Optimizing Bowel Preparation: An Interprofessional Nursing, Radiology, and Health Assistant Approach to Patient Safety and Diagnostic Accuracy
Abstract
Background: Colonoscopy is the gold standard for detecting colorectal pathology, but its diagnostic accuracy depends on adequate bowel preparation. Poor preparation compromises mucosal visualization, increases procedural risk, and leads to missed lesions and repeat procedures.
Aim: To review bowel preparation strategies, contraindications, and interprofessional roles in optimizing patient safety and diagnostic outcomes.
Methods: A comprehensive literature-based analysis was conducted, synthesizing evidence on preparation regimens, physiologic considerations, contraindications, and team-based interventions. The review emphasizes pharmacologic classifications, dosing strategies, and quality assessment tools such as the Boston Bowel Preparation Scale (BBPS).
Results: Isosmotic polyethylene glycol (PEG)-based regimens remain the safest and most effective, particularly in patients with comorbidities. Low-volume PEG with ascorbic acid improves tolerability but is contraindicated in G6PD deficiency. Hyposmotic PEG-3350 regimens may cause electrolyte disturbances, while hyperosmotic agents like magnesium citrate and sodium sulfate require caution in renal impairment. Sodium phosphate is largely avoided due to nephropathy risk. Split-dose administration consistently improves cleansing quality and adenoma detection rates. Interprofessional collaboration—physicians, nurses, and pharmacists—enhances adherence and safety, while patient education significantly improves outcomes.
Conclusion: Effective bowel preparation is a multidisciplinary process integrating regimen selection, patient-centered education, and objective quality assessment. Individualized planning and team-based interventions reduce incomplete colonoscopies, improve lesion detection, and enhance patient safety.
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References
Mitchell RM, McCallion K, Gardiner KR, Watson RG, Collins JS. Successful colonoscopy; completion rates and reasons for incompletion. The Ulster medical journal. 2002 May:71(1):34-7
Shah HA, Paszat LF, Saskin R, Stukel TA, Rabeneck L. Factors associated with incomplete colonoscopy: a population-based study. Gastroenterology. 2007 Jun:132(7):2297-303
ASGE Standards of Practice Committee, Saltzman JR, Cash BD, Pasha SF, Early DS, Muthusamy VR, Khashab MA, Chathadi KV, Fanelli RD, Chandrasekhara V, Lightdale JR, Fonkalsrud L, Shergill AK, Hwang JH, Decker GA, Jue TL, Sharaf R, Fisher DA, Evans JA, Foley K, Shaukat A, Eloubeidi MA, Faulx AL, Wang A, Acosta RD. Bowel preparation before colonoscopy. Gastrointestinal endoscopy. 2015 Apr:81(4):781-94. doi: 10.1016/j.gie.2014.09.048.
Wexner SD, Beck DE, Baron TH, Fanelli RD, Hyman N, Shen B, Wasco KE, American Society of Colon and Rectal Surgeons, American Society for Gastrointestinal Endoscopy, Society of American Gastrointestinal and Endoscopic Surgeons. A consensus document on bowel preparation before colonoscopy: prepared by a task force from the American Society of Colon and Rectal Surgeons (ASCRS), the American Society for Gastrointestinal Endoscopy (ASGE), and the Society of American Gastrointestinal and Endoscopic Surgeons (SAGES). Gastrointestinal endoscopy. 2006 Jun:63(7):894-909
Rex DK, Bond JH, Winawer S, Levin TR, Burt RW, Johnson DA, Kirk LM, Litlin S, Lieberman DA, Waye JD, Church J, Marshall JB, Riddell RH, U.S. Multi-Society Task Force on Colorectal Cancer. Quality in the technical performance of colonoscopy and the continuous quality improvement process for colonoscopy: recommendations of the U.S. Multi-Society Task Force on Colorectal Cancer. The American journal of gastroenterology. 2002 Jun:97(6):1296-308
Rex DK, Petrini JL, Baron TH, Chak A, Cohen J, Deal SE, Hoffman B, Jacobson BC, Mergener K, Petersen BT, Safdi MA, Faigel DO, Pike IM, ASGE/ACG Taskforce on Quality in Endoscopy. Quality indicators for colonoscopy. The American journal of gastroenterology. 2006 Apr:101(4):873-85
Chokshi RV, Hovis CE, Hollander T, Early DS, Wang JS. Prevalence of missed adenomas in patients with inadequate bowel preparation on screening colonoscopy. Gastrointestinal endoscopy. 2012 Jun:75(6):1197-203. doi: 10.1016/j.gie.2012.01.005.
