Bowel preps and Shudh Colon Cleanse
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Transcript of Bowel preps and Shudh Colon Cleanse
Vijaypal Arya M.D, F.A.C.P, F.A.C.G, A.G.A.FClinical Assistant Prof., Hofstra-Northwell Health.
Director, Endoscopy Unit, WHMC
First colonoscopic polypectomy
(1971) by Dr Hiromi Shinya1 and
Dr William Wolf (Beth Israel
Medical Center)
Adenoma – Carcinoma sequence2
Colonoscopy – Gold standard for
Colon Cancer Screening2
1 Sivak et al., 2004, 2Winawer et al., 1993
Percentage of adults aged 50 years and older who ever had a colorectal endoscopy, by race / ethnicity: 1987-2005
National Cancer Institute Database
Source: National Endoscopy Database/Clinical Outcomes Research Initiative
Mortality Person years of life lost
Janne and Mayer 2000
8.1 million screening colonoscopies/yr are required in the US1
and 14-17 million Colonoscopies in total.
Within 5 years, Colonoscopy screening in New York State for
those 50 and over climbs from 42% to 66% [2003-2008,
Citywide Colon Cancer Control Coalition (C5)]
1Ladabaum et al 2005
Consequences: More Pt. Discomfort
More Complications
Prolonged Procedure
Repeat Exams
Incomplete Exams
Missed lesions / Lost Polyps
Patient Dissatisfaction
Physician Dissatisfaction
≈ 20-25%
Male gender Age>60 yrs BMI>25 Cirrhosis Constipation Stroke Dementia Neurological – MS
Diverticulosis
Diabetes mellitus Prior colon resection Appendectomy Hysterectomy Timing of colonoscopy
(afternoon) In patient status Poor patient
education/Compliance
1Ness et al., 2007 2Chung et al., 2009 3Borg et al., 2009 4Sanaca et al., 2006
Endoscopist perspective
Safe
Effective
Excellent visualization
No electrolyte imbalances
No effect on bowel mucosa
No procedural difficulty
Easy patient acceptance for screening colonoscopy
Patient perspective
Safe
Palatable/tolerable/low volume
Least dietary restrictions
Least time consuming
Least side effects
No incontinence during travel
No sleep disturbance
No enema
Economical
1980
DIET: 24 – 48hrs. ENEMA LAXATIVE: Dulcolax
PEG Mechanism of action Registered name Tolerability
PEG-ELS Non-absorbable solutionthat should pass through thebowel without net absorption or secretion
Colyte (Schwarz) –Flavors: Cherry, Citrus-Berry, Lemon-Lime,Orange, PineappleGolytely (Braintree) Flavors: Pineapple
Large volumes (4L) arerequired to achieve aCathartic effect. Palatability is the major concern (5-15%)
SF-ELS The elimination of sodiumsulfate resultsin a lowerluminal sodium concentration. Hence, themechanism of action isdependent on the osmoticeffects of PEG.
Nulytely (Braintree) Flavors: Cherry, Lemon-lime, Orange, PineappleTriLyte (Schwarz) Flavors: Cherry, Citrus-Berry, Lemon-lime,Orange, Pineapple.
