A Phase 2 evaluation of a new flavored peg and sulfate solution compared to an over-the-counter laxative, peg and sports drink bowel preparation combination.

BACKGROUND: Acceptability and tolerance of bowel preparation is critical to overcome patient hesitancy in undergoing colon cancer screening and surveillance colonoscopy. To improve patient experience, a new sports drink-flavored bowel preparation containing polyethylene glycol (PEG) and sulfate salts (FPSS) was developed to provide a similar experience to a commonly used but not United States Food and Drug Administration (FDA) approved PEG and sports drink bowel preparation (PEG-SD), while also achieving improved cleansing efficacy. METHODS: This FPSS preparation, approved by the FDA in June 2023, was evaluated in a non-randomized Phase 2 study in which 40 patients requiring colonoscopy were prepared with FPSS and 20 with PEG-SD. RESULTS: Overall cleansing success was high with FPSS based on unblinded local endoscopist assessment (93%) and blinded central reading (97%), exceeding PEG-SD which achieved success rates of 84% (local read), 74% and 68% (blinded central reads). Similar differences favoring FPSS were seen for excellent preparations and cleansing success by colon segment as rated by local endoscopists. Both preparations were well-tolerated, with 93% of FPSS patients rating their preparation as Tolerable to Very Easy to consume, compared to 100% of PEG-SD. Patients who had previously taken a preparation for colonoscopy found FPSS and PEG-SD better than their prior preparation (73% and 70%, respectively) and nearly all would request their assigned study preparation again in the future. About two thirds of FPSS patients agreed that the preparation tasted similar to a sports drink. CONCLUSION: The new sports drink-like flavored preparation compares favorably to PEG-SD for bowel cleansing efficacy while achieving similar patient satisfaction. The study was registered at www. CLINICALTRIALS: gov (NCT03328507) on 01/11/2017.

Comparison of a Novel, Flavor-optimized, Polyethylene Glycol and Sulfate Bowel Preparation With Oral Sulfate Solution in Adults Undergoing Colonoscopy.

INTRODUCTION: A new bowel preparation for colonoscopy has been developed containing poorly absorbed sulfate salts and polyethylene glycol 3350, which retain water within the intestinal lumen resulting in copious diarrhea, thereby cleansing the bowel. The product was formulated to be safe and effective with a sports drink-like flavor. This study evaluated the new flavored polyethylene glycol and sulfate solution (FPSS) compared with a Food and Drug Administration-approved bowel preparation containing sulfate salts only [oral sulfate solution (OSS)]. METHODS: Five hundred adults were enrolled in this multicenter, noninferiority study. Subjects were assigned FPSS or OSS administered in split-dose regimens (PM/AM). FPSS subjects took 2 L of the flavored osmotic solution (1 L at night and 1 L in the morning). OSS was taken according to its approved labeling. Colonoscopies were graded globally and segmentally by blinded local investigators using a 4-point scale (excellent, good, fair, and poor), with "good" and "excellent" considered successful. Safety was assessed by adverse events (AEs) and laboratory testing. RESULTS: A high rate of cleansing success was seen with FPSS (94%), which was noninferior to OSS (94%). This conclusion was confirmed by blinded central readers. Segmental success rates were >90% for both preparations, including the right colon. Questionnaire ratings indicated the FPSS experience was preferred over OSS with 87% of FPSS subjects noting their preparation was "tolerable" to "very easy" to consume versus 74% for OSS. The majority of FPSS subjects agreed their preparation tasted like a sports drink. Gastrointestinal symptoms were the most common AEs. There was no difference between preparations for any AE and no clinically significant differences in laboratory parameters. CONCLUSIONS: The new sports drink-like flavored preparation achieved a high level of cleansing in the study, demonstrating noninferiority to OSS. FPSS was well-tolerated with low rates of expected gastrointestinal symptoms. The optimized flavor of FPSS resulted in significantly better acceptance ratings.

A Safety and Efficacy Comparison of a New Sulfate-Based Tablet Bowel Preparation Versus a PEG and Ascorbate Comparator in Adult Subjects Undergoing Colonoscopy.

