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Sunday, December 2, 2007

Laxative Cleanout for Colonoscopy

Laxative Preparation for Colonoscopy

Note: The Colonoscopy Chronicles attempts to provide information that is as accurate as possible. It is not intended as medical advice. You should consult your personal physician regarding your own medical condition

In order to do a colonoscopy properly, the colon has to be completely clear of stool. This means that prior to the procedure, the patient has to take some sort of laxative preparation to cleanse the colon. As a general rule, this is the part of the entire process of colonoscopy that patients hate the most! I can’t tell you how many times patients have told me,”The procedure was easy, it’s just that prep that was tough”.

There are a huge variety of laxative preparations that have been used over the years. Each has its pros and cons-and none are perfect. Unfortunately, many of them can cause cramps and nausea, and they can be just downright nasty tasting. Some seem less effective than others and can leave some residual stool in the colon, which limits the effectiveness of the test. Others can lead to dehydration and electrolyte (sodium, potassium) abnormalities that can be dangerous. Some have even been associated with severe kidney damage.

I am not going to give you a comprehensive review of every colonoscopy prep available. But I will speak from personal experience about the ones I have prescribed in the in the past and the ones I currently use.

PEG Preps

There are a number of PEG preps on the market. The common denominator here is that the active ingredient is PEG(polyethylene glycol). PEG is a molecule that helps draw water into the lining of the intestine, which then flushes the intestinal contents out. These laxative preps also contain extra sodium and potassium to replace that which is often lost in this process. The PEG solutions are appealing for their safety, and effectiveness. They are of particular importance in patients with kidney failure or heart failure. Other types of preps may cause fluid and electrolyte disturbance that are particularly harmful in these conditions, whereas the PEG preps have much less chance of doing so. The downside of these solutions is that they taste lousy. They have a somewhat salty, sweet taste that can get on your nerves, especially when you have to drink such a large amount of it. Even though there are flavoring packets available for many of the solutions, they are still not particularly pleasant.

Despite these imperfections, I believe that PEG preps are generally the best currently available, and I recommend them for almost all my patients undergoing colonoscopy.

I’ll briefly review some of the PEG solutions available. The original PEG preps consisted of a four liter solution(almost 1 gallon). There are several of these that are still available, and are in common use today. These include: Golytely, Colyte, and NuLytely. The main advantage of the 4 liter solutions is price:they are about half the price of the 2 liter solutions. These cost in the $25-30 range.

Due to the fact that many people have trouble consuming 4 liters of a PEG solution over 4 hours, lower volume PEG solutions were developed. These include HalfLytely and MoviPrep. The HalfLytley involved taking two laxative pills followed by 2 liters of PEG solution. The MoviPrep consists of a one liter solution of PEG which is repeated as few hours later. The main disadvantage of these preps is the pricing, which is in the $50-60 range.

I have prescribed almost all of the above preps. I think that they are all basically safe and effective. Since the 2 liter solutions are easier to take, I favor them if the patient is willing and able to afford the additional cost. Of the two liter preps, I favor MoviPrep, since the dulcolax tablets in the HalfLytely can cause additional cramping. However, in fairness to the manufacturers of HalfLytley, at the time I was prescribing it, the recommended dose included 4 dulcolax tabs. This was recently changed to two, and I have not yet tried this new formulation-which was designed to reduce the crampiness.

Other Common Laxative Preps

While I generally do not use these preps, I will briefly discuss them.

Fleets Phosphosoda-This is a solution that has been around for many years, and is a fairly effective laxative. It became popular as a lower volume alternative to the 4 liter PEG solutions. Patients complained of its bad taste, and it could cause the usual cramps and nausea that the other preps caused. In 2006 the Food and Drug Administration reported that 21 cases of a rare form of kidney failure had been associated with this prep. Many physicians stopped using this form of prep following this report.

Pill Prep-The idea of replacing drinking up to a gallon of lousy tasting fluid with downing a few pills is very appealing. Unfortunately, there are several reasons why I don’t favor pill preps: 1) You need to take a large number of pills (32) 2)I find the cleanout to be less satisfactory than the PEG preps 3)The pills are made of essentially the same chemical contained in the Fleets Phosphosoda, and therefore may have the same potential for kidney damage

Odds and Ends

There are a million and one other ways to cleanse the colon, and I won’t get into every single one that is used. I will mention that your physician may recommend an enema(which is basically a small volume of liquid that is inserted into the rectum-designed to clear out the last few inches of the colon)-in addition to the laxatives you need to drink.

