Colon Cleansing

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Colon Cleansing

• Maureen Donovan R.N BSN
• Endoscopy Unit
• Massachusetts General Hospital

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Interesting Facts

• Colon Cancer is the third most common cancer in
  the U.S
• Colon Cancer is the second leading cause of
  cancer related deaths in the U.S
• Non selective , colon cancer randomly strikes
  both sexes, all races and all ages
• Strong genetic link , increased incidence in
  persons with first degree family members who have
  been diagnosed with colon cancer

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Goals for Prepping

• Eliminate fecal contents for endoscopic
  examination
• Eliminate fecal contents and cleanse bowel prior
  to surgical procedures
• Reduces potential for septic complications in
  endoscopy and surgery
• Reduce the potential for missed diagnosis by
  making the intestines clear to viewers

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Types of Mechanical Preps

• Laxatives
• Enemas
• Oral Gastrointestinal Lavage Solutions (PEG)
• Saline Laxatives

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Laxatives

• Stimulant laxatives such as Bisacodyl ,Senna ,
  and others
• Act by increasing peristalsis and promoting fluid
  secretion into intestinal lumen
• Sometimes harsh and ineffective cleaning

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Laxatives continued

• Hyperosmotic Laxatives such as Mannitol,
  Sorbitol and Lactulose.
• Work by exerting osmotic effect drawing water
  into the intestine ,increasing the amount of
  water in stool, softens stool and increases the
  frequency of passage
• Causes diarrhea with electrolyte looses
• Man made sugars can adversely affect diabetics
• Actual cases of explosion within colon with use
  of electrocautery due to production of hydrogen
  gas from bacterial fermentation of agent

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Enemas

• Enemas have been in existence almost as long as
  mankind. References to bowel cleansing date back
  to the Egyptians in 1500 B.C., and enemas were
  used by Babylonians,Indians,Chinese and Native
  Americans.
• More effective in in- patient settings
• Less effective in out-patient settings
• Effective as an adjunct to other preps or in
  scenario where patient compliance is an
  issue/concern at time of arrival
• Generally leaves too much residue behind,
  disabling adequate visibility therefore
  increasing risk of missing a possibly cancerous
  polyp

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Oral Gastrointestinal Lavage Solutions

• Balance electrolyte solution with polyethylene
  glycol (PEG)
• Golytely, Nulytely,Trilyte,Colyte
• A non absorbable osmotic agent that increases
  fecal water content and decreases
  gastrointestinal transit time
• Safer for patients with renal, heart or liver
  disease

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Saline Laxatives

• Laxatives containing magnesium or phosphate
• Fleets Phosphosoda, Visicol tablets and Fleet
  prep kits
• Works by the hyperosmotic effect of poorly
  absorbed magnesium or phosphate in the small
  intestines
• Better tolerated than PEG preps and can be
  equally effective in colon cleansing

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Saline Laxatives continued

• Safety of these bowel preps are an issue
• Associated with significant changes in volume
  status,dehydration, electrolyte abnormalities
  ,renal failure and in rare cases seizures
• Not for use in patients known to have advanced
  liver disease,acute/chronic renal failure, recent
  MI, CHF,acites and any underlying electrolye
  abnormalities

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Saline laxatives continued

• March 2006 the FDA issued an alert regarding the
  use of Saline laxative preps and potential side
  effects
• December 2008 the FDA placed a black box warning
  on Fleet Phosphosoda to emphasize that this prep
  should only be used with extreme caution in at
  risk patients
• After the issue of the black box warning the
  Fleet co. advised retailers to remove the product
  from OTC areas, making the prep now only
  available with a perscription

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The patients perception

• Disgusting
• Nauseating
• Like drinking a gallon of sea water butno day
  at the beach!
• Tastes like cr..!
• Terrible cramps and bloating
• Couldnt sleep all night
• My bottom is so sore
• Worse than the procedure itself

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The bottom line

• There is no virtual prep
• There is no perfect/easy/ideal prep
• Traditional colon preps are still the best
  currently available products
• Care givers need to be informed about all
  available prep options
• Patient misunderstanding /or non-compliance may
  lead to delayed screening ,personal harm, missed
  diagnosis of colon cancer

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Do no harm

• Bowel preps can cause
• Explosive diarrhea
• Abdominal cramping / pain
• Chills
• Fullness / bloating
• Nausea vomiting
• Aggravate painful hemorrhoids and fissures
• Cause local excoriation and anal discomfort

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Adjuncts to Mechanical Prep

• Diet
• Hydration
• Fasting for Sedation
• Medication Modification

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Review foods to avoid 2-3 days before procedure
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Some high fiber foods to avoid
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More high fiber foods to avoid
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A light breakfast can be consumed the day before!
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Or an early light lunch if the procedure is later!
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Its clear liquids now!
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Just remember nothing red
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Remember calories and electrolyes
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As long as theyre not red!
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Clear liquid diet dos donts
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Nothing by mouth 4-6 hours before procedure
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Nothing by mouth 4-6 hours prior to procedure
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Medication Modification

• Important/Individualized
• Review pre procedure
• PCP/ Specialist directed
• Adhere to local policy
• Anticoagulation/Diabetes Management

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Anticoag Management

• Individualized/ PCP or Specialist directed
• Review Pre- procedure
• Follow local policy
• Labs should be evaluated before procedure-
  appropriate action to follow
• Review Post- procedure
• Communicate with GI team throughout encounter

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Med Modification - Anticoagulants
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Med Modification -Diabetes

• Important / Individualized
• PCP / Specialist directed
• FBS checked on admission and as needed
• Meds and results communicated to team for
  appropriate management of IVF and RX
• Follow local policy

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Prepare the prep and refrigerate over night, the
colder it is the more palatable it is!
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Drinking the prep thru a straw helps!
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Adding flavor packets helps!
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Sucking on lollipops helps!
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Patients need to know once the prep starts to
work they will need to be near a toilet
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Using baby wipes instead of toilet tissue can
help alleviate local anal irritation
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Confused? We can help
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Summary

• Early detection is part and parcel to reducing
  the mortality associated with colon cancer.
• Therefore it is critical to convince patients
  that regular screening is worth the preparation
  and discomfort associated with it
• Nurses in the Endoscopy who utilize effective
  coaching and teaching strategies with patients
  undergoing colon cleansing for procedures play an
  important role in the outcomes.

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