Vijaypal Arya M.D, F.A.C.P, F.A.C.G, A.G.A.FClinical Assistant Prof., Hofstra-Northwell Health.

Director, Endoscopy Unit, WHMC

First colonoscopic polypectomy

(1971) by Dr Hiromi Shinya1 and

Dr William Wolf (Beth Israel

Medical Center)

Adenoma – Carcinoma sequence2

Colonoscopy – Gold standard for

Colon Cancer Screening2

1 Sivak et al., 2004, 2Winawer et al., 1993

Percentage of adults aged 50 years and older who ever had a colorectal endoscopy, by race / ethnicity: 1987-2005

National Cancer Institute Database

Source: National Endoscopy Database/Clinical Outcomes Research Initiative

Mortality Person years of life lost

Janne and Mayer 2000

8.1 million screening colonoscopies/yr are required in the US1

and 14-17 million Colonoscopies in total.

Within 5 years, Colonoscopy screening in New York State for

those 50 and over climbs from 42% to 66% [2003-2008,

Citywide Colon Cancer Control Coalition (C5)]

1Ladabaum et al 2005

Consequences: More Pt. Discomfort

More Complications

Prolonged Procedure

Repeat Exams

Incomplete Exams

Missed lesions / Lost Polyps

Patient Dissatisfaction

Physician Dissatisfaction

≈ 20-25%

Male gender Age>60 yrs BMI>25 Cirrhosis Constipation Stroke Dementia Neurological – MS

Diverticulosis

Diabetes mellitus Prior colon resection Appendectomy Hysterectomy Timing of colonoscopy

(afternoon) In patient status Poor patient

education/Compliance

1Ness et al., 2007 2Chung et al., 2009 3Borg et al., 2009 4Sanaca et al., 2006

Endoscopist perspective

Safe

Effective

Excellent visualization

No electrolyte imbalances

No effect on bowel mucosa

No procedural difficulty

Easy patient acceptance for screening colonoscopy

Patient perspective

Safe

Palatable/tolerable/low volume

Least dietary restrictions

Least time consuming

Least side effects

No incontinence during travel

No sleep disturbance

No enema

Economical

1980

DIET: 24 – 48hrs. ENEMA LAXATIVE: Dulcolax

PEG Mechanism of action Registered name Tolerability

PEG-ELS Non-absorbable solutionthat should pass through thebowel without net absorption or secretion

Colyte (Schwarz) –Flavors: Cherry, Citrus-Berry, Lemon-Lime,Orange, PineappleGolytely (Braintree) Flavors: Pineapple

Large volumes (4L) arerequired to achieve aCathartic effect. Palatability is the major concern (5-15%)

SF-ELS The elimination of sodiumsulfate resultsin a lowerluminal sodium concentration. Hence, themechanism of action isdependent on the osmoticeffects of PEG.

Nulytely (Braintree) Flavors: Cherry, Lemon-lime, Orange, PineappleTriLyte (Schwarz) Flavors: Cherry, Citrus-Berry, Lemon-lime,Orange, Pineapple.

SF-PEG is better tastingthan Golytely, but stillrequires the consumptionof 4L in its standardregimen

PEG Mechanism Registered name Tolerability

Low Volume

PEG/PEG-3350 and

Bisacodyl Delayed-

Release Tablets

Bisacodyl and magnesium

citrate are added to PEG

Halflytely

(Braintree)

Flavors: Lemon-lime

Abdominal

cramping and

bloating (14%)

Low Volume PEG-

3350 and Bisacodyl

Delayed-Release

Tablets

An additional low volume

PEG 3350 without

electrolytes with adjuncts

such as bisacodyl

Miralax

(Schering-Plough)

Not FDA approved

Abdominal cramping

Bloating

Seizures

Severe hyponatremia

2-L PEG with

Ascorbate

(Gatorade is allowed)