INTRODUCTION: A new tablet-based bowel prep for colonoscopy has been developed containing poorly absorbed sulfate salts which act to retain water within the intestinal lumen resulting in a copious diarrhea, thereby cleansing the bowel. This study evaluated the safety and efficacy of these oral sulfate tablets (OST) compared with a US FDA-approved bowel prep solution containing PEG3350, electrolytes, and ascorbate (polyethylene glycol and ascorbate [PEG-EA]). METHODS: Five hundred fifteen adult patients (mean 57y) were enrolled in this single-blind, multicenter, noninferiority study. Subjects were assigned either PEG-EA or OST to be administered in a split-dose regimen starting the evening before colonoscopy. PEG-EA was taken according to its approved labeling (1 L of prep solution with 16 oz. of additional water) in the evening and again in the morning. OST patients took a total of 24 tablets. OST patients were administered 12 tablets in the evening, and the following morning. Patients consumed 16 ounces of water with each dose of 12 tablets and drank an additional 32 oz. of water with each dose. Colonoscopies were performed by blinded investigators. Cleansing efficacy was evaluated globally and segmentally using a 4-point scale (Excellent-no more than small bits of feces/fluid which can be suctioned easily; achieves clear visualization of the entire colonic mucosa. Good-feces and fluid requiring washing and suctioning, but still achieves clear visualization of the entire colonic mucosa. Fair-enough feces even after washing and suctioning to prevent clear visualization of the entire colonic mucosa. Poor-large amounts of fecal residue and additional bowel preparation required). Scores of Good or Excellent were considered to be a success. Safety was assessed by spontaneously reported adverse events, solicited ratings of expected prep symptoms, and laboratory testing. RESULTS: A high rate of cleansing success was seen with OST (92%), which was noninferior to PEG-EA (89%). Only a small proportion of subjects rated their expected gastrointestinal symptoms as severe (<5% for both preps). No clinically significant differences were seen between preps for chemistry and hematology parameters. No serious adverse experiences were reported with OST. DISCUSSION: Sulfate tablets achieved a high level of cleansing in the study, comparable with US FDA-approved preps. OST was noninferior to PEG-EA in this study and achieved significantly more Excellent preps overall and in the proximal colon. The OST prep was well-tolerated, with a similar rate of spontaneously reported adverse experiences to PEG-EA and a low rate of severe expected gastrointestinal symptoms.

A Prospective Multicenter Study Evaluating Endoscopy Competence Among Gastroenterology Trainees in the Era of the Next Accreditation System.

PURPOSE: The Next Accreditation System requires training programs to demonstrate competence among trainees. Within gastroenterology (GI), there are limited data describing learning curves and structured assessment of competence in esophagogastroduodenoscopy (EGD) and colonoscopy. In this study, the authors aimed to demonstrate the feasibility of a centralized feedback system to assess endoscopy learning curves among GI trainees in EGD and colonoscopy. METHOD: During academic year 2016-2017, the authors performed a prospective multicenter cohort study, inviting participants from multiple GI training programs. Trainee technical and cognitive skills were assessed using a validated competence assessment tool. An integrated, comprehensive data collection and reporting system was created to apply cumulative sum analysis to generate learning curves that were shared with program directors and trainees on a quarterly basis. RESULTS: Out of 183 fellowships invited, 129 trainees from 12 GI fellowships participated, with an overall trainee participation rate of 72.1% (93/129); the highest participation level was among first-year trainees (90.9%; 80/88), and the lowest was among third-year trainees (51.2%; 27/53). In all, 1,385 EGDs and 1,293 colonoscopies were assessed. On aggregate learning curve analysis, third-year trainees achieved competence in overall technical and cognitive skills, while first- and second-year trainees demonstrated the need for ongoing supervision and training in the majority of technical and cognitive skills. CONCLUSIONS: This study demonstrated the feasibility of using a centralized feedback system for the evaluation and documentation of trainee performance in EGD and colonoscopy. Furthermore, third-year trainees achieved competence in both endoscopic procedures, validating the effectiveness of current training programs.

Effect of individualized feedback on learning curves in EGD and colonoscopy: a cluster randomized controlled trial.

