This document describes a randomized study that evaluated the efficacy of lukewarm saline water and exercise (yoga poses) as a colonoscopy preparation method called Shudh. The Shudh method involves drinking boluses of lukewarm saline solution while performing targeted yoga poses and deep breathing exercises. It is hypothesized that the bolus drinking, combined with the effects of gravity, posture changes, abdominal exercises, and relaxation response from yoga improves gastric emptying and colonic motility for better bowel cleansing compared to conventional preps. The study found the Shudh method resulted in faster times to first bowel movement and total time spent on preparation compared to bolus drinking alone.

1. Efficacy of Lukewarm Saline Water and Exercise as
Colonoscopy Preparation – A Randomized,
Endoscopist Blinded Study
(Presidential Award Recipient, ACG 2009)
Vijaypal Arya M.D, F.A.C.P, F.A.C.G, A.G.A.F.
Clinical Asst Prof. of Medicine , Hofstra Northwell School of Medicine.
Director, Endoscopy Unit
Wyckoff Heights Medical Center.
President, Vikalp Inc.

2. Colon Polypectomy

3. DISCOVERY OF THE CENTURY
Polypectomy snare

4. Beth Israel Medical Center
1 Sivak et al., 2004, 2Winawer et al., 1993
Dr Hiromi Shinya1 and Dr William Wolf
 1971 - First colonoscopic polypectomy
COLONOSCOPY

5. • Third most common cancer in USA
- 131,607 new cases/year (2012) 67,700
men, 63907 women
• Second Leading cause of cancer
death in men and women
- 51,690 deaths (2012)
• Average patient CRC death
- Losses 13 years of life
• A person at age of 50 has about
- 5 % lifetime risk
- 2.5% CRC death rate
CRC Facts

7. Average Risk Factors for Colorectal Cancer
• Male > Female

8. • AGE: 90% of cases occur at age 50 and
above
Average Risk Factors for Colorectal Cancer

9. • Asymptomatic
Average Risk Factors for Colorectal Cancer

10. CRC Etiology
• Environmental
– Stress
– Activity
– Diet
• Genetic – Sporadic 85-90% Avg risk
• - HCCS 5-10% High risk

11. Consumption of red meat and
Saturated fat
Refined carbohydrates
Alcohol
Lack of regular physical activity.
Low fruit and vegetable intake.
A low-fiber and high-fat diet.
Overweight and obesity.
Tobacco use.
INCREASED RISK
Dietary factors implicated in colorectal
carcinogenesis

13. North America has highest rate of Obesity-
related cancers
•Colon
•Rectum
•Pancreas
•Esophagus
•Others

14. Dietary fiber
Vegetables
Fruits
Antioxidant/ vitamins
Calcium
folate (B Vitamin)
DECREASED RISK
Dietary factors implicated in colorectal
carcinogenesis

15. Colonoscopy
Colonoscopy is considered the gold standard for colorectal cancer screening

16. Success of
colonoscopy
Patient
acceptance
Endoscopist
skill
Colon
preparation

17. PREP QUALITY

18. Bowel Preparation
• Dreaded more than procedure itself
• Patient perspective
High volume
Unpalatable
Dietary restriction
Complex instructions
Day before v/s split dose
Impact on work or daily activity
Tolerability (side effects)

19. Consequences:
 More Pt. Discomfort
 More Complications
 Prolonged Procedure
 Repeat Exams
 Incomplete Exams
 Missed lesions / Lost Polyps
 Patient Dissatisfaction
 Physician Dissatisfaction
POOR PREP
≈ 20-25%

20. CONVENTIONAL PREPS

21. Bowel Prep with Sitting & Watching TV:
Is it good for colonoscopy outcome??

22. SHUDH INSPIRATION
 A patient of Indian descent used “Shankh
Prakshalana (BLS and exercise)” as a
preparation for colonoscopy
 The preparation was of such excellent quality
that we were inspired to conduct our studies
 Pilot
 Randomized -DVD

23. INSTRUCTIONS
 Mindfulness: No Distractions
Make sure you have a designated bathroom

24.  Drink continuously rather than sipping slowly
 8 oz (240 ml) in less than one minute
 16 oz (480 ml) in less than two minutes
 Alternate with Yoga Poses
 Use restroom as desired
 Continue until return is clear
INSTRUCTIONS

