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1.
Simethicone decreases bloating and improves bowel preparation effectiveness: a systematic review and meta-analysis.
Moolla, M, Dang, JT, Shaw, A, Dang, TNT, Tian, C, Karmali, S, Sultanian, R
Surgical endoscopy. 2019;(12):3899-3909
Abstract
BACKGROUND Simethicone is an adjunct frequently used during bowel preparation before colonoscopy and currently there is no consensus on whether it should be recommended in standard bowel preparation. We performed a systematic review and meta-analysis to determine the effect simethicone has on bowel cleanliness, adenoma detection rate (ADR), and tolerability. METHODS We searched the literature for studies that compared colon cleansing of patients that received standard bowel preparation alone and in combination with simethicone prior to colonoscopy. The primary outcomes were colon cleanliness, ADR, and tolerability. RESULTS Sixteen randomized controlled trials with 5630 patients were included in meta-analysis. Overall, polyethylene glycol (PEG) with simethicone improves colon cleansing compared with PEG alone (odds ratio [OR] 1.48, CI 1.11 to 1.97, P = 0.008). This improvement was seen for single dosing (OR 1.83, CI 1.20 to 2.79, P = 0.005) but not for split dosing (OR 1.32, CI 0.72 to 2.43, P = 0.38). Overall, simethicone had no effect on ADR (OR 1.22, CI 0.81 to 1.83, P = 0.33), but in patients receiving single dosing, simethicone significantly increased ADR (OR 1.96, CI 1.22 to 3.16, P = 0.005). The rates of nausea (OR 0.96, CI 0.75 to 1.24, P = 0.75), vomiting (OR 1.00, CI 0.69 to 1.44, P = 0.99), and abdominal pain (OR 0.69, CI 0.40 to 1.18, P = 0.17) were not significantly different between PEG and PEG + simethicone cohorts. For abdominal bloating, the PEG cohort had greater odds of experiencing bloating than the PEG + simethicone cohort (OR 2.33, CI 1.70 to 3.20, P < 0.00001). CONCLUSIONS Simethicone improves colon cleanliness and ADR; however, this improvement is not seen in patients receiving split-dose PEG. Furthermore, simethicone decreases abdominal bloating but has no effect on nausea, vomiting, and abdominal pain. Simethicone may be a useful bowel preparation adjunct in patients unable to receive split-dose PEG.
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2.
Meta-analysis of randomized controlled trials challenging the usefulness of purgative preparation before small-bowel video capsule endoscopy.
Gkolfakis, P, Tziatzios, G, Dimitriadis, GD, Triantafyllou, K
Endoscopy. 2018;(7):671-683
Abstract
BACKGROUND The usefulness of purgative preparation before small-bowel video capsule endoscopy is controversial. We aimed to examine the effect of purgative preparation on small-bowel video capsule endoscopy outcomes. METHODS We performed literature searches in MEDLINE and the Cochrane library for randomized controlled trials evaluating the effect of purgative preparation (polyethylene glycol, sodium phosphate, others) vs. clear-liquid diet/fasting in patients undergoing small-bowel capsule endoscopy. Meta-analysis outcomes included the examination's diagnostic yield, small-bowel mucosal visualization quality, the examination's completion rate, and gastric and small-bowel transit times. The effect size on study outcomes was calculated using a fixed- or random-effect model, as appropriate, and is shown as the risk ratio (RR) with 95 % confidence interval (CI). RESULTS We identified 12 eligible trials with 17 sets of data including 1221 subjects. Significant heterogeneity was detected with no evidence of publication bias. As compared with clear-liquid diet, purgative bowel preparation did not increase capsule endoscopy diagnostic yield (RR 1.17 [95 %CI 0.97 to 1.40]; P = 0.11). Neither the small-bowel mucosal visualization quality (RR 1.14 [95 %CI 0.96 to 1.35]; P = 0.15) nor completion rate for the examination (RR 0.99 [95 %CI 0.95 to 1.04]; P = 0.76) significantly improved after purgative preparation. Purgatives also had no effect on video capsule endoscopy gastric and small-bowel transit times. CONCLUSIONS Our analysis challenges the usefulness of purgative preparation for improving the diagnostic yield of small-bowel video capsule endoscopy and the quality of small-bowel mucosal visualization.
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3.
