Post written by Mehul Lamba, FRACP, from the Department of Gastroenterology and Hepatology, Royal Brisbane and Women’s Hospital, Herston, Queensland, Australia.

Capsule endoscopy (CE) is an investigation of choice for the assessment of suspected small intestinal bleeding.

Because CE lacks the ability to wash or suction intestinal contents, diagnostic utility is reliant on adequate small-bowel preparation.

Purgative bowel preparation is commonly used to cleanse the small intestine before CE, but no robust evidence supports an improvement in diagnostic yield in comparison with clear fluid-only preparation.

Moreover, symptoms of patient intolerance are not uncommon with purgative preparations. Therefore, their routine use before CE needs to be further examined.

Several randomized controlled trials have been performed over the years to assess the use of various types of purgative bowel preparation and its effect on diagnostic yield and small-bowel visualization quality.

However, the majority of the studies had a small sample size and consequently were underpowered or used subjective or nonstandardized scores to assess diagnostic yield and small-bowel visualization quality.

Therefore, there was a need for an adequately powered, randomized controlled trial using validated objective scores to assess clinical efficacy of purgative bowel preparation compared with clear fluid-only preparation.

We undertook a multicenter, blinded, randomized controlled trial assessing clinical effectiveness of 2 types of purgative regimen (2 L of polyethylene glycol [PEG] and 1 L of PEG + sodium ascorbate, respectively) and a control group (clear fluid only) in patients with suspected small intestinal bleeding undergoing CE. All patients ingested the capsule endoscope with simethicone 200 mg in 150 mL of water.

A total of 229 patients completed the study. We found no difference in diagnostic yield (incidence of highly relevant or less relevant lesions) across the 3 study groups. The use of purgatives was not associated with an improvement in overall or distal small-bowel visualization quality as assessed using the Brotz score. The overall gastric transit time and the small-bowel transit time were similar across the study arms.

In addition, significantly more patients assigned to purgative arms reported nausea, bloating, and abdominal pain than the control arm. Therefore, our results do not support routine use of purgative preparation in patients undergoing CE for investigation of small intestinal bleeding.

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