SF-PEG is better tastingthan Golytely, but stillrequires the consumptionof 4L in its standardregimen
PEG Mechanism Registered name Tolerability
Low Volume
PEG/PEG-3350 and
Bisacodyl Delayed-
Release Tablets
Bisacodyl and magnesium
citrate are added to PEG
Halflytely
(Braintree)
Flavors: Lemon-lime
Abdominal
cramping and
bloating (14%)
Low Volume PEG-
3350 and Bisacodyl
Delayed-Release
Tablets
An additional low volume
PEG 3350 without
electrolytes with adjuncts
such as bisacodyl
Miralax
(Schering-Plough)
Not FDA approved
Abdominal cramping
Bloating
Seizures
Severe hyponatremia
2-L PEG with
Ascorbate
(Gatorade is allowed)
The osmotic activity of
PEG, sodium sulfate,
NaCl, KCl, Sodium
ascorbate, and ascorbic
acid
MoviPrep (Salix) Abdominal
distension, anal
discomfort, thirst,
nausea, and
abdominal pain
PEG and NaP based preparations are known to cause local cellular injury,
although the actual clinical significance of this side effect is not known1
PEG based solutions are unpalatable2
PEG is non biodegradable, posing environmental threat – Stable even after
30 years after environmental exposure3
The sodium phosphate [NaP] solutions are associated with acute renal
toxicity even in healthy patients, posing a potential malpractice dilemma4
1Butcher et al., 2005 2Wexner et al., 2006 3Glastrup et al., 2006 4Markowitz et al., 2005
NCCAM / NIH
$ 70 Billion / Yr
According to a 2007 CDC survey, 38% of American adults
reported using CAM therapy in the previous12 months
Another national survey found that 15 million American
adults used Yoga at some point in their lives1
1Barnes et al., 2008
Credible scientific research is needed to demonstrate
the medical value of CAM therapies, their appeal is
clearly substantial
Yoga originated in India
more than 5,000 years ago
“Yoga” translates as “to
unify” – referring to a union
of mind and body
Studies on transcendental meditation have shown that experienced practitioners are able to exert autonomous nervous control– Studies on Yogi1
Beneficial effects of yoga on cardiovascular and neuron-endocrine systems have been reported in a number of studies2
Yoga has also been shown to improve myocardial perfusion and help in the regression of coronary lesions3
2Lin et al., 2001 3Gopal et al., 19741Kothari et al., 1973
Pros: 2500-5000 yrs old ( 600 B.C.) Beneficial for healthy life style Inexpensive
Cons: Lack of well-designed studies Difficult to standardize
Vijaypal Arya, Kalpana A. Gupta, Swarn V. Arya75-54 Metropolitan Ave. Middle Village, NY -11379
(718) 326-0400
A patient of Indian descent used “Shankh Prakshalana (BLS and exercise)” as a preparation for colonoscopy
The preparation was of such excellent quality that we were inspired to conduct this pilot study
METHODS
Upon informed consent, 54 patients between ages of 18 and 65 included in this study
– Group A: n = 27 ; BLS
– Group B: n = 27 ; Nulytely prep
*Protocol of this nonrandomized pilot study was approved by IRB at WHMC
Inclusion criteria Normal BMP
Exclusion criteria Hypertension Diabetes mellitus Arthritis Salt sensitivity
Patient Name—_____________ Age______ Sex M F Race____________Criteria—
Exclusion: Free of salt sensitiveness, hypertension, diabetes, arthritis, constipationInclusion: Normal BMP
Day of Consultation—Weight_______Height_______
Consent Form: SIGNED.Group: 1 2 Prep Form: EXPLAINED.Patient Response Form: COMPLETE. Day of Procedure—
Weight______Height______
Physician Form: COMPLETE.
INSTRUCTIONS (Day before colonoscopy)
Group A Patients in group A were given a
DVD of the shankh prakshalana postures to watch and practice
Regular mid-day meal From 2pm on - only clear liquids*
*Apple juice, grape juice, Gatorade, clear broth, hard candy, popsicles, Jell-O, tea and coffee
Group B As per the manufacturer’s
instructions, patient drank Nulytely at home
INSTRUCTIONS (Day of colonoscopy)
Group A NPO status after 12 midnight Reported to the endoscopy suit at 9am Asked to turn off phones and beepers
and to relax Examination room - quiet with an
available dedicated bathroom Vital signs and weight were recorded Instructed to perform light yoga
exercises alternating with drinking BLS
Group B Patients drank NuLytely at home Presented to endoscopy suit in the
morning
Instructions about the intake of BLS
9 grams of sodium chloride in one liter of lukewarm water (99 -102 °F)
Patients were instructed to drink 8 - 16 ounces continuously as a bolus
Two subgroups of patients within Group A: 16 oz. bolus ("16 oz. subgroup") and 8 oz. ("8 oz. subgroup")
Patients did yoga exercises – until bowel movements were clear Interrupt the process whenever there is urge to defecate, and not to
strain during defecation
INSTRUCTONS
Drink continuously rather than sipping slowly 8 oz (240 ml) in less than one minute 16 oz (480 ml) in less than two minutes
Ready position While inhale While exhale
Ready Inhale and to right Inhale and to left
Ready position Inhale Inhale
Ready position Inhale Inhale
Ready position Inhale Inhale
All colonoscopies were performed by a single gastroenterologist [VA].