The osmotic activity of

PEG, sodium sulfate,

NaCl, KCl, Sodium

ascorbate, and ascorbic

acid

MoviPrep (Salix) Abdominal

distension, anal

discomfort, thirst,

nausea, and

abdominal pain

PEG and NaP based preparations are known to cause local cellular injury,

although the actual clinical significance of this side effect is not known1

PEG based solutions are unpalatable2

PEG is non biodegradable, posing environmental threat – Stable even after

30 years after environmental exposure3

The sodium phosphate [NaP] solutions are associated with acute renal

toxicity even in healthy patients, posing a potential malpractice dilemma4

1Butcher et al., 2005 2Wexner et al., 2006 3Glastrup et al., 2006 4Markowitz et al., 2005

NCCAM / NIH

$ 70 Billion / Yr

According to a 2007 CDC survey, 38% of American adults

reported using CAM therapy in the previous12 months

Another national survey found that 15 million American

adults used Yoga at some point in their lives1

1Barnes et al., 2008

Credible scientific research is needed to demonstrate

the medical value of CAM therapies, their appeal is

clearly substantial

Yoga originated in India

more than 5,000 years ago

“Yoga” translates as “to

unify” – referring to a union

of mind and body

Studies on transcendental meditation have shown that experienced practitioners are able to exert autonomous nervous control– Studies on Yogi1

Beneficial effects of yoga on cardiovascular and neuron-endocrine systems have been reported in a number of studies2

Yoga has also been shown to improve myocardial perfusion and help in the regression of coronary lesions3

2Lin et al., 2001 3Gopal et al., 19741Kothari et al., 1973

Pros: 2500-5000 yrs old ( 600 B.C.) Beneficial for healthy life style Inexpensive

Cons: Lack of well-designed studies Difficult to standardize

Vijaypal Arya, Kalpana A. Gupta, Swarn V. Arya75-54 Metropolitan Ave. Middle Village, NY -11379

(718) 326-0400

A patient of Indian descent used “Shankh Prakshalana (BLS and exercise)” as a preparation for colonoscopy

The preparation was of such excellent quality that we were inspired to conduct this pilot study

METHODS

Upon informed consent, 54 patients between ages of 18 and 65 included in this study

– Group A: n = 27 ; BLS

– Group B: n = 27 ; Nulytely prep

*Protocol of this nonrandomized pilot study was approved by IRB at WHMC

Inclusion criteria Normal BMP

Exclusion criteria Hypertension Diabetes mellitus Arthritis Salt sensitivity

Patient Name—_____________ Age______ Sex M F Race____________Criteria—

Exclusion: Free of salt sensitiveness, hypertension, diabetes, arthritis, constipationInclusion: Normal BMP

Day of Consultation—Weight_______Height_______

Consent Form: SIGNED.Group: 1 2 Prep Form: EXPLAINED.Patient Response Form: COMPLETE. Day of Procedure—

Weight______Height______

Physician Form: COMPLETE.

INSTRUCTIONS (Day before colonoscopy)

Group A Patients in group A were given a

DVD of the shankh prakshalana postures to watch and practice

Regular mid-day meal From 2pm on - only clear liquids*

*Apple juice, grape juice, Gatorade, clear broth, hard candy, popsicles, Jell-O, tea and coffee

Group B As per the manufacturer’s

instructions, patient drank Nulytely at home

INSTRUCTIONS (Day of colonoscopy)

Group A NPO status after 12 midnight Reported to the endoscopy suit at 9am Asked to turn off phones and beepers

and to relax Examination room - quiet with an

available dedicated bathroom Vital signs and weight were recorded Instructed to perform light yoga

exercises alternating with drinking BLS

Group B Patients drank NuLytely at home Presented to endoscopy suit in the

morning

Instructions about the intake of BLS

9 grams of sodium chloride in one liter of lukewarm water (99 -102 °F)

Patients were instructed to drink 8 - 16 ounces continuously as a bolus

Two subgroups of patients within Group A: 16 oz. bolus ("16 oz. subgroup") and 8 oz. ("8 oz. subgroup")

Patients did yoga exercises – until bowel movements were clear Interrupt the process whenever there is urge to defecate, and not to

strain during defecation

INSTRUCTONS

Drink continuously rather than sipping slowly 8 oz (240 ml) in less than one minute 16 oz (480 ml) in less than two minutes

Ready position While inhale While exhale

Ready Inhale and to right Inhale and to left

Ready position Inhale Inhale

Ready position Inhale Inhale

Ready position Inhale Inhale

All colonoscopies were performed by a single gastroenterologist [VA].

