Administration of olive oil followed by a low volume of polyethylene glycol-electrolyte lavage...

ORIGINAL ARTICLE: Clinical Endoscopy

Administration of olive oil followed by a low volume ofpolyethylene glycol-electrolyte lavage solution improvespatient satisfaction with right-side colonic cleansing overadministration of the conventional volume of polyethyleneglycol-electrolyte lavage solution for colonoscopy preparation

Evren Abut, MD, Hakan Guveli, MD, Bulent Yasar, MD, Cengiz Bolukbas, MD, Filiz Fusun Bolukbas, MD,Ali Tuzun Ince, MD, Tulin Kendir, MD, Ali Remzi Dalay, MD, Oya Ovunc Kurdas, MD

Istanbul, Sanliurfa, Turkey

doi:

ww

Background: Proper bowel cleansing before colonoscopy is essential for satisfactory evaluation of the colon.The required consumption of a large volume of salty-tasting liquid, 4 L of polyethylene glycol-electrolyte lavagesolution (PEG-ELS), is the primary limitation to achieving this goal.

Objective: To achieve better patient satisfaction with efficient bowel cleansing, we compared the effects of theconventional volume (4 L) of PEG-ELS with those of a low volume (2 L) in combination with pretreatment usingdifferent laxatives, such as magnesium hydroxide (milk of magnesia) and olive oil.

Design: Randomized, controlled study.

Setting: A single research hospital.

Patients: Patients undergoing elective colonoscopy.

Interventions: A total of 120 patients were randomized to 1 of 3 different preparation regimens: 39 patientswere prepared with a conventional volume (4 L) of PEG-ELS (Preparation [Prep] 1), and the remaining patientswere prepared with a lower volume (2 L) of PEG-ELS and pretreatment with a laxative, either 15 g of magnesiumhydroxide (40 patients, Prep 2) or 60 mL of olive oil (41 patients, Prep 3) 3 hours before PEG-ELS administration.

Main Outcome Measurements: The primary outcome was the efficacy of colonic cleansing on the left andright sides. Secondary outcomes were patient satisfaction and side effects.

Results: The olive oil regimen (Prep 3) resulted in significantly more adequate bowel cleansing of the right colon thanadministration of the conventional volume of PEG-ELS (Prep 1) and the magnesium hydroxide (Prep 2) regimen (97.6%vs 74.5% and 72.5%, respectively, P Z .007). However, this difference was not observed in the left colon (91.5%, 85.5%,and 91.8% for Preps 1, 2, and 3, respectively, P Z .776). When asked, 38 patients (95%) taking Prep 2, 35 patients (85.3%)taking Prep 3, and only 11 patients (28.2%) taking Prep 1 preferred the same preparation regimen if they requireda future colonoscopy (P Z.006), based on ease of use and taste. The side effects were comparable in each group.

Limitations: The limitations of this study include the relatively small sample size, the single-center studydesign, and the use of a nonvalidated symptom scoring system.

Conclusion: Pretreatment with olive oil before administration of a low volume of PEG-ELS enhances bothpatient satisfaction and the quality of right-side colonic cleansing over the administration of the conventionalvolume of PEG-ELS for colonoscopy preparation. Although the magnesium hydroxide regimen (Prep 2) wasthe preferred regimen in this study, its colonic cleansing effectiveness was not as great as those of the other reg-imens. Based on our results, the olive oil regimen is recommended, especially for patients who are not able toconsume large volumes of liquids, such as the elderly, and those who are suspected of having subtle right-sidecolonic lesions. (Gastrointest Endosc 2009;70:515-21.)

Abbreviations: PEG-ELS, polyethylene glycol-electrolyte lavage solution;

Prep, preparation; SPS, sodium phosphate solution.

DISCLOSURE: All authors disclosed no financial relationships relevant to thispublication.

Copyright ª 2009 by the American Society for Gastrointestinal Endoscopy

0016-5107/$36.00

10.1016/j.gie.2009.01.002

w.giejournal.org Volume 70, No. 3 : 2009 GASTROINTESTINAL ENDOSCOPY 515

Olive oil and PEG-ELS for colonic cleansing Abut et al

Colonoscopy became the standard procedure for thediagnosis and treatment of diseases of the colon in theearly 1960s.1 Adequate bowel cleansing is a prerequisitefor proper evaluation of the entire colonic mucosa duringa colonoscopy. Poor colonic cleansing may preventdetection of clinically significant pathological lesions. Fur-thermore, it may lead to a prolonged duration or resched-uling of the colonoscopy.

