Conventional regimen versus split-dose regimen in bowel preparation: Results of a randomized controlled trial

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Published May 1, 2025
https://doi.org/10.62438/tunismed.v103i5.5514
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Vol. 103 No. 5 (2025): Tunis Med May 2025

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Soumaya Nsibi
Department of Hepato-Gastroenterology, Mongi Slim Hospital, Faculty of Medicine of Tunis, University of Tunis El Manar, Tunis, Tunisia.
Abdelwahab Nakhli
Department of Hepato-Gastroenterology, Mongi Slim Hospital, Faculty of Medicine of Tunis, University of Tunis El Manar, Tunis, Tunisia.
Cyrine Ben Mehrez
Department of Hepato-Gastroenterology, Mongi Slim Hospital, Faculty of Medicine of Tunis, University of Tunis El Manar, Tunis, Tunisia.
Nesrine Hemdani
Department of Hepato-Gastroenterology, Mongi Slim Hospital, Faculty of Medicine of Tunis, University of Tunis El Manar, Tunis, Tunisia.
Zeineb Benzarti
Department of Hepato-Gastroenterology, Mongi Slim Hospital, Faculty of Medicine of Tunis, University of Tunis El Manar, Tunis, Tunisia.
Bochra Bouchabou
Department of Hepato-Gastroenterology, Mongi Slim Hospital, Faculty of Medicine of Tunis, University of Tunis El Manar, Tunis, Tunisia.
Rym Ennaifer
Department of Hepato-Gastroenterology, Mongi Slim Hospital, Faculty of Medicine of Tunis, University of Tunis El Manar, Tunis, Tunisia.

Abstract

Introduction-Aim: Good bowel preparation is essential for colonoscopies. This study aimed to compare the quality of bowel preparation between the split-dose regimen (SD), recommended by European endoscopy societies, and the conventional regimen (CR) in Tunisia, where SD is not routinely adopted, and to identify factors leading to poor preparation in both groups.


Methods: We performed a randomized controlled trial, spread over four months (January-April 2019). Patients were randomly assigned to two groups at a 1:1 ratio: SD or CR.


Results: One hundred and thirty-three patients were included: 65 in the SD group and 68 in the CR group. SD showed better bowel cleansing than CR by comparing the mean Boston score in the two groups (6.05 versus 4.75,  p =<0.001). Tolerance of the preparations was comparable between the groups. Factors associated with poor preparation in the SD group were constipation (p=0.04) colonoscopy indication (screening) (p=0, 01) and public transport (p=0.001). In multivariate analysis, constipation and public transport were independent factors in poor preparation with a relative risk of 4.9 and 26 respectively. For the CR group, age <65 years (p=0.022), low level of education (p=0.03) and unemployment (p=0.015) were predictive factors for poor preparation. In multivariate analysis the low level of education was an independent risk factor for poor preparation with a relative risk of 20.


Conclusion: Our study showed that SD provides better bowel preparation than CR without altering the tolerance. In addition, factors predictive of poor preparation in the SD group were modifiable, unlike those of CR.

Keywords:

