Recommendations for follow-up interval after colonoscopy with inadequate bowel preparation in a national colonoscopy quality registry

Published:September 22, 2021DOI:

      Background and Aims

      Endoscopist recommendations regarding a repeat colonoscopy after inadequate bowel cleanliness have not been fully described. Our aim was to evaluate the timing of recommendations for repeat colonoscopy after inadequate bowel preparation using a large, national colonoscopy registry.


      We performed a cross-sectional analysis of all outpatient screening and surveillance colonoscopies among adults ages 50 to 75 reported in the GI Quality Improvement Consortium from 2011 to 2018. The primary outcome was a recommendation to repeat colonoscopy within 1 year. Secondary outcomes were recommendations based on indication of colonoscopy and colonoscopy findings and predictors of a recommendation to follow-up within 1 year.


      There were 260,314 colonoscopies with inadequate bowel preparation performed at 672 different sites by 4001 endoscopists. Of these, 31.9% contained a recommendation for follow-up within 1 year. This did not differ meaningfully by examination indication. The severity of colonoscopy findings influenced the recommendations for follow-up (within 1 year in 84.0% of cases with adenocarcinoma, 51.8% with any advanced lesion, and 23.2% with 1-2 small adenomas). Younger age, more severe pathology, location in the Northeast, and performance by an endoscopist with an adenoma detection rate ≥25% were associated with recommendations for follow-up within 1 year.


      Only some colonoscopies with inadequate bowel preparation are recommended to be repeated within 1 year, which may have implications for potential missed lesions. Further understanding of reasons driving recommendations is an important next step to improving guideline-concordant colonoscopy practice.


      ADR (adenoma detection rate), ASA (American Society of Anesthesiologists), GIQuIC (GI Quality Improvement Consortium), USMSTF (U.S. Multi-Society Task Force)
      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'


      Subscribe to Gastrointestinal Endoscopy
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect


        • Froehlich F.
        • Wietlisbach V.
        • Gonvers J.J.
        • et al.
        Impact of colonic cleansing on quality and diagnostic yield of colonoscopy: the European Panel of Appropriateness of Gastrointestinal Endoscopy European multicenter study.
        Gastrointest Endosc. 2005; 61: 378-384
        • Harewood G.C.
        • Sharma V.K.
        • de Garmo P.
        Impact of colonoscopy preparation quality on detection of suspected colonic neoplasia.
        Gastrointest Endosc. 2003; 58: 76-79
        • Saltzman J.R.
        • Cash B.D.
        • Pasha S.F.
        • et al.
        • ASGE Standards of Practice Committee
        Bowel preparation before colonoscopy.
        Gastrointest Endosc. 2015; 81: 781-794
        • Gupta S.
        • Lieberman D.
        • Anderson J.C.
        • et al.
        Recommendations for follow-up after colonoscopy and polypectomy: a consensus update by the US Multi-Society Task Force on Colorectal Cancer.
        Gastroenterology. 2020; 158: 1131-1153
        • Johnson D.A.
        • Barkun A.N.
        • Cohen L.B.
        • et al.
        Optimizing adequacy of bowel cleansing for colonoscopy: recommendations from the U.S. Multi-Society Task Force on Colorectal Cancer.
        Gastrointest Endosc. 2014; 80: 543-562
        • Lieberman D.A.
        • Rex D.K.
        • Winawer S.J.
        • et al.
        Guidelines for colonoscopy surveillance after screening and polypectomy: a consensus update by the US Multi-Society Task Force on Colorectal Cancer.
        Gastroenterology. 2012; 143: 844-857
        • Ben-Horin S.
        • Bar-Meir S.
        • Avidan B.
        The impact of colon cleanliness assessment on endoscopists' recommendations for follow-up colonoscopy.
        Am J Gastroenterol. 2007; 102: 2680-2685
        • Hillyer G.C.
        • Basch C.H.
        • Lebwohl B.
        • et al.
        Shortened surveillance intervals following suboptimal bowel preparation for colonoscopy: results of a national survey.
        Int J Colorectal Dis. 2013; 28: 73-81
        • Larsen M.
        • Hills N.
        • Terdiman J.
        The impact of the quality of colon preparation on follow-up colonoscopy recommendations.
        Am J Gastroenterol. 2011; 106: 2058-2062
        • Calderwood A.H.
        • Holub J.L.
        • Greenwald D.A.
        • et al.
        Yield and practice patterns of surveillance colonoscopy among older adults: an analysis of the GI Quality Improvement Consortium.
        Am J Gastroenterol. 2019; 114: 1811-1819
      1. U.S. Census Regions.
        (Available at:)
        • Chokshi R.V.
        • Hovis C.E.
        • Colditz G.A.
        • et al.
        Physician recommendations and patient adherence after inadequate bowel preparation on screening colonoscopy.
        Dig Dis Sci. 2013; 58: 2151-2155
        • Butterly L.F.
        • Nadel M.R.
        • Anderson J.C.
        • et al.
        Impact of colonoscopy bowel preparation quality on follow-up interval recommendations for average-risk patients with normal screening colonoscopies: data from the New Hampshire Colonoscopy Registry.
        J Clin Gastroenterol. 2020; 54: 356-364
        • Winawer S.J.
        • Zauber A.G.
        • Fletcher R.H.
        • et al.
        Guidelines for colonoscopy surveillance after polypectomy: a consensus update by the US Multi-Society Task Force on Colorectal Cancer and the American Cancer Society.
        Gastroenterology. 2006; 130: 1872-1885
        • Winawer S.
        • Fletcher R.
        • Rex D.
        • et al.
        Colorectal cancer screening and surveillance: clinical guidelines and rationale-Update based on new evidence.
        Gastroenterology. 2003; 124: 544-560
        • Calderwood A.H.
        • Anderson J.C.
        • Robinson C.M.
        • et al.
        Endoscopist specialty predicts the likelihood of recommending cessation of colorectal cancer screening in older adults.
        Am J Gastroenterol. 2018; 113: 1862-1871
        • Anderson J.C.
        • Baron J.A.
        • Ahnen D.J.
        • et al.
        Factors associated with shorter colonoscopy surveillance intervals for patients with low-risk colorectal adenomas and effects on outcome.
        Gastroenterology. 2017; 152: 1933-1943
        • Murphy C.C.
        • Sandler R.S.
        • Grubber J.M.
        • et al.
        Underuse and overuse of colonoscopy for repeat screening and surveillance in the Veterans Health Administration.
        Clin Gastroenterol Hepatol. 2016; 14: 436-444
        • Mysliwiec P.A.
        • Brown M.L.
        • Klabunde C.N.
        • et al.
        Are physicians doing too much colonoscopy? A national survey of colorectal surveillance after polypectomy.
        Ann Intern Med. 2004; 141: 264-271
        • Lebwohl B.
        • Kastrinos F.
        • Glick M.
        • et al.
        The impact of suboptimal bowel preparation on adenoma miss rates and the factors associated with early repeat colonoscopy.
        Gastrointest Endosc. 2011; 73: 1207-1214
        • Johnson M.R.
        • Grubber J.
        • Grambow S.C.
        • et al.
        Physician non-adherence to colonoscopy interval guidelines in the Veterans Affairs Healthcare System.
        Gastroenterology. 2015; 149: 938-951
        • Lai E.J.
        • Calderwood A.H.
        • Doros G.
        • et al.
        The Boston Bowel Preparation Scale: a valid and reliable instrument for colonoscopy-oriented research.
        Gastrointest Endosc. 2009; 69: 620-625
        • Aronchick C.
        • Lipshultz W.
        • Wright S.
        Validation of an instrument to assess colon cleansing.
        Am J Gastroenterol. 1999; 94: 2667
        • Clark B.T.
        • Rustagi T.
        • Laine L.
        What level of bowel prep quality requires early repeat colonoscopy: systematic review and meta-analysis of the impact of preparation quality on adenoma detection rate.
        Am J Gastroenterol. 2014; 109 (quiz 1724): 1714-1723