The Efficacy of 4 Liters of Clear Liquids for Small Bowel Preparation Prior to Video Capsule Endoscopy

Nicholas Placone; Runalia Bahar; Surinder Mann

doi:10.5946/ce.2019.213

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Original Article The Efficacy of 4 Liters of Clear Liquids for Small Bowel Preparation Prior to Video Capsule Endoscopy: Nicholas Placone¹, Runalia Bahar², Surinder Mann^2,; Clinical Endoscopy 2020;53(6):713-718.
DOI: https://doi.org/10.5946/ce.2019.213
Published online: March 31, 2020

¹Department of Internal Medicine, University of California, Davis, Sacramento, CA, USA

²Division of Gastroenterology and Hepatology, University of California, Davis, Sacramento, CA, USA

Correspondence: Surinder Mann Division of Gastroenterology and Hepatology, University of Southern California, 2011 Zonal Ave HMR 101, Los Angeles, CA 90089-9091, USA Tel: +1-530-902-1303, Fax: +1-323-442-5425, E-mail: surinder.mann@med.usc.edu

• Received: November 11, 2019 • Accepted: February 18, 2020

This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/3.0/) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

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Abstract
INTRODUCTION
MATERIALS AND METHODS
RESULTS
DISCUSSION
NOTES
REFERENCES

See letter "Ideal Method for Small Bowel Preparation before Video Capsule Endoscopy" in Volume 53 on page 631.

Abstract

Background/Aims
Optimal small bowel (SB) preparation for video capsule endoscopy (VCE) is controversial. Our study aimed to support the use of a specified volume of 4 liters of clear liquids for bowel preparation for VCE.
Methods
A retrospective review of 284 patients who underwent SB preparation with 2 liters of polyethylene glycol (PEG) and 284 patients who had 4 liters of clear liquid preparation. We analyzed image quality, endoscopic findings, completion rate, and transit times.
Results
The 4-liter clear liquid group had significantly higher mean image quality scores when compared to the PEG group (2.908±0.77 to 2.669±0.64, p<0.0001), as well as more studies with adequate preparation (72% to 64%, p=0.0214). Although the PEG group had more endoscopic findings on VCE (40% to 23%, p<0.0001), there was a significant difference in the indications for the procedure between the groups. There was no difference in the capsule completion rate or SB transit time.
Conclusions
Our data demonstrate significantly higher mean image quality scores when using a specified volume of 4 liters of clear liquid compared to 2 liters of PEG. This study supports the growing evidence of the effectiveness of a 4-liter clear liquid SB preparation as opposed to PEG for VCE.
Keywords: Clear liquids; Polyethylene glycol; Small bowel preparation; Video capsule endoscopy

INTRODUCTION

Wireless video capsule endoscopy (VCE), first introduced in 2000 and approved by the FDA in 2001, provided a novel method of complete visualization of the small bowel (SB) [1]. VCE has become a well-supported diagnostic tool and is the first-line diagnostic test after upper endoscopy and colonoscopy in obscure gastrointestinal bleeding. It also aids in the evaluation of other pathologies including iron deficiency anemia, Crohn’s disease, and Celiac disease and the SB for polyps or tumors [2,3]. The diagnostic yield of VCE relies on visualization of the SB mucosa, which may be obscured by bile, bubbles, debris, and other particles. Numerous different preparations have been used to minimize these factors including a clear liquid-only diet, polyethylene glycol (PEG), sodium phosphate, picosulfate plus magnesium sulfate [4], magnesium citrate [5], cholestyramine and hydrotalcite [6], linaclotide [7], coffee enema [8], Ensure [9], and mannitol [10]. Early data, as well as more recent studies, suggest that purgative bowel preparation with PEG solution may enhance SB visualization and improve diagnostic yield when compared to fasting or a clear liquid diet alone [11-14]. Independent consensus groups in Europe (2009) and Korea (2013) also recommend purgative bowel preparation with PEG prior to VCE [15,16]. On the other hand, many randomized controlled trials and large meta-analyses have failed to show PEG to be superior to fasting or a clear liquid-only diet for bowel preparation prior to VCE [4,17-19]. The most recent consensus statement from Enns et al. in 2017 recommended a purgative SB preparation prior to VCE; however, there was insufficient evidence to recommend one specific preparation over another [20]. Notably, a study by Pons Beltrán et al. in 2011 showed that a 4-liter clear liquid preparation was better tolerated and had a similar diagnostic yield when compared to the 2-liter and 4-liter PEG preparations [21]. Hence, the ideal SB preparation prior to VCE remains a controversial topic.