The colonoscopy preparation was rated on a four point grading scale: ◦ Poor prep- 1◦ Sub-optimum- 2◦ Optimum- 3◦ Excellent- 4
Photographs were taken to substantiate the grading system.
Excellent Optimum
Sub optimum Poor
Excellent Optimum
Sub optimum Poor
PRIMARY AIM: To compare the BLS/Yoga group A with the NuLytely control group B
on total prep scores and scores at each of the six assessed sites: rectum, sigmoid, left colon, transverse colon, right colon, and cecum
SECONDARY AIMS, WITHIN THE YOGA GROUP: Determine how the 8 oz. v/s 16 oz. bolus drink – affects the quality of
preparation and speed of action, measured by time to first bowel movement and time to complete the prep regimen
To compare pre- and post-procedure electrolyte levels: Na, K, Cl, CO2,
BUN, Creatinine, and Glucose
Comparisons between groups in the study were made using the
Mann-Whitney test for each of the continuous measures. This test
was employed to compare the total prep scores: yoga group A vs.
NuLytely® control group B; and within the yoga group to gauge
how the 8 oz. v/s 16 oz. of solution intake affected the quality of
colon lavage
A comparison of pre- and post-procedure electrolyte levels was
made using the Wilcoxon signed rank test. The difference
between the measures was calculated as Post minus Pre
Group A Group BTotal patients N=27
N (%)N=27N (%)
Sex Male Female
8 (29.6)19 (70.4)
15 (55.5)12 (44.5)
Age 20-40 40-60 >60
17 (62.9)9 (33.3)1 (3.7)
2 (7.4)19 (70.4)9 (33.3)
Race Caucasian African American Hispanic Other
14 (51.8) 2 (7.4)
7 (25.9)4 (14.8)
17 (62.9)2 (7.4)7 (25.9)1 (3.7)
Arya et al., 2008
*Data in Group B is from package insert
The time to first bowel movement and total
preparation time is less in LWS/YOGA group cf.
NuLytely
The total solution drank is almost identical in both
groups
24 patients in group A and 21 people group B have either excellent or optimal preparation. Even though the difference in not statistically significant, according to the results, BLS is either equal or better than the regular bowel prep in healthy patients
Score BLS/YOGA NuLytely P-valueRectum 3.52 3.3 <0.2252Sigmoid 3.48 3.19 <0.1853Left colon 3.48 2.44 <0.0003Transverse colon 3.52 2.33 <0.0001Right colon 3.41 2.63 <0.0060Cecum 3.22 2.44 <0.0177Total 20.63 16.48 <0.0007
*The average total prep score for BLS/Yoga group is significantly better than NuLytely group (statistically significant ) and also in left and transverse colon segments.
Score 8 oz. “Bolus”Score (SD)
16 oz. “Bolus”Score (SD)
P-value
Rectum 3.00 (1.21) 3.93 (0.26) <0.0102
Sigmoid 3.08 (1.16) 3.80 (0.41) <0.0693
Left colon 3.17 (1.19) 3.73 (0.46) <0.2655
Transverse colon 3.17 (1.19) 3.80 (0.41) <0.1535
Right colon 3.08 (1.16) 3.67 (0.49) <0.2201
Cecum 3.00 (1.21) 3.40 (0.63) <0.5786
Total 18.50 (6.84) 22.33 (2.06) <0.2376
*16 oz. “Bolus” subgroup achieved better bowel cleaning score cf. 8 oz. “Bolus” subgroup (not statistically significant)
*The difference is statistically significant for both parameters
8 oz. “Bolus”Minutes (SD)
16 oz. “Bolus”Minutes (SD)
P-value
Total time spent 119.17 (39.30)
87.80 (38.60) <0.0310
Time to first bowel movement
57.42 (21.05)
25.80 (4.83) <0.0001
*All patients enrolled in the study completed the BLS/Yoga process and none of them refused to repeat in future.