The colonoscopy preparation was rated on a four point grading scale: ◦ Poor prep- 1◦ Sub-optimum- 2◦ Optimum- 3◦ Excellent- 4

Photographs were taken to substantiate the grading system.

Excellent Optimum

Sub optimum Poor

Excellent Optimum

Sub optimum Poor

PRIMARY AIM: To compare the BLS/Yoga group A with the NuLytely control group B

on total prep scores and scores at each of the six assessed sites: rectum, sigmoid, left colon, transverse colon, right colon, and cecum

SECONDARY AIMS, WITHIN THE YOGA GROUP: Determine how the 8 oz. v/s 16 oz. bolus drink – affects the quality of

preparation and speed of action, measured by time to first bowel movement and time to complete the prep regimen

To compare pre- and post-procedure electrolyte levels: Na, K, Cl, CO2,

BUN, Creatinine, and Glucose

Comparisons between groups in the study were made using the

Mann-Whitney test for each of the continuous measures. This test

was employed to compare the total prep scores: yoga group A vs.

NuLytely® control group B; and within the yoga group to gauge

how the 8 oz. v/s 16 oz. of solution intake affected the quality of

colon lavage

A comparison of pre- and post-procedure electrolyte levels was

made using the Wilcoxon signed rank test. The difference

between the measures was calculated as Post minus Pre

Group A Group BTotal patients N=27

N (%)N=27N (%)

Sex Male Female

8 (29.6)19 (70.4)

15 (55.5)12 (44.5)

Age 20-40 40-60 >60

17 (62.9)9 (33.3)1 (3.7)

2 (7.4)19 (70.4)9 (33.3)

Race Caucasian African American Hispanic Other

14 (51.8) 2 (7.4)

7 (25.9)4 (14.8)

17 (62.9)2 (7.4)7 (25.9)1 (3.7)

Arya et al., 2008

*Data in Group B is from package insert

The time to first bowel movement and total

preparation time is less in LWS/YOGA group cf.

NuLytely

The total solution drank is almost identical in both

groups

24 patients in group A and 21 people group B have either excellent or optimal preparation. Even though the difference in not statistically significant, according to the results, BLS is either equal or better than the regular bowel prep in healthy patients

Score BLS/YOGA NuLytely P-valueRectum 3.52 3.3 <0.2252Sigmoid 3.48 3.19 <0.1853Left colon 3.48 2.44 <0.0003Transverse colon 3.52 2.33 <0.0001Right colon 3.41 2.63 <0.0060Cecum 3.22 2.44 <0.0177Total 20.63 16.48 <0.0007

*The average total prep score for BLS/Yoga group is significantly better than NuLytely group (statistically significant ) and also in left and transverse colon segments.

Score 8 oz. “Bolus”Score (SD)

16 oz. “Bolus”Score (SD)

P-value

Rectum 3.00 (1.21) 3.93 (0.26) <0.0102

Sigmoid 3.08 (1.16) 3.80 (0.41) <0.0693

Left colon 3.17 (1.19) 3.73 (0.46) <0.2655

Transverse colon 3.17 (1.19) 3.80 (0.41) <0.1535

Right colon 3.08 (1.16) 3.67 (0.49) <0.2201

Cecum 3.00 (1.21) 3.40 (0.63) <0.5786

Total 18.50 (6.84) 22.33 (2.06) <0.2376

*16 oz. “Bolus” subgroup achieved better bowel cleaning score cf. 8 oz. “Bolus” subgroup (not statistically significant)

*The difference is statistically significant for both parameters

8 oz. “Bolus”Minutes (SD)

16 oz. “Bolus”Minutes (SD)

P-value

Total time spent 119.17 (39.30)

87.80 (38.60) <0.0310

Time to first bowel movement

57.42 (21.05)

25.80 (4.83) <0.0001

*All patients enrolled in the study completed the BLS/Yoga process and none of them refused to repeat in future.

