Optimizing Your Colonoscopy Prep: A Comprehensive Guide

A colonoscopy is a vital screening procedure used to detect colorectal cancer and other gastrointestinal issues. Since colorectal cancer is on the rise in people younger than age 50, national guidelines have recently pushed the starting age for colorectal cancer screening down to 45. The quality of the preparation directly impacts the accuracy of the examination. This article provides a comprehensive guide to colonoscopy preparation, incorporating the latest evidence-based practices to ensure a thorough and comfortable experience.

Understanding the Importance of Colonoscopy

A colonoscopy is a medical procedure that allows healthcare providers to inspect the inner lining of your large intestine (colon). The procedure uses a colonoscope (“scope”) - a long flexible tube with a light and camera at the end - to examine the inside lining of the colon. It allows the doctor performing the test to find and remove precancerous polyps and early colorectal cancers. This examination is crucial for identifying various gastrointestinal conditions, including benign formations like colon polyps, precancerous lesions, and early signs of colorectal cancer. By detecting abnormalities early, a colonoscopy serves as a diagnostic tool and a preventive measure, potentially catching and addressing issues before they develop into more serious conditions.

The Core of Colonoscopy Prep: Bowel Cleansing

Due to the nature of the colonoscopy procedure, having a clear colon is essential. This is why knowing what to do before colonoscopy, involving a thorough cleansing of the colon, is so critical. An effectively cleansed colon ensures that the images obtained are as clear as possible, allowing for the most accurate diagnosis and enabling effective treatment planning if any issues are discovered. The day before the test, you will do a bowel prep to empty and clean your colon. The bowel prep includes a strong laxative and liquid diet. Following the directions of the bowel prep makes it easier for your doctor to detect polyps and other abnormalities during the colonoscopy.

Dietary Guidelines Before Your Colonoscopy

Preparing your diet before a colonoscopy is critical for ensuring that your colon is clean and ready for the procedure. A clear and clean colon allows for the most effective and safest examination possible. Patients rate the preparation as the most difficult aspect of a colonoscopy. This is due in part to the unavoidable, unpleasant process of drinking a purgative so that we can get a clear view of the colon.

Transitioning to a Low-Residue Diet

Three days before your procedure, you should begin a “low-residue diet” to limit high-fiber foods, which your colon takes longer to clear. Five to two days before the procedure: Begin to reduce fiber intake. Choose low-fiber alternatives such as white bread instead of whole grain, and cooked vegetables instead of raw. High-fiber foods that you should avoid include:

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Whole-grain breads, oatmeal/cereals, granola
Nuts, seeds, raw/dried vegetables or fruit (NO salads)
Beverages with pulp
Nutritional supplements that contain fiber
Pepper, beans, corn/popcorn

Foods that you may eat include:

Cream of wheat/grits, white rice, refined pastas/noodles
Cooked fresh/canned vegetables and vegetables without seeds including asparagus, beets, carrots, mushrooms, green beans, potatoes without skin
Bananas, soft cantaloupe, honeydew, avocado
Chicken, fish, beef, pork, tofu, eggs
Margarine, butters/oils, smooth sauces and dressings
Cakes, cookies, pudding, ice cream without nuts or seeds, hard candy, popsicles, yogurt, and cheese

The Clear Liquid Diet: What You Can and Cannot Consume

Beginning one full day before your procedure, you must begin a clear liquid diet, which means that you should NOT eat any solid foods and should ONLY drink clear liquids. For example, if your procedure is on Thursday morning, you should not eat any solid foods for Wednesday breakfast, lunch, and dinner and should only drink liquids that are clear. Aim to drink at least 12 tall glasses (about 8-10 ounces each) of clear liquids throughout the day in addition to what you drink with your bowel prep solution/medication. One day before the procedure: Switch to a clear liquid diet. This includes water, broth, and clear juices like apple or white grape (avoid red or purple).

A clear liquid diet consists of drinking only “clear” liquids, such as:

Water
Mineral water
Clear fruit juices without pulp (apple, white grape, white cranberry, lemonade, etc)
Clear soft drinks
Clear sports drinks
Broth (chicken, beef, vegetable, or bone broth)
Popsicles or gelatin (such as Jell-O)
Coffee or tea (without milk)
Ensure clear or other clear meal-replacement drinks

Alcohol can make you dehydrated and you should not drink alcohol while preparing for your test.

The Final Hours: Fasting Before the Procedure

Beginning four hours before your procedure, you should STOP drinking clear liquids. This means that you should not have anything to eat or drink beginning four hours before your procedure. Day of the procedure: Do not eat or drink anything at least two hours before your appointment.

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Resuming Your Normal Diet

After your procedure, you will be able to resume a normal diet, unless otherwise instructed by your doctor.

Medication Management: A Crucial Aspect of Colonoscopy Prep

Proper medication management and adequate hydration are crucial components of preparing for a colonoscopy. Understanding the prep for colonoscopy includes knowing what medications you can and cannot take before your procedure. If you are taking any prescription medications, make sure to ask your doctor if they can be taken before your colonoscopy.

You can take most prescription and non-prescription medications right up to the day of the colonoscopy.
Take your usual morning medicines, especially those for blood pressure, at least four hours prior to your procedure with a small amount of water.

Medications to Stop Before the Procedure

Stop medications that are for diarrhea (Imodium, Kaopectate) or contain iron 7 days prior to your procedure.
Blood thinners may need to be temporarily discontinued prior to procedure. The length of time you will need to stop your medication depends upon which drug you are taking. If you are on a blood thinner, you should consult with your prescribing doctor about whether you should continue or discontinue these medications. Do not stop these medications without first talking to your doctor. You will restart these medicines after the procedure, unless otherwise directed by your doctor.
You will need to temporarily discontinue GLP-1 medications (such as Ozempic or Trulicity) prior to your procedure.