Hassan C, Fuccio L, Bruno M, Pagano N, Spada C, Carrara S, Giordanino C, Rondonotti E, Curcio G, Dulbecco P, Fabbri C, Della Casa D, Maiero S, Simone A, Iacopini F, Feliciangeli G, Manes G, Rinaldi A, Zullo A, Rogai F, Repici A. A predictive model identifies patients most likely to have inadequate bowel preparation for colonoscopy. Clinical gastroenterology and hepatology : the official clinical practice journal of the American Gastroenterological Association. 2012 May:10(5):501-6. doi: 10.1016/j.cgh.2011.12.037.
Nguyen DL, Wieland M. Risk factors predictive of poor quality preparation during average risk colonoscopy screening: the importance of health literacy. Journal of gastrointestinal and liver diseases : JGLD. 2010 Dec:19(4):369-72
DiPalma JA, Brady CE 3rd. Colon cleansing for diagnostic and surgical procedures: polyethylene glycol-electrolyte lavage solution. The American journal of gastroenterology. 1989 Sep:84(9):1008-16
Di Palma JA, Rodriguez R, McGowan J, Cleveland Mv. A randomized clinical study evaluating the safety and efficacy of a new, reduced-volume, oral sulfate colon-cleansing preparation for colonoscopy. The American journal of gastroenterology. 2009 Sep:104(9):2275-84. doi: 10.1038/ajg.2009.389.
Markowitz GS, Stokes MB, Radhakrishnan J, D'Agati VD. Acute phosphate nephropathy following oral sodium phosphate bowel purgative: an underrecognized cause of chronic renal failure. Journal of the American Society of Nephrology : JASN. 2005 Nov:16(11):3389-96
Gremse DA, Sacks AI, Raines S. Comparison of oral sodium phosphate to polyethylene glycol-based solution for bowel preparation for colonoscopy in children. Journal of pediatric gastroenterology and nutrition. 1996 Dec:23(5):586-90
Lieberman DA, Ghormley J, Flora K. Effect of oral sodium phosphate colon preparation on serum electrolytes in patients with normal serum creatinine. Gastrointestinal endoscopy. 1996 May:43(5):467-9
Clarkston WK, Tsen TN, Dies DF, Schratz CL, Vaswani SK, Bjerregaard P. Oral sodium phosphate versus sulfate-free polyethylene glycol electrolyte lavage solution in outpatient preparation for colonoscopy: a prospective comparison. Gastrointestinal endoscopy. 1996 Jan:43(1):42-8
Holte K, Nielsen KG, Madsen JL, Kehlet H. Physiologic effects of bowel preparation. Diseases of the colon and rectum. 2004 Aug:47(8):1397-402
Frizelle FA, Colls BM. Hyponatremia and seizures after bowel preparation: report of three cases. Diseases of the colon and rectum. 2005 Feb:48(2):393-6
Rex DK, McGowan J, Cleveland Mv, Di Palma JA. A randomized, controlled trial of oral sulfate solution plus polyethylene glycol as a bowel preparation for colonoscopy. Gastrointestinal endoscopy. 2014 Sep:80(3):482-91. doi: 10.1016/j.gie.2014.03.043.
Enestvedt BK, Tofani C, Laine LA, Tierney A, Fennerty MB. 4-Liter split-dose polyethylene glycol is superior to other bowel preparations, based on systematic review and meta-analysis. Clinical gastroenterology and hepatology : the official clinical practice journal of the American Gastroenterological Association. 2012 Nov:10(11):1225-31. doi: 10.1016/j.cgh.2012.08.029.
