Colonoscopy Ps and Qs

By Dr. March Seabrook, Gastroenterologist, SCMA Board Member

March is known for being "National Colorectal Cancer Awareness Month". Dr. March Seabrook, a gastroenterologist and an advocate for early screening and prevention, shares with us the "Colonoscopy Ps and Qs".

There are several things that everyone should know before having a colonoscopy. I call this the Colonoscopy Ps and Qs.

Patient Selection – Colorectal screening is generally recommended for everyone over the age of 50.  However, it is important to discuss this with your physician because all patients are different and though colonoscopy may be the preferred strategy, perhaps it may not be the appropriate test for you.  It is best to talk to the physician performing the procedure to go over your medical history as that may affect your preparation, where the procedure is to be performed and the type of sedation.  Colonoscopy is NOT just a simple test.  

Physician – Who is actually performing the procedure?  A gastroenterologist clearly has the most training and experience.  Many gastroenterologists have at least three years of advanced training and perform well over 1000 colonoscopies per year.  This is what they do every day.  The physician performing your colonoscopy may not be a gastroenterologist.  Make sure you know their training and experience.  Also find out if they are credentialed to perform this and other procedures at the local hospital. 

Preparation – Most will say this is the worst part of the entire procedure.  Yes, you do have to get “cleaned out.”  It is critical to the quality of the procedure that the colon is well prepped.  There are a number of effective preps and the one that is chosen may be determined by your specific medical situation.  None of the preps are particularly pleasant.  However, going though this is probably better than having surgery or receiving chemotherapy.

Proper Facility – The majority of these procedures can be performed in convenient outpatient endoscopy centers.  The entire experience usually takes no more than a couple of hours. Make sure the facility is certified and accredited.  However, there may be reason that your physician believes it should be performed in the hospital based on other medical factors.  The cost at an endoscopy center is usually substantially less than a hospital.  When you come in for your procedure, a nurse will get you ready for the procedure and place an IV.  During the procedure you will be on your left side in somewhat of a fetal position. The procedure usually takes approximately 20 minutes to perform.  After the colonoscopy you will spend about 30 minutes in the recovery area depending on the sedation.   There will be some restrictions about activities for the rest of the day and perhaps some restrictions for medications (especially blood thinners) and other activities if polyps are removed. 

Proper Sedation – Your comfort is important and sedation is a critical part of the procedure.  With proper sedation you should remember virtually nothing about the examination.  There are two major forms of sedation.  First, patients may receive a combination of drugs (usually Demerol and Versed) and this is called conscious sedation.  It works well but wears off slowly. The patient is not totally asleep, but doesn’t have any memory of the procedure.  A small percentage of people are difficult to sedate with these drugs primarily because of other medications they may be taking.  Secondly, many patients are now sedated with Propofol (the “Michael Jackson drug”).  This drug works quickly and wears off quickly.  You are asleep with this medication.  Using this drug requires either an anesthesiologist or nurse anesthetist and does add a cost to the procedure.  Regardless of the type of sedation, you need to have someone responsible to take you home after the procedure.

Pathology – If polyps are removed or if biopsies are obtained for other reasons, they are sent for examination under the microscope. The lab and the pathologist play an important part in this process.  Most specimens are sent to local pathologists.  You should be notified of the results of any specimens sent for evaluation.  This usually takes a week or so.  Your doctor will generally be able to tell you if anything is very concerning just by examining the tissue at the time of the procedure.

Quality Follow up –  If you have an excellent prep and a complete colonoscopy and you have no polyps and no family history of colorectal cancer, you may not need another colonoscopy for up to 10 years (or maybe never depending on your age and other medical factors).  This is quite a powerful test compared to a mammogram, Pap smear, or prostate exam that is generally performed annually.  However, many people do have polyps.  It depends on the number, size, and type of polyps that will determine when a follow up colonoscopy is recommended.  For instance if you have one or two small adenomatous (considered precancerous) polyps, the recommendations would be to repeat the examination in five years.  If you have three or more or if you have larger or more “advanced” polyps, you may need a repeat examination in three years. 

Quality Monitoring – All physicians want to deliver the highest quality care that they can for their patients.  However, no one cares more about the patient than the patient.  Make sure your physician is qualified to perform the procedure.  Make sure the endoscopy center is certified and accredited.  As part of accreditation, the facility is engaged in various programs to assess patient satisfaction and quality improvement.  A quality program will also be monitoring and submitting their data to a national registry to compare their physicians to the rest of the country.  Some of the data that is being evaluated is how often a complete procedure (“cecal intubation”) is performed, the number of polyps identified and removed and the timing of a follow up evaluation.  One of the best ways to find a good physician in your area is to ask other patients or even better, ask someone that works in the hospital in the same area where the physician works.  They have the opportunity to see all of physicians and how they perform technically and how they interact with patients, families, and staff.  Be careful if you are only relying on the internet for information as the main reason to see a certain physician.

Like many aspects of medical treatment, the future of screening will be individualized to each person’s own set of circumstances. These personal characteristics will help us define who and how often and with what method that patient should be screened.  But for now, the best way to prevent (not treat or cure) colorectal cancer is to identify and remove precancerous polyps.