ParameterPatient number
N (%)Solution palatability Unpleasant Pleasant
2 (7.4)25 (92.6)
Exercise Difficult Easy
1 (3.7)26 (96.3)
Score Mean difference (SD) P-valueSodium 0.20 (3.40) <1.000
Potassium 0.09 (0.47) <1.000
Chloride 6.60 (2.70) <0.0020
CO2 -5.44 (3.78) <0.0156
BUN -3.00 (2.69) <0.0039
Creatinine -0.022 (0.11) <0.4219
Glucose -9.00 (6.00) <0.0039
Pre and post procedural electrolyte abnormalities are not clinically and statistically significant for Sodium, Potassium and Creatinine. Even though the abnormalities are statistically significant for Chloride, Bicarbonate and Glucose, no clinical significance is noticed
The results demonstrated “LWS/Yoga” as a very
effective method of Bowel Prep in healthy individuals
These results are comparable to NuLytely with
minimal or no electrolyte imbalances and better oral
tolerability
DISCUSSION
Bowel preparation was identified as the most objectionable
aspect of the colonoscopy procedure1
Inadequate visualization with poor preparation and patient
intolerability still remained as the major concerns to be
solved2
The search for an ideal bowel preparation for colonoscopy is
a still ongoing – A new method might be the BLS/Yoga for
healthy patients
1Harewood et al., 2002 2Brown et al., 2004
Yoga
• Postures• Exercise• Breathing• Gravity
The 0.9% normal saline, also known as “Physiological Saline,” has an osmolarity of about 300 mosm, matching the osmolarity of plasma.
The saline solution empties from the stomach rapidly and exponentially
(29) – First order kinetics of gastric emptying
As the solution is isotonic, it should not get absorbed from the gastrointestinal tract, especially when consumed in bolus form.
The resulting high flow rate allows minimal time for ionic exchange.
Gastric emptying:. 50% will be emptied in every 8-12 minutes
Intestinal transit (NS @ flow rate of 10ml/min):
Jejunum: Absorption of 4-8 meq/L/30cm
Ileum: Active transport Most of the sodium and chloride
absorption takes place in ileum Colonic transit: Absorption is more in
ascending colon (active transport) With bolus intake the absorption of
sodium presumably be less as the sodium absorption is regulated by the net water movement in each segment
Jeejeebhoy KN, Olay foundation
Normal saline has been shown to stimulate gastro-colic reflex1
The gastro-colic cholinerergic propulsive reflex might be playing an important role in the success of this process1
Right colonic volume of the content is important in the initiation1
With gastro-colic reflex in action, the contents of hepatic flexure of colon move to splenic flexure instantaneously - without segmentation
Tansy et al., 1972 and 1973
Numerous studies have been done in the past using balanced
electrolyte solutions (BES) as colon prep1,2,3,4
In those previous studies, BES (high volume – 10-12L) was
administered in the subjects over a period of time (4-6hrs)
Majority of these studies reported weight gain and minor
electrolyte imbalances as adverse effects
None of those studies used “normal saline as bolus”
administration and Yoga postures/exercises
BALANCED ELECTROLYTE SOLUTIONS
1Crapp et al., 1971, 2Hewitt et al., 1973, 3Levy et al., 1976, 4Postuma 1981.
Study Report Solution Rate Total Volume
Electrolyte Imbalance
Wt. Gain
Levy at el. Gastroenterology.
1976
NaClNaHCO3
KClRoom Temp
1L/40 min. consumed
10L/4 hours3905±1098 ml(1000-6000 ml)
None 1.1 kg
Postuma. Pediatric Surgery. 1982
NaCl,KClWarm
1-2L/hr Infused
9±2L/7±2 hours
Mild ↑ Cl 0.9 kg / Pt
Crapp et al., Lancet. 1971
Warmed Isotonic saline
KCl was added later
3-4L/60hr 9-12L Not reported 1.9+/-0.8kg
Hewitt at el. The Lancet. 1973
NaCl, KClNaHCO3
Distilled water (37°)
75 ml/mininfused
9-13L/2-3 hours
Not reported 1.5 L / Hr fluid
absorption
Chattopadhyay at el. Pediatric Surgery.
