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“No direct evidence supports the recommendation and widespread use of sterile water during gastrointestinal endosco-py procedures,” lead author Deepak Agrawal, MD, chief of gastroenterology & hepatology at the Dell Medical School, University Texas at Austin, and colleagues, wrote in Gastro Hep Advances. “Guidelines recommending sterile water during endoscopy are based on limited evidence and mostly expert opinions.”
After reviewing the literature back to 1975, Dr. Agrawal and colleagues considered the use of sterile water in endoscopy via three frameworks: medical evidence and guidelines, environmental and broader health effects, and financial costs.
Only 2 studies – both from the 1990s – directly compared sterile and tap water use in endoscopy. Neither showed an increased risk of infection from tap water. In fact, some cultures from allegedly sterile water bottles grew pathogenic bacteria, while no patient complications were reported in either study.
“The recommendations for sterile water contradict observations in other medical care scenarios, for example, for the irrigation of open wounds,” Dr. Agrawal and colleagues noted. “Similarly, there is no benefit in using sterile water for enteral feeds in immunosuppressed patients, and tap water enemas are routinely acceptable for colon cleansing before sigmoidoscopies in all patients, irrespective of immune status.”
Current guidelines, including the 2021 US multisociety guideline on reprocessing flexible GI endoscopes and accessories, recommend sterile water for procedures involving mucosal penetration but acknowledge low-quality supporting evidence. These recommendations are based on outdated studies, some unrelated to GI endoscopy, Dr. Agrawal and colleagues pointed out, and rely heavily on cross-referenced opinion statements rather than clinical data.
They went on to suggest a concerning possibility: all those plastic bottles may actually cause more health problems than prevent them. The review estimates that the production and transportation of sterile water bottles contributes over 6,000 metric tons of emissions per year from US endoscopy units alone. What’s more, as discarded bottles break down, they release greenhouse gases and microplastics, the latter of which have been linked to cardiovascular disease, inflammatory bowel disease, and endocrine disruption.
Dr. Agrawal and colleagues also underscored the financial toxicity of sterile water bottles. Considering a 1-liter bottle of sterile water costs $3-10, an endoscopy unit performing 30 procedures per day spends approximately $1,000-3,000 per month on bottled water alone. Scaled nationally, the routine use of sterile water costs tens of millions of dollars each year, not counting indirect expenses associated with stocking and waste disposal.
Considering the dubious clinical upside against the apparent environmental and financial downsides, Dr. Agrawal and colleagues urged endoscopy units to rethink routine sterile water use.
They proposed a pragmatic model: start the day with a new sterile or reusable bottle, refill with tap water for subsequent cases, and recycle the bottle at day’s end. Institutions should ensure their tap water meets safety standards, they added, such as those outlined in the Joint Commission’s 2022 R3 Report on standards for water management.
Dr. Agrawal and colleagues also called on GI societies to revise existing guidance to reflect today’s clinical and environmental realities. Until strong evidence supports the need for sterile water, they wrote, the smarter, safer, and more sustainable option may be simply turning on the tap.
The investigators disclosed relationships with Guardant, Exact Sciences, Freenome, and others.
In an editorial accompanying the study and comments to GI & Hepatology News, Dr. Seth A. Gross of NYU Langone Health urged gastroenterologists to reconsider the use of sterile water in endoscopy.
While the rationale for bottled water has centered on infection prevention, Gross argued that the evidence does not hold up, noting that this practice contradicts modern values around sustainability and evidence-based care.
The two relevant clinical studies comparing sterile versus tap water in endoscopy are almost 30 years old, he said, and neither detected an increased risk of infection with tap water, leading both to conclude that tap water is “safe and practical” for routine endoscopy.
Gross also pointed out the inconsistency of sterile water use in medical practice, noting that tap water is acceptable in procedures with higher infection risk than endoscopy.
“Lastly,” he added, “most people drink tap water and not sterile water on a daily basis without outbreaks of gastroenteritis from bacterial infections.”
Gross’s comments went beyond the data to emphasize the obvious but overlooked environmental impacts of sterile water bottles. He suggested several challenging suggestions to make medicine more ecofriendly, like reducing travel to conferences, increasing the availability of telehealth, and choosing reusable devices over disposables.
But “what’s hiding in plain sight,” he said, “is our use of sterile water.”
While acknowledging that some patients, like those who are immunocompromised, might still warrant sterile water, Gross supported the review’s recommendation to use tap water instead. He called on GI societies and regulatory bodies to re-examine current policy and pursue updated guidance.
“Sometimes going back to the basics,” he concluded, “could be the most innovative strategy with tremendous impact.”
Seth A. Gross, MD, AGAF, is clinical chief in the Division of Gastroenterology & Hepatology at NYU Langone Health, and professor at the NYU Grossman School of Medicine, both in New York City. He reported no conflicts of interest.