· Whatever prep you and your physician agree to use, make sure you understand the directions your physician gives you, and follow them carefully.
· Often the solution is more palatable if you chill it. Taking a bite or two of lemon sorbet in between drinking the PEG solution made it a little more tolerable.
· Remember, the better your cleanout, the better your physician can see inside your colon. This increases the chance of detecting abnormalities like polyps. So be an active partner in the process.

Remember, after you’ve finished your laxative cleanout-the worst is over!!

Next installment: Types of anesthesia used in colonoscopy

Thursday, November 22, 2007

Where to Have Your Colonoscopy-and Happy Thanksgiving!

Note: The Colonoscopy Chronicles attempts to provide information that is as accurate as possible. It is not intended as medical advice. You should consult your personal physician regarding your own medical condition.

In our last post, we discussed who should perform your colonoscopy. As promised, we’ll now cover where you should have it done.

Your basic options are as follows:

Hospital Endoscopy Department
Ambulatory Surgery Center(ASC)
Physicians Office

So what’s your best bet? Sorry folks, this one is not as black and white as who should do your colonoscopy. You can have a safe, high quality experience at any of these three options. Here are a few factors to consider:

Safety: This is of utmost importance. Patients often have the perception that the hospital is “safer”. I don’t necessarily share this view. Certainly, the hospital has far more resources to care for acutely ill patients. The main “seconds to minutes” emergency that can result from colonoscopy is that of respiratory depression. This means decreased breathing, and drop in the blood oxygen level, related to the anesthesia. The key here is that the staff at the center where the procedure is being done need to know how to manage this situation properly.

At my center, which is an ASC, our staff is trained in Advanced Cardiac Life Support(ACLS) and we have a certified anesthesiologist present, who is an expert in managing respiratory emergencies. When patients ask me”Isn’t is safer to do the procedure at the hospital”, I sort of chuckle to myself, because to my way of thinking, I’d rather have an anesthesiologist two feet away from the patient in case of an airway emergency-like we have in my office-as opposed to having them come over from a different section of the building –as is often the case in the hospital. Therefore, I feel that a colonoscopy in our office/ASC is certainly just as safe as colonoscopy in the hospital. But this is not necessarily the case in every ASC or office. It is quite reasonable to be sure that wherever procedure is performed that there are staff who are trained and experienced in handling airway/respiratory emergencies. You have every right to ask about this in advance of your procedure.

One additional way you can check on a facility is to see if it is accredited. There are several organizations that evaluate outpatient facilities. The most prominent of these organizations are JCAHO(The Joint Commision on Accreditation) and AAAHC(American Association of Ambulatory Surgery Centers). In order to be accredited, a center has to go through a rigorous evaluation. This is not a rubber stamp process. Our center is AAAHC accredited, and the process was very impressive. The AAAHC evaluated all of our policies and procedures, and did thorough on-site inspection of our facility.

Cost: Once you’re comfortable with the safety aspects of the center where you’re going to have your colonoscopy, make sure you check out the cost! Some insurance carriers will specify where you should have the procedure; if you don’t use their “preferred” facility, it might cost you an exorbitant amount of money-so check this out well in advance of the procedure.

If your health insurance plan allows you a choice of location, you may want to do some cost comparison. Fees involved in colonoscopy may include: 1)The professional fee of the physician performing the colonoscopy 2)The professional fee of the anesthesiologist-if there is one involved(sometimes the physician doing the colonoscopy gives the anesthesia, and does not involve an anesthesiologist) 3)The facility fee that the hospital/ASC/office charges 4)If any biopsies are performed, there is an additional professional fee and facility fee involved.

You are well within your rights to ask what the costs of any of the above charges will be. The center where the procedure is being done should certainly be able to tell you what their charges are for the facility fee. Hospitals are generally have the highest facility fees, but this is highly variable. Don’t be surprised if you get quizzical looks when you ask about the pricing, since most facilities aren’t used to having this question asked by patients!

Physician Preference: The most important component of the colonoscopy is the experience and proficiency of the physician performing it. Your physician may have a preference for where you have the procedure done. It certainly makes sense to have the colonoscopy done at the venue where the physician is comfortable with the environment. You are certainly entitled to ask the physician why he or she prefers a particular location. If you have a strong preference for another location, you should discuss it with your physician.

Have a Happy Thanksgiving!

Thursday, November 15, 2007

Who Should Do Your Colonoscopy?

Who Should Do Your Colonoscopy?

Note:While the information contained in The Colonoscopy Chronicles will be as accurate as possible, it is not intended as medical advice. You should consult your personal physician regarding your own medical issues.

