Search Results (22)

Background: The optimal bowel preparation regimen for a small bowel capsule endoscopy (SBCE) remains uncertain. The PrepRICE clinical trial showed that the administration of purgatives after the capsule reached the duodenum improved the mucosal visualization and diagnostic yield. However, it was limited to patients with suspected mid-gastrointestinal bleeding who met strict inclusion criteria. This work aims to report real-life results after the implementation of the new protocol and to compare them with those of the PrepRICE trial. Methods: A prospective analysis was performed on all consecutive patients who underwent an SBCE between December of 2024 and December of 2025. The quality of the small bowel visualization (QSBV), gastric transit time (GTT), small bowel transit time (SBTT), adequate visualization rate, and complete examination rate were assessed. The QSBV was evaluated according to the Brotz quantitative scale. Results: A total of 188 patients were included (52.1% male; median age 56 years [IQR 30]). The median Brotz scale scores were 9 (IQR 1), 9 (IQR 1), 8 (IQR 2), and 8 (IQR 1) in the first, second, and third terciles and overall, respectively (compared to 9, 9, 9, 9 in PrepRICE, p < 0.001). No significant differences were found in the complete examination rate (96.8% vs. 99%, p = 0.43), adequate visualization rate (91.3% vs. 92.0%, p = 0.68), GTT and SBTT. Conclusions: The real-life results were good and similar to those of the original study, with a high rate of complete examination and adequate visualization, with slightly weaker QSBV compared to that reported in the periprocedural group in the PrepRICE study yet still superior to the preprocedural groups. Full article

Background/Objectives: Adequate bowel preparation (BP) is crucial for effective colorectal cancer (CRC) surveillance in ulcerative colitis (UC). While active inflammation is known to negatively impact cleansing, data regarding predictors of BP quality specifically in UC patients with inactive disease remain limited. This study aimed to investigate risk factors for inadequate BP in UC patients in clinical/endoscopic remission and to compare the efficacy of 1L-PEG-ASC versus 2L-PEG regimens. Methods: A multicentric, retrospective, cohort study was conducted across eight Italian centers. Consecutive adult outpatients with UC undergoing colonoscopy between January-2021 and December-2022 who were in endoscopic and clinical remission were included. Boston Bowel Preparation Scale (BBPS) was assessed in patients undergoing 1L-PEG-ASC or 2L-PEG bowel preparation. Univariable and multivariable logistic regression analyses were performed to identify risk factors for inadequate BP and compare outcomes between PEG regimens. Results: A total of 379 patients were included (58% M, mean age 52.3 ± 15.4 years). The overall rate of adequate BP was 90.5%. Traditional risk factors, including demographic, clinical, and endoscopic characteristics, were not predictive of inadequate preparation in this remission cohort. Comparing regimens, 1L-PEG-ASC yielded significantly higher median total BBPS scores compared to 2L-PEG (8 [IQR 7–9] vs. 6 [IQR 6–8]; p < 0.001) and a higher exam completion rate (99.5% vs. 95.7%; p = 0.02), although the difference in adequate BP rates did not reach statistical significance (92.6% vs. 87.7%; p = 0.12). Multivariable analysis confirmed that 2L-PEG was independently associated with lower odds of achieving higher BBPS scores (OR 0.30; 95% CI 0.20–0.45). Conclusions: In UC patients with clinical and endoscopic remission, BP adequacy rates are high and comparable to the general population, suggesting that traditional IBD-related risk factors are less relevant in the absence of active inflammation. However, the 1L-PEG-ASC regimen demonstrated superior cleansing quality and exam completion rates compared to 2L-PEG. These findings support the prioritization of 1L-PEG-ASC to optimize mucosal visualization during CRC surveillance in this population. Full article