BACKGROUND AND AIMS: Gastroenterology fellowships need to ensure that trainees achieve competence in upper endoscopy (EGD) and colonoscopy. Because the impact of structured feedback remains unknown in endoscopy training, this study compared the effect of structured feedback with standard feedback on trainee learning curves for EGD and colonoscopy. METHODS: In this multicenter, cluster, randomized controlled trial, trainees received either individualized quarterly learning curves or feedback standard to their fellowship. Assessment was performed in all trainees using the Assessment of Competency in Endoscopy tool on 5 consecutive procedures after every 25 EGDs and colonoscopies. Individual learning curves were created using cumulative sum (CUSUM) analysis. The primary outcome was the mean CUSUM score in overall technical and overall cognitive skills. RESULTS: In all, 13 programs including 132 trainees participated. The intervention arm (6 programs, 51 trainees) contributed 558 EGD and 600 colonoscopy assessments. The control arm (7 programs, 81 trainees) provided 305 EGD and 468 colonoscopy assessments. For EGD, the intervention arm (-.7 [standard deviation {SD}, 1.3]) had a superior mean CUSUM score in overall cognitive skills compared with the control arm (1.6 [SD, .8], P = .03) but not in overall technical skills (intervention, -.26 [SD, 1.4]; control, 1.76 [SD, .7]; P = .06). For colonoscopy, no differences were found between the 2 arms in overall cognitive skills (intervention, -.7 [SD, 1.3]; control, .7 [SD, 1.3]; P = .95) or overall technical skills (intervention, .1 [SD, 1.5]; control, -.1 [SD, 1.5]; P = .77). CONCLUSIONS: Quarterly feedback in the form of individualized learning curves did not affect learning curves for EGD and colonoscopy in a clinically meaningful manner. (Clinical trial registration number: NCT02891304.).

The characterization, management, and future considerations for ErbB-family TKI-associated diarrhea.

PURPOSE: Diarrhea is recognized as a common adverse event associated with tyrosine kinase inhibitors (TKIs), with those targeting the ErbB family of receptors being associated with the highest rate of diarrhea. METHODS: This paper reviews data on the incidence, timing, and duration of diarrhea associated with US Food and Drug Administration-approved ErbB family-targeted TKIs from the published literature, and sets forth recommendations for management. RESULTS: In the absence of anti-diarrheal prophylaxis the incidence of any-grade diarrhea varies and typically occurs early during the course of treatment. Although it is difficult to determine if the incidence and severity of diarrhea is related to inhibition of a particular kinase target because of the multi-targeted and overlapping activity of many agents, evidence suggests that second-generation TKIs with broader target profiles (i.e., afatinib, lapatinib, neratinib) result in a higher incidence of diarrhea compared with highly specific first- (erlotinib, gefitinib) or third- (osimertinib) generation agents. The mechanisms responsible for TKI-associated diarrhea are not fully understood and are likely multi-factorial, involving dysregulated ion transport, inflammation, and mucosal injury. Management strategies have been developed-and continue to be refined-to prevent and reduce the severity and duration of TKI-associated diarrhea. For agents associated with more significant symptoms, anti-diarrheal prophylaxis reduces the incidence and severity of diarrhea, and ongoing studies are evaluating specific strategies to further reduce incidence and duration of TKI-associated diarrhea. CONCLUSIONS: Continued investigations into risk factors and pharmacogenomic markers for diarrhea may further improve management of this common toxicity.

Faecal microbiota transplantation: applications and limitations in treating gastrointestinal disorders.

The process of stool transfer from healthy donors to the sick, known as faecal microbiota transplantation (FMT), has an ancient history. However, only recently researchers started investigating its applications in an evidence-based manner. Current knowledge of the microbiome, the concept of dysbiosis and results of preliminary research suggest that there is an association between gastrointestinal bacterial disruption and certain disorders. Researchers have studied the effects of FMT on various gastrointestinal and non-gastrointestinal diseases, but have been unable to precisely pinpoint specific bacterial strains responsible for the observed clinical improvement or futility of the process. The strongest available data support the efficacy of FMT in the treatment of recurrent Clostridium difficile infection with cure rates reported as high as 90% in clinical trials. The use of FMT in other conditions including inflammatory bowel disease, functional gastrointestinal disorders, obesity and metabolic syndrome is still controversial. Results from clinical studies are conflicting, which reflects the gap in our knowledge of the microbiome composition and function, and highlights the need for a more defined and personalised microbial isolation and transfer.

Does Carbohydrate Challenge Testing Predict Clinical Response in Small Intestinal Bacterial Overgrowth?