Do adjuvants add to the efficacy and tolerance of bowel preparations? A meta-analysis of randomized trials.
Restellini, S, Kherad, O, Menard, C, Martel, M, Barkun, AN
Endoscopy. 2018;(2):159-176
Abstract
UNLABELLED BACKGROUND AND STUDY AIMS : Recommendations on adjuvant use with bowel preparations remain disparate. We performed a meta-analysis determining the clinical impact of adding an adjuvant to polyethylene glycol (PEG), sodium phosphate, picosulfate (PICO), or oral sulfate solutions (OSS)-based regimens. METHODS Systematic searches were made of MEDLINE, EMBASE, Scopus, CENTRAL and ISI Web of knowledge for randomized trials from January 1980 to April 2016 that assessed preparations with or without adjuvants, given in split and non-split dosing, and PEG high- (> 3 L) or low-dose (≤ 2 L) regimens. Bowel cleansing efficacy was the primary outcome. Secondary outcomes included patient willingness to repeat the procedure, and polyp and adenoma detection rates. RESULTS Of 3093 citations, 77 trials fulfilled the inclusion criteria. Overall, addition of an adjuvant compared with no adjuvant, irrespective of the type of preparation and mode of administration, yielded improvements in bowel cleanliness (odds ratio [OR] 1.23 [1.01 - 1.51]) without greater willingness to repeat (OR 1.40 [0.91 - 2.15]). Adjuvants combined with high-dose PEG significantly improved colon cleansing (OR 1.96 [1.32 - 2.94]). The odds for achieving adequate preparation with low-dose PEG with an adjuvant were not different to high-dose PEG alone (OR 0.95 [0.73 - 1.22]), but yielded improved tolerance (OR 3.22 [1.85 - 5.55]). However, split high-dose PEG yielded superior cleanliness to low-dose PEG with adjuvants (OR 2.53 [1.25 - 5.13]). No differences were noted for OSS and PICO comparisons, or for any products regarding polyp or adenoma detection rates. CONCLUSIONS Critical heterogeneity precludes firm conclusion on the impact of adjuvants with existing bowel preparations. Additional research is required to better characterize the methods of administration and resulting roles of adjuvants in an era of split-dosing.
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Systematic review and meta-analysis: is bowel preparation still necessary in small bowel capsule endoscopy?
Yung, DE, Rondonotti, E, Sykes, C, Pennazio, M, Plevris, JN, Koulaouzidis, A
Expert review of gastroenterology & hepatology. 2017;(10):979-993
Abstract
INTRODUCTION Optimal bowel preparation for small bowel capsule endoscopy(SBCE) is controversial. This meta-analysis aimed to investigate the effects of laxatives in SBCE. METHODS A comprehensive literature search was conducted for studies investigating the use of laxatives in SBCE. The primary outcome was diagnostic yield(DY) for SB findings; secondary outcomes SB visualization quality(SBVQ) and completion rate(CR). Pooled odds ratios(ORs) with 95% confidence intervals(CIs) and number needed to treat(NNT) were calculated. RESULTS Forty studies (4380 patients with laxatives, 2185 without) were included. Laxative use did not improve DY of SB findings overall (OR 1.11 (95%CI 0.85-1.44)) or for significant SB findings (OR 1.10 (95%CI 0.76-1.60)). However, SBVQ improved with the use of laxatives (OR 1.60 (95%CI 1.08-2.06)), NNT 14. The OR for completed SBCE was 1.30 (95%CI 0.95-1.78). Patients given polyethylene glycol(PEG) had lower DY than sodium phosphate(NaP). SBVQ improved more with NaP (NNT 7) than PEG (NNT 53). CONCLUSIONS Laxatives do not significantly improve DY or CR in SBCE, but do improve SBQV. The use of laxatives may be beneficial in patients likely to have subtle findings. There are significant differences in methodology/definitions between studies, hence the need for standardized visualization scoring and recording of SBCE findings.
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5.
Sodium phosphate versus polyethylene glycol for colonoscopy bowel preparation: an updated meta-analysis of randomized controlled trials.