Background and Objectives: Colorectal cancer caused over 1.9 million new cases and 0.9 million deaths in 2020, ranking third in incidence and second in cancer mortality worldwide. Poor bowel preparation may hide adenomas, increasing the colorectal cancer risk. This retrospective study aims to identify differences and associations in bowel preparation quality in relation to gender, age, timing of preparation, and the type of cleansing agent used. Materials and Methods: We analyzed the quality of bowel preparation in a total of 4609 colonoscopies performed between June 2019 and April 2022. We used t-tests and ANOVA to assess differences in bowel preparation quality according to participants’ characteristics. The multivariable linear and logistic regression analyses were used to evaluate the association between bowel preparation quality, withdrawal time, adequate bowel preparation, and total colonoscopy. Results: 70.9% of patients had adequate bowel preparation quality. Enema (β = −0.20, p < 0.001), bisacodyl (β = −0.16, p < 0.001), and senna solution (β = −0.03, p = 0.012) were linked to poorer bowel preparation quality in comparison with polyethylene glycol. Older age was associated with a slight decrease in the probability of adequate bowel preparation (adjusted OR 0.98 per year, p < 0.001), whereas female gender was associated with an increase in this probability (OR 1.18, p = 0.038). Bowel preparation in winter is associated with a lower likelihood of adequate preparation compared to summer (OR 0.74, p = 0.004). The type of bowel preparation agent affected outcomes, with enema (OR 0.22, p < 0.001) and bisacodyl (OR 0.35, p < 0.001) associated with the less clean bowels. Longer withdrawal time was inversely associated with adequate preparation (OR 0.94, p < 0.001). For total colonoscopy, the strongest predictor was adequate bowel preparation (OR 23.6, p < 0.001), with gender, ulcerative colitis, and polyps also influencing the outcome. Conclusions: Age, gender, season, medications, withdrawal time, and the type of colorectal lesions influence bowel preparation quality. Personalized approaches, including patient education and targeted interventions, might contribute to improved bowel preparation, especially in older patients, and should be evaluated in future studies. Full article

Background: Colon capsule endoscopy (CCE) has seen increased adoption since the COVID-19 pandemic, offering a non-invasive alternative for lower gastrointestinal investigations. However, inadequate bowel preparation remains a key limitation, often leading to higher conversion rates to colonoscopy. Manual assessment of bowel cleanliness is inherently subjective and marked by high interobserver variability. Recent advances in artificial intelligence (AI) have enabled automated cleansing scores that not only standardise assessment and reduce variability but also align with the emerging semi-automated AI reading workflow, which highlights only clinically significant frames. As full video review becomes less routine, reliable, and consistent, cleansing evaluation is essential, positioning bowel preparation AI as a critical enabler of diagnostic accuracy and scalable CCE deployment. Objective: This CESCAIL sub-study aimed to (1) evaluate interobserver agreement in CCE bowel cleansing assessment using two established scoring systems, and (2) determine the impact of AI-assisted scoring, specifically a TransUNet-based segmentation model with a custom Patch Loss function, on both interobserver and intraobserver agreement compared to manual assessment. Methods: As part of the CESCAIL study, twenty-five CCE videos were randomly selected from 673 participants. Nine readers with varying CCE experience scored bowel cleanliness using the Leighton–Rex and CC-CLEAR scales. After a minimum 8-week washout, the same readers reassessed the videos using AI-assisted CC-CLEAR scores. Interobserver variability was evaluated using bootstrapped intraclass correlation coefficients (ICC) and Fleiss’ Kappa; intraobserver variability was assessed with weighted Cohen’s Kappa, paired t-tests, and Two One-Sided Tests (TOSTs). Results: Leighton–Rex showed poor to fair agreement (Fleiss = 0.14; ICC = 0.55), while CC-CLEAR demonstrated fair to excellent agreement (Fleiss = 0.27; ICC = 0.90). AI-assisted CC-CLEAR achieved only moderate agreement overall (Fleiss = 0.27; ICC = 0.69), with weaker performance among less experienced readers (Fleiss = 0.15; ICC = 0.56). Intraobserver agreement was excellent (ICC > 0.75) for experienced readers but variable in others (ICC 0.03–0.80). AI-assisted scores were significantly lower than manual reads by 1.46 points (p < 0.001), potentially increasing conversion to colonoscopy. Conclusions: AI-assisted scoring did not improve interobserver agreement and may even reduce consistency amongst less experienced readers. The maintained agreement observed in experienced readers highlights its current value in experienced hands only. Further refinement, including spatial analysis integration, is needed for robust overall AI implementation in CCE. Full article