ParameterPatient number

N (%)Solution palatability Unpleasant Pleasant

2 (7.4)25 (92.6)

Exercise Difficult Easy

1 (3.7)26 (96.3)

Score Mean difference (SD) P-valueSodium 0.20 (3.40) <1.000

Potassium 0.09 (0.47) <1.000

Chloride 6.60 (2.70) <0.0020

CO2 -5.44 (3.78) <0.0156

BUN -3.00 (2.69) <0.0039

Creatinine -0.022 (0.11) <0.4219

Glucose -9.00 (6.00) <0.0039

Pre and post procedural electrolyte abnormalities are not clinically and statistically significant for Sodium, Potassium and Creatinine. Even though the abnormalities are statistically significant for Chloride, Bicarbonate and Glucose, no clinical significance is noticed

The results demonstrated “LWS/Yoga” as a very

effective method of Bowel Prep in healthy individuals

These results are comparable to NuLytely with

minimal or no electrolyte imbalances and better oral

tolerability

DISCUSSION

Bowel preparation was identified as the most objectionable

aspect of the colonoscopy procedure1

Inadequate visualization with poor preparation and patient

intolerability still remained as the major concerns to be

solved2

The search for an ideal bowel preparation for colonoscopy is

a still ongoing – A new method might be the BLS/Yoga for

healthy patients

1Harewood et al., 2002 2Brown et al., 2004

Yoga

• Postures• Exercise• Breathing• Gravity

The 0.9% normal saline, also known as “Physiological Saline,” has an osmolarity of about 300 mosm, matching the osmolarity of plasma.

The saline solution empties from the stomach rapidly and exponentially

(29) – First order kinetics of gastric emptying

As the solution is isotonic, it should not get absorbed from the gastrointestinal tract, especially when consumed in bolus form.

The resulting high flow rate allows minimal time for ionic exchange.

Gastric emptying:. 50% will be emptied in every 8-12 minutes

Intestinal transit (NS @ flow rate of 10ml/min):

Jejunum: Absorption of 4-8 meq/L/30cm

Ileum: Active transport Most of the sodium and chloride

absorption takes place in ileum Colonic transit: Absorption is more in

ascending colon (active transport) With bolus intake the absorption of

sodium presumably be less as the sodium absorption is regulated by the net water movement in each segment

Jeejeebhoy KN, Olay foundation

Normal saline has been shown to stimulate gastro-colic reflex1

The gastro-colic cholinerergic propulsive reflex might be playing an important role in the success of this process1

Right colonic volume of the content is important in the initiation1

With gastro-colic reflex in action, the contents of hepatic flexure of colon move to splenic flexure instantaneously - without segmentation

Tansy et al., 1972 and 1973

Numerous studies have been done in the past using balanced

electrolyte solutions (BES) as colon prep1,2,3,4

In those previous studies, BES (high volume – 10-12L) was

administered in the subjects over a period of time (4-6hrs)

Majority of these studies reported weight gain and minor

electrolyte imbalances as adverse effects

None of those studies used “normal saline as bolus”

administration and Yoga postures/exercises

BALANCED ELECTROLYTE SOLUTIONS

1Crapp et al., 1971, 2Hewitt et al., 1973, 3Levy et al., 1976, 4Postuma 1981.

Study Report Solution Rate Total Volume

Electrolyte Imbalance

Wt. Gain

Levy at el. Gastroenterology.

1976

NaClNaHCO3

KClRoom Temp

1L/40 min. consumed

10L/4 hours3905±1098 ml(1000-6000 ml)

None 1.1 kg

Postuma. Pediatric Surgery. 1982

NaCl,KClWarm

1-2L/hr Infused

9±2L/7±2 hours

Mild ↑ Cl 0.9 kg / Pt

Crapp et al., Lancet. 1971

Warmed Isotonic saline

KCl was added later

3-4L/60hr 9-12L Not reported 1.9+/-0.8kg

Hewitt at el. The Lancet. 1973

NaCl, KClNaHCO3

Distilled water (37°)

75 ml/mininfused

9-13L/2-3 hours

Not reported 1.5 L / Hr fluid

absorption

Chattopadhyay at el. Pediatric Surgery.

