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confirmed in a large study with various groups of patients. Third, there were ten colonoscopists involved in this study. Although all the endoscopists were trained in using the scale with photographs illustrating each point on the OBPS, and the degree of agreement was acceptable according to a κ coefficient of greater than 0.4, the study could have been more powerful if all the colonoscopies had been performed by a single colonoscopist. Fourth, there was a discrepancy between “better” overall satisfaction and a “similar” propensity of willingness to repeat the bowel preparation regimen among the elderly patients. Further tailored evaluation of a large group of elderly patients is needed to verify this. As mentioned above, the use of the conventional dose of sodium phosphate is theoretically limited for patients with any condition that can increase the absorption or decrease the elimination of phosphate. If we think a lower volume of sodium phosphate might be safer, then this must be verified in individual cases since the mechanism of an adverse reaction to sodium phosphate and its risk factors has not been fully discovered. Further evaluation of the safety profile is mandatory. In conclusion, a regimen of magnesium citrate and a single dose of oral sodium phosphate was as effective as the conventional two doses of sodium phosphate, and our new regimen was well tolerated. Therefore, this regimen could be a good option to routinely prepare for morning colonoscopy. COMMENTS Background Oral sodium phosphate is a hyperosmolar, low-volume laxative for colonoscopy bowel preparation, and it is known to be as effective as polyethylene glycol solution. It is generally better tolerated, but the bad taste and uncomfortable abdominal symptoms such as nausea and vomiting frequently lead to poor compliance with the oral sodium phosphate regimen, and all this can subsequently cause incomplete bowel cleansing. Moreover, potential adverse reactions associated with hyperphosphatemia may develop. Innovations and breakthroughs This is the first clinical study to evaluate the efficacy and tolerability of magnesium citrate and a single dose of oral sodium phosphate for bowel preparation prior to morning colonoscopy. The findings demonstrated this modified regimen, in which the volume of sodium phosphate was reduced by half was as effective and tolerable as the conventional sodium phosphate regimen. Applications The study results suggest that magnesium citrate and a single dose of oral sodium phosphate can be an effective and satisfactory option to routinely prepare for morning colonoscopy. Terminology Magnesium citrate acts as an osmotic laxative which is often used for bowel preparation Peer review In this well designed paper the author has proposed a combination of magnesium citrate the day before the procedure and sodium phosphate early in the morning of the day of the procedure, associated with one tablet of bisacodyl as compared to standard cleansing using two doses of sodium phosphate, with one tablet of bisacodyl. The paper is interesting and the design is adequate, as are the results and comments. REFERENCES 1 Harewood GC, Sharma VK, de Garmo P. Impact of colonos- WJG|www.wjgnet.com Choi YS et al . Alternative cleansing regimen using magnesium citrate copy preparation quality on detection of suspected colonic neoplasia. Gastrointest Endosc 2003; 58: 76-79 2 Rex DK, Imperiale TF, Latinovich DR, Bratcher LL. Impact of bowel preparation on efficiency and cost of colonoscopy. Am J Gastroenterol 2002; 97: 1696-1700 3 Cohen SM, Wexner SD, Binderow SR, Nogueras JJ, Daniel N, Ehrenpreis ED, Jensen J, Bonner GF, Ruderman WB. Prospective, randomized, endoscopic-blinded trial comparing precolonoscopy bowel cleansing methods. Dis Colon Rectum 1994; 37: 689-696 4 Frommer D. Cleansing ability and tolerance of three bowel preparations for colonoscopy. Dis Colon Rectum 1997; 40: 100-104 5 Hsu CW, Imperiale TF. Meta-analysis and cost comparison of polyethylene glycol lavage versus sodium phosphate for colonoscopy preparation. Gastrointest Endosc 1998; 48: 276-282 6 Golub RW, Kerner BA, Wise WE Jr, Meesig DM, Hartmann RF, Khanduja KS, Aguilar PS. Colonoscopic bowel preparations--which one? A blinded, prospective, randomized trial. Dis Colon Rectum 1995; 38: 594-599 7 Casais MN, Rosa-Diez G, Pérez S, Mansilla EN, Bravo S, Bonofiglio FC. Hyperphosphatemia after sodium phosphate laxatives in low risk patients: prospective study. World J Gastroenterol 2009; 15: 5960-5965 8 Sica DA, Carl D, Zfass AM. Acute phosphate nephropathy-an emerging issue. Am J Gastroenterol 2007; 102: 1844-1847 9 Desmeules S, Bergeron MJ, Isenring P. Acute