Background/Objectives: The effectiveness of 1 L PEG-ASC preparation in inflammatory bowel disease (IBD) patients is still unclear. The aim of this study was to determine the efficacy and safety of 1 L PEG-ASC in a series of IBD patients. Methods: Data from a study conducted on a series of 284 patients collected in three centers between 2020 and 2025 were analyzed. The primary outcome was cleansing success whereas success in the right colon, polyp detection, adverse events, and patient reported outcomes were secondary endpoints. Results: The mean age was 43.28 ± 12.21 years and 170 (59.8%) patients were male. Out of 141 ulcerative colitis (UC) patients, 45 (32%) presented with a Mayo score of 3. The Mean Simple Endoscopic Score Crohn’s Disease (SES-CD) score in CD patients was 7.2 ± 7.04. Overall and right colon cleansing success were reported in 267 patients (94.2%), of which 134 CD (93.9%) and 133 UC (94.6%) patients (p = 0.81). The overall BBPS score was 7.47 ± 1.44, specifically 7.52 ± 1.23 in CD and 7.40 ± 1.62 in UC patients (p = 0.76). Overall, 19 patients (6.7%) were diagnosed with polyps with a mean number of polyps per colonoscopy of 0.08 ± 0.03. The preparation was completely taken by 264 (92.9%) patients, and 247 patients (86.9%) declared their willingness to repeat the bowel preparation. Severe nausea was observed in 1 (0.3%) patient and no other severe adverse events were recorded. Conclusions: The 1 L PEG-ASC preparation is well-tolerated and safe in IBD patients. Full article

Background/Objectives: Adequate bowel preparation is essential for high-quality colonoscopy. The clarity of the final rectal effluent can predict its sufficiency and guide additional preparation if necessary. For an objective and reliable clarity assessment, the stool collection method may be as important as the evaluation itself. This study was designed to compare the sensitivity of clarity assessments of effluent collected using two methods: a disposable cardboard bedpan with a white bag (Group I) and a 50 mL transparent plastic container (Group II). Methods: A prospective, single-center, randomized, comparative study was conducted between August 2024 and January 2025. Based on predefined criteria, 37 of 177 randomized patients were excluded, and 140 were analyzed. Results: Inadequate bowel preparation was correctly identified by a team member in 71% of Group I and 23% of Group II (p = 0.033). In adequate cases, the detection sensitivity was 88% and 85% (Groups I and II, respectively; p = 0.854). Significantly more patients in Group II either withdrew or failed to submit a photograph of the final rectal effluent. Patients’ verbal assessments did not differ significantly between the groups, regardless of bowel preparation quality. Conclusions: Patient self-assessment was an unreliable indicator of bowel cleanliness, highlighting the need for objective, standardized pre-colonoscopy evaluation methods. The use of a disposable cardboard bedpan with a white bag to collect the final rectal effluent may improve the accuracy of predicting inadequate preparation and patient compliance and may allow timely adjustments to bowel cleansing prior to colonoscopy in routine endoscopy practice. Full article

Background: Acute phosphate nephropathy (APN) is an underrecognized cause of acute kidney injury (AKI), typically associated with the use of oral sodium phosphate (OSP)-based bowel preparations. It is characterized by calcium phosphate crystal deposition within the renal tubules and may result in permanent renal impairment. Despite known risks, phosphate-containing solutions are still widely used without sufficient risk stratification. Methods: We retrospectively evaluated 517 native kidney biopsies performed in our nephrology clinic between 2017 and 2022. Among these, 12 patients with unexplained AKI and recent colonoscopy history were identified. In nine cases, non-specific tubular deposits on routine staining prompted further histochemical analysis. All had a history of recent OSP-based bowel cleansing. The use of von Kossa staining confirmed calcium phosphate deposition, consistent with APN. Results: Out of 517 kidney biopsies performed during the study period, 9 patients were diagnosed with APN based on histopathological findings following recent colonoscopy and OSP-based bowel cleansing. The mean age was 58.7 years, and three were female. Hypertension was present in seven patients, diabetes mellitus in three, and epilepsy in two; one patient had no comorbidities. Baseline renal function was normal (mean serum creatinine 0.86 mg/dL) and increased to 1.76 mg/dL at three months post-exposure. All biopsies revealed tubulointerstitial calcium phosphate deposits and interstitial inflammation; mesangial hypercellularity was observed in five cases, tubular atrophy in three, and acute tubular necrosis in one. All samples stained positive with von Kossa staining. Over time, all patients developed chronic kidney disease, and one progressed to end-stage renal disease requiring dialysis. Conclusions: In patients presenting with unexplained AKI and recent OSP-based bowel preparation, APN should be considered in the differential diagnosis. When routine histology is inconclusive, definitive diagnosis may require special histochemical staining. Risk-based restrictions on phosphate-containing agents are warranted to reduce preventable kidney injury. Full article