2004
NaClKCl
70 ml/kg/ 60 min infused
250 ml/ kg Insignificant Not reported
Fluid secretion in the gastro intestinal tract is primarily by active transepithelial secretion of chloride ions(26)
Fluid absorption is by uptake of sodium
(26) It is known that depending on the
electrolyte composition of the meal, chloride secretion can be inhibited or stimulated (26)
Electrogenic sodium absorption takes place in the distal colon with a final outcome of stool dehydration (28)
Potassium movement in the gastrointestinal tract is passive.
During fasting: Sodium coupled with chloride is actively
absorbed against an electrochemical gradient by the intestinal mucosa (27)
Lavage Solution with Minimal Water and Electrolyte Absorption or Secretion
Ingestion of large volume of BES has previously been shown to be an effective method of cleaning the colon for diagnostic studies.
This study has shown that total gut perfusion with BES (25-30ml/min) results in absorption of 2400mL water and 375meq of Na in 3hrs.
This might be hazardous to pts who are unable to excrete salt and water load.
4 solutions with varying composition are used in this study and solution D has been associated with near zero net movement of electrolytes
Davis at el., 1980
NaCl (mM)
Na2S04 (mM)
KCl (mM)
NaHC03 (mM)
Mannitol (mM)
PEG (g/L)
Osmol (mOsmol/kg)
D 25 40 10 20 80 5 273
BES 110 10 30 5
Lavage Solution with Minimal Water and Electrolyte Absorption or Secretion
Comparison of Solution D and BES:In normal subjects there was no significant change in hemoglobin concentration, hematocrit, or, serum electrolytes during administration of any of these solutions.There was no clinically significant electrolyte imbalance was mentioned.There was a mean weight gain of 0.54kg/hr of perfusion with BES
Subjects N Sol. Infusion rate (ml/min)
Water (ml/hr)
Na(meq/hr)
K(meq/hr)
CL(meq/hr)
HCO3(meq/hr)
Normal* 5 BES 30±1 -819±29 -127±4 -10±1 -110±6 -26±2
Normal 5 D 28±1 +56±35 0±7 0±1 +11±5 -5±2
Normal 5 D 20±1 -20±40 -7±6 -1±2 -2±5 -4±2
Liver dz 1 D 29 +78 -5 -1 +8 -2
Renal dz 1 D 20 -137 -26 -1 -8 -7
Normal 5 E 38±1 -130±40 -8±8 -3±1 +8±4 -10±1
Davis at el., 1980
Age Gender BMI Volume Calorie content Exercise Temperature Posture Breathing
Aged individuals have slower liquid gastric emptying and
same rates of solid gastric emptying (significance
unknown)1
Males have faster gastric emptying rates for solids and
liquids than females2 (equal in elderly population)3
Gastric emptying in the obese is normal with large meals,
but is delayed in small meals4
1Moore et al., 1983 2Datz et al., 1987, 3Horowitz et al., 1984, Christian et al., 1986
Gastric emptying of solids
More than volume it is dependent on the calorie content as equal calorie carbohydrate and triglyceride solid food emptied in the same time
Gastric emptying of liquids
Dependent on initial volume (first order kinetics) and calorie content of liquid.
Normal saline (non nutrient liquid) emptying is dependent on initial volume intake.
Experiment: Effect of different meal volumes on the speed of gastric emptying in 5
dogs w/ duodenal fistulas using:
Liquids (150, 200, 600, 1200 mL of phosphate buffer)
Solids (150, 300, 600g of cooked beef steak)
Results: Steak emptying was independent of meal volume
Liquid emptying was dependent on original meal volume; meal volume
ACCELERATED gastric emptying of liquids
Trituration of the steak accounted for emptying at a fixed rate
Lin et al., 1992
Study: Gastric emptying patterns in response to different volumes of test-meals.
Method: test meal= 2% solution of pectin, 3-5% sucrose, w/phenol red added as a marker.
