To the Editor,

The occurrence of acute gastropathy associated with various low-volume bowel preparation agents provides essential insights for clinical practice, particularly with respect to safety considerations in patients undergoing esophagogastroduodenoscopy (EGD) and colonoscopy. Recently, Park et al. compared the adverse drug effects of oral sulfate tablets (OST) and 1 L polyethylene glycol with ascorbic acid (PEG/Asc) on the gastric mucosa.¹ Acute gastric mucosal lesions, such as erythema, erosions, and hematins, were found to be significantly more prevalent in OST users than in PEG/Asc users. The implications of this finding are profound, as the adverse effects of OST may influence the quality of EGD interpretations, especially in patients susceptible to mucosal irritation, such as those at a high risk of gastric cancer. Therefore, these results suggest that while OST may be convenient in the tablet form and preferred by many patients, its gastric safety profil warrants caution for use in patients requiring a detailed examination for the detection of gastric neoplasia as well as for those taking anti-thrombotics or non-steroidal anti-inflammatory drugs (NSAIDs).

In real practice, the prevalence of acute gastropathy in OST users raises several questions about the mechanisms contributing to this risk. Since OST with a high sulfate content can have a delayed dissolution, resulting in prolonged contact with the gastric mucosa, the hyperosmolar properties of OST seem to provoke direct mucosal irritation and erosive damage to the stomach lining. In addition, it has been suggested that the greater curvature is particularly susceptible to gastric mucosal injury due to the influence of gravity.¹

As Park et al. pointed out, acute gastric lesions induced by OST can be misinterpreted as abnormal findings unrelated to the preparation agent, which results in unnecessary endoscopic biopsies and follow-up EGD. This can increase the anxiety and healthcare costs of patients. Therefore, it is important to recognize the possible artifact effects of OST on EGD results when endoscopists interpret these findings. Moreover, endoscopists performing EGD after bowel preparation with OST should be aware of the potential for drug-induced mucosal changes, which could be mistaken for abnormal findings.

On the other hand, 1-L PEG/Asc appears to pose a lower risk of gastric injury.² PEG/Asc differs in composition and osmotic activity, probably resulting in reduced gastric irritation. Considering PEG/Asc achieved a level of bowel cleansing efficacy equivalent to that seen with OST, this agent may be a safer alternative, especially for the abovementioned high-risk patients. The low incidence of gastric mucosal injury in PEG/Asc users could be explained by its lower osmotic effect and rapid clearance from the stomach, resulting in reduced mucosal exposure time. Recently, oral lactulose (200 mL of lactulose 3.33 g/5 mL diluted in 600 mL of water with 15 mL of simethicone) has also been suggested as a novel low-volume bowel preparation regimen.³ Considering lactulose has been commonly used for the treatment of constipation without increased risks of gastrointestinal bleeding, PEG/Asc and lactulose can be safely used in those undergoing both colonoscopy and EGD, especially when simultaneous screenings are required.

Furthermore, the study by Park et al. raises important considerations for clinical practice guidelines. The current guidelines and recent clinical trials for bowel preparation primarily focus on efficacy in colon cleansing without paying attention to gastric mucosal injury.^4-6 It would thus be better to recommend a personalized bowel preparation agent suited to the patient's condition. For example, the guidelines could recommend PEG/Asc over OST in high risk gastric cancer patients undergoing simultaneous EGD and colonoscopy examination or in those taking anti-thrombotic or NSAIDs undergoing colonoscopy.

In summary, endoscopists should be aware of potential changes to the gastric mucosa while performing EGD after bowel preparation with OST. Furthermore, PEG/Asc and lactulose should be considered instead of OST, particularly in individuals who are at a high risk of gastric mucosal damage.

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