Objectives: To assess the impact of bowel cleansing quality on polyp detection rate (PDR) and adenoma detection rate (ADR) and explore predictors of lesion detection rate in patients undergoing colonoscopy. Methods: This is a post-hoc analysis of a multicenter randomized controlled trial (RCT) comparing 1L polyethylene glycol plus ascorbate (1L PEG+ASC) vs. 4L PEG as bowel preparation for colonoscopy. Results: PDR was significantly higher (35.6% vs. 18.5%, p = 0.013), and ADR was higher even if not significantly (25.6% vs. 16.7%, p = 0.153) in patients with Boston Bowel Preparation Scale (BBPS) ≥6 over BBPS <6. Comparing patients with BBPS = 9 over BBPS = 7–8, no significant differences were found in PDR (34.5% vs. 38.4%, p = 0.483) nor ADR (24.1% vs. 27.2%, p = 0.553). At multivariable regression analysis, older age (OR = 1.042, 95%CI = 1.021–1.063; p < 0.001), shorter intubation time (OR = 0.891, 95%CI = 0.816–0.972; p = 0.010), higher withdrawal time (OR = 1.171, 95%CI = 1.094–1.253; p < 0.001) and full consumption of the first dose (OR = 8.368, 95%CI = 1.025–68.331; p = 0.047) were independently associated with ADR. Conclusions: This post-hoc analysis of a RCT showed that excellent cleansing (BBPS = 9) over high-quality cleansing (BBPS = 7–8) does not significantly improve PDR or ADR. Neither cleansing success nor preparation types were independently associated with ADR. Compliance with bowel preparation, timing of colonoscopy and withdrawal time are key elements for adequate ADR with potential implications for reducing interval colorectal cancer. Full article

Background and Study Aim: Colonoscopy holds the highest volume of all endoscopic procedures, allowing for large colonoscopy databases to serve as valuable datasets for quality assurance. We aimed to build a comprehensive colonoscopy database for quality assurance and the training of future AIs. Materials and Methods: As part of a cluster-randomized controlled trial, a designated, onsite medical student was used to acquire procedural and patient-specific data, ensuring a high level of data integrity. The following data were thereby collected for all colonoscopies: full colonoscopy vides, colonoscope position (XYZ-coordinates), intraprocedural timestamps, pathological report, endoscopist description, endoscopist planning, and patient-reported discomfort. Results: A total of 1447 patients were included from the 1st of February 2022 to the 21st of November 2023; 1191 colonoscopies were registered as completed, 88 were stopped due to inadequate bowel cleansing, and 41 were stopped due to patient discomfort. Of the 1191 completed colonoscopies, 601 contained polypectomies (50.4%), and 590 did not (49.6%). Comparing colonoscopies with polypectomies to those without the withdrawal time (caecum to extubating the scope) was significantly longer for all parts of the colon (p values < 0.001), except the transverse colon (p value = 0.92). The database was used to train an AI, automatically and objectively evaluating bowel preparation. Conclusions: We established the most thorough database in colonoscopy with previously inaccessible information, indicating that the transverse colon differs from the other parts of the colon in terms of withdrawal time for procedures with polypectomies. To further explore these findings and reach the full potential of the database, an AI evaluating bowel preparation was developed. Several research partners have been identified to collaborate in the development of future AIs. Full article

