Preventing Colorectal Cancer, a not-for-profit organization, encourages policymakers, health officials, health plan executives and others to support colonoscopies as the Gold Standard colorectal cancer screening method. This issue brief is one in a series of publications arming consumers, providers and others with information about patient colorectal health screenings. In particular, this brief provides patients with an overview of what to expect from the colonoscopy preparation process and emphasizes the importance of following through with proper colonoscopy preparation.
The Issue: Prepping for a Colonoscopy
Scheduling and receiving a colorectal screening colonoscopy are important steps in preventing colorectal cancer. However, due to the nature of the procedure, the patient must take an active role in following the preparation instructions in order for a screening to have optimal results. Research indicates that approximately 1-in-4 to 1-in-6 patients are inadequately cleansed in preparation for a colonoscopy screening.1
Why is an adequately cleansed bowel so critical when performing a colonoscopy screening? A proper cleansing influences multiple aspects of the colonoscopy procedure; but to understand why, one must first understand the process.
A gastroenterologist passes a colonscope, a long flexible tube with a television camera on the tip,2 through the entire colon. If there is debris in the colon due to improper cleansing or preparation, small abnormalities such as polyps or even a small cancer could be obscured. This inadequate detection can lead to multiple negative, and even dangerous, outcomes. Improper preparation could lead to a repeated colonoscopy sooner than required,3 increased procedure time or even a missed diagnosis of what could have been a critical finding. The procedure might also need to be aborted, which would necessitate rescheduling the colonoscopy for another time in the future and require the patient to undergo another round of prep. All of these factors can have a negative impact on the patient, as well as lead to an increase in health care costs for both the patient and the health care system overall.
Understanding the Preparation Process
So where does the patient start? The initial consultation with the patient’s doctor will result in not only a discussion of the entire colonoscopy process but also the importance of the patient’s role in preparing for the procedure. The patient could possibly hear this preparation referred to using various terminology, but some of the most common terms used are “bowel preparation”, “colon prep”, “colonoscopy prep” and “bowel prep”. All of these terms relate to a process which is undertaken before a diagnostic procedure that is intended to remove all stool, feces and food particles from the colon.4
Preparation will usually involve a slight modification of the patient’s diet 2-3 days prior to the procedure as well as a prep medication. The cost of a prep kit can vary based on factors such as the type of kit, kit manufacturer and the patient’s geographic location. Normally, the price for a prep kit is under $100, but it is important to note that this cost is not always covered by insurance. Patients should check with their insurance company to determine all charges covered, as well as ask their doctor about the possibility of coupons or additional discounts.5
Medication Prep Options
Patient factors that are considered when prescribing a particular prep medication include the patient’s medical history, current medications being taken, and any prior reactions to a medication if there has been a colonoscopy performed previously. Because these factors can vary greatly from patient-to-patient, it is always important for every individual to keep an open line of communication with their health care providers to ensure that the most appropriate medication is prescribed. Doing so will help to minimize side effects, allow for affective bowl cleansing and support a more optimal colonoscopy procedure overall.
There are two main types of preparation medications that are used to prepare a patient before a colonoscopy. Sodium phosphate is a laxative in a tablet form that is taken with large quantities of water. This preparation pulls water into the colon to clean it out. However, there can occasionally be some issues with this type of prep, which is why it may not be recommended for those with kidney disease. It is always best practice for every patient to consult with their doctor and discuss any health issues that may exist.
