1. Top of page
  2. Abstract
  7. COSTS
  9. References

Adequate cleansing is essential for reliable diagnostic and surgical colon procedures. Accuracy and safety depend on good preparation. Patient compliance is enhanced by simplicity and well-tolerated methods.

Several methods are available. Diet and cathartic regimens utilize clear liquids or diets designed to leave a minimal colonic residue. Laxatives, cathartics and enemas are employed. Gut lavage solutions are osmotically balanced electrolyte lavage products. Oral sodium phosphate solutions and tablets are available and are attractive because of good efficacy with a small volume of administration.

For colonoscopy and colon surgery preparation, these methods have been proven safe and effective. For barium enema X-ray, lavage requires an adjunctive agent such as bisacodyl to enhance barium coating. Overall, all regimens are well-tolerated.

This review discusses the development and clinical experience with various colon cleansing regimens.


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Proper colonic examination and surgery require a clean luminal environment. Poorly visualized mucosa leads to missed diagnoses and increases the risks of peritoneal contamination if the complication of perforation occurs.1[2]–3 Residual faecal matter also poses the risk of ignition of combustible gases during electrocautery.1[2][3][4][5][6]–7 Research attention has been directed towards providing safe and effective colon preparation whilst improving patient tolerance of cleansing methods.

Ideally, a colon preparation would provide safe and rapid cleansing acceptable to patients, with little or no discomfort. Most of the presently available methods do not meet these criteria and few have been carefully studied.1


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Traditional cleansing methods have evolved from barium enema preparation techniques and local experience. These methods were empirically modified for colonoscopy and colon surgery. Diet is restricted to 1–4 days of liquids or foods that provide a minimal colonic faecal residue.8, 9 Laxatives and enemas are used and adequate cleansing is usually achieved. Table 1 lists the features of the common diet and cathartic regimens.3 Patient discomfort, inconvenience, and poor compliance with the diet and cathartic methods has led to the development of alternative forms of bowel cleansing.

Table 1.   Diet and cathartic regimen Thumbnail image of


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Orthograde gut lavage was provided in the form of saline or balanced electrolyte solutions administered orally or by nasogastric tube in amounts varying from 7 L to 12 L. Lavage led invariably to patient discomfort, and intolerance in up to 11% of patients.10 There was also net sodium retention and fluid shifts.


Davis et al. formulated an osmotically balanced electrolyte lavage solution, polyethylene glycol-electrolyte lavage solution (PEG-ELS, Colyte, Schwarz Pharma, Inc., Milwaukee, WI; GoLytely, Braintree Laboratories, Inc., Braintree, MA), which had minimal net water or electrolyte secretion or absorption.11 Clinical trials established the safety and efficacy of PEG-ELS for colon cleansing preparation for colonoscopy, excretory urography, intravenous pyelography and colon surgery.9, 12[13]–14, 19[20]–21


In an attempt to improve compliance by decreasing the salty taste and ‘rotten egg’ smell from sodium sulphate, a sulphate-free-polyethylene glycol electrolyte lavage solution (SF-ELS, NuLytely, Braintree Laboratories, Inc.) was developed.22 SF-ELS has even less absorption or secretion of water or electrolytes than PEG-ELS. Whereas the mechanism of action of cleansing by PEG-ELS was affected by osmotic properties of PEG and by the electrochemical gradient for fluid transport created by sodium sulphate, SF-ELS action is primarily based on the osmotic effects of PEG. The PEG polymer interacts with water molecules, isolating water from the bulk of the solution.23 When PEG reaches a molecular weight greater than 1500, as seen with PEG 3350 in PEG-ELS and SF-ELS, it is poorly absorbed from the gastrointestinal tract. PEG, in this manner, can safely obligate intraluminal water retention. Its inert property prevents bacterial fermentation. PEG can also be quantitatively recovered from stool when fed by mouth.24 Studies involving urinary excretion of PEG and sulphur when using PEG-ELS showed no change in urinary PEG or sulphate levels, although the authors acknowledged that renal tubular reabsorption may have affected these results.25

SF-ELS was found to be safe and effective for diagnostic procedures and surgery.26[27][28][29]–30 Of those who expressed a preference, SF-ELS was preferred over PEG-ELS; 76.6% vs. 23.4%, respectively, P < 0.001.26


Further attempts at improving palatability include the addition of flavouring agents. Table 2 lists the available products and flavours.