Our site previously conducted a randomized controlled prospective non-inferiority trial comparing a specified volume of 4 liters of clear liquid to 2 and 4 liters of PEG. The results showed the 4-liter clear liquid preparation was non-inferior in terms of image quality to both PEG groups and was better tolerated with fewer reported side effects [22]. The use of a specified volume of 4 liters of clear liquids may facilitate adequate SB preparation. Since the completion of our study, we have almost exclusively used a 4-liter clear liquid preparation for VCE studies at our center. We aim to corroborate our previously collected data with a larger sample size in order to evaluate whether 4 liters of clear liquid as an SB preparation for VCE provides a comparable image quality to that of PEG.

MATERIALS AND METHODS

We conducted a retrospective review of consecutive out-patient VCEs conducted from June 2011 to December 2012, during which time a 2-liter PEG was exclusively used for SB preparation. We compared these findings to VCEs conducted from March 2017 to May 2018 when a 4-liter clear liquid SB preparation was used. Patients are instructed to consume only liquids which are clear, such as water, broth, sports drink, tea etc. All patients in both groups received 30 mL of simethicone prior to the procedure. PillCamTM Small Bowel capsule and Rapid ReaderTM software was used in all patients in both groups. Due to the lower completion rate for patients undergoing VCE as inpatients as opposed to outpatients [23], we excluded inpatient VCE. Data collected included patient demographics (age, height, weight, sex, past medical history), indication for procedure, gastric transit time (GTT), small intestine transit time (SITT), image quality, and endoscopic findings.

Since only one clinician reviews VCE at our site, the image quality for all procedures was reported by the same reviewer. Image quality was graded on a scale of 1 to 4, with a score of 1 representing poor preparation, 2 fair, 3 good, and 4 excellent. Mean image quality score and standard deviation between the two groups were calculated. We also compared the proportion of VCEs in each group that was considered to have “adequate” preparation. Adequate preparation was defined as an image quality score of 3 (good) or better. This qualitative scoring system was validated by Brotz et al. for inter-observer and intra-observer reliability and relies on the percent of mucosa visualized, along with other factors including the degree of fluid and debris, bubbles, bile/chyme staining, and brightness [24]. When the entire SB is evaluated, a score of good or excellent requires >90% visualization of the mucosa throughout the entire SB [24].

Our primary outcome was image quality between the two groups. Secondary outcomes were endoscopic diagnosis, proportion of studies with adequate preparation, SITT, GTT, and capsule completion rate. Statistical analysis was conducted with a t-test using mean and standard deviation for continuous variables and a Chi-squared test for categorical variables. We set the significance at p<0.05.

RESULTS

A total of 284 consecutive VCEs from June 2011 to December 2012 with the 2-liter PEG SB preparation and 284 consecutive patients from March 2017 to May 2018 who used the 4-liter clear liquid SB preparation were reviewed. Ten patients in the clear liquid group and 8 in the PEG group were not included in the analysis of image quality or endoscopic findings due to the capsule staying in the stomach. An additional 10 patients were not included in the image quality analysis for the PEG group because although endoscopic findings were recorded, the exam had insufficient transit of the SB to accurately grade the overall image quality of the study. Therefore, 264 patients in the PEG group and 276 patients in the clear liquid group were included in the image quality analysis and 274 patients in the PEG group and 276 patients in the clear liquid group were included in the endoscopic findings data. GTT time was not recorded for 24 patients in the PEG group and 18 in the clear liquid group due to the capsule staying in stomach, endoscopic implantation of the capsule in the duodenum, or a history of gastric bypass surgery, leaving n=260 for the PEG group and n=266 for the clear liquid group for the calculation of GTT. SITT was unable to be recorded in some incomplete examinations, as well as in 4 additional patients in the PEG group as it was unclear exactly when the capsule exited the SB. Therefore, n=249 for the PEG group and n=252 for the clear liquid group for the calculation of SITT.

