Colonoscopy

Colonoscopy is the endoscopic examination of the colon and the distal part of the small bowel with a CCD camera or a fiber optic camera on a flexible tube passed through the anus. It may provide a visual diagnosis (e.g. ulceration, polyps) and grants the opportunity for biopsy or removal of suspected lesions.

Virtual colonoscopy, which uses 2D and 3D imagery reconstructed from computed tomography (CT) scans or from nuclear magnetic resonance (MR) scans, is also possible, as a totally non-invasive medical test, although it is not standard and still under investigation regarding its diagnostic abilities. Furthermore, virtual colonoscopy does not allow for therapeutic maneuvers such as polyp/tumour removal or biopsy nor visualization of lesions smaller than 5 millimetres. If a growth or polyp is detected using CT colonography, a standard colonoscopy would still need to be performed.

Colonoscopy can remove polyps as small as one millimetre or less. Once polyps are removed, they can be studied with the aid of a microscope to determine if they are precancerous or not.

Colonoscopy is similar to but not the same as sigmoidoscopy, the difference being related to which parts of the colon each can examine. While colonoscopy allows an examination of the entire colon (measuring four to five feet in length), sigmoidoscopy allows doctors to view only the final two feet of the colon. A sigmoidoscopy is often used as a screening procedure for a full colonoscopy, in many instances in conjunction with a fecal occult blood test (FOBT), which can detect the formation of cancerous cells throughout the colon. Other times, a sigmoidoscopy is preferred to a full colonoscopy in patients having an active flare of ulcerative colitis or Crohn’s disease to avoid perforation of the colon. Additionally, surgeons have lately been using the term pouchoscopy to refer to a colonoscopy of the ileo-anal pouch.

Conditions that call for colonoscopies include gastrointestinal hemorrhage, unexplained changes in bowel habit and suspicion of malignancy. Colonoscopies are often used to diagnose colon cancer, but are also frequently used to diagnose inflammatory bowel disease. In older patients (sometimes even younger ones) an unexplained drop in hematocrit (one sign of anemia) is an indication that calls for a colonoscopy, usually along with an esophagogastroduodenoscopy (EGD), even if no obvious blood has been seen in the stool (feces).

Fecal occult blood is a quick test which can be done to test for microscopic traces of blood in the stool. A positive test is almost always an indication to do a colonoscopy. In most cases the positive result is just due to hemorrhoids; however, it can also be due to diverticulosis, inflammatory bowel disease (Crohn’s disease, ulcerative colitis), colon cancer, or polyps. However—since its development by Dr. Hiromi Shinya and Dr. William I. Wolff in the 1960s–polypectomy has become a routine part of colonoscopy, allowing for quick and simple removal of polyps without invasive surgery.

Due to the high mortality associated with colon cancer and the high effectivity and low risks associated with colonoscopy, it is now becoming a routine screening test for people 50 years of age or older. Subsequent rescreenings are then scheduled based on the initial results found, with a five- or ten-year recall being common for colonoscopies that produce normal results. Patients with a family history of colon cancer are often first screened during their teenage years.

A study published in the New England Journal of Medicine (September 18, 2008) has found that among people who have had an initial colonoscopy that found no polyps, the risk of developing colorectal cancer within five years is extremely low. Therefore, there is no need for those people to have another colonoscopy sooner than five years after the first screening.

The colon must be free of solid matter for the test to be performed properly. For one to three days, the patient is required to follow a low fiber or clear-liquid only diet. Examples of clear fluids are apple juice, chicken and/or beef broth or bouillon, lemon-lime soda, lemonade, sports drink, and water. It is very important that the patient remain hydrated. Orange juice, prune juice, and milk containing fibre should not be consumed, nor should liquids dyed red, purple, orange, or sometimes brown; however, cola is allowed. In most cases, tea (no milk) or black coffee (no milk) are allowed.

The day before the colonoscopy, the patient is either given a laxative preparation (such as Bisacodyl, phospho soda, sodium picosulfate, or sodium phosphate and/or magnesium citrate) and large quantities of fluid, or whole bowel irrigation is performed using a solution of polyethylene glycol and electrolytes. Often, the procedure involves both a pill-form laxative and a bowel irrigation preparation with the polyethylene glycol powder dissolved into any clear liquid, preferably a sports drink which contain electrolytes.

In this case, a typical procedure regimen then would be as follows: in the morning of the day before the procedure, a 238 mg bottle of polyethylene glycol powder should be poured into 64 oz. of the chosen clear liquid, which then should be mixed and refrigerated. Two (2) bisacodyl 5 mg tablets are taken 3 pm; at 5 pm, the patient starts drinking the mixture (approx. 8 oz. each 15-30 min. until finished); at 8 pm, take two (2) bisacodyl 5 mg tablets; continue drinking/hydrating into the evening until bedtime with clear permitted fluids. A common brand name of bisacodyl is Ducolax, and store brands are available. A common brand name of polyethylene glycol powder is MiraLax. It may be advisable to schedule the procedure early on a given day so the patient need not go without food and only limited fluids the morning of the procedure on top of having to go through the foregoing preparation procedures the preceding day.

Since the goal of the preparation is to clear the colon of solid matter, the patient should plan to spend the day at home in comfortable surroundings with ready access to toilet facilities. The patient may also want to have at hand moist toilettes or a bidet for cleaning the anus. A soothing salve such as petroleum jelly applied after cleaning the anus will improve patient comfort.