25. UPWARD STRETCH
Ready position While inhale While exhale

26. SIDE STRETCH
Ready Inhale and to right Inhale and to left

27. TWIST STRETCH
Ready position Inhale Inhale

28. Ready position Inhale Inhale
PUSH UP

29. Ready position Inhale Inhale
SQUATTING

30. How it Works

31. SHUDH
SOLUTION
• 0.9% NS
• Lukewarm
• Isocaloric
BOLUS
DRINKING
• First order
kinetics -
GE
• Gastro-
colic reflex
YOGA
• Postures
• Exercise
• Breathing??
• Gravity
• ANS role
COMPONENTS OF SHUDH METHOD OF BOWEL
PREPARATION

32. ROLE OF BOLUS DRINKING
• Rapid consumption (dumping) – Central role
• First order kinetics of Gastric emptying
- More volume empties into the intestines (maintains high flow rate)
• Prominent role of Gastro-colic cholinergic propulsive reflex ?
*8 oz. “Bolus”
Minutes (SD)
16 oz. “Bolus” Minutes
(SD)
P-value
Total time spent 119.17 (39.30) 87.80 (38.60) <0.0310
Time to first bowel
movement
57.42 (21.05) 25.80 (4.83) <0.0001
*Arya et al., JACM. 2010

33. EFFECT OF TEMPERATURE ON
GARTRIC EMPTYING
• Lukewarm temperature:
– Relaxing effect on the cervical esophagus (enhances the effect of
bolus drinking)
– Adaptive relaxation of gastric muscle (allows greater volume to
be consumed)
• Cold liquids inhibits gastric emptying

34. EFFECT OF GRAVITY AND POSTURE ON
GARTRIC EMPTYING
• Gravity and posture influence the intra-gastric
distribution of liquids:
– Lying on right side improves gastric emptying of saline
– Result in more rapid emptying of non-nutrient inert liquids
• Duodenal feedback receptors are not stimulated
• Role of CCK? (Mg and Na salts cause CCK release)

35. EFFECT OF GRAVITY AND POSTURE
ON GARTRIC EMPTYING
• Yoga poses involve:
– Changes in gravity: Standing and Lying down
– Changes in posture: Right and left sided body movements & arms at various
positions
– Deep inhalation and exhalation can change the gastric configuration
– Vestibular fluid movements influence gastric emptying
• May have an accelerating effect on gastric emptying

36. EFFECT OF DEEP BREATHING ON
GARTRIC EMPTYING
• Yoga poses start with deep inhalation and end with deep
exhalation
– Movements of diaphragm change the gastric
configuration and gastric emptying
– Deep breathing is a known parasympathetic
stimulator and it may accelerate gastric emptying

37. INHALATION

38. EXHALATION

39. STRETCHING
TO RIGHT SIDE

40. STRETCHING
TO LEFT SIDE

41. EFFECT OF EXERCISE ON GI MOTILITY
• Exercise improved colonoscopy preparation (Kim et al., Am J
Gastro. 2005)
• We call Yoga poses as “Targeted Yoga Poses”:
– Poses 1-4: Improved gastric emptying
– Pose 5: Increased intra-abdominal pressure
improving colonic motility

42. THE ROLE OF YOGA ITSELF
“Modern biomedical research identified mechanisms by
which mind and body interact”
“Advanced practitioners of Yoga regulate ANS”
 ANS influences GI motility
• For the relaxed mind in a relaxed body - Thinking clean
may play a role in becoming so”
• Shankh Prakshalana began as purification process, after all

43. OTHER USES
•Detoxification (every 3 to 4 months)
•Irritable Bowel Syndrome
•Mild Constipation

44. CAUTION
•Salt Sensitivity
•Chronic Heart, Liver, and Kidney Diseases
•Arthritis
•Pregnancy
•Diabetes; uncontrolled
•Gastrointestinal Obstruction
•Severe Constipation

45. The complete explanation of yoga cannot be put in
words, it can only be experienced
-BKS Iyengar

46. Yoga is the only exercise on this planet from which you
gain energy instead of burning energy.
-Bikram Choudhury

47. Thank you