Real-World Application of Shankhaprakshalana (a Yogic Technique) in Bowel Preparation for Colonoscopy in a Busy Outpatient Clinic: An External Validation Study

Abstract

Objectives

Achieving optimal bowel preparation is pivotal for successful colonoscopy. However, in the real-world scenario, this is challenging. A recent study by Panigrahi et al sheds light on Shankhaprakshalana (SP) as a promising method in achieving optimal bowel preparation before colonoscopy. Our primary aim was to evaluate the effectiveness of SP in the bustling environment of a real-world outpatient clinic.

Materials and Methods

It was a prospective study conducted at Kalinga Gastroenterology Foundation, Cuttack, between May and August 2024. Patients requiring colonoscopy underwent bowel preparation by SP using the previously described methodology. Patients having poor performance status, diagnosed with bowel stricture and with history of abdominal surgery, and those unable to perform SP were excluded. Bowel preparation was assessed using Boston Bowel Preparation Scale (BBPS).

Results

SP was performed in 101 patients. The mean age of the patients was 43.57 (±13.54) years. The mean BBPS score was 8.6 (±0.7). Bowel preparation was adequate in all patients (100%). The mean segmental BBPS for the three segments of the colon (right, transverse, and left) were 2.8 (±0.3), 3.0 (±0.6), and 3.0 (±0.6), respectively. Bowel preparation was completed in 143 (±24) minutes, with an average of 6 (±2) motions. The cecal intubation time was 7 (±3) minutes and the median visual analog scale (VAS) score for patient-reported discomfort during colonoscopy was 0 (0–5). Ninety-seven percent of the patients were willing to repeat the procedure using SP.

Conclusions

In a busy, outpatient setting, SP is an efficacious and highly acceptable bowel preparation regimen prior to colonoscopy.

Keywords

bowel preparation solutions - bowel evacuants - effectiveness - acceptability - yoga

Introduction

The most crucial part in a colonoscopy is bowel preparation. Achieving optimal bowel preparation is pivotal for successful colonoscopy, a procedure widely practiced across medical settings worldwide. Although there is no single “ideal” bowel preparation agent, a good bowel preparation agent is expected to adequately cleanse the bowel while not altering the bowel histology; in addition, it should be safe, tolerated well, and affordable.[1]

Currently, the rates of reported inadequate bowel preparation across various settings worldwide hover between 15 and 35%, although as per guidelines, it is necessary to have an adequate bowel preparation rate of greater than 90% as a quality indicator of colonoscopy.[2] In the real-world setting of the busy clinical practice, especially in the South Asian region where patients often endure long journeys to see the physicians, ensuring adequate bowel preparation can be challenging.

The most commonly used agent currently in bowel preparation is polyethylene glycol (PEG). Although both split-dose and single-dose regimens are used, the split-dose regimen has been found to be superior.[3] However, the use of split-dose regimen has many disadvantages: intake of a relatively larger volume of solution, sleep disturbances, inconvenience in timing, issues with palatability, and adverse effects like bloating, cramps, nausea, and vomiting. In addition, patients often come from far-off places in remote, rural areas and it becomes very difficult for them to adhere to the split-dose regimen. Same-day single-dose regimes also have their limitations. Same-day single-dose regimens are usually recommended when afternoon colonoscopies are scheduled since these are usually administered at least 6 hours prior to colonoscopy. In addition, a slightly higher rate of adverse events like nausea and vomiting have been reported in same-day single-dose regimens.[4]

In this context, a recent study by Panigrahi et al, conducted in a tertiary care hospital and research institute, sheds light on Shankhaprakshalana (SP) as a promising solution to this problem.[5] The findings of this study underscore the effectiveness and safety of SP in achieving optimal bowel cleansing before colonoscopy. The authors have used SP, which is an ancient yogic technique involving intake of warm saline water followed by performance of five “asanas” or postures in a proper sequence.[5] Although each asana has been postulated to have a particular physiologic function, in the traditional yogic texts, there is no mechanistic evidence to prove that yet. However, SP has been found to be efficacious in cleansing the colon, in addition to having beneficial effects in patients with hypertension and irritable bowel syndrome.[6] [7]

Our primary aim in this study was to evaluate the effectiveness of SP in a busy setting of a real-world outpatient clinic. We used the same methodology used by Panigrahi et al and tried to validate their findings.

