Oral purgative and simethicone before small bowel capsule endoscopy

AIM:To evaluate small bowel cleansing quality,diagnostic yield and transit time,comparing three cleansing protocols prior to capsule endoscopy.METHODS:Sixty patients were prospectively enrolled and randomized to one of the following cleansing protocols:patients in Group A underwent a 24 h liquid diet and overnight fasting;patients in Group B followed protocol A and subsequently were administered 2 L of polyethylene glycol(PEG) the evening before the procedure;patients in Group C followed protocol B and were additionally administered 100 mg of simethicone 30 min prior to capsule ingestion.Small bowel cleansing was independently assessed by two experienced endoscopists and classified as poor,fair,good or excellent according to the proportion of small bowel mucosa under perfect conditions for visualization.When there was no agreement between the two endoscopists,the images were reviewed and discussed until a consensus was reached.The preparation was considered acceptable if > 50% or adequate if > 75% of the mucosa was in perfect cleansing condition.The amount of bubbles was assessed independently and it was considered significant if it prevented a correct interpretation of the images.Positive endoscopic findings,gastric emptying time(GET) and small bowel transit time(SBTT) were recorded for each examination.RESULTS:There was a trend favoring Group B in achieving an acceptable(including fair,good or excellent) level of cleansing(Group A:65%;Group B:83.3%;Group C:68.4%) [P = not significant(NS)] and favoring Group C in attaining an excellent level of cleansing(Group A:10%;Group B:16.7%;Group C:21.1%)(P = NS).The number of patients with an adequate cleansing of the small bowel,corresponding to an excellent or good classification,was 5(25%) in Group A,5(27.8%) in Group B and 4(21.1%) in Group C(P = 0.892).Conversely,7 patients(35%) in Group A,3 patients(16.7%) in Group B and 6 patients(31.6%) in Group C were considered to have poor small bowel cleansing(P = 0.417),with significant fluid or debris such that the examination was unreliable.The proportion of patients with a significant amount of bubbles was 50% in Group A,27.8% in Group B and 15.8% in Group C(P = 0.065).This was significantly lower in Group C when compared to Group A(P = 0.026).The mean GET was 27.8 min for Group A,27.2 min for Group B and 40.7 min for Group C(P = 0.381).The mean SBTT was 256.4 min for Group A,256.1 min for Group B and 258.1 min for Group C(P = 0.998).Regarding to the rate of complete examinations,the capsule reached the cecum in 20 patients(100%) in Group A,16 patients(88.9%) in Group B and 17 patients(89.5%) in Group C(P = 0.312).A definite diagnosis based on relevant small bowel endoscopic lesions was established in 60% of the patients in Group A(12 patients),44.4% in Group B(8 patients) and 57.8% in Group C(11 patients)(P = 0.587).CONCLUSION:Preparation with 2 L of PEG before small bowel capsule endoscopy(SBCE) may improve small bowel cleansing and the quality of visualization.Simethicone may further reduce intraluminal bubbles.No significant differences were found regarding GET,SBTT and the proportion of complete exploration or diagnostic yield among the three different cleansing protocols.

Bisacodyl plus split 2-L polyethylene glycol-citrate-simethicone improves quality of bowel preparation before screening colonoscopy

