효과적인대장정결법 김태준 삼성서울병원소화기내과
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1 효과적인대장정결법 김태준 삼성서울병원소화기내과
2 부적절한장정결 Efficacy blurring - 긴검사시간 - 낮은맹장도달율 & 선종발견율 Risk intensification - 시술관련합병증증가 Waste of cost - 검사반복 - 내시경의사의 workload 증가 Patient dissatisfaction
3 장정결에따른선종발견율차이 Multi-centers prospective study Harewood, et al. Gastrointest Endosc 2003
4 Missed polyps Hong SN, et al. Clin Endosc 2012
5 장정결의중요성 : 중간암의위험인자 부적절한장정결 선종발견율 중간암
6 부적절한장정결의정의 Preparation should be sufficient to allow polyp detection > 5 mm. If inadequate, exam even to cecum should be repeated with a more aggressive preparation regimen within 1 year. Johnson DA, et al. Gastroenterology 2014
7 Aronchick Bowel Preparation Scale Scale Characteristic Mucosal visualization Excellent Small clear liquid > 95% Good Large clear liquid > 90% Fair Small semisolid stool > 90% Poor Semisolid stool < 90% Inadequate Solid stool Invisible
8 Boston Bowel Preparation Scale Score Characteristic Mucosal visualization 3 Clear Entire mucosa 2 Minimal residual Most of mucosa 1 Residual stool, liquid Part of mucosa 0 Solid stool Not seen
9 Boston Bowel Preparation Scale 438 men underwent colonoscopy and then repeat colonoscopy within 60 days, missed adenoma > 5mm BBPS score Comparisons of scores Difference in miss rates BBPS = 9 BPPS has the best data for a validated scoring system. BBPS = 7-8 vs BBPS 9 4.0% (-6.3% to 14.4%) BBPS = 6 vs BBPS % (-3.1% to 25.8%) Early repeat colonoscopy in patients with a BPPS score of 0 or 1 in any colon segment. BBPS = 5 vs BBPS 9 9.8% (-8.0% to 27.7%) BBPS = 1-4 vs BBPS % (6.6% to 50.1%) Any segments vs All segments 13.7% (0.8% to 26.6%) BBPS = 1 BBPS = 2-3 Clark, et al. Gastroenterology 2016
10 Sub-optimal bowel preparation 27% European Data The European Panel of Appropriateness of GI Endoscopy European multicenter study (n=5,832) USA Data 23.1% Clinical Outcomes Research Initiative (CORI) national endoscpoic database (n=93,004) Froechilch F Gastrointest Endosc 2005 Harewood GC Gastrointest Endosc 2003 The US Multi-Society Task Force on CRC - Aimed at raising the adequate preparation at least 85%
11 Sub-optimal bowel preparation 5%, Korean Data, 2L PEG/A split dose vs. 1L PEG/A and bisacodyl (n=210) Kang SH, et al. Gastrointest Endosc 2017
12 Adequate bowel preparation Korea, PEG/A, SPMC > 85% UK, PEG/A, SPMC < 85% Jeon SR, et al. Int J Colorectal Dis 2015 Worthington J, et al. Curr Med Res Opin 2008
13 장정결제선택요인 Efficacy Safety Tolerability Cleansing efficacy first and patient tolerability second
14 PEG 4L split dose standard method Systemic review and meta-analysis of 9 RCT including 2,477 patients ENESTVEDT, et al. Clin Gastroenterol Hepatol 2012
15 Previous poor bowel preparation 4L split-dose PEG vs 2L split-dose PEG+Asc 3-day low-residue diet and received 10 mg of bisacodyl Gimeno-Garcia, et al. Am J Gastroenterol 2017
16 High-volume PEG Large volume : 4L, isosmotic agents (nonabsorbable solution) 4L split-dose PEG : current standard method Does not result in significant physiologic changes and safe for patients with pre-existing electrolyte imbalances and co-morbidities (Renal failure, CHF, advanced liver disease with ascites ) Does not alter the histologic features of the mucosa (can be used in patients with IBD )
17 High-volume PEG Adverse events N/V, abdominal pain, Mallory-Weiss tear, rare pulmonary aspiration, Pancreatitis, colitis Cardiac arrhythmia
18
19 대장내시경기피원인
20 환자선호도와재검에대한의지 Johnson DA, et al. Gastroenterology 2014
21 Why should be split-dose? Meta-analysis of 5 RCT including 1,232 patients Better satisfaction and adherence of patients Fewer prep discontinuations (OR 0.53, P = 0.04) Increased adequate preparations (OR 3.70, P < 0.01) Less frequent adverse symptoms (N/V and bloating) Higher willingness to repeat the same preparation Johnson DA, et al. Gastroenterology 2014
22 Why should be split-dose? RCT including 895 patients of split-dose Marmo, et al. Gastrointest Endosc 2010
23 Split-dose increases ADR Multi-center RCT including 690 patients Radaelli, et al. Gut 2017
24