Material and Methods

Study Design

It was a prospective study conducted at Kalinga Gastroenterology Foundation, Cuttack, for a period of 4 months between May and August 2024. Consecutive patients requiring colonoscopy underwent bowel preparation by SP using the previously described methodology.[5] Patients having comorbidities (chronic liver disease, kidney disease, heart failure), poor performance status, diagnosed with bowel stricture and with a past history of gastrointestinal surgery, and those expressing inability to perform SP were excluded. Bowel preparation was assessed using the Boston Bowel Preparation Scale (BBPS).

The study adhered to the ethics prescribed in the Helsinki Declaration (1975) after approval from the ethics committee of the institution. An informed written consent was obtained from all study participants. Patients' characteristics, history, and colonoscopic findings were obtained and analyzed.

Shankhaprakshalana

While Panigrahi et al advised patients to have a low-residue diet on the day before colonoscopy, we avoided it in order to make it more natural and convenient for patients.[5] We did not recommend any special diet (low-residue diet, clear liquids, etc.) to patients prior to colonoscopy. SP was performed by patients (supervised by a yoga instructor) on the very day of scheduled colonoscopy at 8:30 a.m. Two tablespoons of salt were added to each liter of warm saline water. The patients were then asked to take warm saline water (400 mL), following which the five asanas were performed in the following sequence:

1. Tadasana: stretching the arm while standing.

2. Tiryaka Tadasana: arm and side body stretch while standing.

3. Katichakrasana: twisting stretches while standing.

4. Tiryaka Bhujangasana: an upward-facing dog position, followed by twisting stretch.

5. Udarakarshanasana: a tip-toe position with a twisting stretch.

A pictorial representation of these asanas is shown in [Supplementary Fig. S1].

One cycle of SP consists of each asana repeated eight times. Between cycles, the patients were asked to drink warm saline water (400 mL). Six supervised (by trainer) SP cycles were completed; thus, the patients consumed, in total, 2,400 mL of warm saline water. The patients were asked to use the toilet in between the asanas. The detailed regimen of SP has already been previously described.[5]

Colonoscopy

The colonoscope used for the procedure was Fujinon EC-250 WL5. All colonoscopies were performed by one experienced endoscopist. The quality of bowel preparation was assessed by the BBPS. A BBPS score of ≥6 denotes adequate colon cleansing. Colonoscopic images were reviewed by another endoscopist who was blinded to the method of bowel evacuation. Confirmation of cecal intubation was done with identification of the anatomical cecal landmarks, including appendicular orifice and ileocecal valve. Segmental and total BBPS scores were recorded. The visual analog scale (VAS) score during colonoscopy was also recorded to estimate patient reported pain during the procedure. The colonoscopies were performed without any anesthesia.

Statistical Analysis

Statistical Package for Social Sciences (SPSS) version 25.0 (IBM Corp., Armonk, NY, United States) was used for data analysis. Continuous variables were presented as mean values with corresponding standard deviations, while categorical variables were shown as frequencies and percentages. The cecal intubation rate was determined by dividing the number of successful cecal intubations by the total number of colonoscopies performed. The polyp detection rate was defined as the proportion of colonoscopies in which at least one polyp was identified.

Results

A total of 106 colonoscopies were carried out at our clinic in the course of the study; bowel preparation in 101 colonoscopies were done by the SP method. In the remaining five patients, bowel preparation was done using PEG. All 106 patients were offered the SP method for bowel preparation, out of which 101 agreed. Three patients refused SP citing inability to perform yogic asanas, while two of them expressed doubts over the ability of SP to cleanse the bowel and instead expressed their wish to undergo bowel preparation using PEG, which is the conventional method. None of the 101 patients mentioned any serious difficulty in performing the SP bowel preparation technique. None of the patients who underwent SP dropped out. The patients did not have to bear any cost for the SP bowel preparation technique.

The mean age of the study subjects was 43.57 ± 13.54 years. Around one-third of the patients were aged ≥50 years in our study group. One-third of the patients were females. The median distance that patients traveled to reach our center was 110 km (range, 5–450 km). The baseline characteristics of the 101 patients are summarized in [Table 1].

