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Academic Journal of Gastroenterology & Hepatology - AJGH

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Open Access Research Article

A Single Center Cohort Study Evaluating the Quality of Colonoscopy Bowel Preparation in Adult Persons with Cystic Fibrosis

Alexander Chen1, Arvind Bussetty1, Jing Shen2 and Keerthana Kesavarapu2*

1Department of Internal Medicine, Rutgers Robert Wood Johnson Medical School, USA

2Department of Gastroenterology and Hepatology, Rutgers Robert Wood Johnson Medical School, USA

Corresponding Author

Received Date:August 02, 2024;  Published Date:August 28, 2024

Abstract

Background: Persons with Cystic Fibrosis (PwCF) have increased early incidence and progression of adenomas. Anecdotal evidence and limited literature show suboptimal bowel preparation in PwCF compared to controls when using standard bowel preparation. This study aims to understand the adequacy of bowel preparation in PwCF undergoing colonoscopy.
Methods: This is retrospective review comparing adults with CF who underwent colonoscopy for any indication between January 2016 and December 2023 with age and gender matched controls. Bowel preparation was subjectively evaluated as “excellent” or “good” by the endoscopist was combined and categorized as “Acceptable” and bowel preparation evaluated as “fair”, “poor” or “inadequate” was combined and categorized “Unacceptable”.
Results: 20 PwCF (age 39, F=6) underwent colonoscopy from 2016 to 2023. Indications for colonoscopy in our PwCF included CRC screening (50%), gastrointestinal bleeding (20%), abdominal/rectal pain (10%), evaluation of iron deficiency anemia (10%), and multiple indications (15%). While nonsignificant, PwCF compared to controls had higher odds of having “Unacceptable” bowel preparation (40% vs. 30%, OR 1.62; 95% CI, 0.43- 6.13, p = 0.48). A subgroup analysis among pwCF did not identify risk factors that might contribute to “Unacceptable” bowel preparation including history of constipation, pancreatic insufficiency, gastroesophageal reflux disease, hepatic disease, intraabdominal surgeries or use of highly effective modulator therapy and opioids.
Discussion: This study identified elevated rates of “Unacceptable” bowel preparation in PwCF. Given elevated incidence and progression of adenomas and advanced adenomatous polyps at an earlier age, an aggressive bowel regimen is recommended by the Cystic Fibrosis Foundation.

Keywords: Cystic Fibrosis; Colon Cancer; Polyps; Colonoscopy; Bowel Preparation

Background

Cystic fibrosis (CF), an autosomal recessive genetic disorder caused by mutations in the cystic fibrosis transmembrane conductance regulator (CFTR) gene, results in multiorgan system dysfunction affecting the respiratory, reproductive and gastrointestinal tract [1]. Advances in treatment have led to improvements in median survival from 6.3 years (95% CI, 35.1- 37.9) in 2006 to 53.1 years (95% CI, 51.6-54.7) in 2021 [2]. This rise in survival has put pwCF at increased risk of gastrointestinal cancers including colorectal cancer (CRC).

Risk of CRC in people with cystic fibrosis (PwCF) is 5-10 times greater than the general population and 25-30 times greater than the general population after organ transplantation [3]. Additionally, there is evidence that colon cancer is diagnosed at younger ages in PwCF compared to patients without. Screening and diagnostic colonoscopies have demonstrated an increasing prevalence of adenomatous and advanced adenomatous colon polyps [4]. As a result, the American Gastroenterology Association (AGA) in conjunction with the Cystic Fibrosis Foundation recommends CRC screening starting at age 40 in PwCF with colonoscopy being the preferred method based on recent guidelines [3].

Furthermore, PwCF who undergo standard bowel preparation have been shown to have worse bowel preparation than people without CF (PwoCF) [5,6], which contributes to increased likelihood of missed polyps during colonoscopy [7]. These studies include patients between 2001 and 2015, likely prior to widespread use of highly effective modulator therapy (HEMT). Intensive bowel preparation, specifically a protocol developed by the University of Minnesota [4,8] has been used and recommended to ensure optimized bowel preparation. This study aims to evaluate the quality of bowel preparation in PwCF on HEMT undergoing colonoscopy and identify risk factors contributing to inadequate bowel preparation.