phosphate nephropathy and renal failure. N Engl J Med 2003; 349: 1006-1007 10 Markowitz GS, Stokes MB, Radhakrishnan J, D'Agati VD. Acute phosphate nephropathy following oral sodium phosphate bowel purgative: an underrecognized cause of chronic renal failure. J Am Soc Nephrol 2005; 16: 3389-3396 11 Carl DE, Sica DA. Acute phosphate nephropathy following colonoscopy preparation. Am J Med Sci 2007; 334: 151-154 12 Markowitz GS, Radhakrishnan J, D'Agati VD. Towards the incidence of acute phosphate nephropathy. J Am Soc Nephrol 2007; 18: 3020-3022 13 Hookey LC, Depew WT, Vanner S. The safety profile of oral sodium phosphate for colonic cleansing before colonoscopy in adults. Gastrointest Endosc 2002; 56: 895-902 14 Belsey J, Epstein O, Heresbach D. Systematic review: oral bowel preparation for colonoscopy. Aliment Pharmacol Ther 2007; 25: 373-384 15 Tan HL, Liew QY, Loo S, Hawkins R. Severe hyperphosphataemia and associated electrolyte and metabolic derangement following the administration of sodium phosphate for bowel preparation. Anaesthesia 2002; 57: 478-483 16 Martin RR, Lisehora GR, Braxton M Jr, Barcia PJ. Fatal poisoning from sodium phosphate enema. Case report and experimental study. JAMA 1987; 257: 2190-2192 17 Ullah N, Yeh R, Ehrinpreis M. Fatal hyperphosphatemia from a phosphosoda bowel preparation. J Clin Gastroenterol 2002; 34: 457-458 18 Azzam I, Kovalev Y, Storch S, Elias N. Life threatening hyperphosphataemia after administration of sodium phosphate in preparation for colonoscopy. Postgrad Med J 2004; 80: 487-488 19 Farah R. Fatal acute sodium phosphate enemas intoxication. Acta Gastroenterol Belg 2005; 68: 392-393 20 Aydogan T, Kanbay M, Uz B, Kaya A, Isik A, Bozalan R, Erkman M, Akcay A. Fatal hyperphosphatemia secondary to a phosphosoda bowel preparation in a geriatric patient with normal renal function. J Clin Gastroenterol 2006; 40: 177 21 US Food and Drug Administration. Science backgrounder: Safety of sodium phosphates oral solution. 2001. Available from: URL: http://www.fda.gov/Drugs/DrugSafety/PostmarketDrugSafetyInformationforPatientsandProviders/ ucm173897.htm 22 US Food and Drug Administration. Science background 247 January 14, 2011|Volume 17|Issue 2|
Choi YS et al . Alternative cleansing regimen using magnesium citrate paper: Acute phosphate nephropathy and renal failure associated with the use of oral sodium phosphate bowel cleansing products. Available from: URL: http://www.fda. gov/Drugs/DrugSafety/PostmarketDrugSafetyInformationforPatientsandProviders/ucm161581.htm 23 Rex DK. Phosphate nephropathy. Am J Gastroenterol 2008; 103: 807 24 Fine A, Patterson J. Severe hyperphosphatemia following phosphate administration for bowel preparation in patients with renal failure: two cases and a review of the literature. Am J Kidney Dis 1997; 29: 103-105 25 Rex DK. Dosing considerations in the use of sodium phosphate bowel preparations for colonoscopy. Ann Pharmacother 2007; 41: 1466-1475 26 Sanaka MR, Shah N, Mullen KD, Ferguson DR, Thomas C, WJG|www.wjgnet.com McCullough AJ. Afternoon colonoscopies have higher failure rates than morning colonoscopies. Am J Gastroenterol 2006; 101: 2726-2730 27 Sharma VK, Steinberg EN, Vasudeva R, Howden CW. Randomized, controlled study of pretreatment with magnesium citrate on the quality of colonoscopy preparation with polyethylene glycol electrolyte lavage solution. Gastrointest Endosc 1997; 46: 541-543 28 Sharma VK, Chockalingham SK, Ugheoke EA, Kapur A, Ling PH, Vasudeva R, Howden CW. Prospective, randomized, controlled comparison of the use of polyethylene glycol electrolyte lavage solution in four-liter versus two-liter volumes and pretreatment with either magnesium citrate or bisacodyl for colonoscopy preparation. Gastrointest Endosc 1998; 47: 167-71 S- Editor Sun H L- Editor O’Neill M E- Editor Zheng XM 248 January 14, 2011|Volume 17|Issue 2|
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Robert JL Fraser, Daw Park Jacob Ge
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Italy Donato F Altomare, Bari Piero
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Fernando Azpiroz, Barcelona Ramon B
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S Contents EDITORIAL TOPIC HIGHLIGH
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Contents APPENDIX FLYLEAF EDITORS F
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Ouyang D et al . Pancreatic endocri
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Diamantis G et al . Quality of life
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19 Li T, Weng SG, Leng XS, Peng JR,
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Table 2 Surgical procedures for muc
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