AIM:To compare the bowel cleansing efficacy,tolerability and acceptability of split 2-L polyethylene glycol(PEG)-citrate-simethicone(PEG-CS)plus bisacodyl(BIS)vs 4-L PEG for fecal occult blood test-positive screening colonoscopy.METHODS:This was a randomised,observer-blind comparative study.Two hundred and sixty-four subjects underwent screening colonoscopy(mean age 62.5±7.4years,male 61.7%).The primary objective of the study was to compare the bowel cleansing efficacy of the two preparations.Interventions:BIS plus PEG-CS:3 tablets of 5-mg BIS at 16:00,PEG-CS 1-L at 19:00 and 1-L at7:00,4-L PEG:3-L at 17:00,and 1-L at 7:00.Colonoscopy was carried out after 11:00,at least 3 h after the completion of bowel preparation.Bowel cleansing was evaluated using the Harefield Cleansing Scale.RESULTS:Bowel preparation was successful for 92.8%of subjects in the PEG-CS group and for 92.1%of subjects in the 4-L PEG(RR=1.01;95%CI:0.94-1.08).BIS+PEG-CS was better tolerated than 4-L PEG.A greater rate of patients in the BIS+PEG-CS group had no difficulty and/or were willing to repeat the same preparation compared to split-dose 4-L PEG group.Subjects in the BIS+PEG-CS group rated the prep as good or satisfactory in 90.6%as compared to 77%in the 4-L PEG(P=0.003).Subjects receiving BIS+PEGCS stated they fully adhered to instructions drinking all the 2-L solution in 97.1%compared with 87.3%in the4-L PEG(P=0.003).CONCLUSION:BIS plus split 2-L PEG-CS was as effective as but better tolerated and accepted than split4-L PEG for screening colonoscopy.This new procedure may increase the positive attitude and participation to colorectal cancer screening colonoscopy.

Same-day 2-L PEG-citrate-simethicone plus bisacodyl vs split 4-L PEG: Bowel cleansing for late-morning colonoscopy

AIM: To evaluate the efficacy, tolerability, acceptability and feasibility of bisacodyl plus low volume polyethyleneglycol-citrate-simeticone(2-L PEG-CS) taken the same day as compared with conventional split-dose 4-L PEG for late morning colonoscopy. METHODS: Randomised, observer-blind, parallel group, comparative trial carried out in 2 centres. Out patients of both sexes, aged between 18 and 85 years, undergoing colonoscopy for diagnostic investigation, colorectal cancer screening or follow-up were eligible. The PEG-CS group received 3 bisacodyl tablets(4 tablets for patients with constipation) at bedtime and 2-L PEG-CS in the morning starting 5 h before colonoscopy. The control group received a conventional 4-L PEG formulation given as split regimen; the morning dose was taken with the same schedule of the low volume preparation. The Ottawa Bowel Preparation Scale(OBPS) score was used as the main outcome measure.RESULTS: A total of 164 subjects were enrolled and 154 completed the study; 78 in the PEG-CS group and 76 in the split 4-L PEG group. The two groups were comparable at baseline. The OBPS score in the PEG-CS group(3.09 ± 2.40) and in the PEG group(2.39 ± 2.55) were equivalent(difference +0.70; 95%CI:-0.09-1.48). This was confirmed by the rate of successful bowel cleansing in the PEG-CS group(89.7%) and in the PEG group(92.1%)(difference-2.4%; 95%CI:-11.406.70). PEG-CS was superior in terms of mucosa visibility compared to PEG(85.7% vs 72.4%, P = 0.042). There were no significant differences in caecum intubation rate, time to reach the caecum and withdrawal time between the two groups. The adenoma detection rate was similar(PEG-CS 43.6% vs PEG 44.7%). No serious adverse events occurred. No difference was found in tolerability of the bowel preparations. Compliance was equal in both groups: more than 90% of subjects drunk the whole solution. Willingness to repeat the same bowel preparations was about 90% for both regimes. CONCLUSION: Same-day PEG-CS is feasible, effective as split-dose 4-L PEG for late morning colonoscopy and does not interfere with work and daily activities the day before colonoscopy.