Table 2.   Available bowel preparation products Thumbnail image of


Metoclopramide has been studied as an adjuvant agent to gut lavage prior to colonoscopy.31, 32 The adequacy of preparation was not influenced and symptoms associated with lavage were not decreased. Additionally, cisapride does not have proven benefit as a prokinetic for improving gut lavage.33

Bisacodyl enhances barium coating and is required for barium enema X-ray examinations.17, 29 After PEG-ELS, senna and bisacodyl have shown no significant differences in the quality of preparation or amounts of residual colonic fluid during colonoscopy.34, 35 However, bisacodyl and magnesium citrate deserve further attention because different administration regimens may improve patient acceptance and reduce the volume of PEG-ELS required for adequate cleansing.36, 37

Simethicone reduces the formation of bubbles seen during colonoscopy and there are favourable tolerance reports by patients.38

Enemas offer no significant improvement to gut lavage and may produce anorectal trauma.39 Patient compliance with the cleansing regimen is reduced.


Gastric outlet obstruction predisposes to aspiration. Concern is also raised for those who require nasogastric administration. Such patients are at risk of aspiration. Careful attention should be given to ensure that the tube is properly positioned in the stomach to avoid tracheal administration of lavage solutions. The head of the patient’s bed should be elevated during and after administration and the patient should be carefully observed.

Caution is also advised for the patient with possible intestinal obstruction. A 1-L trial can be used before giving the complete lavage. Significant colonic or gastric obstruction is a contraindication to lavage preparation.2

Mallory–Weiss tears and bleeding reactivation have been seen.2 Pill malabsorption has been reported, but most pills recovered and tested show that they are ‘ghosts’ of the wax tablet matrix, without active medication.40, 41

Clinically significant haematologic or electrolyte changes have not been seen in trials of gut lavage preparation, but there is always concern and high risk patients should be observed carefully.2, 3 There are anecdotes of anasarca, peripheral oedema, asystole, and pulmonary oedema.2 Overall, PEG-ELS and SF-ELS are preferred for safety in subjects with renal, hepatic and cardiac conditions where fluid balance is tenuous.2 The regimens are safe and accepted by older patients.42

PEG appears to be non-toxic. Animal studies show no effect on body or organ weight, kidney or liver function, or organ microscopy.43 There was insignificant absorption of PEG given to normal human volunteers and inflammatory bowel disease patients.25 There are also reports of systemic allergic reaction to PEG solutions, although serious side-effects have been rare.44[45][46]–47

Administration advice

Patients are advised to chill the solutions for palatability and to reconstitute with bottled water to avoid the chlorine taste of tap water. Our group allows normal breakfast and lunch with clear liquids for supper. Church found the same-day morning preparation to have an advantage when compared to afternoon lavage the day before.48 The preparation is started at 6 pm and the 1.5 L/h lavage rate is accomplished by drinking 10 oz every 10 min. A timer is recommended. Patients are advised to complete 4 L or until rectal effluent becomes clear in appearance. For urgent preparation, such as for gastrointestinal bleeding, as little as 500 mL may be needed.49[50]–51

Patients should avoid oral iron and constipating agents for 7–10 days. They are asked to not eat red or purple juices or foods that will give the colon a colour residual during colonoscopy. Beans, red jelly and watermelon should be avoided. Flavouring, sweeteners or nutritional substances should not be added because the resulting changes in osmolarity will increase the salt and water absorption.