Cheng, J, Tao, K, Shuai, X, Gao, J
Surgical endoscopy. 2016;(9):4033-41
Abstract
BACKGROUND Adequate bowel cleansing is of great importance for a high-quality colonoscopy examination. Nevertheless, whether sodium phosphate or polyethylene glycol is a gold standard agent for bowel preparation is still under debate. In consideration of the clinical needs, we thus performed an updated meta-analysis of randomized controlled trials concerning the comparison between both regimens. The efficacy, safety and acceptability of each regimen are major indicators to measure and appraise. METHODS By searching PubMed, EMBASE, Web of Science and Cochrane Library databases, 15 original trials published from 2000 to 2014 were included as eligible studies. We carried out data extraction and subsequent pooling analysis for each indicator in a standard manner. Sensitivity analysis was performed by elimination of low-quality trials, while a funnel plot and Egger's test were employed to analyze the publication bias across studies. RESULTS Our pooling analysis revealed that patients undergoing sodium phosphate as a cleansing agent displayed better acceptability, compliance, cleansing scores, preparation taste, polyp detection rate and less adverse effects including nausea, vomiting and abdominal pain (P < 0.05). In terms of procedure time, adequate preparation rate and electrolyte concentration, there was no significant difference between both regimens (P > 0.05). The pooling analysis offered stable conclusions which were verified by our sensitivity analysis. There was no publication bias across studies as a symmetric funnel plot was demonstrated and the result of Egger's test was P = 0.56. CONCLUSIONS Regarding preparation efficacy, safety and acceptability, sodium phosphate was a better agent than polyethylene glycol for colonoscopy bowel cleansing, with its advantages of higher efficacy, better tolerability and acceptability as well as comparable safety.
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6.
Split-Dose Preparations Are Superior to Day-Before Bowel Cleansing Regimens: A Meta-analysis.
Martel, M, Barkun, AN, Menard, C, Restellini, S, Kherad, O, Vanasse, A
Gastroenterology. 2015;(1):79-88
Abstract
BACKGROUND & AIMS There are different regimens of preparing the colon for colonoscopy, including polyethylene glycol (PEG), sodium phosphate, picosulfate, or oral sulfate solutions. We performed a meta-analysis to determine the efficacy of split-dose vs other colon preparation regimens, the optimal products for use, and the most effective preparation volumes. METHODS We performed systematic searches of MEDLINE, EMBASE, Scopus, CENTRAL, and ISI Web of knowledge databases, from January 1980 to March 2014, for published results from randomized trials that assessed split-dose regimens vs day-before colonoscopy preparation. We excluded studies that included pediatric or hospitalized patients, or patients with inflammatory bowel disease. The primary outcome was efficacy of bowel cleansing. Secondary outcomes included side effects or complications, outcomes of procedures, patients' willingness to repeat the procedure, and the amount of time required for patients to resume daily activities. RESULTS We identified 47 trials that fulfilled our inclusion criteria (n = 13,487 patients). Split-dose preparations provided significantly better colon cleansing than day-before preparations (odds ratio [OR], 2.51; 95% confidence interval, 1.86-3.39), as well as day-before preparations with PEG (OR, 2.60; 95% confidence interval, 1.46-4.63), sodium phosphate (OR, 9.34; 95% confidence interval, 2.12-41.11), or picosulfate (OR, 3.54; 95% confidence interval, 1.95-6.45). PEG split-dose preparations of 3 L or more yielded greater bowel cleanliness than lower-volume split-dose regimens (OR, 1.89; 95% confidence interval, 1.01-3.46), but only in intention-to-treat analysis. A higher proportion of patients were willing to repeat split-dose vs day-before cleansing (OR, 1.90; 95% confidence interval, 1.05-3.46), and low-volume split-dose preparations vs high-volume split-dose preparation (OR, 4.95; 95% confidence interval, 2.21-11.10). There were no differences between preparations in other secondary outcome measures. However, there was variation among studies in definitions and main and secondary outcomes. CONCLUSIONS Based on meta-analysis, split-dose regimens increase the quality of colon cleansing and are preferred by patients compared with day-before preparations. Additional research is required to evaluate oral sulfate solution-based and PEG low-volume regimens further.
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7.
Which is the optimal bowel preparation for colonoscopy - a meta-analysis.
