What are the follow-up recommendations for a patient with a normal Boston Bowel Preparation Scale (BBPS) score after a colonoscopy?

Normal BBPS Score Follow-Up Recommendations

For patients with adequate bowel preparation defined as BBPS scores ≥6 (all segment scores ≥2), proceed with standard screening or surveillance intervals based on colonoscopy findings, with normal colonoscopy requiring 10-year follow-up. 1

Defining Adequate Bowel Preparation

A BBPS total score ≥6 with all individual segment scores ≥2 constitutes adequate bowel preparation that allows detection of adenomas >5 mm and permits assignment of standard screening/surveillance intervals. 1, 2

• The 2025 US Multi-Society Task Force on Colorectal Cancer identifies BBPS as the most reliable and thoroughly validated bowel preparation scale. 1
• Prospective data from 438 male veterans demonstrated that BBPS segment scores of 2 or 3 in all colonic segments had adequate preparation for detecting adenomas >5 mm, with miss rates for adenomas >5 mm being noninferior between BBPS scores of 2 versus 3 (5.2% vs 5.6%, difference -0.4%). 2
• Any segment with BBPS score <2 is inadequate and requires repeat colonoscopy within 12 months. 1

Follow-Up Intervals Based on Findings

Normal Colonoscopy (No Polyps)

• Return in 10 years for next screening colonoscopy when BBPS ≥6 and examination is complete to cecum with adequate withdrawal time. 3, 4
• Among 2,295 negative screening colonoscopies with BBPS ≥2 in all segments, 10-year follow-up was recommended in 90% of cases. 4

Low-Risk Adenomas (1-2 Small Tubular Adenomas <10mm)

• Return in 7-10 years for surveillance colonoscopy, with timing favoring 7 years if concerns exist about baseline examination quality or incomplete excision. 3, 5
• These patients have metachronous advanced neoplasia risk of only 4.9%, similar to those with normal colonoscopy. 5

Intermediate-Risk Adenomas (3-4 Small Tubular Adenomas <10mm)

• Return in 3-5 years for surveillance colonoscopy, with flexibility based on examination quality and complete polyp removal. 5

High-Risk Adenomas

• Return in exactly 3 years for any adenoma ≥10mm, tubulovillous/villous histology, high-grade dysplasia, or 5-10 adenomas <10mm. 3, 5, 6

Very High-Risk Findings (>10 Adenomas)

• Return in 1 year and consider genetic testing for familial adenomatous polyposis or other hereditary syndromes. 3, 5

Critical Quality Requirements

All surveillance intervals assume the following quality metrics were met:

• Complete examination to cecum with photo documentation 6
• Adequate bowel preparation (BBPS ≥6 with all segments ≥2) 1
• Minimum withdrawal time of 6 minutes 3, 6
• Complete removal of all detected neoplastic lesions 6

If any quality metric is not met, shorten the surveillance interval to ensure adequate follow-up. 5

Important Caveats About BBPS Scores

BBPS Score 6 vs 7-9

• While BBPS ≥6 is considered adequate, BBPS score of exactly 6 is associated with higher numbers of missed polyps and adenomas compared to BBPS 7-9 in short-term follow-up colonoscopy (1.84 vs 1.56 polyps, P=0.001; 1.02 vs 0.88 adenomas, P=0.034). 7
• Perform more thorough examination when BBPS is exactly 6, particularly in segments with BBPS score of 2, which showed higher polyp detection rates at follow-up (P=0.001). 7

Paradoxical Finding with Pristine Preparation

• Polyp detection rates actually decrease at the highest levels of bowel cleanliness (BBPS 9) compared to BBPS 6-8 (46% vs 51-53%, P=0.002). 8
• Avoid overconfidence when encountering pristine bowel preparation—maintain careful inspection technique and adequate withdrawal time despite excellent cleanliness. 8

BBPS Score 1 in Any Segment

• Segments with BBPS score of 1 have significantly higher miss rates for adenomas >5mm (15.9%) compared to segments with scores of 2 (5.2%) or 3 (5.6%). 2
• Screening/surveillance intervals would be incorrect for 43.5% of patients with BBPS score of 1 in one or more segments, supporting early repeat colonoscopy. 2

Special Circumstances

Non-Screening/Surveillance Indications

• When colonoscopy is performed for alarm symptoms (GI bleeding) or positive FIT, bowel preparation may be adequate for that indication even if not adequate for screening/surveillance purposes. 1
• Document this distinction clearly to ensure appropriate future screening intervals are followed. 1

Partial Adequate Preparation

• If descending colon, sigmoid, and rectum are well-visualized during average-risk screening with otherwise inadequate preparation proximally, consider treating as flexible sigmoidoscopy with return in 5 years or use of non-endoscopic screening tests. 1