Paediatric use

Gut lavage has been used for infants and children for colonoscopy.1, 52[53]–54 In these studies, efficacy was acceptable but compliance is limited by the volume needed for adequate cleansing. Lavage remains the preferred method because of its superior cleansing and limited adverse effects.1, 53

PEG-ELS has been used in children for encopresis, cystic fibrosis and chronic constipation.55[56][57][58][59][60][61]–62 When given in a large volume for colon cleansing or a ‘clean out’ for constipation, a steady-state equilibrium across intestinal mucosa is achieved and there is no net absorption or secretion of fluids or electrolytes.11, 22 When given in small doses regularly, such as for chronic constipation, steady-state is not reached and the salt components are absorbed.63 For these patients, a PEG laxative is available.64, 65


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Oral sodium phosphate (Fleet Phospho-soda, C.B. Fleet, Inc., Lynchburg, VA) has received attention because its small volume and oral administration is attractive. The dose is 45 mL, diluted to 90 mL with water, given twice, the evening before and on the morning of the procedure. The preparation contains 48 g (400 mmol) of monobasic sodium phosphate and 18 g (130 mmol) of dibasic sodium phosphate per 100 mL, making it very hypertonic.24 This phosphate salt appears to act through an osmotic effect, and must be diluted before ingestion to prevent vomiting and followed by adequate oral fluids to prevent dehydration. Oral sodium phosphate is well-accepted by patients and has been found to be very effective as a colon cleansing preparation in several randomized studies.66[67][68][69][70][71][72]–73

There have been concerns in the past, however, regarding the safety of this preparation method due to the reports of deaths from accidental overdose.74, 75 Vanner et al. found no significant changes in intravascular volume when compared with PEG lavage solution, although transient hyperphosphatemia was noted up to a level of 7 mg/dL.66 Two studies have reported significant hyperphosphatemia and hypocalcemia, with mean rises in phosphorus of 7.6 ± 0.1 mg/dL and mean falls in total and ionized calcium of 8.4 ± 0.1 and 4.6 ± 0.1 mg/dL, respectively, in one study.76, 77 However, no adverse clinical outcomes were observed and some authors feel that these changes were not clinically significant.78, 79 The intestinal absorption of dietary phosphorus appears to be constant at 60–65% over a wide range of intake.75 Indeed, there have been reports of increased mortality due to increased phosphate absorption in patients, although the exact pathophysiologic mechanism is unclear.80 It is thought that prolonged retention due to ileus, impaction, or intestinal obstruction may facilitate phosphate absorption.75 It has been postulated that hyperphosphatemia may therefore result from excess dosages, increased rates of absorption, or impaired renal excretion.75

Elevations in serum phosphorus lead to decreased serum calcium by causing calcium phosphate salt deposition.81 This may occur when the calcium–phosphate solubility product (which is normally 40) is exceeded, risking potential soft tissue calcification in the kidneys, heart, blood vessels, cornea, lungs, and gastric mucosa.76 In seven normal study subjects administered two 45-mL dosages of oral sodium phosphate, the peak of the mean in vitro solubility product was 60.9, well above the normal range.77

Oral sodium phosphate is safe and effective for the majority of patients, but these biochemical effects raise concern. Phosphate preparations should be avoided in patients with significant renal, cardiac or hepatic diseases or in those in whom fluid and electrolyte balance is delicate. Because of occult renal disease, it is advised that serum creatinine be checked before using oral sodium phosphate.

An investigational colon cleansing agent, sodium phosphate monobasic, monohydrate and sodium phosphate dibasic, anhydrous (Visacol, InKine Pharmaceutical Co., Inc., Blue Bell, PA) uses a tablet formulation. Forty preparation tablets taken with ten 10-oz glasses of water are administered. Preliminary abstract data support its efficacy and patient acceptance when compared to SF-ELS and the authors conclude that the calcium, phosphorus and electrolyte shifts seen were minor, transient and clinically insignificant.82


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Table 2 lists the average retail pharmacy and selected internet costs for cleansing products.


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There are several options for colon cleansing for diagnostic and surgical procedures. Orthograde lavage using PEG-ELS or SF-ELS is preferred for preparation for endoscopic and surgical procedures and this method is acceptable for barium enema X-ray if adjunctive agents such as bisacodyl are used. Diet, cathartic and enema methods are options, as are phosphate preparations which have proven efficacy. Because efficacy is similar and adequate for most preparations, choice is based on patient acceptance, cost and underlying medical conditions. There has been improvement over the restrictive clear liquid diet, cathartic and enema methods, but the search for an ideal cleansing method continues.

  1. Dr DiPalma serves as a medical director consultant to Braintree, Laboratories, Inc., Braintree, MA, USA.


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