In an editorial accompanying the study and comments to GI & Hepatology News, Dr. Seth A. Gross of NYU Langone Health urged gastroenterologists to reconsider the use of sterile water in endoscopy.
While the rationale for bottled water has centered on infection prevention, Gross argued that the evidence does not hold up, noting that this practice contradicts modern values around sustainability and evidence-based care.
The two relevant clinical studies comparing sterile versus tap water in endoscopy are almost 30 years old, he said, and neither detected an increased risk of infection with tap water, leading both to conclude that tap water is “safe and practical” for routine endoscopy.
Gross also pointed out the inconsistency of sterile water use in medical practice, noting that tap water is acceptable in procedures with higher infection risk than endoscopy.
“Lastly,” he added, “most people drink tap water and not sterile water on a daily basis without outbreaks of gastroenteritis from bacterial infections.”
Gross’s comments went beyond the data to emphasize the obvious but overlooked environmental impacts of sterile water bottles. He suggested several challenging suggestions to make medicine more ecofriendly, like reducing travel to conferences, increasing the availability of telehealth, and choosing reusable devices over disposables.
But “what’s hiding in plain sight,” he said, “is our use of sterile water.”
While acknowledging that some patients, like those who are immunocompromised, might still warrant sterile water, Gross supported the review’s recommendation to use tap water instead. He called on GI societies and regulatory bodies to re-examine current policy and pursue updated guidance.
“Sometimes going back to the basics,” he concluded, “could be the most innovative strategy with tremendous impact.”
Seth A. Gross, MD, AGAF, is clinical chief in the Division of Gastroenterology & Hepatology at NYU Langone Health, and professor at the NYU Grossman School of Medicine, both in New York City. He reported no conflicts of interest.
In an editorial accompanying the study and comments to GI & Hepatology News, Dr. Seth A. Gross of NYU Langone Health urged gastroenterologists to reconsider the use of sterile water in endoscopy.
While the rationale for bottled water has centered on infection prevention, Gross argued that the evidence does not hold up, noting that this practice contradicts modern values around sustainability and evidence-based care.
The two relevant clinical studies comparing sterile versus tap water in endoscopy are almost 30 years old, he said, and neither detected an increased risk of infection with tap water, leading both to conclude that tap water is “safe and practical” for routine endoscopy.
Gross also pointed out the inconsistency of sterile water use in medical practice, noting that tap water is acceptable in procedures with higher infection risk than endoscopy.
“Lastly,” he added, “most people drink tap water and not sterile water on a daily basis without outbreaks of gastroenteritis from bacterial infections.”
Gross’s comments went beyond the data to emphasize the obvious but overlooked environmental impacts of sterile water bottles. He suggested several challenging suggestions to make medicine more ecofriendly, like reducing travel to conferences, increasing the availability of telehealth, and choosing reusable devices over disposables.
But “what’s hiding in plain sight,” he said, “is our use of sterile water.”
While acknowledging that some patients, like those who are immunocompromised, might still warrant sterile water, Gross supported the review’s recommendation to use tap water instead. He called on GI societies and regulatory bodies to re-examine current policy and pursue updated guidance.
“Sometimes going back to the basics,” he concluded, “could be the most innovative strategy with tremendous impact.”
Seth A. Gross, MD, AGAF, is clinical chief in the Division of Gastroenterology & Hepatology at NYU Langone Health, and professor at the NYU Grossman School of Medicine, both in New York City. He reported no conflicts of interest.
Like diners saving on drinks,
“No direct evidence supports the recommendation and widespread use of sterile water during gastrointestinal endosco-py procedures,” lead author Deepak Agrawal, MD, chief of gastroenterology & hepatology at the Dell Medical School, University Texas at Austin, and colleagues, wrote in Gastro Hep Advances. “Guidelines recommending sterile water during endoscopy are based on limited evidence and mostly expert opinions.”
After reviewing the literature back to 1975, Dr. Agrawal and colleagues considered the use of sterile water in endoscopy via three frameworks: medical evidence and guidelines, environmental and broader health effects, and financial costs.
Only 2 studies – both from the 1990s – directly compared sterile and tap water use in endoscopy. Neither showed an increased risk of infection from tap water. In fact, some cultures from allegedly sterile water bottles grew pathogenic bacteria, while no patient complications were reported in either study.
“The recommendations for sterile water contradict observations in other medical care scenarios, for example, for the irrigation of open wounds,” Dr. Agrawal and colleagues noted. “Similarly, there is no benefit in using sterile water for enteral feeds in immunosuppressed patients, and tap water enemas are routinely acceptable for colon cleansing before sigmoidoscopies in all patients, irrespective of immune status.”
Current guidelines, including the 2021 US multisociety guideline on reprocessing flexible GI endoscopes and accessories, recommend sterile water for procedures involving mucosal penetration but acknowledge low-quality supporting evidence. These recommendations are based on outdated studies, some unrelated to GI endoscopy, Dr. Agrawal and colleagues pointed out, and rely heavily on cross-referenced opinion statements rather than clinical data.