The patient may be asked to skip aspirin and aspirin-like products such as salicylate, ibuprofen, and similar medications for up to ten days before the procedure to avoid the risk of bleeding if a polypectomy is performed during the procedure. A blood test may be performed before the procedure.

During the procedure the patient is often given sedation intravenously, employing agents such as fentanyl or midazolam. Although meperidine (Demerol) may be used as an alternative to fentanyl, the concern of seizures has relegated this agent to second choice for sedation behind the combination of fentanyl and midazolam. The average person will receive a combination of these two drugs, usually between 25 to 100 µg IV fentanyl and 1–4 mg IV midazolam. Sedation practices vary between practitioners and nations; in some clinics in Norway, sedation is rarely administered.

Some endoscopists are experimenting with, or routinely use, alternative or additional methods such as nitrous oxide and propofol, which have advantages and disadvantages relating to recovery time (particularly the duration of amnesia after the procedure is complete), patient experience, and the degree of supervision needed for safe administration. This sedation is called “twilight anesthesia.” For some patients it is not fully effective, so they are indeed awake for the procedure and can watch the inside of their colon on the colour monitor. Substituting propofol for midazolam, which gives the patient quicker recovery, is gaining wider use, but requires closer monitoring of respiration.

A meta-analysis found that playing music improves patient tolerability of the procedure.

The first step is usually a digital rectal examination, to examine the tone of the sphincter and to determine if preparation has been adequate. The endoscope is then passed through the anus up the rectum, the colon (sigmoid, descending, transverse and ascending colon, the cecum), and ultimately the terminal ileum. The endoscope has a movable tip and multiple channels for instrumentation, air, suction and light. The bowel is occasionally insufflated with air to maximize visibility. Biopsies are frequently taken for histology.

In most experienced hands, the endoscope is advanced to the junction of where the colon and small bowel join up (cecum) in under 10 minutes in 95% of cases. Due to tight turns and redundancy in areas of the colon that are not “fixed”, loops may form in which advancement of the endoscope creates a “bowing” effect that causes the tip to actually retract. These loops often result in discomfort due to stretching of the colon and its associated mesentery. Manoeuvres to “reduce” or remove the loop include pulling the endoscope backwards while torquing the instrument. Alternatively, body position changes and abdominal support from external hand pressure can often “straighten” the endoscope to allow the scope to move forward. In a minority of patients, looping is often cited as a cause for an incomplete examination. Usage of alternative instruments leading to completion of the examination has been investigated, including use of pediatric colonoscope, push enteroscope and upper GI endoscope variants.

For screening purposes, a closer visual inspection is then often performed upon withdrawal of the endoscope over the course of 20 to 25 minutes. Lawsuits over missed cancerous lesions have recently prompted some institutions to better document withdrawal time as rapid withdrawal times may be a source of potential medical legal liability. This is often a real concern in clinical settings where high caseloads could provide financial incentive to complete colonoscopies as quickly as possible.

Suspicious lesions may be cauterized, treated with laser light or cut with an electric wire for purposes of biopsy or complete removal polypectomy. Medication can be injected, e.g. to control bleeding lesions. On average, the procedure takes 20–30 minutes, depending on the indication and findings. With multiple polypectomies or biopsies, procedure times may be longer. As mentioned above, anatomic considerations may also affect procedure times.

After the procedure, some recovery time is usually allowed to let the sedative wear off. Outpatient recovery time can take an estimate of 30–60 minutes. Most facilities require that patients have a person with them to help them home afterwards (again, depending on the sedation method used).

One very common aftereffect from the procedure is a bout of flatulence and minor wind pain caused by air insufflation into the colon during the procedure.

An advantage of colonoscopy over x-ray imaging or other, less invasive tests, is the ability to perform therapeutic interventions during the test. A polyp is a growth of excess of tissue that can develop into cancer. If a polyp is found, for example, it can be removed by one of several techniques. A snare device can be placed around a polyp for removal. Even if the polyp is flat on the surface it can often be removed.

The pain associated with the procedure is not caused by the insertion of the scope but from inflating of the colon in order to do the inspection. The scope is basically a long, flexible tube about a centimeter in diameter, that is, roughly as big around as your little finger. This is less than the diameter of an average stool so just as there is normally no pain from the daily passage of food inside your colon , there should be no pain from a normal insertion.

The colon is wrinkled and corrugated like an accordion, or a clothes-dryer exhaust tube. This gives it the large surface area needed for digestion. But in order to inspect this surface, the doctor must blow it up like a balloon, to get the creases out. This is done using a powered air compressor a lot like the one used to inflate a car’s tires.

Your stomach, intestines and colon have a “second brain” wrapped around them. This “second brain” has at least sensor nerves, decision processes, and motor nerves, so that it runs the chemical factory of your digestion completely by itself, without your having to think about it. It uses 95% of all serotonin in the body. And it uses other complex hormone signals and nerve signals to communicate with your brain and the rest of your body.

Normally a colon’s job is to digest food, and to detect when you get sick. Harmful bacteria in rancid food create unexpected gas. So your colon has distension sensors that can tell when there is unexpected gas pushing the colon walls out. Then your “second brain” tells you to feel sick–you are having intestinal difficulties. In the case of bad food, you would stop moving around. You would sit groaning in the bathroom until your body eliminated the food. This is why doctors often recommend a total anesthesia or a partial “twilight” sedative to lessen your brain’s awareness of the pain.

Once your colon has been inflated, the doctor inspects it with the scope on the way out, as it is slowly pulled backwards. If any polyps are found, they can be cut out at this point.

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