March is Colon Cancer Awareness month and with it fast approaching, it’s important to know the myths of getting a colonoscopy. Colonoscopy is a life-saving test to examine the colon (or large intestine) to screen for colon cancer and colon polyps. Colon cancer is the second leading cause of colon cancer deaths amongst non-smokers and is the most preventable cancer. Despite the fact that colonoscopy saves lives, only about 60% of people who should get the test actually do so. The reasons include lack of access to colonoscopy, primary providers not recommending the test, and fear of colonoscopy due to myths.
I was thinking about what topic to write about for my next blog post. I concluded that I should write about colonoscopy and try to dispel myths about this life-saving procedure. I did an online search to get an idea of what’s out there in the virtual world. I came across some useful information. However, I thought that I could add to the conversation by addressing the myths from a gastroenterologist’s perspective.
- The ‘Prep’ Is Horrible
Firstly, the purpose of a colonoscopy ‘prep’ is to cleanse the colon of all fecal matter so that at the time of the colonoscopy your colon is as clean as possible so that the smallest of polyps can be identified and removed. The stories of the horrible ‘prep’ stem mainly from the days when we would prescribe a gallon of cleansing ‘prep’ solution. Those days are gone, or at least they should be. Examples of the gallon ‘preps’ include GoLytely and NuLytely. Now there are several small volume ‘prep’ solutions available including SuPrep, Prepopik, and MoviPrep. These small volume ‘preps’ work because they are taken in split-dosing where one drinks half of the prescribed amount the day before the colonoscopy and then the other half on the morning of the colonoscopy. The cleansing results with these small volume ‘preps’ are excellent and there is no advantage of using the large volume preps. In fact, even when large volume ‘preps’ are given in split-dose, they don’t offer an advantage over the small volume ‘preps’ so why use them? Split-dose bowel ‘preps’ are the standard of care, whether you are prescribed a large volume or small volume ‘prep.’ The typical reason that larger volume preparations are prescribed is because of cost reasons. Some insurers will only cover the large volume preparations. The smaller volume ‘preps’ retail for about $75 and I think this would be money well spent if need be.Remember that in addition to the colon ‘prep’ you will need to drink clearliquids only for the 24-hour period prior to your colonoscopy. I instruct my patients that they can drink soft drinks, sports drinks, fruit juices, tea, soup broth, Jell-O or gelatin, popsicles, or Gummy Bears (see my blog about Gummy Bears).I also allow my patients to drink coffee as long as it is without milk or cream. I personally think a glass of wine, beer, or a cocktail is fine to take during this clear liquid period. Your gastroenterologist may feel otherwise and I would ask that you respect his/her instructions. It is important to avoid red or purple liquids as these colors might be confused with blood in the colon.
- The Colonoscopy Will Hurt
Colonoscopy should not hurt. OK, the only thing that might hurt is the intravenous needle that is inserted into your arm. Colonoscopy is typically performed with either of two types of intravenous sedative medications: conscious sedation or propofol.
Conscious sedation refers to the use of a benzodiazepine such as midazolam (Versed) along with a narcotic such as fentanyl (Sublimaze). The vast majority of patients do well with conscious sedation. However, patients who are taking narcotics, sleep medications, or anti-anxiety medications are often difficult to sedate with conscious sedation. It is often difficult to predict who will not do well with conscious sedation; that is, these patients will either require large dosages of the medications or who will simply not be able to be adequately sedated.The problems with conscious sedation have led to the increasing use of propofol (Diprivan). Don’t be frightened to learn that propofol is the drug that Michael Jackson was receiving. What happened to Michael was gross negligence and malpractice. When used properly, propofol is a wonder drug that is effective and safe. Propofol is typically administered by an anesthesiologist or nurse anesthesthetist. Having another provider administer the propofol allows the gastroenterologist to focus completely on the colonoscopy. With conscious sedation, the gastroenterologist administers the medications and has to monitor the patient’s vital signs in addition to focusing on the colonoscopy. Propofol guarantees that you will go to sleep. It is impossible to not be adequately sedated with Propofol. With propofol the patient typically wakes up very quickly after the colonoscopy and the overall recovery time is quicker than with conscious sedation. Moreover, unlike with conscious sedation, one does not have a ‘hangover’ feeling and post-procedure nausea is non-existent. Most patients wake up and describe having some of the best sleep they’ve ever had.I use only propofol in my practice and I can guarantee to my patients that they will not feel a thing during the colonoscopy.Some patients experience abdominal discomfort after a colonoscopy due to retained air. This really shouldn’t happen and typically results from the inadequate suctioning of air from the colon as the colonoscope is withdrawn. More often, we are using carbon dioxide (CO2) instead of air to insufflate (or fill the colon) to maximize visualization. Any residual carbon dioxide in the colon is absorbed and this helps to prevent abdominal pain and distention after a colonoscopy.
My last comment about this myth is that opting for a virtual colonoscopy because of the fear of pain makes no sense to me. As I’ve mentioned, a colonoscopy should not hurt. A virtual colonoscopy is a CT scan of the abdomen that is performed by a radiologist. The virtual colonoscopy reconstructs the colon in 3-dimensions (3-D). The problems with a virtual colonoscopy are several. Firstly, the virtual colonoscopy is not as accurate as a well-performed colonoscopy. Colonoscopy finds more polyps than a virtual colonoscopy. Secondly, a virtual colonoscopy is performed with a tube placed in through the anus to instill air or insufflate. Patients find this uncomfortable and the air that is insufflated can lead to pain. Sedation is not given for a virtual colonoscopy. Thirdly, you still have to drink a ‘prep’ solution. Lastly, if a polyp is found at virtual colonoscopy then you will be referred for a colonoscopy to have the polyp removed as a virtual colonoscopy does not allow the ability to remove polyps.