Efficacy of small-volume simethicone given at least 30 min before gastroscopy

AIM To evaluate the efficacy of 5 m L simethicone solution in decreasing gastric foam if given at least 30 min before gastroscopy.METHODS This was a randomized, placebo controlled, endoscopist blinded study performed at Changi General Hospital. Patients were at least 21 years old, had no prior sur-gical resection of the upper gastrointestinal tract, and scheduled for elective diagnostic gastroscopies. The primary outcome was the total mucosal visibility score(TMVS) which was evaluated using Mc Nally score. The sample size was calculated to be 24 per group(SD 2.4, 80% power, P < 0.05, 2-sample t test). RESULTS Fifty-four patients were randomised to receive either simethicone [1 m L liquid simethicone(100 mg) in 5 m L of water] or placebo(5 m L of water) at least 30 min before their gastroscopy. Six accredited consultants conductedthe gastroscopy, and the interobserver agreement of scoring TMVS was good with a Kappa statistic of 0.73. The simethicone group had significantly better mean TMVS compared to placebo(5.78 ± SD 1.65 vs 8.89 ± SD 1.97, P < 0.001). The improvement was statistically significant for the duodenum and the gastric antrum, angularis, body, and fundus. Percent 51.9 of patients in the simethicone group had a TMVS of 4(no bubbles at all) to 5(only 1 area with minimal bubbles), while in the placebo group 3.7% of patients had TMVS of 4 or 5. The number needed to treat was 2.1 to avoid a TMVS of 6 and more. The simethicone group also had a significantly shorter procedure time with less volume of additional flushes required during gastroscopy to clear away obscuring gastric foam.CONCLUSION With a premedication time of at least 30 min, 5 m L simethicone can significantly decrease gastric foam, decrease the volume of additional flushes, and shorten gastroscopy time.

Impact of simethicone on bowel cleansing during colonoscopy in Chinese patients

BACKGROUND Four-liter polyethylene glycol(PEG)solutions are effective for bowel cleansing,but their large volume might hinder patient compliance.Due to the unique features of Asians,4 L PEG might be a suboptimal bowel preparation in predominantly ethnically Asian countries.In view of this,a balance should be achieved between the volume and effectiveness.The ideal bowel cleansing regimen for a colonoscopy has yet to be determined in a Chinese population.AIM To compare the cleansing efficacy of 3 L PEG plus simethicone with 4 L PEG.METHODS A total of 291 patients were randomly allocated to two groups:Group 1(n=145)received 4 L split-dose PEG(4-P);group 2(n=146)received 3 L split-dose PEG plus simethicone(3-PS).Bowel-cleansing efficacy was evaluated by endoscopists using the Boston bowel preparation scale(BBPS)and the bubbles score.RESULTS Although there were no significant differences in the total BBPS score or the adequate rate of bowel preparation between the two groups,the BBPS score of the right-side colon was significantly higher in the 3-SP group(2.37±0.54 vs 2.21±0.78;P=0.04).Moreover,the use of simethicone significantly reduced bubbles in all colon segments(P<0.001).The mean withdrawal time was significantly shorter in the 3-PS group(8.8±3.4 vs 9.6±2.3;P=0.02).Furthermore,significantly more proximal adenomas were detected in the 3-PS group(53.6%vs 45.7%;P=0.03).In addition,the proportions of patients with nausea and bloating were significantly lower in the 3-SP group(P<0.01 for both).More patients in the 3-PS group expressed willingness to repeat the bowel preparation(87.7%vs 76.6%,P=0.01).CONCLUSION Three-liter PEG shows satisfactory bowel cleansing despite the decrease in dosage,and addition of simethicone with better bubble elimination and enhanced patient acceptance offers excellent potential impact on the detection of proximal adenomas in Chinese patients.

Randomized, double-blinded, placebo-controlled trial evaluating simethicone pretreatment with bowel preparation during colonoscopy

BACKGROUND The presence of small air bubbles and foam are an impediment to a successful colonoscopy. They impair an endoscopist’s view and diminish the diagnostic accuracy of the study. This has been particularly noted to be of concern with the switch to lower volume polyethylene glycol (PEG) and bisacodyl combination preparation. AIM To evaluate the effect of oral simethicone addition to bowel preparation on intraluminal bubbles reduction during colonoscopy. METHODS Described is a prospective, randomized, multi-center, double-blinded, placebocontrolled study to evaluate the use of premixed simethicone formulation with split-regimen, low-volume PEG-bisacodyl combination bowel preparation for 168 outpatients undergoing screening, surveillance, and diagnostic colonoscopies. Primary outcome includes evaluation of bubbles during colonoscopy graded using the Intraluminal Bubbles Scale. Secondary outcomes include evaluation of the Boston Bowel Preparation Scale (BBPS), total number of polyps, polyp size differentiation, polyp laterality, adenoma detection, mass detection, cecal insertion time, withdrawal time, and patient-reported adverse events. RESULTS Higher Intraluminal Bubbles grades III and IV (less than 75% of the mucosa cleared of bubbles/foam requiring intervention with simethicone infused wash) were detected in the placebo group [Simethicone n = 4/84 vs Placebo n = 20/84 (P = 0.007)]. BBPS total score was 7.42 [standard deviation (SD)=± 1.51] in the simethicone group and 7.28 (SD =± 1.44) in the placebo group (P = 0.542) from a total of 9. Significantly higher number of adenomas were detected in the simethicone group (P = 0.001). CONCLUSION The addition of simethicone to bowel preparation is well advised for its antifoaming properties. The results of this study suggest that addition of oral simethicone can improve bowel wall visibility.

