As a gastroenterologist in full-time clinical practice, I perform colonoscopies. In my over 20 years of practice, I have performed more than 10,000 colonoscopies (I stopped counting long ago). I have prescribed many different colonoscopy preparations (aka colonoscopy prep or prep) from the 4-liter solutions (e.g. GoLytely) on through the current low-volume, split-dosing solutions (e.g. SuPrep). I no longer prescribe anything other than the low volume split-dosing prep solutions. I have seen almost all pathological findings one can possibly diagnose from polyps, to cancer, to colitis, etc. I also have a very good understanding of how a patient can best prepare for a colonoscopy. I would like to share my pre-colonoscopy checklist that I give to my patients—that is, what a patient needs to know and do to best prepare for this life-saving, important procedure.
I want to first suggest that you use my checklist in conjunction with what your gastroenterologist has prescribed for you. Please do not replace anything that I suggest with what your gastroenterologist has recommended without discussing this with your gastroenterologist or his/her staff. This information should complement the information provided by your gastroenterologist.
In terms of colonoscopy preps, it is considered the standard of care to ‘split’ the prep solution. What is meant by this is that you should drink part of the prep solution on the day prior to the colonoscopy and the remainder of the prep solution about 5 hours from the scheduled time of your colonoscopy. Most gastroenterologists will have their patients drink half of the prep solution on the day prior to the colonoscopy and the other half 5 hours prior to the scheduled time of the colonoscopy—this is what I prescribe for my patients. Some gastroenterologists will prescribe the 4-liter preps and have the patient drink ¾ of the prep on the day prior to the colonoscopy and the other ¼ on the day of the colonoscopy, typically 5 hours prior to the scheduled time of the colonoscopy. It is no longer considered acceptable for a patient to consume the entire prep on the day prior to the colonoscopy. While this may seem to be a convenience for the patient, this is actually a compromising disservice because it leads to an inferior cleansing of the colon. In this situation, polyps can be missed especially polyps in the beginning part of the colon (right colon or ascending colon or proximal colon). These proximal colon polyps are often flat and have the highest potential to either be malignant (cancerous) or become malignant. Examples of these types of polyps include the sessile serrated adenomas. When the prep solution is prescribed in split-dosing, the second dose rinses the bile and mucous that accumulates overnight. When you do not split the prep dose, this greenish-yellow sticky film of bile and mucous adheres to the colon lining and hides these polyps. There is essentially no reason not to use split-dose preps. The other part of the prep process is to consume only clear liquids for 24-hours prior to the scheduled time of your colonoscopy. On a prior blog post I discuss what is considered a clear liquid (gummy bears are a clear liquid!). You will likely want to stock up on clear liquids for this day of reckoning.
It is important that your gastroenterologist be aware of any underlying medication allergy and medical problem(s) that you have and every medication and supplement that you take. It is vitally important that your gastroenterologist know about any blood thinning medication that you take. It might be necessary for you to stop a blood thinning medication a day or more prior to the colonoscopy to avoid any bleeding risk in case a biopsy needs to be obtained or a polyp removed. If you have diabetes, your gastroenterologist may have you adjust your diabetic medications. If you have sleep apnea or are obese (body mass index or BMI > 35), you should notify your gastroenterologist.
Your gastroenterologist may want to see you in the office for a pre-colonoscopy visit. In my practice, I do not find this to be necessary in most cases. It comes down to the preference and comfort level of the gastroenterologist. I review a patient’s chart prior to scheduling a colonoscopy and will direct those patients with a complicated medical history to have a pre-colonoscopy visit.
You will receive a sedative medication for the colonoscopy. This will either be Propofol or a combination of a narcotic and a valium-like medication (usually Versed). Propofol is typically administered by an anesthesiologist or a nurse anesthetist. The gastroenterologist typically administers the narcotic and valium-like medication without the assistance of an anesthesiologist or nurse anesthetist. Regardless of the type of sedative medication you receive, you will not be allowed to drive for the remainder of the day. Therefore, a responsible adult will need to accompany you home. Don’t forget to have this person’s phone number to give to the endoscopy center staff in case they need to be contacted to pick you up earlier or later than expected. You may feel completely well and feel like you can drive after the procedure. Don’t! One’s hand-eye coordination will likely be impaired for hours after the procedure. You should also not ride a bike, use an exercise machine, etc. The day following the colonoscopy should be fine to resume all of these activities.
You should dress comfortably on the day of the colonoscopy. I think a cotton t-shirt, sweat pants, socks, and shoes that easily slip on and off are fine. Do not wear jewelry because you will likely be asked to remove the jewelry. Do not wear nail polish as this may interfere with the finger probe that monitors your oxygen level. Do not apply skin lotion to the chest, arms or legs as this may interfere with the EKG lead pads adhering to your skin.
After the colonoscopy, it is important that you understand the results of the colonoscopy and also when you will need your next colonoscopy. Your gastroenterologist may speak with you in the recovery area to review the results or may delegate this to a discharge nurse. You may or may not have a follow up office visit as every gastroenterologist handles this differently. If a biopsy is obtained or a polyp removed, some type of follow up needs to occur. This may take the shape of a phone call from your gastroenterologist or a staff member, a follow up office visit, or a letter summarizing the findings. Just make sure that you understand the findings/results and what this may mean in terms of any treatment if necessary, and when you are due for your next colonoscopy.
You will likely be asked by the endoscopy center staff if you have an Advanced Medical Directive. This is a document explaining what you would like to have done in the case of an emergency. A colonoscopy is an extremely safe procedure and likelihood of an untoward event is very low. Nevertheless, this is an opportunity to put together such a document if you have not done so already.
Typically, patients are at the endoscopy center for about a total of 2 hours which includes checking in, filling out any paperwork, undergoing the colonoscopy, and recovery. Sometimes delays occur and I would suggest bringing reading material or your smart phone (to access emails, reading material or listen to music).
Lastly, it is likely that you will be provided with a post-colonoscopy survey to provide feedback for your doctor and the endoscopy center and staff. This feedback is important.
In summary, here is the checklist:
- You should be using a split-dose prep solution
- Diet restricted to clear liquids for 24-hours prior to the colonoscopy
- Notify your gastroenterologist of allergies, medical problems, and medications especially blood thinners
- Responsible adult to accompany you home
- Dress comfortably. No nail polish or skin lotion
- Understand the results/findings and when you are due for your next colonoscopy
- Provide an Advanced Medical Directive
- Bring reading material or a smart phone
- Fill out the post-procedure survey
Here’s to your colon health!
Frank Farrell, MD, MPH, AGAF