Marshall JB, Pineda JJ, Barthel JS, King PD. Prospective, randomized trial comparing sodium phosphate solution with polyethylene glycol-electrolyte lavage for colonoscopy preparation. Gastrointestinal endoscopy. 1993 Sep-Oct:39(5):631-4
Pockros PJ, Foroozan P. Golytely lavage versus a standard colonoscopy preparation. Effect on normal colonic mucosal histology. Gastroenterology. 1985 Feb:88(2):545-8
Marschall HU, Bartels F. Life-threatening complications of nasogastric administration of polyethylene glycol-electrolyte solutions (Golytely) for bowel cleansing. Gastrointestinal endoscopy. 1998 May:47(5):408-10
Rees DC, Kelsey H, Richards JD. Acute haemolysis induced by high dose ascorbic acid in glucose-6-phosphate dehydrogenase deficiency. BMJ (Clinical research ed.). 1993 Mar 27:306(6881):841-2
Fordtran JS, Santa Ana CA, Cleveland MvB. A low-sodium solution for gastrointestinal lavage. Gastroenterology. 1990 Jan:98(1):11-6
DiPalma JA, Marshall JB. Comparison of a new sulfate-free polyethylene glycol electrolyte lavage solution versus a standard solution for colonoscopy cleansing. Gastrointestinal endoscopy. 1990 May-Jun:36(3):285-9
Matro R, Daskalakis C, Negoianu D, Katz L, Henry C, Share M, Kastenberg D. Randomised clinical trial: Polyethylene glycol 3350 with sports drink vs. polyethylene glycol with electrolyte solution as purgatives for colonoscopy--the incidence of hyponatraemia. Alimentary pharmacology & therapeutics. 2014 Sep:40(6):610-9. doi: 10.1111/apt.12884.
Hoy SM, Scott LJ, Wagstaff AJ. Sodium picosulfate/magnesium citrate: a review of its use as a colorectal cleanser. Drugs. 2009:69(1):123-36. doi: 10.2165/00003495-200969010-00009.
Lai EJ, Calderwood AH, Doros G, Fix OK, Jacobson BC. The Boston bowel preparation scale: a valid and reliable instrument for colonoscopy-oriented research. Gastrointestinal endoscopy. 2009 Mar:69(3 Pt 2):620-5. doi: 10.1016/j.gie.2008.05.057.
Gurudu SR, Ramirez FC, Harrison ME, Leighton JA, Crowell MD. Increased adenoma detection rate with system-wide implementation of a split-dose preparation for colonoscopy. Gastrointestinal endoscopy. 2012 Sep:76(3):603-8.e1. doi: 10.1016/j.gie.2012.04.456.
Bryant RV, Schoeman SN, Schoeman MN. Shorter preparation to procedure interval for colonoscopy improves quality of bowel cleansing. Internal medicine journal. 2013 Feb:43(2):162-8. doi: 10.1111/j.1445-5994.2012.02963.x.
Seo EH, Kim TO, Park MJ, Joo HR, Heo NY, Park J, Park SH, Yang SY, Moon YS. Optimal preparation-to-colonoscopy interval in split-dose PEG bowel preparation determines satisfactory bowel preparation quality: an observational prospective study. Gastrointestinal endoscopy. 2012 Mar:75(3):583-90. doi: 10.1016/j.gie.2011.09.029.
Liu X, Luo H, Zhang L, Leung FW, Liu Z, Wang X, Huang R, Hui N, Wu K, Fan D, Pan Y, Guo X. Telephone-based re-education on the day before colonoscopy improves the quality of bowel preparation and the polyp detection rate: a prospective, colonoscopist-blinded, randomised, controlled study. Gut. 2014 Jan:63(1):125-30. doi: 10.1136/gutjnl-2012-304292.
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Copyright (c) 2025 Wejdan Ibrahim Alaithan, Ali Hussain Mohammed Salwi, Nasser Hussain Mohammed Tawhari, Mousa Ahmed Ibrahim Bakri, Abdulrhman Mohammed Otayf, Marzog Awwad Alotaibi, Sattam Mansour Abulkhair, Radiyh Abdullah Almarzooq, Norah Yaseen Hassn Alameer, Abdullah Mosawed Hamad Darraj, Hour ibrahim Al ibrahim
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