2004

NaClKCl

70 ml/kg/ 60 min infused

250 ml/ kg Insignificant Not reported

Fluid secretion in the gastro intestinal tract is primarily by active transepithelial secretion of chloride ions(26)

Fluid absorption is by uptake of sodium

(26) It is known that depending on the

electrolyte composition of the meal, chloride secretion can be inhibited or stimulated (26)

Electrogenic sodium absorption takes place in the distal colon with a final outcome of stool dehydration (28)

Potassium movement in the gastrointestinal tract is passive.

During fasting: Sodium coupled with chloride is actively

absorbed against an electrochemical gradient by the intestinal mucosa (27)

Lavage Solution with Minimal Water and Electrolyte Absorption or Secretion

Ingestion of large volume of BES has previously been shown to be an effective method of cleaning the colon for diagnostic studies.

This study has shown that total gut perfusion with BES (25-30ml/min) results in absorption of 2400mL water and 375meq of Na in 3hrs.

This might be hazardous to pts who are unable to excrete salt and water load.

4 solutions with varying composition are used in this study and solution D has been associated with near zero net movement of electrolytes

Davis at el., 1980

NaCl (mM)

Na2S04 (mM)

KCl (mM)

NaHC03 (mM)

Mannitol (mM)

PEG (g/L)

Osmol (mOsmol/kg)

D 25 40 10 20 80 5 273

BES 110 10 30 5

Lavage Solution with Minimal Water and Electrolyte Absorption or Secretion

Comparison of Solution D and BES:In normal subjects there was no significant change in hemoglobin concentration, hematocrit, or, serum electrolytes during administration of any of these solutions.There was no clinically significant electrolyte imbalance was mentioned.There was a mean weight gain of 0.54kg/hr of perfusion with BES

Subjects N Sol. Infusion rate (ml/min)

Water (ml/hr)

Na(meq/hr)

K(meq/hr)

CL(meq/hr)

HCO3(meq/hr)

Normal* 5 BES 30±1 -819±29 -127±4 -10±1 -110±6 -26±2

Normal 5 D 28±1 +56±35 0±7 0±1 +11±5 -5±2

Normal 5 D 20±1 -20±40 -7±6 -1±2 -2±5 -4±2

Liver dz 1 D 29 +78 -5 -1 +8 -2

Renal dz 1 D 20 -137 -26 -1 -8 -7

Normal 5 E 38±1 -130±40 -8±8 -3±1 +8±4 -10±1

Davis at el., 1980

Age Gender BMI Volume Calorie content Exercise Temperature Posture Breathing

Aged individuals have slower liquid gastric emptying and

same rates of solid gastric emptying (significance

unknown)1

Males have faster gastric emptying rates for solids and

liquids than females2 (equal in elderly population)3

Gastric emptying in the obese is normal with large meals,

but is delayed in small meals4

1Moore et al., 1983 2Datz et al., 1987, 3Horowitz et al., 1984, Christian et al., 1986

Gastric emptying of solids

More than volume it is dependent on the calorie content as equal calorie carbohydrate and triglyceride solid food emptied in the same time

Gastric emptying of liquids

Dependent on initial volume (first order kinetics) and calorie content of liquid.

Normal saline (non nutrient liquid) emptying is dependent on initial volume intake.

Experiment: Effect of different meal volumes on the speed of gastric emptying in 5

dogs w/ duodenal fistulas using:

Liquids (150, 200, 600, 1200 mL of phosphate buffer)

Solids (150, 300, 600g of cooked beef steak)

Results: Steak emptying was independent of meal volume

Liquid emptying was dependent on original meal volume; meal volume

ACCELERATED gastric emptying of liquids

Trituration of the steak accounted for emptying at a fixed rate

Lin et al., 1992

Study: Gastric emptying patterns in response to different volumes of test-meals.

Method: test meal= 2% solution of pectin, 3-5% sucrose, w/phenol red added as a marker.