In current practice, polyethylene glycol-electrolyte la-vage solution (PEG-ELS)2 and sodium phosphate solution(SPS)3 have been used since the 1980s and 1990s, respec-tively, because of their abilities to achieve rapid colonoscopypreparation, even though they have many limitations. Im-portantly, approximately 20% of patients who consumedPEG-ELS or SPS did not have adequate bowel cleansing.4

Furthermore, SPS is generally not recommended for pa-tients with renal failure, congestive heart failure, uncon-trolled hypertension, or ascites because of its potentialrisks for clinically significant alterations in serum electrolytelevels and hemodynamic stability.5-8

Numerous clinical trials have assessed prokinetic (me-toclopramide, cisapride, and tegaserod)9-13 and laxativeagents (magnesium citrate and bisacodyl)14-16 as adjunctsto standard or lower volumes of PEG-ELS. Among thesepreparations, no additive effect was demonstrated for me-toclopramide or cisapride on bowel cleansing. However,Sharma et al15 found that pretreatment with magnesiumcitrate or bisacodyl in addition to 2 L of PEG-ELS was su-perior to 4 L of PEG-ELS in terms of the preparation qual-ity and patient satisfaction. Evaluation of the effectivenessof a range of laxatives may indicate preferred laxatives withsuperior results.

To our knowledge, there is no study examining the ef-fects of other magnesium salts, such as magnesium hy-droxide, or natural laxatives, such as olive oil, for thispurpose. This study compared the quality of coloniccleansing, patient satisfaction, and side effects of a conven-tional volume (4 L) of PEG-ELS with those of a low (2 L)volume of PEG-ELS combined with pretreatment witha laxative, either magnesium hydroxide (milk of magnesia)or olive oil.

MATERIALS AND METHODS

This was a prospective, randomized, controlled study,and the study protocol was carried out in accordancewith the Declaration of Helsinki as revised in 1989. Allpatients signed approved informed consent forms beforeenrollment in the study.

Study populationPatients of either sex who were at least 18 years of age

and were scheduled for elective outpatient colonoscopywere eligible for participation in this study.

516 GASTROINTESTINAL ENDOSCOPY Volume 70, No. 3 : 2009

Capsule Summary

What is already known on this topic

d Many bowel preparations have been studied forprecolonoscopy cleansing, but none is clearly superiorto the others.

What this study adds to our knowledge

d In a randomized trial of 120 patients undergoingcolonoscopy, 60 mL of olive oil ingested before 2 L ofpolyethylene glycol-electrolyte lavage solution (PEG-ELS)resulted in superior cleaning of the right colon comparedwith 4 L of PEG-ELS or 15 g of magnesium hydroxidefollowed by 2 L of PEG-ELS.

Patients who met at least one of the following criteriawere excluded: (1) age younger than 18 years; (2) hospital-ized patients undergoing colonoscopy; (3) disturbed bowelmovements (!2 bowel movements per week or O3 bowelmovements per day in the past 3 months); (4) evidence ofacute or chronic renal failure; (5) cardiovascular diseases(including recent myocardial infarction, congestive heartfailure, unstable angina pectoris, unstable hypertension,and cardiac arrhythmias); (6) ascites; (7) electrolyte imbal-ance, including hyponatremia, hypokalemia, hyperphos-phatemia, hypocalcemia, and hypomagnesemia; (8) activeinflammatory bowel disease; (9) previous partial or subtotalcolectomy; (10) ileus and/or suspected bowel obstruction;(11) pregnancy or breast-feeding; and (12) childbearingpotential without adequate contraception.

Study designIn the screening period, the patient’s medical history,

demographic data, bowel habits (number of bowel move-ments per day), indications for colonoscopy, and bodyweight were noted. For all patients, clinical hemodynamic,hematological, and biochemical measurements, includingwhole blood count, blood sugar, blood urea nitrogen,creatinine, and serum electrolyte (sodium, potassium,chloride, phosphorus, ionized calcium and magnesium)levels were performed.