There were no significant differences in the baseline characteristics of the two groups (Table 1). However, the indications for the procedure were significantly different between the two groups. Specifically, the clear liquid group had statistically significantly more examinations ordered for indications of anemia and other, whereas the PEG group had significantly more studies ordered to rule out SB tumor, evaluate for Crohn’s or inflammatory bowel disease, or evaluate for arteriovenous malformation (AVM) (Table 2). The preparation quality for the PEG group and the clear liquids group was 2.669±0.64 and 2.908±0.77, respectively (Table 2; p<0.0001). Significantly more studies achieved an adequate preparation quality score in the clear liquid group than in the PEG group (Table 3; p=0.0214). There were no significant differences in the capsule completion rate or SITT, although the GTT was significantly longer in the PEG group than in the clear liquid group (Table 3; p<0.05). When comparing endoscopic diagnoses between the two groups, the PEG group had a greater percentage of clinically significant findings from VCE (40% to 23%, p<0.0001), with more findings of AVMs (14% to 4%, p<0.001) and non-specific mucosal flattening (5% to 0%, p=0.001), whereas the clear liquid group had significantly more diagnoses of ileitis (7% to 3%, p=0.017) (Table 4).

DISCUSSION

There remains a lack of consensus on optimal SB preparation prior to VCE. Meta-analyses have inconsistently shown the benefit of one preparation over another. While some meta-analyses of available data have shown that purgative bowel preparations with PEG or sodium phosphate have better image quality and diagnostic yield when compared to fasting or a clear liquid diet [11,14], a number of randomized control trials and meta-analyses have not reproduced these results [4,17-19]. Furthermore, the mixed results of Yung et al. meta-analysis in 2017 showed no difference in diagnostic yield between the two bowel preparations, but it was noted that the purgative group had better image quality [17]. The data from our study add to the growing evidence questioning whether bowel preparation with PEG is necessary prior to VCE. Our study showed improved image quality in the 4-liter clear liquid group when compared to the 2-liter PEG group, in addition to the higher proportion of VCE studies with adequate preparation quality in the clear liquid group. These results corroborate the data from two previously published randomized controlled trials that independently showed either the non-inferiority of or no significant difference between a 4-liter clear liquid preparation compared to PEG [21,22].

An important consideration when choosing an SB preparation is patient tolerability and preparation compliance. Due to the retrospective nature of our study, we were unable to directly compare tolerability between the two groups. However, tolerability has been studied in two different randomized control trials. In a prospective study comparing 4 liters of clear liquid, PEG, and aqueous sodium phosphate by Pons Beltrán et al., tolerability was evaluated directly by patient questionnaire [21]. The 4 liters of clear liquid preparation was associated with the least interference with patients’ daily activity and nocturnal rest (p=0.001) and better compliance compared to PEG (p=0.002) [21]. Another prospective study by Bahar et al. showed that patients who underwent a 4-liter clear liquid preparation had a lower difficulty of completion rate than those who underwent preparation with either 2 liters (p=0.013) or 4 liters of PEG (p<0.001), as well as a lower rate of side effects compared to those with 4 liters of PEG (p<0.0167) [22].

In addition to overall image quality, it has been suggested that the advantage of using purgative preparations such a PEG may lie in their ability to specifically improve image quality in the distal ileum [25]. However, in addition to the overall better image quality scores, there were also significantly more diagnoses of ileitis in the clear liquid group than in the PEG group. Although the image quality of each section of bowel was not directly recorded in our study, based on the higher rate of finding ileitis in the clear liquid group, we can extrapolate that the distal SB preparation in the clear liquid group yielded an image quality adequate to diagnose lesions in the ileum.

Interestingly, our study demonstrated a greater number of endoscopic diagnoses in the PEG group than in the clear liquid group, despite the lower image quality in the PEG group. However, it is important to note when considering this result that there was also a significant difference in the indications for the procedure between the two groups, which likely led to this difference in endoscopic findings. For example, one notable difference between the groups was significantly more studies were ordered to evaluate the SB for AVMs in the PEG group, which likely contributed to the increased rate of endoscopic findings of AVM in the PEG group. This suggests that the higher number of endoscopic findings in the PEG group is attributable to differences in the indications for the procedure between the two groups and is not a reflection of image quality and differences in the quality of preparation. It is important to note, however, that the 4-liter clear liquid group had significantly more findings of ileitis despite having fewer procedures ordered specifically to rule out Crohn’s disease. Although we cannot say whether this was due to better image quality in the distal ileum, this finding further suggests that the greater number of endoscopic findings in the PEG group should not be interpreted as indicating better preparation or a higher diagnostic yield.

