VA) health care system, but the prevalence of PCCRC and its associated mortality are unknown. To examine PCCRC prevalence and its all-cause mortality (ACM) and CRC-specific mortality (CSM) within the VA health care system. This retrospective cohort study used VA-Medicare administrative data to identify 29 877 veterans aged 50 to 85 years with newly diagnosed CRC between January 1, 2003, and December 31, 2013. Patients whose colonoscopy occurred less than 6 months before CRC diagnosis with no other colonoscopy within the previous 36 months were categorized as having detected CRC (DCRC). Those who had a colonoscopy that did not detect CRC between 6 and 36 months before CRC diagnosis were categorized as having postcolonoscopy CRC (PCCRC-3y). A third group included patients with CRC and no colonoscopy within the prior 36 months. The final analysis of the data was performed in September 2022. Prior receipt of colonoscopy. Cox proportional hazards regression (with censoring, last follow-up December 31, 2018) analyses were conducted to compare PCCRC-3y and DCRC for 5-year ACM and CSM after CRC diagnosis. Of 29 877 patients with CRC (median [IQR] age, 67 [60-75] years; 29 353 [98%] male; 5284 [18%] Black, 23 971 [80%] White, and 622 [2%] other), 1785 (6%) were classified as having PCCRC-3y and 21 811 (73%) as having DCRC. The 5-year ACM rates were 46% vs 42% for patients with PCCRC-3y vs patients with DCRC. The 5-year CSM rates were 26% vs 25% for patients with PCCRC-3y vs patients with DCRC. In multivariable Cox proportional hazards regression analysis, there was no significant difference in ACM and CSM between patients with PCCRC-3y (adjusted hazard ratio [aHR], 1.04; 95% CI, 0.98-1.11; P = .18) and patients with DCRC (aHR, 1.04; 95% CI, 0.95-1.13; P = .42). However, compared with patients with DCRC, patients with no prior colonoscopy had significantly higher ACM (aHR, 1.76; 95% CI, 1.70-1.82; P < .001) and CSM (aHR, 2.22; 95% CI, 2.12-2.32; P < .001). Compared with patients with DCRC, patients with PCCRC-3y had significantly lower odds of having undergone colonoscopy performed by a gastroenterologist (odds ratio, 0.48; 95% CI, 0.43-0.53; P < .001). This study found that PCCRC-3y constituted 6% of CRCs in the VA system, which is similar to other settings. Compared with patients with CRC detected by colonoscopy, those with PCCRC-3y have comparable ACM and CSM.

Postcolonoscopy Colorectal Cancer as a Quality Metric—Identifying Opportunities to Improve Outcomes

Charles J. Kahi, MD, MSc; Laura J. Myers, PhD; Patrick O. Monahan, PhD; Barry C. Barker, MA; Timothy E. Stump, MA; Thomas F. Imperiale, MD

A study to assess the Nurses knowledge &amp; compliance to the protocol of adequate bowel preparation for colonoscopy

Introduction: Cleansing the colon before a colonoscopy is called bowel preparation, or “prep.” It involves taking medication that causes frequent, loose bowel movements to empty the colon. The medication is taken by mouth and typically comes in liquid form. Bowel cleansing is one of the most important parameters included in the evaluation of colonoscopy quality. The available evidence suggests that inadequate bowel preparation reduces the diagnostic yield of colorectal neoplasia and increases post-colonoscopy colorectal cancer risk. Nowadays, up to 30% of patients referred for colonoscopy have poor bowel cleansing. Recently, several studies have analyzed the risk factors for inadequate bowel cleansing as well as the strategies to optimize bowel preparation. Poor bowel preparation has been shown to be associated with low lower-quality dilators of colonoscopy performance. Patients with Personal History of Inadequate Bowel Preparation, Diabetes Mellitus, Chronic Constipation, and a History of Colorectal Resection are at risk of inadequate bowel preparation for colonoscopy. Methodology: In November 2022, there was an increase in consultant complaints about inadequate Bowel preparation for the patient in the ward &amp; ICU which impacted on proper diagnosis of the actual reason the patient took admitted at Apollo Hospitals, Bhubaneswar. So on basis of the complaints, a quasi-experimental group pre-test was conducted &amp; found the less compliance. To look forward to checking the compliances, training &amp; educational materials were prepared on basis of protocol of adequate bowel preparation for colonoscopy (education materials contained agents, methods (single/split) of preparation, dietary patterns, stool consistency assessment) &amp; started implement from December 2022 onwards in both one to one &amp; group teaching. And by end of February 2023, a post-test was conducted to assess the improvement of knowledge of Nurses. To collect the data of their practices on adequate bowel preparation a structured PIP (performance Improvement Project) tool was used &amp; total sample took 100 assigned Register Nurses who all were assigned the In-patients for Colonoscopy. Results: With constant reinforcement, educational materials on adequate Bowel preparation of Colonoscopy &amp; knowledge assessment of assigned nurses made an impact on the effective intervention in adequate Bowel preparation. The impact of compliance to assess the knowledge &amp; interventions of nurses in adherence to the protocol of Adequate Bowel preparation for colonoscopy. The knowledge of Nurses found less compliance in the Pre-Test which was conducted after consultant’s complaints in the month of November 2022 with 55.83% &amp; then after training &amp; educational materials were prepared on basis of protocol of adequate bowel preparation for colonoscopy {education materials contained agents, methods (single/split) of preparation, dietary patterns, stool consistency assessment)} &amp; started implement from December 2022 onwards in both one to one &amp; group teaching. And by end of February 2023, a post-test was conducted to assess the improvement of knowledge of Nurses &amp; found compliance percentage of 78.33%. And Compliance with adherence to the proper method of Bowel Preparation Protocol found compliances month on month, in December 2022 it was 30.29%, in January 2023 it improves to 55.26% &amp; reaches with compliances of 78.94% by the end of February 2023. Conclusion: In patients under the care of nurses who underwent enhanced education on bowel preparation had significantly better bowel preparation quality and higher compliance rates than those in inpatients of the control group. Nurses’ education was identified as an independent risk factor for bowel preparation quality. To make bowel preparation adequate &amp; sufficient frequent updating on knowledge of the recruited nurses need to be done on regular basis.