Tan, JJ, Tjandra, JJ
Colorectal disease : the official journal of the Association of Coloproctology of Great Britain and Ireland. 2006;(4):247-58
Abstract
OBJECTIVE To assess which bowel preparation agent is most effective. METHODS A search of randomized trials between January 1990 and July 2005 was obtained, using MEDLINE and PubMed databases, and the Cochrane Central Register of Controlled Trials. Meta-analysis was performed using the Forest plot review. RESULTS Sodium phosphate (NaP) was more effective in bowel cleansing than polyethylene glycol (PEG) - odds ratio 0.75 (95%CI: 0.65-0.88; P = 0.0004); and sodium picosulphate (SPS) - odds ratio 0.52 (95%CI: 0.34-0.81; P = 0.004). PEG and SPS were comparable in bowel cleansing ability, odds ratio 1.69 (95%CI: 0.92-3.13; P = 0.09). NaP was more easily completed by patients compared to PEG, odds ratio 0.16 (95%CI: 0.09-0.29; P < 0.00001). More patients were able to complete SPS than PEG, but this was not statistically significant - odds ratio 0.56 (95%CI: 0.28-1.13; P = 0.11). NaP and PEG were comparable in terms of adverse events, odds ratio 0.98 (95%CI: 0.82-1.17; P = 0.81), although NaP resulted in more asymptomatic hypokalaemia and hyperphosphataemia. NaP and SPS appeared to have similar incidence of adverse events. PEG resulted in more adverse events than SPS, odds ratio 3.82 (95%CI: 1.60-9.15; P = 0.003). CONCLUSIONS NaP was more effective in bowel cleansing than PEG or SPS and was comparable in terms of adverse events. Patients have more difficulty completing PEG than NaP and SPS. Biochemical changes associated with a small-volume preparation like NaP, albeit largely asymptomatic, mandate caution in patients with cardiovascular or renal impairment.
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8.
Laxatives for the treatment of hemorrhoids.
Alonso-Coello, P, Guyatt, G, Heels-Ansdell, D, Johanson, JF, Lopez-Yarto, M, Mills, E, Zhou, Q
The Cochrane database of systematic reviews. 2005;(4):CD004649
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Abstract
BACKGROUND Symptomatic hemorrhoids are a common medical condition, which increase in prevalence in women during pregnancy and postpartum. Although the evidence appears to be inconclusive, narrative reviews and clinical practice guidelines recommend the use of laxatives (and fiber) for the treatment of hemorrhoids and relief of symptoms. This is due to their safety and low cost. OBJECTIVES To evaluate the impact of laxatives on a wide range of symptoms in people with symptomatic hemorrhoids. SEARCH STRATEGY We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library Issue 2, 2005), MEDLINE (1966 to 2005), EMBASE (1980 to 2005), CINAHL (1982 to 2005), BIOSIS, and AMED (Allied and Alternative Medicine Database), for eligible trials (including conference proceedings). We sought missing and additional information from authors, industry, and experts in the field. SELECTION CRITERIA We selected all published and unpublished randomised controlled trials that compared any type of laxative to placebo or no therapy in any patient population. DATA COLLECTION AND ANALYSIS Two authors independently screened studies for inclusion and retrieved all potentially relevant studies. Data were extracted from studies that met our selection criteria on study population, intervention used, pre-specified outcomes, and methodology. We extracted methodological information for the assessment of internal validity: existence and method of generation of the randomization schedule, and method of allocation concealment; blinding of caregivers and outcomes assessors; numbers of and reasons for participants lost to follow up; and use of validated outcome measures. MAIN RESULTS Seven randomised trials enrolling a total of 378 participants to fiber or a non-fiber control were identified. Meta-analyses using random-effects models showed that laxatives in the form of fiber had a beneficial effect in the treatment of symptomatic hemorrhoids. The risk of not improving hemorrhoids and having persisting symptoms decreased by 53% in the fiber group (risk reduction (RR) 0.47, 95% CI 0.32 to 0.68). These results are compatible with large treatment effects regarding prolapse, pain, itching, although the pooled analyses showed a tendency toward no-effect for these parametres. The effect on bleeding showed a significant difference in favour of the fiber (RR 0.50, 95% CI 0.28 to 0.89). Studies including data on multiple follow ups (usually after six weeks and three months) showed consistent results over time. However, we have to stress two possible limitations of this review: the risk of publication bias, and only moderate study quality. AUTHORS' CONCLUSIONS The use of fiber shows a consistent beneficial effect for relieving overall symptoms and bleeding in the treatment of symptomatic hemorrhoids.