There are a few potential explanations for the difference in the indications for the procedure between the two groups. For our study, we wanted to review consecutive outpatient VCEs to minimize selection bias, which was difficult owing to the numerous different bowel preparations for VCE used between January 2013 and February 2017. Therefore, we selected date ranges during which only one bowel preparation regimen was used. We found that we exclusively used 2 liters of PEG prior to January 2013 and 4 liters of clear liquid after February 2017. The difference in the time period of the two groups may partially explain the significant differences in the indication for procedure as shown in Table 2.

One limitation of our study is that our institution has only one clinician who reads capsule endoscopies; therefore, we used a single reviewer with a standardized method and verification by multiple reviewers was not possible. Additionally, we used data that were recorded at the time of the capsule endoscopy and the endoscopist was not blinded to which preparation the patient had received. Although the 1–4 grading system we used to record image quality is widely used, it still has the potential for human error given its subjectivity. However, when validating this scoring method, Brotz et al. found that its intra-observer reliability outperformed its inter-observer reliability and that reliability improved when comparing a score of adequate preparation (defined as a score of good or excellent) versus inadequate preparation (a score of poor or fair), which corroborates our decision to also compare these two groups [24]. Development of objective methods to evaluate image quality in VCE has shown promise, such as computed cleansing scores [26,27], though they are not widely in use at this time. Future studies may benefit from using an objective tool to compare image quality between different SB preparations.

Optimal bowel preparation prior to VCE remains controversial. Although bowel preparation with PEG and other purgative solutions is commonly used, they are often poorly tolerated and inconsistently show superiority in terms of image quality and diagnostic yield compared to a clear liquid diet. Our current study demonstrates improved image quality with a specified volume of 4 liters of clear liquid compared to 2 liters of PEG as an SB preparation prior to VCE. These data further support our previously conducted randomized non-inferiority study [22], as well as the increasing evidence in favor of using 4 liters of clear liquid for SB preparation prior to VCE.

Conflicts of Interest: The authors have no financial conflicts of interest.

Authors’ contribution

Conceptualization: Nicholas Placone, Runalia Bahar, Surinder Mann

Data curation: NP, RB

Formal analysis: NP

Methodology: SM

Writing-original draft: NP

Writing-review&editing: RB, SM

Table 1.

Baseline Demographics of Patients

Variables	2 liters PEG (n=284)	4 liters clear liquid (n=284)	p-value
Age (mean, SD)	58.75±15.40	60.36±14.74	0.204
Sex, Male/Female, n (%)	112 (39)/172 (61)	108 (38)/176 (62)	0.730
BMI (mean, SD)	28.6±6.8	28.9±7.3	0.613
Prior abdominal surgery, n (%)	158 (56)	153 (54)	0.673
Diabetes mellitus, n (%)	84 (30)	74 (26)	0.349
Renal disease, n (%)	33 (12)	20 (7)	0.061
Liver disease, n (%)	17 (6)	25 (9)	0.200

BMI, body mass index; PEG, polyethylene glycol; SD, standard deviation.

Table 2.

Indication for Procedure

Variables	2 liters PEG (n=284)	4 liters clear liquid (n=284)	p-value
Anemia (n, %)	158 (56)	185 (65)	0.021
GI bleed - Overt (n, %)	34 (12)	22 (8)	0.091
GI bleed - Occult (n, %)	4 (1)	5 (2)	0.737
Chronic abdominal pain (n, %)	34 (12)	30 (11)	0.596
Diarrhea (n, %)	16 (6)	26 (9)	0.109
Rule out small bowel tumor/polyp (n, %)	28 (10)	13 (5)	0.015
Suspect Crohn’s or IBD (n, %)	22 (8)	7 (3)	0.004
Rule out celiac disease (n, %)	10 (4)	4 (1)	0.104
Evaluate for AVM (n, %)	12 (4)	2 (1)	0.007
Malabsorption (n, %)	1 (0)	1 (0)	1.000
Weight loss (n, %)	0 (0)	5 (2)	0.061
Other (n, %)	3 (1)	11 (4)	0.030

Multiple indications possible for one procedure.

AVM, arteriovenous malformation; GI, gastrointestinal; IBD, inflammatory bowel disease; PEG, polyethylene glycol.

Table 3.