Background: During esophagogastroduodenoscopy performed with colonoscopy, gastric and duodenal erythema, erosions, and ulcerations are often observed. This investigation was designed to review the prevalence of gastroduodenal lesions in patients who have undergone wireless capsule endoscopy using standard bowel cleansing preparations, but no endoscopy or sedation. Methods: A retrospective analysis was conducted on patients referred for capsule endoscopy. Records and capsule reports were reviewed for the patient demographics, preparation prescribed, procedural indications, and gastroduodenal findings. The preparations studied included polyethylene glycol lavage (PEG), PEG plus bisacodyl (PEG + bis), bisacodyl (bis), oral sulfate solution (OSS), and no prep. Results: Among the 1236 records, 498 (40.3%) were men and 738 (59.7%) were women. The mean age was 56 years +/− 18 years SD. The percentage of patients with lesions after any bowel preparation was 52.7% for gastric lesions and 23.6% for duodenal lesions. The percentage of patients with gastroduodenal lesions was 58.3% with prep, compared to 38.2% without prep. These findings were statistically significant, with an RR of 1.53 [1.19–1.94] (p-value = 0.00004). This difference was more pronounced in the OSS group RR of 1.65 [1.29–2.1] and bisacodyl group RR of 1.64 [1.25–2.15] compared to the PEG group RR of 0.95 [0.7–1.3]. Conclusions: This study showed that patients undergoing wireless capsule endoscopy who received bowel preparations had a significant increase in gastric and duodenal lesions. Of the preparations studied, OSS was associated with a greater number of gastroduodenal lesions, while PEG was the least associated with lesions, with an occurrence similar to the non-prep group. The clinical significance of these lesions remains undetermined. Endoscopists should be aware that preparations are associated with gastroduodenal lesions to avoid the misinterpretation and misdiagnosis of these lesions. Full article

Background: Various predictive models have been published to identify outpatients with inadequate colonic cleansing who may benefit from intensified preparations to improve colonoscopy quality. The main objective of this study was to compare the accuracy of three predictive models for identifying poor bowel preparation in outpatients undergoing colonoscopy. Methods: This cross-sectional study included patients scheduled for outpatient colonoscopy over a 3-month period. We evaluated and compared three predictive models (Models 1–3). The quality of colonic cleansing was assessed using the Boston Bowel Preparation Scale. We calculated the area under the curve (AUC) and the corresponding 95% confidence interval for each model. Additionally, we performed simple and multiple logistic regression analyses to identify variables associated with inadequate colonic cleansing and developed a new model. Results: A total of 649 consecutive patients were included in the study, of whom 84.3% had adequate colonic cleansing quality. The AUCs of Model 1 (AUC = 0.67, 95% CI [0.63–0.70]) and Model 2 (AUC = 0.62, 95% CI [0.58–0.66]) were significantly higher than that of Model 3 (AUC = 0.54, 95% CI [0.50–0.58]; p < 0.001). Moreover, Model 1 outperformed Model 2 (p = 0.013). However, the new model did not demonstrate improved accuracy compared to the older models (AUC = 0.671). Conclusions: Among the three compared models, Model 1 showed the highest accuracy for predicting poor bowel preparation in outpatients undergoing colonoscopy and could be useful in clinical practice to decrease the percentage of inadequately prepared patients. Full article

Background and Objectives: Proper bowel preparation is of paramount importance for enhancing adenoma detection rates and reducing postcolonoscopic colorectal cancer risk. Despite recommendations from gastroenterology societies regarding the optimal rates of successful bowel preparation, these guidelines are frequently unmet. Various approaches have been employed to enhance the rates of successful bowel preparation, yet the quality of cleansing remains suboptimal. Intensive bowel preparation techniques, supplementary administration of bowel solutions, and educational interventions aimed at improving patient adherence to instructions have been commonly utilized, particularly among patients at a high risk of inadequate bowel preparation. Expedited strategies conducted on the same day as the procedure have also been endorsed by scientific organizations. More recently, the utilization of artificial intelligence (AI) has emerged for the preprocedural detection of inadequate bowel preparation, holding the potential to guide the preparation process immediately preceding colonoscopy. This manuscript comprehensively reviews the current strategies employed to optimize bowel cleansing, with a specific focus on patients with elevated risks for inadequate bowel preparation. Additionally, the prospective role of AI in this context is thoroughly examined. Conclusions: While a majority of outpatients may achieve cleanliness with standard cleansing protocols, dealing with hard-to-prepare patients remains a challenge. Rescue strategies based on AI are promising, but such evidence remains limited. To ensure proper bowel cleansing, a combination of strategies should be performed. Full article