Colonoscopy, Bowel preparation solutions, Polyethylene glycol

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References

  1. Edwards BK, Ward E, Kohler BA, Eheman C, Zauber AG, Anderson RN, et al. Annual report to the nation on the status of cancer, 1975-2006, featuring colorectal cancer trends and impact of interventions (risk factors, screening, and treatment) to reduce future rates. Cancer. 2010;116(3):544‑73.
  2. Baxter NN, Goldwasser MA, Paszat LF, Saskin R, Urbach DR, Rabeneck L. Association of colonoscopy and death from colorectal cancer. Ann Intern Med. 2009;150(1):1‑8.
  3. Mahmood S, Farooqui SM, Madhoun MF. Predictors of inadequate bowel preparation for colonoscopy: a systematic review and meta-analysis. Eur J Gastroenterol Hepatol. 2018;30(8):819‑26.
  4. Johnson DA, Barkun AN, Cohen LB, Dominitz JA, Kaltenbach T, Martel M, et al. Optimizing adequacy of bowel cleansing for colonoscopy: recommendations from the US multi-society task force on colorectal cancer. Gastroenterology. 2014;147(4):903‑24.
  5. Imperiale TF, Glowinski EA, Lin-Cooper C, Larkin GN, Rogge JD, Ransohoff DF. Five-year risk of colorectal neoplasia after negative screening colonoscopy. N Engl J Med. 2008;359(12):1218‑24.
  6. Romero RV, Mahadeva S. Factors influencing quality of bowel preparation for colonoscopy. World J Gastrointest Endosc. 2013;5(2):39‑46.
  7. Gandhi K, Daskalakis C, Tofani C, Kastenberg DM. Sa1052 patient predictors for inadequate bowel preparation in colonoscopy: a meta-analysis. Gastrointest Endosc. 2016;83(5):AB218.
  8. Radaelli F, Paggi S, Repici A, Gullotti G, Cesaro P, Rotondano G, et al. Barriers against split-dose bowel preparation for colonoscopy. Gut. 2017;66(8):1428‑33.
  9. Bucci C, Rotondano G, Hassan C, Rea M, Bianco MA, Cipolletta L, et al. Optimal bowel cleansing for colonoscopy: split the dose a series of meta-analyses of controlled studies. Gastrointest Endosc. 2014;80(4):566-76.
  10. Jover R, Zapater P, Polanía E, Bujanda L, Lanas A, Hermo JA, et al. Modifiable endoscopic factors that influence the adenoma detection rate in colorectal cancer screening colonoscopies. Gastrointest Endosc. 2013;77(3):381-9.
  11. Hassan C, East J, Radaelli F, Spada C, Benamouzig R, Bisschops R, et al. Bowel preparation for colonoscopy: European Society of Gastrointestinal Endoscopy (ESGE) Guideline – Update 2019. Endoscopy. 2019;51(8):775-94.
  12. Practice Guidelines for Preoperative Fasting and the Use of Pharmacologic Agents to Reduce the Risk of Pulmonary Aspiration: Application to Healthy Patients Undergoing Elective ProceduresAn Updated Report by the American Society of Anesthesiologists Task Force on Preoperative Fasting and the Use of Pharmacologic Agents to Reduce the Risk of Pulmonary Aspiration. Anesthesiol J Am SocAnesthesiol. 2017;126(3):376‑93.
  13. notice_echelle_visuelle_analogique.pdf[Internet].
  14. Kluge MA, Williams JL, Wu CK, Jacobson BC, Schroy PC, Lieberman DA, et al. Inadequate Boston bowel preparation scale scores predict the risk of missed neoplasia on next colonoscopy. Gastrointest Endosc. 2018;87(3):744‑51.
  15. Lai EJ, Calderwood AH, Doros G, Fix OK, Jacobson BC. The Boston bowel preparation scale: a valid and reliable instrument for colonoscopy-oriented research. Gastrointest Endosc. 2009;69(3):620‑5.
  16. Calderwood AH, Schroy PC, Lieberman DA, Logan JR, Zurfluh M, Jacobson BC. Boston bowel preparation scale scores provide a standardized definition of adequate for describing bowel cleanliness. Gastrointest Endosc. 2014;80(2):269‑76.
  17. Calderwood AH, Thompson K, Schroy PC, Lieberman DA, Jacobson BC. Good is better than excellent: bowel preparation quality and adenoma detection rates. Gastrointest Endosc. 2015;81(3):691-9.
  18. Heresbach D, Boustière C, Coffin B, Choukroun G, Hagège H, Burtin P, et al. Consensus en endoscopie digestive: préparation colique pour la coloscopie totale en 2011. Acta Endosc. 2011;41:145‑52.
  19. Martel M, Barkun AN, Menard C, Restellini S, Kherad O, Vanasse A. Split-dose preparations are superior to day-before bowel cleansing regimens: a meta-analysis. Gastroenterology. 2015;149(1):79‑88.
  20. Abdul-Baki H, Hashash JG, ElHajj II, Azar C, Zahabi LE, Mourad FH, et al. A randomized, controlled, double-blind trial of the adjunct use of tegaserod in whole-dose or split-dose polyethylene glycol electrolyte solution for colonoscopy preparation. Gastrointest Endosc. 2008;68(2):294‑300.
  21. Aoun E, Abdul-Baki H, Azar C, Mourad F, Barada K, Berro Z, et al. A randomized single-blind trial of split-dose PEG-electrolyte solution without dietary restriction compared with whole dose PEG-electrolyte solution with dietary restriction for colonoscopy preparation. Gastrointest Endosc. 2005;62(2):213‑8.
  22. El Sayed AMA, Kanafani ZA, Mourad FH, Soweid AM, Barada KA, Adorian CS, et al. A randomized single-blind trial of whole versus split-dose polyethylene glycol-electrolyte solution for colonoscopy preparation. Gastrointest Endosc. 2003;58(1):36‑40.
  23. Manno M, Pigò F, Manta R, Barbera C, Bertani H, Mirante VG, et al. Bowel preparation with polyethylene glycol electrolyte solution: optimizing the splitting regimen. Dig Liver Dis. 2012;44(7):576‑9.
  24. Marmo R, Rotondano G, Riccio G, Marone A, Bianco MA, Stroppa I, et al. Effective bowel cleansing before colonoscopy: a randomized study of split-dosage versus non-split dosage regimens of high-volume versus low-volume polyethylene glycol solutions. Gastrointest Endosc. 2010;72(2):313‑20.
  25. Samarasena JB, Muthusamy RV, Jamal MM. Split-dosed miralax gatorade is an effective, safe, and tolerable option for bowel preparation in low-risk patients: a randomized controlled study. Am J Gastroenterol. 2012;107(7):1036-42.
  26. Park JS, Sohn CI, Hwang SJ, Choi HS, Park JH, Kim HJ, et al. Quality and effect of single dose versus split dose of polyethylene glycol bowel preparation for early-morning colonoscopy. Endoscopy. 2007;39(7):616‑9.
  27. Mohamed R, Hilsden RJ, Dube C, Rostom A. Split-Dose Polyethylene Glycol Is Superior to Single Dose for Colonoscopy Preparation: Results of a Randomized Controlled Trial. Can J Gastroenterol Hepatol. 2016;2016:3181459.
  28. Hassan C, East J, Radaelli F, Spada C, Benamouzig R, Bisschops R, et al. Bowel preparation for colonoscopy: European Society of Gastrointestinal Endoscopy (ESGE) Guideline – Update 2019. Endoscopy. 2019;51(8):775-94.
  29. ung YS, Lee CK, Eun CS, Park DI, Han DS, Kim HJ. Low-volume polyethylene glycol with ascorbic acid for colonoscopy preparation in elderly patients: a randomized multicenter study. Digestion. 2016;94(2):82‑91.
  30. Horton N, Garber A, Hasson H, Lopez R, Burke CA. Impact of single- vs. split-dose low-volume bowel preparations on bowel movement kinetics, patient inconvenience, and polyp detection: a prospective trial. Am J Gastroenterol. 2016;111(9):133.