Higher dose of simethicone decreases colonic bubbles and increases prep tolerance and quality of bowel prep:Meta-analysis of randomized controlled trials

BACKGROUND Antifoaming agents,such as simethicone,may facilitate mucosal inspection during colonoscopy.However,conflicting results have been reported with regard to the impact of simethicone on quality of bowel preparation and adenoma detection rate(ADR).AIM To perform a meta-analysis of trials that have compared simethicone vs placebo during colonoscopy.METHODS A reproducible literature search of multiple medical databases yielded eleven studies(n = 2605) for inclusion.Studies were compared for quality of bowel preparation,bubbles quality,ADR,and tolerability.Two reviewers independently scored the identified studies for methodology and abstracted pertinent data.Pooling was conducted by both fixed-effects and random-effects models.Relative risk(RR) estimates with a 95% confidence interval(CI) were calculated.Heterogeneity was assessed by I-squared index(I2) statistics.RESULTS Patients' demographic characteristics were comparable in all studies.Of the 2605 patients,1300 were in the simethicone group,whereas 1305 were in the placebo group.Inadequate bowel preparation was much lower in the simethicone group than in the placebo group [13% vs 24.6%; RR = 0.51(0.31-0.82); P < 0.0001].The placebo group was more likely to have significant colonic bubbles than was the simethicone group [35% vs 8%; RR = 1.49(1.25-1.76); P = 0.0001].Use of simethicone resulted in a slight,statistically significant increase in ADR compared with the placebo group [26.6% vs 21.6%,RR = 1.07(1.01-1.13); P = 0.02].Higher doses of simethicone(> 478 mg) were more likely to result in significant reduction of inadequate bowel preparation,colonic bubbles,and to improve ADR.CONCLUSION Adding simethicone improved the quality of bowel preparation,visualization,tolerability,and,eventually,ADR.

Effect of antifoaming agent on benign colorectal tumors in colonoscopy:A meta-analysis

BACKGROUND Although several trials have shown that the addition of antifoaming agents to polyethylene glycol(PEG)can improve bowel preparation,whether PEG plus antifoaming agents have a beneficial role in the detection of benign tumors during colonoscopy has yet to be confirmed.Our aim was to clarify whether adding simethicone to PEG solution could improve the detection of benign colorectal tumors.AIM To clarify whether adding simethicone to PEG solution could improve the detection of benign colorectal tumors.METHODS The PubMed,EMBASE,and Cochrane Library databases were searched for articles published prior to September 2019.The outcomes included the detection rates of colorectal adenomas and polyps.RESULT Twenty studies were eligible.Although there was no difference in the colorectal adenoma detection rate(ADR),a significant effect of simethicone for diminutive adenomas(<10 mm)was revealed in the group taking simethicone.We also found that simethicone could significantly improve the ADR in the proximal colon but did not affect the colorectal polyp detection rate.Furthermore,the subgroup analyses revealed a beneficial effect of simethicone on the ADR among Asians(P=0.005)and those with an ADR<25%(P=0.003).Moreover,it was a significant finding that the low dose simethicone was as effective as the high dose one with respect to the detection of benign colorectal tumors.CONCLUSION In summary,the addition of simethicone to PEG might improve the detection of diminutive adenomas in the right colon by colonoscopy in Asia.Low-dose simethicone was recommended for the detection of benign colorectal tumors.However,large clinical trials are necessary to validate our results and determine the ideal dose of simethicone.