Like most boomers-you want to research your procedure in advance. Logically, your first question may be:Who should do the procedure? In short, I would recommend a board-certified Gastroenterologist. This may seem like a bit of a “no-brainer”. After all, aren’t all colonoscopies performed by Gastroenterologists? No! We’ll talk later about what other physicians do colonoscopy.

The vast majority of colonoscopies in the United States are performed by Gastroenterologists. A Gastroenterologist is a physician specifically trained in the field of digestive diseases. The training generally consists of a four-year college program, followed by a four-year medical school, then a three year internship/residency in Internal Medicine, and finally a fellowship in Gastroenterology-usually for three years. During this fellowship, trainees learn in depth about digestive disorders, and also learn to perform endoscopic procedures-including colonoscopy.

Most physicians who complete their training in Gastroenterology become board-certified under the auspices of the American Board of Internal Medicine. Board certification in Gastroenterology means the physician has 1)completed an accredited training program in Internal Medicine, then passed the Internal Medicine Board Exam 2)completed an accredited training program in Gastroenterology, then passed the Gastroenterology Board Exam.

If colonoscopy is not performed by a Gastroenterologists, it would most likely be done by a surgeon or primary care physician-such as an Internist or Family Medicine specialist. It is relatively uncommon for primary care physicians to perform colonoscopy, but in some parts of the country that are underserved by Gastroenterologists, primary care physicians have learned to do the procedure out of necessity.

· Is it necessary for your physician to be a Gastroenterologist in order to perform your colonoscopy?
o No-but studies have shown that colonoscopies performed by non-gastroenterologists are five times more likely to miss colorectal cancer.

· Is it necessary for your Gastroenterologist to be Board Certified?
o No-but it indicates that they have met certain well accepted standards of training.

Comment: Gastroenterologists are generally your best bet-they have generally have the most extensive training and experience with colonoscopy. There are certainly many surgeons and primary care physicians who are well-trained, and highly competent.

I liken it to pitchers in major league baseball. They are generally all amazing athletes, and most of them were well-training in batting at one time, and most were excellent hitters in high school, or even college. However, since they specialize in pitching, they don’t have as many at bats as the position players, and don’t have as much time to take batting practice. Therefore, they generally are not as good hitters as the position players.

Make sure the physician performing your colonoscopy does them frequently. Most Gastroenterologists have performed thousands of colonoscopies. Make sure that their success rates and complication rates meet certain standards.
The success rate(measured by the frequency with which the physician is able to examine the entire colon) should be over 90%. It should be even higher(over 95%) for screening colonoscopies.
The physician’s track record for complications is another measure of competence. The rate of perforation should be lower than 1 in 500 cases-many experts have rates less than 1 in 1000.

Next….Where should you have your colonoscopy?

Monday, October 29, 2007

Welcome to the Colonoscopy Chronicles

Welcome to The Colonoscopy Chronicles-The Baby Boomers Underground Guide to Colonoscopy!

My goal is to entertain, inform, and most importantly to reduce the ridiculous number of deaths from colorectal cancer in America. While the information contained in The Colonoscopy Chronicles will be as accurate as possible, it is not intended as medical advice. You should consult your personal physician regarding your own medical issues.

Let's face it, us boomers are a different breed. We are the generation that won't accept ageing without a fight. When arthritis hampers our running regimen-do we give up running? No! We replace the joint! Unlike our parents' generation, we are more health-conscious. We are into better nutrition, more physical fitness, and we are sold on preventative health measures. We are more savvy about issues that affect our health, and when we see the doctor, we are far more informed than our predecessors.

So, we've all already had our screening colonoscopies at age fifty-right?

Ahh, just as I suspected! Many of you have managed to evade your initial screening colonoscopy. Kudos to those who have already done it. By walking you through the process, I hope to demystify the experience of the colonoscopy.

We'll keep it accurate and up-to-date,yet easy to understand, and hopefully add a little humor to the process! The Chronicles will discuss what's really on your mind, but what you may feel uncomfortable asking your physician.

Topics will include:

  • Who should do your colonoscopy?
  • Where should the procedure be done?
  • What is the best laxative prep?
  • What are the alternatives to colonoscopy?
  • What type of anesthetic is best?
  • How often should the procedure be done?
  • What are the possible complications?
  • What should I expect the day of the exam?

These topics will be presented from the standpoint of a physician who is in your age group, has performed over 15,000 colonoscopies, and who-incidentally-has had a colonoscopy himself!

I look forward to sharing the Chronicles with you.

Doctor Mike