Subject had stomach washed out w/250mL of tap water, and drank chosen test-meal; after a measured interval, gastric contents were withdrawn and measured
Hunt & Macdonald 1954
Results and conclusion: Rate of gastric emptying of a standard test-meal is influenced by interplay
between Volume of meal taken Ratio of the volume in the stomach to the volume that has flowed into the
intestine Distension of the stomach and/or intestine which preceded the ingestion of meal
Non-sucrose meals left the stomach quicker than glucose meals
Test-meal Volumes of meals ranged from 50-1250 mL, composition
varied from pure carbohydrate to ordinary food Analysis Volume of each test-meal delivered to the duodenum in 30
min (assuming that gastric emptying was exponential) Predicted a rate of gastric emptying for each meal, given its
nutritive density and assuming a relationship between stimulus and duodenal receptors
Conclusion Isocaloric concentrations of carbohydrate and triglyceride
produce equal slowing of gastric emptying For a given nutritive density (kcal/mL) the rate of emptying
(mL/min) is independent of the initial volumeHunt & Stubbs 1974
Gastric emptying is significantly reduced by giving a
cold drink, but temperature has no significant effect on
the half-life of emptying after 5min suggesting that meal
temperature affects adaptive relaxation mechanisms
Warm liquids results in greater relaxation of gastric
muscle
Experiment:
Effect of meal temperature and volume on emptying of liquid meals (8 normal
volunteers)
4 drinks investigated: 200mL - 12 C & 37 C; 500mL - 12 C & 37 C
Bateman et al., 1982
Results
The 5min gastric volume was significantly reduced by giving a cold drink of
500mL ( 12 C: 250m, 37 C: 307mL (P<0.05)
Temperature had no significant effect on the half-life of emptying after 5min
Suggest that meal temperature affects adaptive relaxation mechanisms
Warm liquids results in greater relaxation of gastric muscle as indicated by the
reduction in the initial emptying and subsequent higher 5 min gastric volume
Study : Measured emptying of 400 mL drink of orange juice from the stomach (6
healthy volunteers, ages 19-24) ingested at diff. temperatures: 4°C (cold), 37°C (control), 50°C (warm)
Results and Conclusions: Warm & cold drinks emptied from stomach slower than control drink Initial rate of gastric emptying of the cold drink was significantly slower
than the control drink (P<0.05) The difference in the initial emptying rates between warm and control
drinks were not statistically significant Intragastric temperature returned to within 1°C of body temperature 20 to
30 min after ingestion of the warm and cold drink respectively, after which the emptying rates were identical to the control
Sun et al., 1988
Kim et al., found that an exercise as simple as walking improved colonoscopy
preparation among younger, non-obese patients with no history of abdominal
surgery
Animal studies have shown that in both fed and fasted states, exercise induces
giant migratory complexes, defecation and mass movement (44, 45).
Acute aerobic exercise decreased colonic phasic motor activity, resulting in
less resistance to colonic flow, while post exercise increased the amplitude of
propagated waves was thought to enhance propulsion causing, which was
followed by increased propagating waves after stopping (46).
We speculate, in the BLS/Yoga regimen, the first
four postures are specifically aimed at improving
gastric emptying.
The fifth posture (squatting) affects the colonic
motility by increasing the intraabdominal pressure.
Simply lying on one’s right side can increase the gastric emptying
of a saline test meal which does not activate duodenal receptors (37,
38).
Moore, et al noted a marked effect of body posture on radionuclide
measurements of gastric emptying (39).
Gravity, coupled with postural change, influences the gastric
configuration, which in turn changes intragastric meal distribution,
leading to a more rapid emptying of non-nutrient inert liquids (40).
Study: Saline test meals/non-nutrient (750mL NaCl) given by tube into
stomach in sitting, lying on left side, and lying on right side.
Gastric contents were recovered at 10min, the rate of gastric
emptying was assessed from the recovery of the original solution
marked w/phenol red
Similar study with 750mL glucose test meals/nutrient given to the
same subjects in the same positions
Murdoch at el., 1980
Results:
Glucose test meal/nutrient: no significant difference in volume recovered
Conclusion: Posture influences gastric emptying in non-nutrient/ saline meals.
As opposed to glucose test meals that does not activate duodenal receptors, resulting in the slowing of gastric emptying
Test meal Non-Nutrient Volume recovered
NutrientVolume recovered
Lying on Lt. side 431mL 589mL
Lying on Rt. side 215mL (p<0.005) 555mL (p<0.005)
Sitting 308mL 564mL
Murdoch at el., 1980
Study: Effects of posture on gastric emptying, intragastric distribution,
and antropyloroduodenal motility after ingestion of non-nutrient liquid.