- I Won’t Be Able To Handle Not Eating For 24-Hours
I am surprised at the number of patients who actually don’t complain about being starved at the time of the colonoscopy. To be fair, some patients complain about being hungry and most can’t wait until that next meal. I think the reason most patients aren’t ravenously hungry is because in part the mind prepares you for the process. You want to have the best bowel ‘prep’ results and this requires following your physician’s instructions. Your brain and hunger center ‘get it’ and override your stomach’s stubbornness. Additionally, you will be encouraged to drink clear liquids which will help to satisfy your hunger. One’s hunger is satisfied in part by the distention of the intestines, which is accomplished with fluids. You can also eat semi-solid items such as Jell-O or Gummy Bears. Some tips to avoid the hunger assault are to avoid the smells and aromas of food and avoid watching those innumerable food commercials on TV. I suggest watching movies without commercials. Also, if you are someone who cannot survive without that morning cup of coffee, I am one who allows black coffee (without milk or cream). Suffice it to say, you likely will not be starving and you’ll be able to really cherish that next meal.
- A Colonoscopy Is Embarrassing
Gastroenterologists and the endoscopy center staff understand that a colonoscopy is a potentially embarrassing experience for patients. The entire staff makes the experience as ‘un-embarrassing’ as possible. This will take the form of undressing behind a curtain, being provided with blankets to stay warm and covered, and having the colonoscopy performed in a private endoscopy room. You will have your own recovery area—typically a bay where your gurney will be parked and you will be allowed to recover and get dressed. Remember that there will be other patients at the endoscopy center undergoing the same experience.
- There Could Be Complications
If you feel more comfortable with a male or female gastroenterologist, then you should make such a request.
The risks associated with colonoscopy are very rare. They include sedation-related complications, bleeding, and perforation (poking a hole in the colon). Sedation-related complications are rare especially when the sedation (propofol) is administered by an anesthesiologist. Bleeding is a very rare complication, occurring rarely after a large polyp is removed. For large polyps, often we place Hemoclips (small clips) over the polyp site to prevent bleeding. Perforation occurs about once every 2,000 to 5,000 procedures. Typically, the more experienced your gastroenterologist, the less likely perforation is to occur. Suffice it to say, complications are exceedingly rare. The benefits of undergoing a colonoscopy to prevent the second leading cause of cancer-related deaths far outweigh the small risks of complications.Most people have heard that the actress and comedian Joan Rivers died in an endoscopy center. What I have learned about this case I have read in the New York Times. Firstly, Joan Rivers did not die while she was undergoing a colonoscopy. She was undergoing an upper endoscopy to evaluate her upper GI tract. At some point during the endoscopy, a very odd thing happened in that an ENT specialist allegedly performed an examination of her vocal cords which led to a spasm of her vocal cords (laryngospasm). This led to a low oxygen state that led to her demise. This bizarre and tragic case has essentially nothing to do with undergoing a screening colonoscopy in an endoscopy center under typical circumstances. In my over 20 years of clinical practice, I have never heard of a case of laryngospasm involving an endoscopy or colonoscopy.
- Colonoscopy Should Be Performed in A Hospital Vs. An Endoscopy Center
For the typical patient undergoing a screening colonoscopy, there is no advantage to having a colonoscopy performed in a hospital setting. The cost of having a colonoscopy in a hospital is significantly higher than having it performed in an endoscopy center. Endoscopy centers are accredited just like hospital endoscopy centers. Safety is dependent primarily on the skills of the gastroenterologist and not on the location of the procedure. Endoscopy centers are equipped to handle every conceivable emergency. In my practice, I only perform an elective colonoscopy in the hospital for patients with severe underlying medical problems such as those on kidney dialysis, advanced heart disease, or have implanted cardiac defibrillators.
- You Don’t Need A Colonoscopy Until You Have Symptoms (‘I Can Wait’)
Absolutely not. The most common symptom of colon cancer is no symptom at all. The colon is a large diameter tube that can accommodate a large growth without you knowing it. That is why you can pass stool through your colon without your awareness until your rectum has accumulated enough stool to tell you it’s time to have a bowel movement. A colon cancer the size of a walnut can easily kill you. Every man and woman should have a colonoscopy beginning at age 50. If you have a family history of colon cancer, then you should have your first colonoscopy at an earlier age and should discuss this with your healthcare provider.
- I’ll Have To Stay In The Hospital
Not at all. Colonoscopy is a same-day procedure. The vast majority of colonoscopies are performed in an outpatient endoscopy center. Typically, the amount of time you spend at the endoscopy center is about two hours. This includes registering, changing into a gown (etc.), getting your IV started, undergoing the colonoscopy, and recovery time.
- I’ll Have To Take A Lot Of Time Off For Work
At most, you’ll miss two days which would include the day of preparation and the day of the colonoscopy. In my practice, most of my patients work on the day prior to the colonoscopy. They limit their diet to clear liquids and then drink the first bottle of ‘prep’ solution at about 5 p.m. If you can schedule your colonoscopy on a Monday, then you can prep on a Sunday. The day after the colonoscopy is normal in every way, shape and form. You can go back to work and resume your normal activities including exercise.
- I Can’t Afford The Colonoscopy
With the Affordable Care Act (Obamacare), it is now the law that your medical insurance company provides for a screening colonoscopy. Not having a colonoscopy and developing colon cancer is a lot more expensive.
Here’s to your colon health.
Frank Farrell, MD, MPH, AGAF