Low-dose aspirin can be continued and does not need to be stopped prior to your colonoscopy. Insulin/diabetes medication doses may need to be adjusted. Consult your prescribing doctor. Blood-pressure medicines should be continued while preparing for the test. On the day of your test, you should take your blood-pressure medicine with water at least two hours before your test.

The Bowel Prep Solution: Your Cleansing Agent

Most colonoscopy preparations require the use of a laxative solution, which is prescribed to ensure your bowel is completely clear. These are generally strong laxatives designed to induce diarrhea, which cleanses the colon.

Staying Hydrated and Maintaining Electrolyte Balance

Drink plenty of water: Drink at least eight 8-ounce glasses of water the day before your procedure to stay hydrated. Clear fruit juices: Juices like apples and white grapes are recommended because they are light in color and won’t be mistaken for blood during the colonoscopy. Electrolyte solutions: These solutions are vital for maintaining a balance of electrolytes in your body, which can be disrupted by the effects of laxatives and a restricted diet.

Transportation and What to Expect on the Day of the Procedure

You must have someone accompany you home the day of your procedure, even if you take a cab. You will not be able to drive yourself home. You can also use public transportation (taxi or bus), but only if you have an adult who can escort you home. Medical transport may be arranged for safe transportation home. The medical procedure staff must be able to contact whoever will accompany you. If this person cannot be confirmed prior to the procedure, your procedure will be rescheduled for your safety. Colonoscopy is performed in a hospital or medical clinic. Before the procedure starts, you will be given anesthesia or medication through an IV to make you comfortable. Then, the doctor will gently insert the colonoscope into the rectum and guide it through the entire colon. Your doctor will take pictures and remove polyps along the way. He/she will then send the polyps to a lab for further testing. If a polyp cannot be removed, a sample may be taken. This is called a biopsy. The colonoscopy usually takes 15 to 30 minutes to complete.

Challenging the Status Quo: Rethinking the Clear-Liquid Diet

But there’s a second, unnecessary part: Most colonoscopy instructions direct the patient to stick to a clear liquids-only diet for much of the day before, or even for the entire day. On the surface, the rationale seems sound: Sticking to liquids should make it easier for the laxative to do its work. It is true that diet matters for colon cleansing. Certain foods can greatly obscure our views of the colon: corn, nuts, seeds, and many kinds of vegetables. But that leaves many solid foods that people can eat and digest without affecting the quality of their colonoscopy. A low-residue diet, one that is heavy on starch and protein and free of vegetables, is just as effective, and much less difficult to endure, than a diet restricted to clear liquids all day. A pre-colonoscopy diet that includes solid foods is safe and effective, and there are abundant data to prove it.

Evidence Supporting a Low-Residue Diet

A large, randomized trial published in 2013 compared the results of two diet instructions the day before colonoscopy: clear liquids only, or a diet that permits solid foods such as a bagel with cream cheese, a turkey sandwich, and mac and cheese. The solid diet group had just as good clean-outs as the spartan clear-liquids-only group. In the ensuing years, study after study found the same outcome. One systematic review identified 13 randomized trials comparing a low-residue diet to a clear liquid one. We have known for more than 10 years that there is an easier diet to prescribe before a colonoscopy.

Overcoming Resistance to Change

Yet gastroenterologists stubbornly cling to the clear-liquid diet. Academic medical centers, which should be the vanguard of evidence-based and patient-centered care, fail our patients in this matter. When I ask Google “Can you eat solid food the day before your colonoscopy?” the first hit gives me a firm “No” from instructions provided by the University of California Los Angeles: “You must not eat any solid foods the day before your colonoscopy. The clear-liquid diet is unnecessary and harder on the patient. As the pool of people eligible for screening has enlarged to include those age 45 and up, it behooves us to minimize all impediments to this procedure. Part of the answer relates to long-known obstacles to diffusion of innovation. Gastroenterologists may not know about these studies, and they are not learning from patients or colleagues that their preparation dietary instructions are associated with worse patient satisfaction and possibly increased cancellation rates. But knowledge of the literature may not be enough to convince our specialty to make this change. When I ask my colleagues why they continue to prescribe a clear-liquid diet, the most common answer I get is some version of this: “My patients may have difficulty understanding the nuances of the low-residue diet.” This strikes me as pessimistic and even paternalistic. There is no major force pushing gastroenterologists to catch up with the evidence; the pharmaceutical industry and government regulatory authorities, the common spurs of change in medical practice, are not interested in this matter. Medical inertia can be powerful. But change may yet occur, first slowly, and then rapidly once a critical mass is attained. I urge my colleagues to look at their preparation instructions and to consider catching up with the evidence.

Embracing a More Flexible Approach

We can advise patients that the diet on the day before a colonoscopy may include the following foods: cheese, eggs, milk, white bread, olive oil, butter, beef, chicken, fish, white rice, vanilla ice cream, and plain yogurt. They must avoid the following: popcorn, seeds, nuts, corn, multigrain bread, salad, raw and dried fruits, berries, kiwi, broccoli, cauliflower, Brussels sprouts, and cabbage.

Navigating Potential Challenges and Exploring Alternative Therapies

When a routine colonoscopy leads to the detection of potential cancer, it can be an overwhelming experience. Alternative therapies refer to medical treatments that are used instead of traditional therapies, such as chemotherapy and radiation. At the Immunity Therapy Center, we take a front-line approach to serious conditions like colon cancer, lung cancer, and rectal cancer with innovative and personalized alternative therapies.

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