After initial evaluations, patients who met all the inclu-sion criteria and no exclusion criteria were randomized toreceive one of the following preparation (Prep) regimensaccording to a computer-generated randomization list byone physician (HG) who was blinded to the results ofprevious colonoscopies.

Prep 1 consisted of 4 L of PEG-ELS (GoLYTELY; Brain-tree Laboratories, Inc, Boston, Mass) alone, starting at4:00 PM on the day before the colonoscopy at a rate of250 mL every 15 minutes until all the solution has beenconsumed, as recommended by the manufacturer.

Prep 2 consisted of 15 g of magnesium hydroxide (Mag-nesie Calsinee; Carlo Erba, Inc, Istanbul, Turkey) mixed

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Abut et al Olive oil and PEG-ELS for colonic cleansing

with 1 glass of water (250 mL) taken 3 hours before start-ing 2 L of PEG-ELS, which was given in the same fashion asdescribed above.

Prep 3 consisted of 60 mL of olive oil mixed with 1 glassof apple juice taken 3 hours before starting 2 L of PEG-ELS, which was given in the same fashion as describedabove.

Patients in all groups were encouraged to adhere to clearliquid diets from 6:00 AM to midnight on the day before thecolonoscopy, and further oral intake was not allowed aftermidnight. Before the colonoscopy, a physical examinationand clinical hemodynamic, hematological, and biochemicalmeasurements were repeated, as described above. Patientswere asked to complete a questionnaire designed to assessthe bowel preparation’s tolerability, patient satisfaction,and symptoms that were experienced during the colono-scopy preparation. This questionnaire consisted of 18 ques-tions and was based on questionnaires used in similarprevious studies.4,17

To ensure consistency in the evaluations, colonoscopieswere performed by the same attending endoscopist (EA)from 8:00 AM to 12:00 PM without conscious sedation. Be-fore the colonoscopy, all patients were instructed not toreveal their assigned preparation regimen to the endos-copy unit staff. Therefore, all persons present in the en-doscopy unit, including the endoscopist, were blindedto the patient preparation. A Pentax EC-3840F videocolo-noscope (Asahi Optical Co., Tokyo, Japan) was used forall examinations. The duration of the complete endoscopyprocedure and the cecal intubation time were recorded.The quality of colonic cleansing was evaluated by a previ-ously validated grading system (Table 1).4 In this evalua-tion, the left colon was defined as spanning from therectum to the splenic flexure, and the right colon as theregion from the splenic flexure to the cecum.

After completion of the colonoscopy, the symptoms expe-rienced during the procedure (nausea, vomiting, abdominalpain, abdominal distention, and lethargy) were evaluatedaccording to a scoring system that was arbitrarily graded ona 4-point scale. This scale was adapted from previous similarstudies16,17 (none, 0; mild, 1; moderate, 2; severe, 3). Theoverall patient symptom score (range, 0-15) was calculatedas the sum of the individual symptom scores.

Statistical analysisStatistical analyses were performed by using commer-

cially available statistics software (SPSS for Windows10.0, SPSS Inc., Chicago, Ill). At the beginning of the study,a sample size calculation was performed, assuming a 30%difference in the rate of colonic cleansing. To detect thisdifference with a significance level (a) of .05 and a powerof 80% with a 2-tailed test, we calculated that at least 36patients were needed for each treatment group.

Continuous measures were analyzed by using an analy-sis of variance. A paired-samples t test was used tocompare the changes on clinical hemodynamic, hemato-

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logical, and biochemical measurements during the prepa-ration in the 3 groups. Categorical measures wereanalyzed with a c2 test. Ordered categorical measureswere analyzed with the Kruskal-Wallis test as estimatedby the Cochran-Mantel-Haenszel test by using row meanrank scores. The results of the quality of bowel cleansingwere also dichotomized as adequate (excellent, good,and fair results pooled) or inadequate (poor and verypoor results pooled) preparation, and pairwise compari-sons were made with a c2 test for the right colon andFisher’s exact test for the left colon.