Means and Standard Deviations for Small Bowel Preparation Quality, Gastric Transit Time, Small Intestine Transit Time, and Capsule Completion Rate

Variables	2 liters PEG	4 liters clear liquid	p-value
Preparation quality, as Mean^a)	2.669±0.64 (n=264)	2.908±0.77 (n=276)	<0.0001
Number of exams with adequate prep^b)	170 (64) (n=264)	203 (72) (n=276)	0.0214
Gastric transit time in minutes^c)	38.80±43.61 (n=260)	31.20±38.92 (n=266)	0.0353
Small intestine transit time in minutes^c)	222.0±79.94 (n=249)	225.1±90.26 (n=252)	0.687
Capsule completion rate, n (%)	253 (89) (n=284)	252 (89) (n=284)	0.894

PEG, polyethylene glycol.

^a)Preparation quality measured 1=poor; 2=fair; 3=good; 4=excellent.

^b)Preparation considered adequate if quality score 3 or greater.

^c)Time measured in minutes.

Table 4.

Endoscopic Diagnosis, Multiple Diagnoses Possible for a Single Study

Endoscopic findings	2 liters PEG (n=274)	4 liters clear liquid (n=276)	p-value
Normal small bowel (n, %)	174 (64)	221 (80)	<0.0001
AVM/angiodysplasia (n, %)	38 (14)	10 (4)	<0.0001
Active bleed (n, %)	13 (5)	10 (4)	0.511
Small bowel polyp (n, %)	14 (5)	6 (2)	0.066
Diverticulum (n, %)	4 (2)	3 (1)	0.697
Inflammation (erosions, ulcers) of proximal to mid small bowel (n, %)	19 (7)	13 (5)	0.265
Non-specific mucosal flattening (n, %)	13 (5)	1(0)	0.001
Likely celiac disease (n, %)	8 (3)	2 (1)	0.054
Suspected tumor (n, %)	2 (1)	2 (1)	0.994
Stricture (n, %)	7 (3)	4 (2)	0.355
Ileitis (n, %)	7 (3)	19 (7)	0.017
Submucosal bulge (n, %)	3 (1)	1 (0)	0.312
Clinically significant finding (n, %)	110 (40)	63 (23)	<0.0001

Multiple diagnoses possible for a single study.

AVM, arteriovenous malformation; PEG, polyethylene glycol.