Background and objectives: Capsule endoscopy (CE) is a non-invasive method to inspect the small bowel that, like other enteroscopy methods, requires adequate small-bowel cleansing to obtain conclusive results. Artificial intelligence (AI) algorithms have been seen to offer important benefits in the field of medical imaging over recent years, particularly through the adaptation of convolutional neural networks (CNNs) to achieve more efficient image analysis. Here, we aimed to develop a deep learning model that uses a CNN to automatically classify the quality of intestinal preparation in CE. Methods: A CNN was designed based on 12,950 CE images obtained at two clinical centers in Porto (Portugal). The quality of the intestinal preparation was classified for each image as: excellent, ≥90% of the image surface with visible mucosa; satisfactory, 50–90% of the mucosa visible; and unsatisfactory, <50% of the mucosa visible. The total set of images was divided in an 80:20 ratio to establish training and validation datasets, respectively. The CNN prediction was compared with the classification established by consensus of a group of three experts in CE, currently considered the gold standard to evaluate cleanliness. Subsequently, how the CNN performed in diagnostic terms was evaluated using an independent validation dataset. Results: Among the images obtained, 3633 were designated as unsatisfactory preparation, 6005 satisfactory preparation, and 3312 with excellent preparation. When differentiating the classes of small-bowel preparation, the algorithm developed here achieved an overall accuracy of 92.1%, with a sensitivity of 88.4%, a specificity of 93.6%, a positive predictive value of 88.5%, and a negative predictive value of 93.4%. The area under the curve for the detection of excellent, satisfactory, and unsatisfactory classes was 0.98, 0.95, and 0.99, respectively. Conclusions: A CNN-based tool was developed to automatically classify small-bowel preparation for CE, and it was seen to accurately classify intestinal preparation for CE. The development of such a system could enhance the reproducibility of the scales used for such purposes. Full article

Colon capsule endoscopy (CCE) is a promising modality for colonic investigations, but completion rates (CR) and adequate cleansing rates (ACR) must be improved to meet established standards for optical colonoscopy. Improvements should be made with patient acceptability in mind. We aimed to compare a very low-volume polyethylene glycol (PEG) laxative to a conventional high-volume laxative. We carried out a single-center retrospective comparative cohort study including patients referred for CCE. One hundred and sixty-six patients were included in the final analysis, with eighty-three patients in each group. We found a CR and ACR of 77% and 67% in the high-volume group and 72% and 75% in the very low-volume group, respectively. In the high-volume group, 54% had complete transit and adequate cleansing, whereas this was the case for 63% in the very low-volume group. No statistically significant difference in CR, ACR, or a combination of the two was found. A very low-volume bowel preparation regimen was non-inferior to a high-volume regimen before CCE in terms of CR and ACR. Full article

Factors affecting the quality of bowel preparation for colonoscopy in the elderly are not fully known, and current guidelines provide no specific recommendations. This study aimed to assess the difference in bowel cleansing in young and elderly patients and evaluate predictors of bowel cleansing in the elderly. We retrospectively reviewed a prospective cohort of 1289 patients performing colonoscopy after a 1-, 2-, or 4-L PEG-based preparation. All 1289 were included in the analysis. Overall, 44.6% of patients were aged ≥65 years. Cleansing success (CS) was achieved in 77.3% and 70.3% of patients aged <65 years and ≥65 years, respectively. At multivariable analysis, split regimen (OR = 2.43, 95% CI = 1.34–4.38; p = 0.003), adequate cleansing at previous colonoscopy (OR = 2.29, 95% CI = 1.14–4.73; p = 0.02), tolerability score (OR = 1.29, 95% CI = 1.16–1.44; p < 0.001), a low-fiber diet for at least 3 days (OR = 2.45, 95% CI = 1.42–4.24; p = 0.001), and colonoscopy within 5 h after the end of preparation (OR = 2.67, 95% CI = 1.28–5.56; p = 0.008) were independently associated with CS in the elderly. Combining a low-fiber diet for at least 3 days, split preparation, and colonoscopy within 5 h allowed a CS rate above 90% and should always be encouraged. A 1-L PEG-ASC preparation was also associated with greater high-quality cleansing of the right colon and may be preferred. Full article