RESULTS

A total of 224 consecutive outpatients scheduled for elec-tive colonoscopy participated in this study. Ninety-eight ofthese patients were excluded because they met one ormore exclusion criteria. Thus, 126 patients were recruitedand equally randomized to 1 of 3 different preparationregimens (42 patients in each preparation group). After ran-domization, 3 patients in the Prep 1 group, 2 patients in thePrep 2 group, and 1 patient in the Prep 3 group did not keeptheir colonoscopy appointments because of personal rea-sons. The remaining patients were compared by a per-pro-tocol analysis.

There were no significant differences among the 3preparation groups with respect to age, sex, race, bodyweight, frequency of bowel movements, or indicationsfor colonoscopy (Table 2). All patients completely con-sumed their assigned preparations.

There was no significant difference among the groupswith respect to changes in body weight (median, –1 kgin each group, P Z .555). Orthostatic hypotension wasnot reported in any patient during the pretreatment eval-uation or after the preparation. Hematological and bio-chemical changes during the colonoscopic preparationwere not different among the groups (P O .05), except

TABLE 1. Grading system for evaluation of colonoscopic

bowel cleansing

1. Excellent Small volume of clear liquid or O95%

of surface visible

2. Good Large volume of clear liquid covering

5%-25% of the surface but O90% of

the surface visible

3. Fair Some semisolid stool that could be suctioned

or washed away, but O90% of the surface

visible

4. Poor Semisolid stool that could not be suctioned

or washed away with !90% of the surface

visible

5. Very

poor

Repeated preparation needed

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TABLE 2. Demographic data and colonoscopy indications

Prep 1 Prep 2 Prep 3 P value

No. patients 39 40 41

Age (y), mean � SD 49 � 13.9 51.1 � 14.1 46.7 � 10.4 .308

Sex, no. (%)

Male 26 (66.7) 20 (50) 19 (46.3) .154

Female 13 (33.3) 20 (50) 22 (53.7)

Race (%)

White 100 100 100 1.0

Body weight (kg), mean � SD 73.6 � 13.9 71.6 � 10.8 76.8 � 9.9 .131

Frequency of bowel movement, mean � SD 1.0 � 0.4 0.8 � 0.4 1.2 � 0.2 .148

Indication for colonoscopy, no.(%) .734

Polyps surveillance 12 (30.7) 8 (20) 7 (17)

Unexplained GI bleeding 11 (28.2) 13 (32.5) 11 (26.8)

Anemia 6 (15.3) 7 (17.5) 11 (26.8)

IBD (in inactive period) 6 (15.3) 10 (25) 9 (21.9)

Family history of colon cancer 4 (10.2) 2 (5) 3 (7.31)

IBD, Inflammatory bowel disease.

for posttreatment elevations of the hematocrit (from 40 �4.3% to 40.6 � 4.5%) and chloride levels (from 105.1 � 4.1mEq/L to 106.4 � 3.2 mEq/L), which were statisticallysignificant but clinically insignificant in the Prep 3 group(P Z .045 and .046, respectively).

The frequency of symptoms experienced by patientsduring the colonoscopy preparation was comparable,and there was no significant difference among the groups(P O .05) (data not shown).

The taste of the preparation was reported as good ortolerable by 79.5% of the patients taking Prep 1, 80% ofthe patients taking Prep 2, and 72% of the patients takingPrep 3; there was no significant difference among thegroups (P O .05).

In the entire study population, 16 patients taking Prep2 and 19 patients taking Prep 3 were administered thestandard volume of PEG-ELS for preparation for a previouscolonoscopy. Of these patients, 15 patients (93.7%) takingPrep 2 and 14 patients (73.6%) taking Prep 3 found thestandard volume of PEG-ELS to be worse than their as-signed regimen with respect to ease of use (P O .05).When all patients were similarly questioned, 38 patients(95%) taking Prep 2, 35 patients (85.3%) taking Prep 3,and only 11 patients (28.2%) taking Prep 1 would preferto take same preparation regimen if they required a colo-noscopy in the future (P Z .006 by the Kruskal-Wallistest). When the pairwise comparisons were made, it wasseen that the low-volume preparation regimens were pref-erable to the whole-dose regimen (P Z .001 for Prep 1 vs


Prep 2 and P Z .001 for Prep 1 vs Prep 3 by the c2 test,and P Z .264 for Prep 2 vs Prep 3 by Fisher’s exact test).