Methods

This is a retrospective exploratory case-controlled study of PwCF from Rutgers Robert Wood Johnson. Eligible patients included adults >18 years with a confirmed diagnosis of CF based on clinical, sweat, and genetic testing who underwent colonoscopy for any indication between January 2016 and December 2023. Data was extracted from the electronic health records at Rutgers Robert Wood Johnson. The control group consisted of patients who underwent colonoscopy during the same period without the diagnosis of CF and matched for age and gender.

Colonoscopy procedure reports were reviewed for information regarding the colonoscopy’s indication, findings, and prep quality. Given the small sample sizes, any bowel preparation subjectively evaluated as “excellent” or “good” by the endoscopist was combined and categorized as “Acceptable” and bowel preparation evaluated as “fair”, “poor” or “inadequate” was combined and categorized “Unacceptable”.

Patient charts were reviewed to extract demographic data. History and physical documented on the same day of the procedure by the endoscopist were reviewed to evaluate for comorbidities including gastrointestinal reflex, constipation, and pancreatic insufficiency. Medication dispense histories were reviewed to identify prescribed bowel preparation and concurrent medications impacting intestinal transit. Student’s t-test, Chi-squared test and Logistic regression models adjusted for age and gender were then used for analysis.

Results

20 PwCF (age 39, F=6) and 20 age- and gender- matched controls (age 40, F=8) without CF underwent colonoscopy from 2016 to 2023. Table 1 highlights the demographics of both populations. All subjects in this study were prescribed a split prep polyethylene glycol-based bowel preparation solution with a volume of 4 liters.

Table 1:Age- and Gender- Matched Comparison of Medical History and Colonoscopy Findings between PwCF and PwoCF.

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Indications for colonoscopy ranged from CRC screening (50% vs. 40% in PwCF and PwoCF), surveillance of disease activity in inflammatory bowel disease (0% vs. 20% in PwCF and PwoCF), gastrointestinal bleeding (20% vs. 20% in PwCF and PwoCF), abdominal/rectal pain (10% vs. 15% in PwCF and PwoCF), evaluation of iron deficiency anemia (10% vs. 15% in PwCF and PwoCF), and multiple indications (15% in PwCF).

While nonsignificant, PwCF compared to PwoCF had higher odds of having “Unacceptable” bowel preparation (40% vs. 30%, OR 1.62; 95% CI, 0.43-6.13, p = 0.48). Additionally, there was no difference in identifying adenomatous polyps (OR, 1.23; 95% CI, 0.28-5.42, p = 0.78) or hemorrhoids (OR 2.27; 95% CI, 0.60-8.54, p = 0.23) between PwCF and PwoCF.

A subgroup analysis was performed among pwCF to identify risk factors that might contribute to “Unacceptable” bowel preparation. There was no difference in pancreatic insufficiency, gastroesophageal reflux disease, hepatic disease, use of highly effective modulator therapy, or intraabdomial surgeries identified between PwCF who were found to have “Acceptable” compared to those with “Unacceptable” preparation. With respect to factors that could have affected adequacy of bowel prep there was no statistically significant difference in history of opiate use (OR, 1.24; 95% CI, 0.14, 11.36, P = 0.85) or history of constipation (OR, 1.18; 95% CI, 0.17, 8.40, P = 0.87). Amongst PwCF who had adequate prep (12 patients) compared with inadequate prep (8 patients), there was no difference in the number of patients on disease modifying therapy (7/12 vs 4/8 respectively, p = 0.33).

