How to use it
Score each of the three segments after you have washed and suctioned, as you withdraw. Score what you could see once cleaning was done, not how the colon looked on the way in.
| Segment | Includes |
|---|---|
| Right colon | Cecum and ascending colon |
| Transverse colon | Hepatic flexure, transverse colon and splenic flexure |
| Left colon | Descending colon, sigmoid colon and rectum |
If you stopped because the preparation was too poor, score each segment you did not see as 0 (Lai 2009). If the exam was incomplete for another reason, such as a stricture or angulation, or the patient has had a colon resection, the total isn’t valid. Report the segment scores you have (Calderwood 2010).
Report the scores as segments plus total, for example “BBPS 2-3-2 = 7”.
Reading the result
| Result | What it means | Next step |
|---|---|---|
| Every segment 2 or 3 (total 6–9) | Adequate | Set the screening or surveillance interval from the findings (polyp surveillance tool) |
| Any segment 0 or 1, whatever the total | Inadequate | Repeat within 12 months for screening or surveillance; sooner (as soon as possible) after a positive FIT or with alarm symptoms |
Adequate means the exam was good enough to assign a standard screening or surveillance interval (USMSTF 2025). Segment scores of 2 and 3 miss adenomas over 5 mm at similar rates (about 5%). A segment scoring 1 misses about three times as many (15.9%; Clark 2016, back-to-back colonoscopies in 438 men).
Where guidelines differ
- Segment rule or total? USMSTF 2025 and the 2024 ACG/ASGE quality indicators call a preparation inadequate if any segment scores below 2. ESGE’s 2017 performance measures accept a total of 6 or more alone. So 3-3-0 (total 6) passes the ESGE definition but is inadequate by the US rule. This tool follows the stricter segment rule, which matches the missed-adenoma data.
- Repeat timing. ESGE 2019 says within 1 year. USMSTF 2025 says within 12 months for screening or surveillance, and sooner when the colonoscopy was for a positive FIT or another abnormal screening test, or for alarm symptoms. ESGE suggests a same-day or next-day repeat after extra preparation as an option (weak recommendation), and USMSTF notes that same-day measures such as enemas or more laxative can salvage the exam when feasible.
- Canada and Ontario. CAG (2012) and Cancer Care Ontario (2014) ask units to record preparation with a validated scale such as the BBPS. Neither sets a BBPS adequacy cut-off or a repeat interval. Ontario’s ColonCancerCheck surveillance intervals assume adequate preparation.
- Unit targets. Aim for adequate preparation in at least 90% of colonoscopies, for each endoscopist and each unit (USMSTF 2025; ACG/ASGE 2024; ESGE minimum standard 90%).
Pitfalls
- A total of 6 or more is not enough. 3-3-1 adds up to 7 but is inadequate.
- Don’t score before cleaning. The BBPS describes what you could see after washing and suctioning. A colon that cleared well with effort can score 3.
- “Fair” isn’t a result. If your report uses words like good, fair or poor, also say whether the preparation was adequate (USMSTF 2025).
- Don’t set a surveillance interval from an inadequate exam. Arrange the repeat first, then set the interval from the findings of the adequate exam.
- Prevention. Split-dose preparation, a low-fibre diet the day before and clear instructions all improve preparation. The patient guide Getting ready for a colonoscopy follows USMSTF 2025.