The second category of most commonly used preparation is Polyethylene Glycol (PEG) Solutions. There are four types of PEG solutions, all of which work on the principal of a high volume of solution used to clean out the bowel. This is often provided as a powder that is then mixed with water.6
Dosage and Timing
Once the doctor prescribes a specific preparation, the dosing and timing are the next critical steps. The split-dose prep is the recommended standard of care by a recent report released by U.S. Multi-Society Task Force.In this approach, the dosage is divided in half; the first half is usually taken the day prior to the procedure and the second portion is taken 4-6 hours later. This frequently requires the patient to get up in the middle of the night to take the second dose. An alternate option involves a same-day regimen, which may be offered when afternoon examinations are scheduled. It has been observed that a full dosage taken the day before may produce a film that coats the colon and impairs flat lesion detection, and is therefore not a recommended approach.7
Education and Potential Side Effects
Ideally, the patient should be provided with both oral and written instructions about how to prepare for their colonoscopy.8 A trained patient navigator or nurse has been found to be an effective means with which to provide the patient with the information and support needed to allow for a high quality screening. In underserved, low income populations, navigation clinics held in the patient’s native language have been shown to increase the likelihood of not only keeping the colonoscopy appointment, but also lead to more successful completions of colonoscopy screenings.9
Common reactions to the prep medication are bloating, abdominal discomfort or pain, vomiting and/or nausea. On rare occasions, there are more severe side effects which should be reported immediately to the doctor. These unpleasant side effects to the preparation process are often the reasons the patient frequently fails to follow through with proper preparation. However, understanding the importance of colonoscopy prep and knowing what to expect from the process can greatly improve the chances of a patient following through with the instructions.
Reducing the incidence of colorectal cancer begins with the patient’s decision to take the first step and schedule a colonoscopy screening. Screening colonoscopies are the Gold Standard procedure that can help reduce the incidence of colorectal cancer, and proper bowl preparation is critical to ensuring each screening is as accurate as possible. Every patient should consult with their doctor and make certain they receive both written and oral instructions to gain clear understanding of not only the colonoscopy procedure, but also of the importance of proper preparation.
Increasing the screening rate to 80% by 2018 is the primary goal of The National Colorectal Cancer Roundtable.10 A knowledgeable and well-prepared patient is key to making this goal a reality.
About Preventing Colorectal Cancer:
Headquartered in Annapolis, MD, PCC is a not-for-profit 501(c) 6 advocacy organization with the primary mission to educate both public and private stakeholders about the opportunities to reduce the incidence of colorectal cancer through promoting effective screening, prevention and care options for patients. Membership is open to all individuals and groups. For more information, see www.preventingcolorectalcancer.org.
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Annapolis, MD 21403
1 Pyenson B, Scammell C, Broulette J. Costs and repeat rates associated with colonoscopy observed in medical claims for commercial and Medicare populations. (2014). BMC Health Services Research. 2014; 14:92-6963-14-92. Retrieved December 30, 2015 link
2 Rex, DG. 10 Questions You Need to Ask About Colonoscopy. (2009, February 25). The New York Times. Retrieved December 30, 2015 link
3 Rex DK, Imperiale TF, Latinovich DR, Bratcher LL. Impact of bowel preparation on efficiency and cost of colonoscopy. (2002). American Journal of Gastroenterology. 2002; 97:1696-1700. Retrieved December 30, 2015 link
4 ColonoscopyAssist. Learn about Colon Preps. (2013). Retrieved December 30, 2015 link
5 Comparison of Bowel Preparations for Colonoscopy. (2009, January). Retrieved December 30, 2015 link
6 Adamec, C. Different Types of Colonoscopy Preps. (2015, June 24). Retrieved December 30, 2015 link
7 Johnson DA, Barkun AN, Cohen LB, Dominitz JA, Kaltenbach T, et al. Optimizing Adequacy of Bowel Cleansing for Colonoscopy: Recommendations from the US Multi-Society Task Force on Colorectal Cancer. (2014, September 16). Retrieved December 30, 2015 link
8 Comprehensive Cancer Control National Partnership. Implementing a Quality Screening Navigation Program. (2015). Retrieved December 30, 2015 link
9 Osterweil N. Open-Access Colorectal Screening Finds More Polyps, Adenomas.(2015, October 20). Retrieved December 30, 2015 link
10 Simon S. Achieving 80% by 2018 Screening Goal Could Prevent 200,000 Colon Cancer Deaths in Less Than 2 Decades. (2015, March 12). Retrieved December 30, 2015 link