25 Low-volume bowel cleansing agents 2L PEG+Asc 크리쿨산, 쿨프렙산 SPMC (sodium picosulfate + Mg citrate) 피코솔루션, 피코라이트 OSS (Oral sulfate solution) 수프랩 NaP (Sodium phosphate) Tab. 크리콜론
26 Low volume 2L PEG split-dose Low volume (2L) PEG Split-dose vs Single- or Split-dose PEG (4L) Single-dose PEG 4L Split-dose PEG 4L Split-dose PEG 2L Park SS, et al. Am J Gastroenterol 2010
27 Sodium picosulfate/ Mg citrate Sodium picosulfate : Stimulant laxative Magnesium citrate : Osmotic laxative Rare reports of hyponatremia and other electrolyte disturbances (magnesium toxicity) Avoid in patients with renal insufficiency
28 Sodium picosulfate/ Mg citrate Single-dose SPMC vs. Single-dose PEG 2L Split-dose SPMC vs. Single-dose PEG 2L > Katz, et al. Am J Gastroenterol 2013 Rex, et al. Gastrointest Endosc 2013
29 Sodium picosulfate/ Mg citrate
30 오전 오후
31 Oral Sulfate Solution (OSS) Osmotic agent : this solution has not been associated with significant fluid and electrolyte shifts. But limited data available on the safety of OSS
32 Oral Sulfate Solution (OSS) Same day Split-dose % 80.00% % of patients 82.40% 80.30% 60.00% 40.00% 20.00% 0.00% OSS PEG+Asc 2L Palma, et al. Gastrointest Endosc 2010
33 Oral Sulfate Solution (OSS) OSS split-dose vs SPMC split-dose OSS provides superior bowel cleansing efficacy than SPMC Rex, et al. Gastrointest Endosc 2014
34 Sodium Phosphate (NaP) Low-volume hyperosmotic solution, NaP is effective and tolerated by most patients. But serious adverse events unsuitable first-line agent Not recommended in patients with renal insufficiency, pre-existing electrolyte imbalance, CHF, LC, or ascites. 용법 성인에서이약의권장용량은 48 정이며다음과같이약 2 리터의물과함께경구복용한다 : 1. 검사전날저녁 : 이약 6 정을약 240mL 의물과함께 15 분간격으로총 30 정을복용한다. 2. 검사당일 : 검사 3~5 시간전부터시작하여 6 정을약 240mL 의물과함께 15 분간격으로총 18 정을복용한다.
35 장정결제선택 Safety 4L PEG 2L PEG+Asc OSS Efficacy 4L PEG 2L PEG+Asc SPMC OSS NaP Tolerability NaP OSS SPMC 2L PEG+Asc 4L PEG : Standard 2L PEG+Asc : balanced efficacy, safety, tolerability 3 sachet SPMC : better tolerability but limited safety profile OSS : good efficacy and tolerability NaP : better tolerability but limited safety profile
36 Diet During Bowel Cleansing 장정결전식이는? 6PM전까지는제한없이자유롭게 가능하면전날저잔사식 / 유동식 부적절장정결위험인자가있으면유동식
37
38 Risk factors for inadequate bowel preparation Risk factors OR (95% CI) P value Constipation 4.25 ( ) Co-morbidity 3.35 ( ) < Abdominal surgery 1.60 ( ) 0.04 Antidepressants 4.25 ( ) < Calcium antagonists 2.28 ( ) 0.06 Type of bowel prep 3.56 ( ) 0.06 Gimeno-Garcia, et al. Endoscopy 2016
39 Timing of bowel preparation Eun CS, et al. Dig Dis Sci 2011
40 Timing of bowel preparation Eun CS, et al. Dig Dis Sci 2011
41 환자교육의중요성 1. Health care professionals should provide both oral and written patient education instructions for all components of the colonoscopy preparation and emphasize the importance of compliance (Strong recommendation) 2. Patient education program - education tools such as booklets, information leaflets, animations, and visual aids better bowel preparation quality scores Lee YJ, et al. Endoscopy 2015 Tae JW, et al. Gastrointest Endosc 2012
42 Efforts to improve tolerability Low volume purgatives with Bisacodyl, Candy, Coffee, Orange juice, Gatorade Equal bowel preparation efficacy, but better clinical compliance and preference Routine use of adjunctive agents before colonoscopy is not recommended (Weak recommendation)
43 Efforts to improve tolerability Endoscopic assisted bowel preparation Potential indication - Bidirectional endoscopy - Impaired ability to ingest large volumes of bowel preparation Advantages - Better tolerance - Similar quality of bowel preparation compared with oral ingestion Disadvantages - Increased risk of aspiration - Additional time for EGD - Require separate sedation sessions for EGD and colonoscopy - Extra waiting time in hospital between EGD and colonoscopy - Involuntary defecation during EGD
44 Take Home Message 장정결제는분할복용이원칙이다. 당일오전분복후오후검사도효과가좋다. 검사 6시간전에는복용을시작해 3시간전에는완료한다. 장정결이좋지않다면무리하게검사를진행하기보다적절한장정결을유도하여질높은검사를시행하는것이중요하다.
45 경청해주셔서감사합니다
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