REFERENCES

1. Iddan G, Meron G, Glukhovsky A, Swain P. Wireless capsule endoscopy. Nature 2000;405:417.Article PDF
2. Ladas SD, Triantafyllou K, Spada C, et al. European Society of Gastrointestinal Endoscopy (ESGE): recommendations (2009) on clinical use of video capsule endoscopy to investigate small-bowel, esophageal and colonic diseases. Endoscopy 2010;42:220–227.Article PubMed
3. Koulaouzidis A, Rondonotti E, Karargyris A. Small-bowel capsule endoscopy: a ten-point contemporary review. World J Gastroenterol 2013;19:3726–3746.Article PubMed PMC
4. Hookey L, Louw J, Wiepjes M, et al. Lack of benefit of active preparation compared with a clear fluid-only diet in small-bowel visualization for video capsule endoscopy: results of a randomized, blinded, controlled trial. Gastrointest Endosc 2017;85:187–193.Article PubMed
5. Ninomiya K, Yao K, Matsui T, et al. Effectiveness of magnesium citrate as preparation for capsule endoscopy: a randomized, prospective, open-label, inter-group trial. Digestion 2012;86:27–33.Article PubMed
6. Hong-Bin C, Yue H, Chun H, Shu-Ping X, Yue Z, Xiao-Lin L. Randomized controlled trial of cholestyramine and hydrotalcite to eliminate bile for capsule endoscopy. Saudi J Gastroenterol 2016;22:122–126.Article PubMed PMC
7. Stein DJ, Copland A, McDaniel D, Hays RA. Single-dose linaclotide is equal in efficacy to polyethylene glycol for bowel preparation prior to capsule endoscopy. Dig Dis 2019;37:297–302.Article PubMed
8. Kim ES, Chun HJ, Keum B, et al. Coffee enema for preparation for small bowel video capsule endoscopy: a pilot study. Clin Nutr Res 2014;3:134–141.Article PubMed PMC
9. Niv E, Ovadia B, Ron Y, et al. Ensure preparation and capsule endoscopy: a two-center prospective study. World J Gastroenterol 2013;19:1264–1270.Article PubMed PMC
10. Chen HB, Huang Y, Chen SY, et al. Small bowel preparations for capsule endoscopy with mannitol and simethicone: a prospective, randomized, clinical trial. J Clin Gastroenterol 2011;45:337–341.Article PubMed
11. Wu S, Gao YJ, Ge ZZ. Optimal use of polyethylene glycol for preparation of small bowel video capsule endoscopy: a network meta-analysis. Curr Med Res Opin 2017;33:1149–1154.Article PubMed
12. Kotwal VS, Attar BM, Gupta S, Agarwal R. Should bowel preparation, antifoaming agents, or prokinetics be used before video capsule endoscopy? A systematic review and meta-analysis. Eur J Gastroenterol Hepatol 2014;26:137–145.Article PubMed
13. Ito T, Ohata K, Ono A, et al. Prospective controlled study on the effects of polyethylene glycol in capsule endoscopy. World J Gastroenterol 2012;18:1789–1792.Article PubMed PMC
14. Rokkas T, Papaxoinis K, Triantafyllou K, Pistiolas D, Ladas SD. Does purgative preparation influence the diagnostic yield of small bowel video capsule endoscopy?: a meta-analysis. Am J Gastroenterol 2009;104:219–227.Article PubMed PDF
15. Mathus-Vliegen E, Pellisé M, Heresbach D, et al. Consensus guidelines for the use of bowel preparation prior to colonic diagnostic procedures: colonoscopy and small bowel video capsule endoscopy. Curr Med Res Opin 2013;29:931–945.Article PubMed
16. Song HJ, Moon JS, Do JH, et al. Guidelines for bowel preparation before video capsule endoscopy. Clin Endosc 2013;46:147–154.Article PubMed PMC PDF
17. Yung DE, Rondonotti E, Sykes C, Pennazio M, Plevris JN, Koulaouzidis A. Systematic review and meta-analysis: is bowel preparation still necessary in small bowel capsule endoscopy? Expert Rev Gastroenterol Hepatol 2017;11:979–993.Article PubMed
18. Gkolfakis P, Tziatzios G, Dimitriadis GD, Triantafyllou K. Meta-analysis of randomized controlled trials challenging the usefulness of purgative preparation before small-bowel video capsule endoscopy. Endoscopy 2018;50:671–683.Article PubMed PDF
19. Catalano C, Companioni RA, Khankhanian P, et al. Video capsule endoscopy: is bowel preparation necessary? J Investig Med 2016;64:1114–1117.Article PubMed
20. Enns RA, Hookey L, Armstrong D, et al. Clinical practice guidelines for the use of video capsule endoscopy. Gastroenterology 2017;152:497–514.Article PubMed
21. Pons Beltrán V, González Suárez B, González Asanza C, et al. Evaluation of different bowel preparations for small bowel capsule endoscopy: a prospective, randomized, controlled study. Dig Dis Sci 2011;56:2900–2905.Article PubMed PDF
22. Bahar R, Gupta A, Mann SK. Clear liquids versus polyethylene glycol preparation for video capsule endoscopy of the small bowel: a randomized controlled trial. Digestion 2019;99:213–218.Article PubMed
23. Yazici C, Losurdo J, Brown MD, et al. Inpatient capsule endoscopy leads to frequent incomplete small bowel examinations. World J Gastroenterol 2012;18:5051–5057.Article PubMed PMC
24. Brotz C, Nandi N, Conn M, et al. A validation study of 3 grading systems to evaluate small-bowel cleansing for wireless capsule endoscopy: a quantitative index, a qualitative evaluation, and an overall adequacy assessment. Gastrointest Endosc 2009;69:262–270, 270.e1.Article PubMed
25. van Tuyl SA, den Ouden H, Stolk MF, Kuipers EJ. Optimal preparation for video capsule endoscopy: a prospective, randomized, single-blind study. Endoscopy 2007;39:1037–1040.Article PubMed
26. Van Weyenberg SJ, De Leest HT, Mulder CJ. Description of a novel grading system to assess the quality of bowel preparation in video capsule endoscopy. Endoscopy 2011;43:406–411.Article PubMed PDF
27. Klein A, Gizbar M, Bourke MJ, Ahlenstiel G. Validated computed cleansing score for video capsule endoscopy. Dig Endosc 2016;28:564–569.Article PubMed

Figure & Data

REFERENCES

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The Efficacy of 4 Liters of Clear Liquids for Small Bowel Preparation Prior to Video Capsule Endoscopy