OBJECTIVES: Small intestinal bacterial overgrowth (SIBO) is considered a frequent cause of abdominal symptoms in patients with surgically altered intestinal anatomy or dysmotility conditions and is recognized as a contributing factor in the exacerbation of irritable bowel syndrome symptoms. Diagnostic testing can be used to detect the condition. METHODS: The study group comprised patients who had breath hydrogen and methane lactulose challenge testing. All of the patients were treated with antibiotic regimens that have shown benefit for SIBO. The lactulose challenge was administered orally at 15 g. Hydrogen and methane in expired air were measured and hydrogen values were recorded as the hydrogen plus twice the methane result. Breath tests were analyzed for positivity based on single and multiple criteria of fasting baseline elevation, early rise, and second peak hydrogen rise. Global improvement of gastrointestinal symptoms was assessed by telephone contact or record review. RESULTS: One hundred participants (78 women) were included in the analysis. The mean age was 51 years. A total of 15% of participants did not meet any criteria on breath testing for SIBO; 73% had a fasting baseline elevation >10 ppm; and 19% had an increase of >20 ppm above baseline in the first 20 minutes, 48% had a 20-ppm increase in the first 60 minutes, and 32% had a second increase, reflecting a colon peak. Overall, 74% responded to a course of antibiotics, determined by reported improvement in more than half of the symptoms within 3 months. In total, 67% (10/15) of the subjects who tested negative for SIBO, by all criteria, had a favorable response to antibiotics. Among those with positive hydrogen increases, 76.3% with 1 criterion responded, 66.7% with 2 criteria responded, 84.6% with 3 responded, and 76.9% with 4 responded. After antibiotic treatment, 88.7% (47/53) of those who had diarrhea reported improvement, 63.3% (19/30) with constipation reported improvement, and 74.3% (52/70) with baseline bloating experienced improvement. Sixty-five of the 82 patients with pain or discomfort reported improvement (79.3%). Of those treated with a rifaximin regimen, 74.2% (49/66) reported a response to treatment. Twenty of 28 (71.4%) treated with amoxicillin/clavulanate experienced a clinical response. CONCLUSIONS: These data suggest that the response to antibiotic therapy in patients with suspected SIBO is not predicted by carbohydrate SIBO testing results and bring into question the value of such testing.

A randomized, controlled trial of oral sulfate solution plus polyethylene glycol as a bowel preparation for colonoscopy.

BACKGROUND: No bowel preparation for colonoscopy is optimal with regard to efficacy, safety, and tolerability. New options for bowel preparation are needed. OBJECTIVE: To compare a new hybrid preparation consisting of a reduced dose of oral sulfate solution (OSS) plus 2 L of sulfate-free electrolyte lavage solution (SF-ELS) with 2 low-volume preparations based on polyethylene glycol electrolyte lavage solution (PEG-ELS). DESIGN: Two randomized, controlled trials. SETTING: Twenty-four U.S. centers. PATIENTS: A total of 737 outpatients undergoing colonoscopy. INTERVENTIONS: In study 1, OSS plus SF-ELS was given as a split dose, and in study 2, OSS plus SF-ELS was given in its entirety the evening before colonoscopy. In study 1, the active control was 2 L of PEG-ELS plus ascorbic acid (PEG-EA) given as a split dose. In study 2, the control was 10 mg of bisacodyl plus 2 L of SF-ELS taken the evening before colonoscopy. MAIN OUTCOME MEASUREMENTS: Rates of successful (good or excellent) bowel preparation. RESULTS: In study 1, the rates of successful (excellent or good) preparation with OSS plus SF-ELS and PEG-EA were identical at 93.5% for split-dose preparation. OSS plus SF-ELS was noninferior to PEG-EA (P < .001). In study 2, OSS plus SF-ELS resulted in successful preparation in 89.8% of patients compared with 83.5% with bisacodyl plus SF-ELS in a same-day preparation regimen. OSS plus SF-ELS was noninferior to bisacodyl plus SF-ELS (P <.001). In study 1, vomiting was more frequent with OSS plus SF-ELS (13.5% vs 6.7%; P = .042), and bloating was rated worse with PEG-EA (P = .025). In study 2, overall discomfort was rated worse with OSS plus SF-ELS (mean score 2.1 vs 1.8; P = .032). There were no deaths in either study and no serious adverse events considered related to the preparation. LIMITATIONS: Bowel cleansing was not scored by colon segment. Adenoma detection was not compared between the regimens. CONCLUSION: OSS plus SF-ELS is a new, safe, and effective bowel preparation for colonoscopy.

Colon cleansing for colonoscopy 2013: current status.

Colonoscopy requires adequate bowel cleansing to be safe and effective. There are a variety of options available. This review will focus on highlighting new products, administration techniques emphasizing the value of split-dose and same-day regimens, safety, and options for inadequate cleansing.

Endemic fungal infections in inflammatory bowel disease associated with anti-TNF antibody therapy.