Discussion

While this study identified an increased rate of inadequate bowel preparation in 40% of PwCF undergoing standard colonoscopy preparation, it did not elucidate a significant difference between the quality of bowel preparation in PwCF compared to controls. The finding of higher frequency of inadequate preparation is not surprising given the co-morbid diagnosis of constipation, distal intestinal obstruction syndrome and slow gastrointestinal transit time noted in CF [9]. The lack of difference between PwCF and controls in this study is contradictory to anecdotal evidence and limited existing literature that suggests that PwCF has a suboptimal bowel preparation compared to control population. Only one study exists to understand this relationship and highlights that when compared to controls there is a fourfold increased likelihood of poor bowel preparation in PwCF reporting 22% of pwCF having poor preparation compared to 7% in controls [5].

The age- and gender- matched controls in this study had an increased rate of “Unacceptable” bowel preparation, which likely contributed to the lack of difference in bowel preparation between PwCF and controls. The literature highlights up to 25% of all colonoscopies are reported to have an inadequate bowel preparation compared to the 40% in this study [10]. Our controls exhibited a higher rate of co-morbid risk factors like that of our PwCF. Risk factors identified for inadequate bowel preparation as incomplete consumption of preparation and lack of split dosing preparation [11-14]. Additional patient and disease related risk factors including use of antidepressants, co-morbid constipation or abdominal/pelvic surgery serve as independent predictors for inadequate cleansing [15].

Secondly, it is unclear what effect, if any, modulator therapy would have on bowel preparation for PwCF. This study has enrolled 75% of pwCF on HEMT compared to existing literature, which includes patients prior to modulator availability or widespread adoption. This may have resulted in an improved response to standard bowel preparation. However, the GALAXY trial noted only modest effects of modulator therapy on gastrointestinal symptom burden [16].

Inadequate preparation is associated with reduced adenoma detection rates [6]. Given that PwCF are at increased incidence and progression of adenomas and advanced adenomatous polyps at an earlier age, having adequate bowel preparation is vital to early detection and prevention of malignancy [8]. Additionally, the risk of CRC in adults with CF is 5-10 times greater compared to the general population and 25-30 times greater after lung transplantation [17,18]. As a result, an intensive bowel preparation regimen is recommended prior to colonoscopy as seen in table 2. Matson et al demonstrates that CF bowel regimen has a higher proportion of excellent and good preparation and lower rates of poor preparation compared to standard bowel regimen with improved detection of adenomatous polyps [6] (Table 2).

Table 2:

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The major limitations of this study include our reporting of a single-center experience, which resulted in a small sample size. Secondly, the data collected included reliance on subjective assessments of bowel preparation. It is possible that the endoscopist performing the colonoscopy noted adequate bowel preparation after extensive lavage but failed to document this finding.

In conclusion, our study demonstrates that persons with CF have increased rates of suboptimal bowel preparation although similar to that of our age and gender matched controls. Given the well-reported and increased risk of CRC, advanced adenomas and adenomatous polyps, prescribing and recommending an aggressive bowel regimen is paramount to improve early identification and resection of polyps. Bowel preparation recommendations should go hand in hand with early colonoscopy screening and surveillance strategies in this high-risk population.

References
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    2. Foundation CF (2021) Patient Registry Annual Data Report.
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    16. Freeman AJ (2021) Partnering with the cystic fibrosis community to optimize assessment of gastrointestinal symptoms. J Cyst Fibros 20(4): 598-604.
    17. Maisonneuve P (2003) Cancer risk in non-transplanted and transplanted cystic fibrosis patients: a 10-year study. J Natl Cancer Inst 95(5): 381-387.
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Article Details
Citation

  • Alexander Chen, Arvind Bussetty, Jing Shen and Keerthana Kesavarapu*. A Single Center Cohort Study Evaluating the Quality of Colonoscopy Bowel Preparation in Adult Persons with Cystic Fibrosis. Acad J Gastroenterol & Hepatol. 4(1): 2024. AJGH.MS.ID.000576.

Keywords

  • Cystic Fibrosis; Colon Cancer; Polyps; Colonoscopy; Bowel Preparation; Iris Publishers; Iris Publishers Indexing Sites

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