Subject had stomach washed out w/250mL of tap water, and drank chosen test-meal; after a measured interval, gastric contents were withdrawn and measured

Hunt & Macdonald 1954

Results and conclusion: Rate of gastric emptying of a standard test-meal is influenced by interplay

between Volume of meal taken Ratio of the volume in the stomach to the volume that has flowed into the

intestine Distension of the stomach and/or intestine which preceded the ingestion of meal

Non-sucrose meals left the stomach quicker than glucose meals

Test-meal Volumes of meals ranged from 50-1250 mL, composition

varied from pure carbohydrate to ordinary food Analysis Volume of each test-meal delivered to the duodenum in 30

min (assuming that gastric emptying was exponential) Predicted a rate of gastric emptying for each meal, given its

nutritive density and assuming a relationship between stimulus and duodenal receptors

Conclusion Isocaloric concentrations of carbohydrate and triglyceride

produce equal slowing of gastric emptying For a given nutritive density (kcal/mL) the rate of emptying

(mL/min) is independent of the initial volumeHunt & Stubbs 1974

Gastric emptying is significantly reduced by giving a

cold drink, but temperature has no significant effect on

the half-life of emptying after 5min suggesting that meal

temperature affects adaptive relaxation mechanisms

Warm liquids results in greater relaxation of gastric

muscle

Experiment:

Effect of meal temperature and volume on emptying of liquid meals (8 normal

volunteers)

4 drinks investigated: 200mL - 12 C & 37 C; 500mL - 12 C & 37 C

Bateman et al., 1982

Results

The 5min gastric volume was significantly reduced by giving a cold drink of

500mL ( 12 C: 250m, 37 C: 307mL (P<0.05)

Temperature had no significant effect on the half-life of emptying after 5min

Suggest that meal temperature affects adaptive relaxation mechanisms

Warm liquids results in greater relaxation of gastric muscle as indicated by the

reduction in the initial emptying and subsequent higher 5 min gastric volume

Study : Measured emptying of 400 mL drink of orange juice from the stomach (6

healthy volunteers, ages 19-24) ingested at diff. temperatures: 4°C (cold), 37°C (control), 50°C (warm)

Results and Conclusions: Warm & cold drinks emptied from stomach slower than control drink Initial rate of gastric emptying of the cold drink was significantly slower

than the control drink (P<0.05) The difference in the initial emptying rates between warm and control

drinks were not statistically significant Intragastric temperature returned to within 1°C of body temperature 20 to

30 min after ingestion of the warm and cold drink respectively, after which the emptying rates were identical to the control

Sun et al., 1988

Kim et al., found that an exercise as simple as walking improved colonoscopy

preparation among younger, non-obese patients with no history of abdominal

surgery

Animal studies have shown that in both fed and fasted states, exercise induces

giant migratory complexes, defecation and mass movement (44, 45).

Acute aerobic exercise decreased colonic phasic motor activity, resulting in

less resistance to colonic flow, while post exercise increased the amplitude of

propagated waves was thought to enhance propulsion causing, which was

followed by increased propagating waves after stopping (46).

We speculate, in the BLS/Yoga regimen, the first

four postures are specifically aimed at improving

gastric emptying.

The fifth posture (squatting) affects the colonic

motility by increasing the intraabdominal pressure.

Simply lying on one’s right side can increase the gastric emptying

of a saline test meal which does not activate duodenal receptors (37,

38).

Moore, et al noted a marked effect of body posture on radionuclide

measurements of gastric emptying (39).

Gravity, coupled with postural change, influences the gastric

configuration, which in turn changes intragastric meal distribution,

leading to a more rapid emptying of non-nutrient inert liquids (40).

Study: Saline test meals/non-nutrient (750mL NaCl) given by tube into

stomach in sitting, lying on left side, and lying on right side.

Gastric contents were recovered at 10min, the rate of gastric

emptying was assessed from the recovery of the original solution

marked w/phenol red

Similar study with 750mL glucose test meals/nutrient given to the

same subjects in the same positions

Murdoch at el., 1980

Results:

Glucose test meal/nutrient: no significant difference in volume recovered

Conclusion: Posture influences gastric emptying in non-nutrient/ saline meals.

As opposed to glucose test meals that does not activate duodenal receptors, resulting in the slowing of gastric emptying

Test meal Non-Nutrient Volume recovered

NutrientVolume recovered

Lying on Lt. side 431mL 589mL

Lying on Rt. side 215mL (p<0.005) 555mL (p<0.005)

Sitting 308mL 564mL

Murdoch at el., 1980

Study: Effects of posture on gastric emptying, intragastric distribution,

and antropyloroduodenal motility after ingestion of non-nutrient liquid.