Patients with inflammatory bowel disease are susceptible to complications from pharmacologic treatment of their disease. Tumor necrosis factor (TNF)-α inhibitors are being used increasingly in the treatment of inflammatory bowel disease and can be associated with adverse events, including common infections, and rarely the development of serious life-threatening opportunistic infections. TNF-α inhibitors have the ability to prevent an effective patient granulomatous response, and this may be associated with an increased risk of developing mycobacterial and certain fungal infections, including histoplasmosis, blastomycosis, and coccidioidomycosis, endemic in several parts of the United States. The concern for invasive fungal infection was realized during clinical trials and further demonstrated after the marketing of TNF-α inhibitors. Because of this awareness, the Food and Drug Administration developed an adverse event-reporting system to capture cases of infections associated with the use of TNF-α inhibitors. These opportunistic fungi have a great degree of regional variability, and it has been very difficult to quantify the incidence of infection in patients treated with TNF-α inhibitors. Currently, there are no formal guidelines regarding the use of TNF-α inhibitors and these fungal infections. Considering that gastroenterologists have embraced the use TNF-α inhibitors as a valuable armamentarium in the treatment of inflammatory bowel disease, they must be aware of therapy-related infectious complications, including appropriate diagnostic, therapeutic, and preventive strategies. In this article, we explore the association of these fungal entities in relation to the TNF-α inhibitor therapy by considering information provided in the gastroenterology, infectious diseases, rheumatology, and transplant literature. Finally, we provide some recommendations on diagnosis and treatment.

Crohn's disease: the subsequent visit.

The diagnosis and subsequent management of Crohn's disease are challenging for both the patient and the gastroenterologist. After the initial assessment, subsequent visits should assess the patient's readiness to begin therapy, monitor progress if therapy has been initiated, assess for complications of the disease or therapy, and ensure that all appropriate health maintenance measures are current. This article is intended to be a companion to our earlier paper "Crohn's Disease: The First Visit," which was published in Gastroenterology & Hepatology in March 2011. This article will offer a methodologic and sequential approach to subsequent office visits, as well as provide a checklist for the assessment of Crohn's disease.

The role of effective clinician-patient communication in the management of irritable bowel syndrome and chronic constipation.

Irritable bowel syndrome (IBS) and chronic constipation (CC) are common functional bowel disorders that are among the most frequent reasons for referral to a gastroenterologist. Diagnosis and management of these conditions can be challenging for both the clinician and the patient for a number of reasons. Diagnosis can be complicated by the lack of a specific diagnostic test and the fact that IBS and CC are multisymptomatic conditions, whereas management can be suboptimal, because the conditions are often undiagnosed and self-managed by the patient. Furthermore, these are chronic conditions that must be managed over the long term, which can often lead to frustration both on the part of the patient and the clinician. As such, the role of the therapeutic clinician-patient relationship in diagnosis and management of these conditions has been attracting increasing attention. A patient-centered approach with a strong focus on effective communication between the clinician and the patient has been recommended for management of functional bowel diseases such as IBS and CC and has been associated with improved outcomes, increased patient satisfaction, and decreased utilization of care. The potential benefit of such practices as asking open-ended questions, actively listening to the patient, and displaying empathy in strengthening the clinician-patient relationship are highlighted in this manuscript. These skills have broad application in clinical medicine and can be used to improve clinician-patient communication in the management of patients with chronic illnesses.

"Red flag" evaluation yield in irritable bowel syndrome.

BACKGROUND: The diagnosis of irritable bowel syndrome (IBS) is based on clinical criteria. Further diagnostic testing is advised for certain "red flag" alarm or warning signs. AIM: This investigation was designed to examine the yield of testing for "red flags". METHODS: Consecutive patients who were prospectively evaluated and met the ROME III criteria for IBS were reviewed for "red flags" which included: 1) rectal bleeding, 2) iron-deficiency anemia (IDA), 3) weight loss, 4) family history of colon cancer, 5) fever, and 6) age of onset after age 50. The evaluations were reviewed for type of testing and findings. Subjects with nocturnal symptoms and fecal soiling, although not traditional warning signs, were also reviewed. RESULTS: There were 200 patients who met the IBS criteria; 139 (70%) had a "red flag" alarm symptom or sign. Diarrhea predominant-IBS (D-IBS) was seen in 105, constipation predominant-IBS (C-IBS) in 57, alternating, mixed, or pain predominant-IBS in 38. There were 30 men and 170 women. Testing was not often performed in this setting and, when done, the yield was low with few clinically significant diagnostic findings. CONCLUSION: There was a high prevalence of "red flag" symptoms or signs in the prospectively evaluated IBS cohort, but a low frequency of diagnostic testing directed at the investigation of these symptoms or signs. Further systematic study may show that the yield for testing in IBS is low even when "red flags" prompt diagnostic testing.