Comparisons of the mean duration of colonoscopy,mean cecal intubation time, and the number of successfulcecal intubations among the groups revealed no differ-ences. Furthermore, no differences in endoscopic findingsor patient symptom scores were found among the groups(P O .05) (Table 3).

After completion of the procedure, the quality of bowelcleansing was separately assessed for the right and left co-lon. With regard to the right colon (Fig. 1), there wasa significant difference among the groups (P Z .007 bythe Kruskal-Wallis test), and the Prep 3 regimen had a signif-icantly better cleansing effect than the other 2 regimenswhen the results were dichotomized as an adequate andinadequate preparation (P Z .003 for Prep 3 vs Prep 1,P Z .002 for Prep 3 vs Prep 2, and P Z .852 for Prep 1 vsPrep 2 by the c2 test). In contrast, in the left colon, the bowelcleansing effects of all groups were comparable (P Z .776by the Kruskal-Wallis test) (Fig. 2). In addition, when pair-wise comparisons were made as described above, therewere no differences among the groups (P Z 1.000 forPrep 3 vs Prep 1, P Z .312 for Prep 3 vs Prep 2, andP Z .481 for Prep 1 vs Prep 2 by Fisher’s exact test).

There was no need for repeated preparation of the co-lonoscopy because of ineffective cleansing with Prep 3,but very poor colonoscopy preparation with reschedulingwas needed for 7.7% and 10% of the patients taking Prep 1and Prep 2, respectively.

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TABLE 3. Comparison of various parameters related to colonoscopic procedure

Prep 1 Prep 2 Prep 3 P value

Duration of colonoscopy (min), no. � SD 30.5 � 11.8 30.2 � 14.6 27.7 � 22 .711

Cecal intubation time (min), no. � SD 18.3 � 8.4 17.8 � 6.3 15.6 � 7.4 .661

Successful cecal intubation, no. (%) 37 (94.8) 38 (95) 40 (97.5) .742

Endoscopic findings, no. (%) .664

No mucosal lesions 17 (43.5) 19 (47.5) 14 (34.1)

Polyps 7 (17.9) 5 (12.5) 11 (26.8)

Diverticulosis 3 (7.6) 2 (5) 2 (4.8)

Colitis 8 (20.5) 12 (30) 8 (19.5)

Cancer 3 (7.6) 2 (5) 5 (12.1)

Others 1 (2.5) – 1 (2.4)

Patient symptom score (range, 0-15) 2.5 � 1.5 2.9 � 2 1.9 � 1.4 .129

DISCUSSION

Among the natural laxatives, olive oil is considered bysome to be the most commonly recommended, nonpre-scribed, natural medicine for chronic constipation in Euro-pean and other Mediterranean countries. In addition to itsculinary uses, it has been used for centuries as a laxative.In the medical literature, it was first recommended as a lax-ative for chronic constipation in the British Pharmaceuti-cal Codex at a dose of 15 to 30 mL/d in 1911.18

Although a detailed study of its laxative effect is not avail-able, it is generally thought that consumption of morethan 30 mL of olive oil on an empty stomach exceedsthe absorption capacity of the small intestine, which re-sults in the remainder of the oil passing to the colon.The olive oil acts as a lubricant; it coats the bowel wall

Figure 1. Endoscopic evaluation of the bowel-cleansing quality in the

right colon. Values are expressed as the percentage of patients. Prep 1,

4 L of PEG-ELS; Prep 2, 15 g of magnesium hydroxide followed by 2 L

PEG-ELS; Prep 3, 60 mL of olive oil followed by 2 L of PEG-ELS.

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and stool mass with a waterproof film that permits easierpassage through the colon and rectum. Therefore, oliveoil is predicted to enhance the bowel cleansing effect ofPEG-ELS.