They went on to suggest a concerning possibility: all those plastic bottles may actually cause more health problems than prevent them. The review estimates that the production and transportation of sterile water bottles contributes over 6,000 metric tons of emissions per year from US endoscopy units alone. What’s more, as discarded bottles break down, they release greenhouse gases and microplastics, the latter of which have been linked to cardiovascular disease, inflammatory bowel disease, and endocrine disruption.
Dr. Agrawal and colleagues also underscored the financial toxicity of sterile water bottles. Considering a 1-liter bottle of sterile water costs $3-10, an endoscopy unit performing 30 procedures per day spends approximately $1,000-3,000 per month on bottled water alone. Scaled nationally, the routine use of sterile water costs tens of millions of dollars each year, not counting indirect expenses associated with stocking and waste disposal.
Considering the dubious clinical upside against the apparent environmental and financial downsides, Dr. Agrawal and colleagues urged endoscopy units to rethink routine sterile water use.
They proposed a pragmatic model: start the day with a new sterile or reusable bottle, refill with tap water for subsequent cases, and recycle the bottle at day’s end. Institutions should ensure their tap water meets safety standards, they added, such as those outlined in the Joint Commission’s 2022 R3 Report on standards for water management.
Dr. Agrawal and colleagues also called on GI societies to revise existing guidance to reflect today’s clinical and environmental realities. Until strong evidence supports the need for sterile water, they wrote, the smarter, safer, and more sustainable option may be simply turning on the tap.
The investigators disclosed relationships with Guardant, Exact Sciences, Freenome, and others.
Like diners saving on drinks,
“No direct evidence supports the recommendation and widespread use of sterile water during gastrointestinal endosco-py procedures,” lead author Deepak Agrawal, MD, chief of gastroenterology & hepatology at the Dell Medical School, University Texas at Austin, and colleagues, wrote in Gastro Hep Advances. “Guidelines recommending sterile water during endoscopy are based on limited evidence and mostly expert opinions.”
After reviewing the literature back to 1975, Dr. Agrawal and colleagues considered the use of sterile water in endoscopy via three frameworks: medical evidence and guidelines, environmental and broader health effects, and financial costs.
Only 2 studies – both from the 1990s – directly compared sterile and tap water use in endoscopy. Neither showed an increased risk of infection from tap water. In fact, some cultures from allegedly sterile water bottles grew pathogenic bacteria, while no patient complications were reported in either study.
“The recommendations for sterile water contradict observations in other medical care scenarios, for example, for the irrigation of open wounds,” Dr. Agrawal and colleagues noted. “Similarly, there is no benefit in using sterile water for enteral feeds in immunosuppressed patients, and tap water enemas are routinely acceptable for colon cleansing before sigmoidoscopies in all patients, irrespective of immune status.”
Current guidelines, including the 2021 US multisociety guideline on reprocessing flexible GI endoscopes and accessories, recommend sterile water for procedures involving mucosal penetration but acknowledge low-quality supporting evidence. These recommendations are based on outdated studies, some unrelated to GI endoscopy, Dr. Agrawal and colleagues pointed out, and rely heavily on cross-referenced opinion statements rather than clinical data.
They went on to suggest a concerning possibility: all those plastic bottles may actually cause more health problems than prevent them. The review estimates that the production and transportation of sterile water bottles contributes over 6,000 metric tons of emissions per year from US endoscopy units alone. What’s more, as discarded bottles break down, they release greenhouse gases and microplastics, the latter of which have been linked to cardiovascular disease, inflammatory bowel disease, and endocrine disruption.
Dr. Agrawal and colleagues also underscored the financial toxicity of sterile water bottles. Considering a 1-liter bottle of sterile water costs $3-10, an endoscopy unit performing 30 procedures per day spends approximately $1,000-3,000 per month on bottled water alone. Scaled nationally, the routine use of sterile water costs tens of millions of dollars each year, not counting indirect expenses associated with stocking and waste disposal.
Considering the dubious clinical upside against the apparent environmental and financial downsides, Dr. Agrawal and colleagues urged endoscopy units to rethink routine sterile water use.
They proposed a pragmatic model: start the day with a new sterile or reusable bottle, refill with tap water for subsequent cases, and recycle the bottle at day’s end. Institutions should ensure their tap water meets safety standards, they added, such as those outlined in the Joint Commission’s 2022 R3 Report on standards for water management.
Dr. Agrawal and colleagues also called on GI societies to revise existing guidance to reflect today’s clinical and environmental realities. Until strong evidence supports the need for sterile water, they wrote, the smarter, safer, and more sustainable option may be simply turning on the tap.
The investigators disclosed relationships with Guardant, Exact Sciences, Freenome, and others.
FROM GASTRO HEP ADVANCES