What is the recommended bowel preparation protocol for an average adult before colonoscopy, including diet, split‑dose polyethylene glycol (PEG) regimen, medication adjustments, and alternatives for patients with renal insufficiency or intolerance?

How to Perform Bowel Preparation Before Colonoscopy

Use a split-dose regimen with 2 L polyethylene glycol (PEG) solution, where you take half the evening before and complete the second half 4-6 hours before your colonoscopy, finishing at least 2 hours before the procedure. 1

Timing Protocol (Critical for Success)

Split-dose administration is strongly recommended for all patients regardless of preparation volume. 1, 2

For Morning Colonoscopies:

• First dose: Evening before (typically 6-8 PM) 3
• Second dose: Morning of procedure, starting 4-6 hours before colonoscopy time 1, 3, 2
• Complete intake: At least 2 hours before procedure start 1, 3, 2

For Afternoon Colonoscopies:

• Same-day regimen is an acceptable alternative where you take the entire preparation on the day of the procedure 1, 2
• Split-dose remains preferred but same-day is non-inferior for afternoon cases 1

Critical timing rule: Each additional hour between your last purgative dose and colonoscopy decreases preparation quality by approximately 10% 3, 2, 4. The interval should never exceed 5 hours for optimal results 3.

Dietary Modifications

Limit dietary changes to only the day before colonoscopy. 1

Day Before Colonoscopy:

• Breakfast and lunch: Low-residue, low-fiber foods OR full liquids 1
• After starting first dose: Clear liquids only 3, 2
• Continue clear liquids: Until 2 hours before procedure 3

Avoid:

• Red or purple colored liquids 5
• Solid foods or dairy products 5
• Alcohol 5

Medication Selection

No single purgative is superior to others for low-risk patients, so choose based on patient factors. 1

Preferred Options:

2 L preparations are suggested over 4 L due to better tolerability while maintaining adequate cleansing. 1, 2

• 2 L PEG with ascorbate (low-volume) 1, 6
• Sodium picosulfate with magnesium citrate 5, 6
• Oral sodium sulfate solutions 1

For Patients with Renal Insufficiency:

PEG is the only recommended preparation due to its iso-osmolar properties. 6 Avoid hyperosmotic regimens (sodium phosphate, magnesium-based products) in patients at risk for volume overload or electrolyte disturbances. 1, 2, 6

High-Volume Alternative:

• 4 L PEG-electrolyte solution: Provides marginally better cleansing but significantly worse tolerability 1
• Still use split-dosing even with 4 L preparations 1, 2

Medication Adjustments

Hold Before Colonoscopy:

• Iron supplements: Stop at least 7 days before 3
• GLP-1 receptor agonists (e.g., Zepbound, semaglutide): Stop 7 days before due to delayed gastric emptying 7

Timing Considerations:

Do not take oral medications within 1 hour of starting bowel preparation. 5

Adjunctive Measures

Oral simethicone can be added to improve visualization. 1, 2

Patient Education Requirements

Provide both verbal AND written instructions for all preparation components. 1, 2 This is a strong recommendation with high-quality evidence and significantly improves preparation adequacy. 1

Consider patient navigation support (phone calls, automated messaging) to improve compliance, particularly for high-risk patients. 1, 2

Special Populations at Higher Risk for Inadequate Preparation

Medical conditions increasing risk include: 3

• Cirrhosis
• Parkinson disease
• Dementia
• Diabetes mellitus
• Chronic constipation
• History of prior inadequate preparation

For these patients: Consider adding promotility agents, provide enhanced education, and ensure close follow-up. 2

Common Pitfalls to Avoid

• Starting second dose too early: Beginning more than 6 hours before colonoscopy reduces effectiveness 3
• Completing preparation too early: Finishing more than 5 hours before significantly compromises cleansing 3, 4
• Direct ingestion of undissolved powder: Always dissolve powder completely in water to avoid nausea, vomiting, and electrolyte disturbances 5
• Taking other laxatives concurrently: Do not use additional laxatives while on prescribed bowel preparation 5

Quality Targets

Your endoscopy unit should achieve adequate preparation in at least 85%, ideally >90% of cases. 3 Adequate preparation is defined as cleanliness allowing standard screening intervals based on findings. 3

If Preparation Is Inadequate

Check effluent quality on arrival: Brown liquid or solid effluent predicts 54% chance of inadequate preparation. 3 Consider salvage measures including additional oral purgatives before sedation or large-volume enemas. 3

Reschedule within 12 months if preparation remains inadequate after salvage attempts. 2