Antropyloroduodenal pressures measured in 7 healthy patients for 30 min after ingestion of 150 mL of normal saline in 2 positions (sitting & left lateral)

Result: Rates on emptying of the stomach was faster in the sitting

position than in the left lateral position

Anvari et al., 1995

Conclusion: The effects of gravity on gastric emptying on non-nutrient

liquids are likely to reflect changes in both antropyloric motility and intragastric distribution.

Changes in gastric configuration also interact with gravity to determine intragastric distribution. ◦ these changes are more likely to be due to gravity rather

than changes in gastric motility. Gravity:

◦ affects gastric emptying◦ helps determine whether modifications in posture are

associated w/alterations in active gastric pumping or breaking mechanisms or changes in intragastric distribution

Anvari et al., 1995

Study Effect of body posture on gastric emptying measurements of

radiolabeled meals 8 healthy male subjects were fed a standardized meal of beef

stew labeled w/ technetium-99m sulfur colloid, and orange juice. Measurements obtained by gamma camera in lying, sitting,

standing, or combined sitting-standing postures. During the sitting-standing studies, subjects were alternately

sitting and standing and allowed to walk in between the 10 min counting intervals.

During the lying, sitting, and standing only studies, subjects were encouraged to remain motionless.

Moore at el., 1988

Results: The lying position significantly slowed solid phase meal

emptying half times by:102% in sitting-standing position54% in sitting only position66% in standing only position

Activity during the sitting-standing position may also play a role in gastric emptying

Moore et al., 1988

The yoga postures begin with a deep inhalation and end with exhalation

The resulting movements of the diaphragm change the gastric configuration, which in turn has an effect on intragastric meal distribution and gastric emptying

Changes in gastric configuration during diaphragmatic movement are well evident from radiological studies

The authors speculate that deep breathing does in fact have some role in faster gastric emptying

INHALATION

EXHALATION

STRETCHING

TO RIGHT SIDE

STRETCHING

TO LEFT SIDE

Role of Mind-Body interaction?(Neuropeptides such as

Cholecystokinin and VIP has effects on GI motility)

Breathing • Gastric emptying – Presumed to be fast

Varies according to Pt’s medical condition Pt preference Clinical indication “Sleep is important” Travel without incontinence Time of Prep adjusted to time of exam and travel

arrangement Frail, ill & Elderly – Modified prep, Inpatient Obstruction – Suspected – Oral prep may be dangerous

The importance of adhering to prep and adequate hydration during and

after bowel prep should be emphasized

The choice of bowel cleansing should be based on age, health status,

comorbid diseases, and personal preference

A split- dose improves the quality of bowel cleansing, especially in

ascending colon

NaP has better efficacy and tolerability than PEG. NaP should be avoided

in impaired renal function, CHF, advance liver disease, or hypercalcemia

All purgatives have been associated with serious adverse events.

The risk can be minimized by selecting most appropriate prep

What Is Current Knowledge

1-High volume (7-12 Liters) of saline solution infusion

in 4-6 hrs has been shown to be effective for

colonoscopy preps. This can cause dramatic fluid and

electrolyte shifts and currently not recommended.

2-Exercise helps in colonoscopy preps

What Is New Here1-The study demonstrates the effectiveness of Low

volume (3 Liters) BLS/Yoga in colonoscopy preps2-A new mechanism of colon preparation is explored. The

“bolus drinking” (Dumping) of LWS in conjunction with Yoga postures (deep breathing, gravity, gastric configuration, and exercises) achieved faster gastric emptying leading to successful colon prep for colonoscopy

The results are very encouraging and thought

provoking The LWSW + exercise preparation is safe, simple, and

inexpensive Further studies are needed to confirm the initial

promise of this novel approach to colonoscopy

preparation

1. Sivak, Jr., Michael V. "Polypectomy: Looking Back". Gastrointestinal Endoscopy. 2004, 60 (6): 977–982. [PMID 15605015].

“Add fragrance to your thoughts” -Anonymous