Antropyloroduodenal pressures measured in 7 healthy patients for 30 min after ingestion of 150 mL of normal saline in 2 positions (sitting & left lateral)
Result: Rates on emptying of the stomach was faster in the sitting
position than in the left lateral position
Anvari et al., 1995
Conclusion: The effects of gravity on gastric emptying on non-nutrient
liquids are likely to reflect changes in both antropyloric motility and intragastric distribution.
Changes in gastric configuration also interact with gravity to determine intragastric distribution. ◦ these changes are more likely to be due to gravity rather
than changes in gastric motility. Gravity:
◦ affects gastric emptying◦ helps determine whether modifications in posture are
associated w/alterations in active gastric pumping or breaking mechanisms or changes in intragastric distribution
Anvari et al., 1995
Study Effect of body posture on gastric emptying measurements of
radiolabeled meals 8 healthy male subjects were fed a standardized meal of beef
stew labeled w/ technetium-99m sulfur colloid, and orange juice. Measurements obtained by gamma camera in lying, sitting,
standing, or combined sitting-standing postures. During the sitting-standing studies, subjects were alternately
sitting and standing and allowed to walk in between the 10 min counting intervals.
During the lying, sitting, and standing only studies, subjects were encouraged to remain motionless.
Moore at el., 1988
Results: The lying position significantly slowed solid phase meal
emptying half times by:102% in sitting-standing position54% in sitting only position66% in standing only position
Activity during the sitting-standing position may also play a role in gastric emptying
Moore et al., 1988
The yoga postures begin with a deep inhalation and end with exhalation
The resulting movements of the diaphragm change the gastric configuration, which in turn has an effect on intragastric meal distribution and gastric emptying
Changes in gastric configuration during diaphragmatic movement are well evident from radiological studies
The authors speculate that deep breathing does in fact have some role in faster gastric emptying
INHALATION
EXHALATION
STRETCHING
TO RIGHT SIDE
STRETCHING
TO LEFT SIDE
Role of Mind-Body interaction?(Neuropeptides such as
Cholecystokinin and VIP has effects on GI motility)
Breathing • Gastric emptying – Presumed to be fast
Varies according to Pt’s medical condition Pt preference Clinical indication “Sleep is important” Travel without incontinence Time of Prep adjusted to time of exam and travel
arrangement Frail, ill & Elderly – Modified prep, Inpatient Obstruction – Suspected – Oral prep may be dangerous
The importance of adhering to prep and adequate hydration during and
after bowel prep should be emphasized
The choice of bowel cleansing should be based on age, health status,
comorbid diseases, and personal preference
A split- dose improves the quality of bowel cleansing, especially in
ascending colon
NaP has better efficacy and tolerability than PEG. NaP should be avoided
in impaired renal function, CHF, advance liver disease, or hypercalcemia
All purgatives have been associated with serious adverse events.
The risk can be minimized by selecting most appropriate prep
What Is Current Knowledge
1-High volume (7-12 Liters) of saline solution infusion
in 4-6 hrs has been shown to be effective for
colonoscopy preps. This can cause dramatic fluid and
electrolyte shifts and currently not recommended.
2-Exercise helps in colonoscopy preps
What Is New Here1-The study demonstrates the effectiveness of Low
volume (3 Liters) BLS/Yoga in colonoscopy preps2-A new mechanism of colon preparation is explored. The
“bolus drinking” (Dumping) of LWS in conjunction with Yoga postures (deep breathing, gravity, gastric configuration, and exercises) achieved faster gastric emptying leading to successful colon prep for colonoscopy
The results are very encouraging and thought
provoking The LWSW + exercise preparation is safe, simple, and
inexpensive Further studies are needed to confirm the initial
promise of this novel approach to colonoscopy
preparation
1. Sivak, Jr., Michael V. "Polypectomy: Looking Back". Gastrointestinal Endoscopy. 2004, 60 (6): 977–982. [PMID 15605015].
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