Carbohydrate challenge tests: do you need to measure methane?

OBJECTIVE: Breath tests that measure hydrogen (H2) have been judged reliable for the detection of lactose maldigestion (LM) and fructose malabsorption (FM). Recently, methane (CH4) testing has been advocated and measurement of CH4 in addition to H2 has been shown to increase the diagnostic accuracy for LM. PURPOSE: This study was designed to consider the additional yield from CH4 measurement in patients tested for LM and FM. METHODS: Patients reported for testing after an overnight fast, not smoking and with their prior evening meal carbohydrate restricted. After challenge with 50 g lactose or 25 g fructose in water, end-alveolar breath samples collected over a 4-hour duration were analyzed for H2 and CH4. Diagnostic positivity was compared using a cutoff level of 20 ppm increase above fasting baseline for H2 alone, which is consistent with consensus guidelines, versus H2 plus twice CH4, which recognizes that CH4 consumes twice the hydrogen. RESULTS: There were 406 LM performed in 93 men and 313 women. Of those tested, 124 (30%) had a positive test for H2 and 139 (34%) had a positive test for H2 + CH4 ×2. There were 178 FM tests performed in 31 men and 147 women. Of those tested, 17 (9%) had a positive test for H2 and 42 (23%) had a positive test for H2 + CH4 ×2. CONCLUSION: If H2 alone was measured without additional CH4 analysis, 4% of patients with LM and 14% patients with FM would not have been identified.

The role of capsule endoscopy in evaluating inflammatory bowel disease.

Capsule endoscopy is a relatively new technology available in the investigation of IBD. Its place in the algorithm of evaluating IBD is being refined. Capsule endoscopy has the ability to visualize the entire SB with very few complications. It is a sensitive test for the diagnosis of mucosal changes, but should be viewed as complementary to other radiologic evaluations, such as CTE and MRE. Capsule endoscopy is nonspecific and its findings have to be interpreted with caution and in the right clinical setting, because up to one fifth of normal individuals may have subtle changes in the small intestine. Care should also be taken to exclude NSAID use because it mimics findings seen in CD. Capsule endoscopy is an exciting technology that opened the possibility of the evaluation of the SB in the era of "deep remission." It is best applied in patients with a high clinical suspicion for IBD after unremarkable colonoscopy with terminal ileal intubation and radiologic investigation.

Crohn's disease: the first visit.

A Crohn's disease patient's first visit to a new practice is the optimal time to collect important clinical data and identify appropriate therapies. A methodologic approach to this visit is crucial. The focus of this visit should be on preparing the patient for the initiation of treatment, with particular attention to the necessary steps prior to the use of immunosuppressive and biologic agents. This paper is intended to provide recommendations and a checklist for the initial assessment and evaluation of patients with Crohn's disease.

Deep enteroscopy.

Obscure gastrointestinal bleeding has long been a challenging dilemma for gastroenterologists and primary care providers alike. Although many abnormalities can be localized to the small bowel by traditional endoscopic evaluation, deep enteroscopy is often needed to evaluate persistent bleeding of unknown etiology and other conditions. New technology and developments in endoscopic evaluation now provide the necessary tools to explore the small bowel further. These techniques, along with the ability to perform therapeutic interventions, have significantly advanced the management of patients with occult gastrointestinal bleeding and have led to a decline in intraoperative enteroscopy and exploratory laparotomy.

Update on preparation for colonoscopy.

Colonoscopy requires adequate bowel cleansing to be safe and effective. Current options for preparation include dietary restrictions plus cathartics and purgatives, large-volume gut lavage solutions, and sodium phosphate preparations. Gut lavage with or without a stimulant laxative is safe and effective, and traditionally is taken the evening before the procedure. Sodium phosphate formulations also provide effective cleansing, but fluid and electrolyte disturbances can occur. Recent advances include split administration of gut lavage solutions-ingesting only half of the solution the evening prior to, and the rest the morning of, the procedure. Split administration can yield adequate preparations in inpatients, traditionally a difficult group for proper cleansing. A new oral sulfate solution, when commercially available, should provide safe, effective cleaning with a lower ingested volume. This review discusses the current clinical experience of available preparation options and the efforts to make preparation for colonoscopy more tolerable.