Table 1 Baseline characteristics of the study subjects (n = 101)

Parameter	Number (%)
Age (y), mean ± SD Age ≥50 y Age <50 y	43.57 ± 13.54 31 (30.69) 70 (69.30)
Gender Males Females	67 (66.3) 34 (33.7)
Distance from clinic (km), median (range)	110 (5–450)
Indication for colonoscopy Constipation Abdominal pain Hematochezia Chronic diarrhea Anemia	54 (53.4) 17 (16.9) 21 (20.8) 2 (2) 7 (6.93)
Colonoscopy findings Normal Pancolitis/left-sided colitis/proctitis Terminal ileal ulcers/erosions Hemorrhoids only Carcinoma colon Colonic polyps Solitary rectal ulcer syndrome	46 (45.5) 13 (12.8) 11 (10.8) 8 (7.9) 7 (6.9) 14 (13.8) 2 (1.9)

Adequate bowel preparation (BBPS ≥6) was observed in all patients (101/101). A BBPS score of 9/9 was observed in 80 (79.20%) patients. The mean BBPS score was 8.7 ± 0.4. For the different segments of the colon, the BBPS scores were the following: right (2.8 ± 0.3), transverse (3.0 ± 0.6) and left (3.0 ± 0.6). The observations regarding bowel preparation through SP and colonoscopy findings are summarized in [Table 2]. The cecal intubation rate was 100%. The duration of completion of the SP regimen was 143 ± 24 minutes. The average number of motions passed per patient was 6 ± 2. The time taken for cecal intubation was 7 ± 3 minutes. The polyp detection rate was 13.8% (n = 14).

Table 2 Bowel preparation adequacy and colonoscopic findings

Parameter	Mean ± SD/number (%)
Total BBPS score	8.7 ± 0.4
Segmental BBPS score
Right colon Transverse colon Left colon	2.8 ± 0.3 3.0 ± 0.6 3.0 ± 0.6
BBPS 9/9	80 (79.2%)
Number of motions	6 ± 2
Cecal intubation rate	101 (100%)
Cecal intubation time (min)	7 ± 3
Time to complete the SP regimen (min)	143 ± 24
Visual analog scale (VAS) [median (range)]	0 (0–5)

Abbreviations: BBPS, Boston Bowel Preparation Scale; SD, standard deviation; SP, Shankhaprakshalana.

All patients (n = 101) completed the bowel preparation using the SP regimen. Willingness to repeat bowel preparation using SP was seen in 98 (97%) patients. Palatability of the warm saline solution was accepted by 93 (92.1%) patients.

Adverse events that occurred were the following: vomiting, nausea, pain in abdomen, and bloating. These were noted in five patients, which did not require any form of hospitalization. The details of adverse events are summarized in [Table 3].

Table 3 Frequency of adverse events

Adverse events	Number (%)
Nausea	2 (2)
Vomiting	1 (1)
Bloating	1 (1)
Abdominal pain	1 (1)

Discussion

We performed this study to externally validate the findings by Panigrahi et al in bowel preparation in colonoscopy using SP. We used the same methodology used by the authors in the previous study with slight modifications to suit the busy schedule of an outpatient clinic in the real-world setting. We observed very good effectiveness and safety of SP as a bowel cleansing method for colonoscopy, with 100% of patients achieving adequate bowel preparation. In addition, a BBPS score of 9/9 was achieved for almost 80% of patients, which is much higher compared to the original findings by Panigrahi et al where it was only 48.7%. The adverse events noted in our study were negligible and did not require any form of intervention or hospitalization.

In our study, the average duration to complete the SP regimen was observed to be a little over 2 hours. This is similar to the study by Panigrahi et al in which they noted the time to be 133 ± 35 minutes. While split-dose regimens are longer and time-consuming, even same-day single-dose PEG regimens have to be given usually 6 hours prior to colonoscopy.[8] Moreover, we also evaluated the cecal intubation time in our study (7 ± 3 minutes). A cecal intubation time of less than 10 minutes is considered “easy.”[9] Thus, all the patients in our study underwent easy cecal intubation. This can be considered a major advantage of SP as a bowel preparation regimen although comparative studies with PEG are required.

Colonoscopies in an outpatient setting in India and several parts of South Asia are usually performed without sedation. There are also data from a multicentric study in the United Kingdom showing that colonoscopy without sedation can be performed with an acceptable level of discomfort and with acceptable quality standards and is comparable to colonoscopy performed under conscious sedation.[10] However, pain and discomfort during nonsedated colonoscopy remains a vexing problem, often interfering with patients' overall experience during the procedure. There are data to show that looping is a major cause of pain and discomfort during colonoscopy.[11] We therefore used the VAS to try to assess patient-reported discomfort during colonoscopy using the SP regimen. The median VAS score in our group was 0 (0–5). This indicates that the SP regimen might provide an added advantage in minimizing patient discomfort during nonsedated colonoscopy. However, this also requires comparative studies.

