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Introduction

Over the last few decades, there have been breakthroughs in terms of diagnosis and treatment of malignant cells that often develop into cancer. The same advancement is also evident in prevention strategies against malignancy. As a result, a colonoscopy has become an effective method to detect and thereafter remove precancerous lesions from the gut. Scientists have reached a conclusion that a successful implementation of a colonoscopy lower mortality caused by colorectal cancer (CRC) by up to 50%. A successful colonoscopy, however, relies on an adequate bowel preparation for the exercise. Traditionally, patients are subjected to a clear liquid diet (CLD) during a preadmission phase, but recent researches suggest an alternative method known as a low-residue diet (LRD). Nevertheless, there is no clear evidence which regime is best among these two, and this paper will investigate this issue.

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Clinical Question (PICO)

Among patients admitted for bowel preparation prior to a colonoscopy, which one between alternative clear liquid diet (CLD) and low-residue diet (LRD) would be a recommendable standard bowel preparation regime?

Target Population

Target population constitutes patients of all ages admitted for a bowel preparation for colonoscopy procedure.

Recommendation

Although there is not enough evidence to support preference for either of the two preadmission bowel preparation regimes, it is likely that LRD has higher efficacy compared to CLD, especially with regard to patient tolerance for the dietary regime and possibility of repeating the same preparation in the future. Moreover, it should be recommended for patients with higher bowel activities and sufficient vitamins and minerals because with such patients the regime helps decrease intestinal tract activities while prolonging transiting period of the tract and promoting healing of a wound.

Research Agenda

Therefore, it would be proper to do further inquiry into ways that such efficacy, as demonstrated by patients higher tolerance for a low-residue diet (LRD), may be enhanced in the future. Additionally, further research should be done to find out what exactly constitutes evidence-based LRD.

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Discussion/Summary of Evidence

In this analysis, a number of parameters were examined across five studies that were selected for the literature review and meta-analysis. Namely, several studies tested a clear liquid diet against a low-residue diet (Sipe et al., 2013; Stolpman, Solem, Eastlick, Adlis, & Shaw, 2014) but ended up with different conclusions. This difference in conclusions from the comparative studies is attributed to the fact that none of the studies compared the same parameters, although some of them adopted similar study designs (El-Baba et al., 2006; Rapier & Houston, 2006).

Concerning a quality of a bowel preparation, the comparative analysis among three studies, which designs fit the analysis, revealed no difference between the two regimes (Melicharkova, Flemming, Vanner, & Hookey, 2013; Rapier & Houston, 2006). However, the level of evidence for this conclusion was moderate. Overall, the homogeneous studies included in this analysis showed that LRD did not interfere in any way with a bowel preparation in comparison to CLD.

As for efficacy of either dietary regime, the results of the analysis across the three articles included in this review showed that both have similar efficacy. The findings are consistent with those of other similar studies comparing CLD to LRD and show sharp contrast with others that compare CLD to cases where a meal is taken by patient in a standard bowel preparation. However, the study by El-Baba et al. (2006) that compared LRD and CLD gave opposing results. The study concluded that LRD was better than CLD in cleansing bowels of children in a pediatric setting where participants were subjected to food packages and a solution of sodium phosphate administered orally. One reason for these contradictory results may have been the researchers’ choice of sample population, which came from heterogeneous population and caused wide variations (El-Baba et al., 2006).

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Furthermore, having analyzed other parameters including compliance, level of tolerance, and repetition of preparations, the researchers obtained different results. For compliance, for instance, no difference was formally established between studies included in the review. However, it was apparent that patients showed more tolerance toward LRD compared with CLD (Delegge & Kaplan, 2005). The reason for this, as established from the analysis, is that not many patients are able to last for a long time without taking any solid food (El-Baba, et al., 2006; Sipe et al., 2013). In addition, since LRD regime involves use of a low-residue food packages, many patients show high tolerance towards it than CLD that only involves intake of fluids. Moreover, the review also established that because of high tolerance with LRD regime, patients are more likely to repeat similar preparations in future whenever a colonoscopy was found necessary. Yet the same studies that revealed tolerance toward LRD over CLD also reported that patients had problems with dietary requirements listed for LRD, which compromised compliance (Sipe et al., 2013). This was found out beside an observation that LRD was somewhat addressing a few challenges with CLD.