Clin Endosc. 2020;53(6):713-718. Published online March 31, 2020

DOI: https://doi.org/10.5946/ce.2019.213

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The Efficacy of 4 Liters of Clear Liquids for Small Bowel Preparation Prior to Video Capsule Endoscopy

Variables	2 liters PEG (n=284)	4 liters clear liquid (n=284)	p-value
Age (mean, SD)	58.75±15.40	60.36±14.74	0.204
Sex, Male/Female, n (%)	112 (39)/172 (61)	108 (38)/176 (62)	0.730
BMI (mean, SD)	28.6±6.8	28.9±7.3	0.613
Prior abdominal surgery, n (%)	158 (56)	153 (54)	0.673
Diabetes mellitus, n (%)	84 (30)	74 (26)	0.349
Renal disease, n (%)	33 (12)	20 (7)	0.061
Liver disease, n (%)	17 (6)	25 (9)	0.200

Variables	2 liters PEG (n=284)	4 liters clear liquid (n=284)	p-value
Anemia (n, %)	158 (56)	185 (65)	0.021
GI bleed - Overt (n, %)	34 (12)	22 (8)	0.091
GI bleed - Occult (n, %)	4 (1)	5 (2)	0.737
Chronic abdominal pain (n, %)	34 (12)	30 (11)	0.596
Diarrhea (n, %)	16 (6)	26 (9)	0.109
Rule out small bowel tumor/polyp (n, %)	28 (10)	13 (5)	0.015
Suspect Crohn’s or IBD (n, %)	22 (8)	7 (3)	0.004
Rule out celiac disease (n, %)	10 (4)	4 (1)	0.104
Evaluate for AVM (n, %)	12 (4)	2 (1)	0.007
Malabsorption (n, %)	1 (0)	1 (0)	1.000
Weight loss (n, %)	0 (0)	5 (2)	0.061
Other (n, %)	3 (1)	11 (4)	0.030

Variables	2 liters PEG	4 liters clear liquid	p-value
Preparation quality, as Mean^a)	2.669±0.64 (n=264)	2.908±0.77 (n=276)	<0.0001
Number of exams with adequate prep^b)	170 (64) (n=264)	203 (72) (n=276)	0.0214
Gastric transit time in minutes^c)	38.80±43.61 (n=260)	31.20±38.92 (n=266)	0.0353
Small intestine transit time in minutes^c)	222.0±79.94 (n=249)	225.1±90.26 (n=252)	0.687
Capsule completion rate, n (%)	253 (89) (n=284)	252 (89) (n=284)	0.894

Endoscopic findings	2 liters PEG (n=274)	4 liters clear liquid (n=276)	p-value
Normal small bowel (n, %)	174 (64)	221 (80)	<0.0001
AVM/angiodysplasia (n, %)	38 (14)	10 (4)	<0.0001
Active bleed (n, %)	13 (5)	10 (4)	0.511
Small bowel polyp (n, %)	14 (5)	6 (2)	0.066
Diverticulum (n, %)	4 (2)	3 (1)	0.697
Inflammation (erosions, ulcers) of proximal to mid small bowel (n, %)	19 (7)	13 (5)	0.265
Non-specific mucosal flattening (n, %)	13 (5)	1(0)	0.001
Likely celiac disease (n, %)	8 (3)	2 (1)	0.054
Suspected tumor (n, %)	2 (1)	2 (1)	0.994
Stricture (n, %)	7 (3)	4 (2)	0.355
Ileitis (n, %)	7 (3)	19 (7)	0.017
Submucosal bulge (n, %)	3 (1)	1 (0)	0.312
Clinically significant finding (n, %)	110 (40)	63 (23)	<0.0001

Table 1. Baseline Demographics of Patients

BMI, body mass index; PEG, polyethylene glycol; SD, standard deviation.

Table 2. Indication for Procedure

Multiple indications possible for one procedure.

AVM, arteriovenous malformation; GI, gastrointestinal; IBD, inflammatory bowel disease; PEG, polyethylene glycol.

Table 3. Means and Standard Deviations for Small Bowel Preparation Quality, Gastric Transit Time, Small Intestine Transit Time, and Capsule Completion Rate

PEG, polyethylene glycol.

Preparation quality measured 1=poor; 2=fair; 3=good; 4=excellent.

Preparation considered adequate if quality score 3 or greater.

Time measured in minutes.

Table 4. Endoscopic Diagnosis, Multiple Diagnoses Possible for a Single Study