We also observed that 97% of the patients in our study group were willing to repeat colonoscopy (if required) using SP as a bowel preparation regime. In addition, 92% of them found the warm saline solution palatable. Palatability is one of the major areas of concern for patients undergoing elective colonoscopy; one of the commonly cited reasons for inadequate or poor bowel preparations is the unpleasant taste of commercially available bowel preparation solutions including PEG.[12] Similarly willingness to repeat bowel preparation with PEG is often diminished due to the unpleasant taste, and occurrence of events like bloating and nausea, thereby necessitating the use of adjuncts to standard bowel preparation solutions to improve overall experience of patients.[13] In a meta-analysis evaluating the utility of adjuncts to bowel preparation for colonoscopy in improving patient experience and superior bowel cleanliness, it was observed that 35.9% of patients perceived “taste” as one of the worst aspects of bowel preparation.[13] In this context, SP could be a useful alternative given its overall acceptance among patients.

Panigrahi et al have also recently published a pilot randomized controlled trial comparing SP with PEG in bowel preparation prior to colonoscopy.[14] The results of this randomized trial suggest that SP is effective, acceptable, affordable, and relatively safe for bowel preparation and is better and has fewer adverse events compared to the standard PEG electrolyte solution. We feel that incorporating these parameters—cecal intubation time and VAS in the comparison—would lend more credence to the utility of SP as a superior colon cleansing method compared to PEG.

In addition, in another recent study, Panigrahi et al have also evaluated the effectiveness of Laghu Shankha Prakshalana (LSP), a variant of SP as a rescue method in patients who have inadequate bowel preparation using PEG.[15] The authors reported LSP to be a feasible option for rescue bowel preparation, which can be done on the same day within 2 hours of the index colonoscopy, thereby also minimizing expenses of patients. Patients who come for colonoscopy often travel long distances. In our study, the median distance patients had to travel to reach our center was 110 km. Given the fact that availability and functionality of public toilets remain a cause of concern to the general public, patients who follow the split-dose regimen often have to undertake difficult journeys to reach the clinic or have to come on the previous day and stay overnight, which adds to the expenses.

Our study has some limitations. We did not have a comparator arm. However, since Panigrahi et al have already reported their findings in a retrospective study as well as in a pilot randomized trial, we decided to prospectively enroll patients undergoing colonoscopy who were administered the SP regimen. We also recruited only outpatients in our study and thus our results may not be applicable to in-patients. Pre- and postprocedure blood pressure and serum electrolytes were not measured, first, because there are now enough data to suggest the overall safety of this method of bowel preparation and, second, because in a previous study, serum electrolytes had been measured and were not found to have any clinical significance.[16] While we measured the cecal intubation time, we did not objectively measure the cecum to rectum withdrawal time as we followed the general recommendation of withdrawing the colonoscope from cecum to rectum in 6 minutes.

Conclusion

In conclusion, we have tried to validate the findings of Panigrahi et al in a real-world busy outpatient clinic to assess the effectiveness of SP as a bowel evacuant method. The previous study was conducted in a tertiary care hospital and research institute, while the present study has been conducted at an outpatient clinic. Our results validate the findings of Panigrahi et al and establish SP as an effective, safe, and patient-friendly method for bowel preparation prior to colonoscopy.

Conflict of Interest

None declared.

Authors' Contributions

P.A. contributed to the methodology, data curation, investigation, writing—original draft preparation, formal analysis, and validation. A.K.N. contributed to data curation, methodology, and investigation. S.P.S. contributed to conceptualization, methodology, supervision, visualization, validation, resources, writing—reviewing and editing, and project administration. C.R.K. contributed to writing—reviewing and editing. M.K.P. contributed to the methodology and supervision.

Data Availability Statement

The data that support the findings of this study are available from the corresponding author upon reasonable request.

Ethics Approval Statement

Ethical approval was taken from the Kalinga Gastroenterology Foundation (KGF) Institutional Ethics Committee, Cuttack, Odisha

Patient Consent Statement

Informed consent has been taken from all subjects prior to the study.

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Publication History

Article published online:
20 March 2025