Finally, regarding the safety of either regime, it was established in this review that both had comparable levels of safety. However, the challenge is that very few studies were examined and this compromised the amount of evidence from the evaluation. Altogether, for the few studies included in this review, there is little evidence to show that either of the regimes, CLD or LRD, is superior when it comes to a preadmission bowel preparation. Considering the trade-offs between the two, it is clear that LRD addresses limitations of CLD related to tolerance as well as that CLD is more effective in clearing the colon of residue prior to a colonoscopy.

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Implementation Recommendations

There is no standard implementation strategy for a low-residue diet (LRD) thus far. However, it is recommended to administer small food packages orally to patients for approximately from 24 hours to three days prior to a colonoscopy, which should not include high-residue food, milk, and milk products.

Overall, a standard preparation for CLD is simple. Namely, polyethylene glycol-electrolyte (PEG-E) is administered to a patient orally, using nasogastric tube in pediatric setting, to cleanse the patient’s bowel on the eve of a colonoscopy (Sipe et al., 2013). The procedure should be repeated until a clear stool is observed, which would be indicated by fluid light yellow in color or fluid that is free of any sediment. If such oral administration does not give the aforementioned results, then it is advisable for a nurse to use more invasive means to perform a rectal irrigation. The latter means that the invasive method is used to enhance cleansing speed of clear liquid diet using normal saline that is a solution of Sodium Chloride, which is injected into the colon of a patient using a long and flexible tube inserted into the patient’s rectum. In particular, the concentration of the normal saline should be 0.9% and should be administered at 30ml until a maximum of 20ml/kg is attained. Finally, this procedure should be followed by an hourly administration of the normal saline and a removal of contents of the distal colon until clear stool is obtained just at the beginning of the last instillation.

Health Benefits, Side Effects, and Risks

As can be seen from the analysis, probable health benefit of liquid diet is that it helps provide some amount of nutrients and calories to sustain a patient during the preadmission bowel preparation when he or she is restricted from taking meals. Basically, LRD is targeted at decreasing mechanical activity of the intestine of a patient in question while prolonging its transition period (Sipe et al., 2013). Therefore, another health benefit would be that LRD promotes healing of a wound. However, since this dietary regime restricts a patient from consuming such food that propels the intestinal tract activity, it is likely that a prolonged restriction may lead to a deficiency of certain vitamins and minerals (Sipe et al., 2013). Additionally, constipation is another side effect that may be of concern considering a liquid diet; the most often, it is caused by long-term dietary restrictions. Due to the aforementioned risks associated with LRD, it is accepted that patients who have already shown lower activities in their bowels as well as those who have insufficient vitamins and minerals in their bodies should not be subjected to this regime. Moreover, LRD poses the risk of deteriorating further patients’ fragile health conditions.

Conclusion

In summary, any claims that one particular regime of a liquid diet is superior to the other are not warranted. There is little evidence to support that a low-residue diet (LRD) is superior to a clear liquid diet (CLD). If anything, all the most recent studies reviewed point to no clear advantage of using one dietary regime over another. Only one study suggests possible superiority of LRD over CLD, although it is apparent that these contradictory results may have stemmed because of researchers’ approach to choosing participants from different populations. Such sample population was chosen without wide variations; therefore, it may have led to rather absurd conclusion that LRD was superior to CLD. However, the results of the many studies have taken little research into possible disadvantages of LRD, which warrant further research before it may be good enough to confirm this regime as a standard preadmission bowel preparation.

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