In this study, we evaluated the effects of the various co-lon-cleansing regimens on the left and right colon sepa-rately instead of evaluating the colon as a whole becausewe believe that colon-cleansing difficulties are mainly ob-served on the right side of the colon. When the resultswere dichotomized as an adequate (excellent, good, andfair results pooled) or inadequate (poor and very poor re-sults pooled) preparation, the olive oil pretreatment regi-men resulted in a significantly more adequate cleansing inthe right side of the colon than the standard PEG-ELS andmagnesium hydroxide pretreatment regimens (97.6% vs74.5% and 72.5%, respectively, P Z .007). However, each

Figure 2. Endoscopic evaluation of the bowel-cleansing quality in the

left colon. Values are expressed as the percentage of patients. Prep 1, 4

L of PEG-ELS; Prep 2, 15 g of magnesium hydroxide followed by 2 L of

PEG-ELS; Prep 3, 60 mL of olive oil followed by 2 L of PEG-ELS.



regimen had comparable and acceptable effects on left co-lonic cleansing (91.5%, 85.5%, and 91.8% in Preps 1, 2, and3, respectively; P Z .776).

Although the split-dose PEG-ELS regimen has been shownto be superior to whole-dose PEG-ELS,19 we used the stan-dard whole-dose regimen (4 L of PEG-ELS) in our study be-cause the split-dose PEG-ELS regimen was not widelyaccepted for colonoscopy preparation when we plannedthis study. However, when the results of the regimens werecompared across studies, we observed that adequate or sat-isfactory right colonic cleansing was more frequent with theolive oil pretreatment regimen (97.5%) than with the split-dose PEG-ELS regimen (81.31%). However, a prospectivestudy is necessary to properly compare the effects of the oliveoil regimen and split dosing of PEG-ELS.

Adequate bowel cleansing, as expected, has a significantimpact on the detection of clinically significant lesions.2-4

In this study, it was shown that slightly more colonicpolyps were detected, especially in the right colon, inthe olive oil group than in the other groups, althoughthe differences were not significant. Adding olive oil toPEG-ELS may lead to more accurate diagnoses of coloniclesions and reduce the rescheduling of colonoscopies.However, this study had a relatively small sample size todefinitively consider these suggestions.

Patient acceptance and tolerability and the side effectsof the pretreatment regimens are very important factorsthat determine the optimal colon-cleansing approach.5-8

In this study, all preparation regimens were well toleratedand elicited equivalent symptom scores. The magnesiumhydroxide pretreatment regimen was the most preferredregimen with respect to taste, ease of use, nausea, andvomiting. However, because these differences did notreach statistical significance and given its less-adequatecleansing effect, we concluded that pretreatment withmagnesium hydroxide added to the low volume of PEG-ELS is not a suitable colonoscopy preparation regimen.This result is contrary to the findings of studies of magne-sium citrate. This difference can likely be attributed to theweaker laxative effect of magnesium hydroxide relative tomagnesium citrate.13,14 Importantly, the majority of pa-tients who had previously consumed the standard volumeof PEG-ELS in preparing for a previous colonoscopy fa-vored the low-volume preparations.

In summary, this study demonstrates that pretreatmentwith olive oil followed by a low volume of PEG-ELS en-hances both patient satisfaction and the quality of right-side colonic cleansing during colonoscopy preparationover the conventional volume of PEG-ELS. However, theadministration of magnesium hydroxide followed bya low volume of PEG-ELS does not produce a satisfactorycolonic cleansing. Based on our results, the olive oil regi-men is recommended, especially for patients who are notable to consume large volumes of liquids, such as the el-derly, and those who are suspected of having subtleright-side colonic lesions. Furthermore, the results of


this study suggest that the olive oil preparation regimenmay also be appropriate for patients who have chronicrenal failure or are hospitalized and generally havea more complicated and more difficult preparation forthe colonoscopy.

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solution for colonoscopy preparation. Gastrointest Endosc 2003;58:

36-40.

Received July 30, 2008. Accepted January 5, 2009.

Current affiliations: Department of Gastroenterology (E.A., H.G., B.Y., A.T.I.,

T.K., A.R.D., O.O.K.), Haydarpasa Numune Training and Research Hospital,

Istanbul, Turkey, Department of Gastroenterology (C.B., F.F.B.), Faculty of

Medicine, Harran University, Sanliurfa, Turkey.

Reprint requests: Evren Abut, MD, Department of Gastroenterology,

Haydarpasa Numune Training and Research Hospital, Tibbiye Street,

34668, Selimiye/Istanbul, Turkey.


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