Prescription Medications for Constipation

It is not Colonoscopy Chronicles’ intention to provide specific medical advice to users of its blog, instead we provide users with information to help them better understand their health, diagnosed conditions, and the current approaches related to treatment, prevention, screening, and supportive care. Colonoscopy Chronicles urges users to consult with a qualified health care professional for diagnosis and answers to their personal medical questions.

Constipation is an incredibly common problem-by some estimates affecting 27% of the population. One review found that 63 million people in North America are affected. Definitions of constipation vary, but most include the criteria of less than 3 bowel movements per week.

Patients who see me in the office often- in addition to decreased bowel movement frequency-complain of hard stools, straining, of sensation of incomplete bowel movements.

While patients often self-medicate for constipation, it is wise to seek professional medical advice, since constipation can be the result of an underlying serious medical problem, and can even be a sign of colon cancer. When I see a patient with constipation, I generally review their dietary habits, review their medication list looking for medications that may be contributing to their constipation,  and perform a thorough physical exam. Depending on the situation, I may order blood tests looking for such issues as an underachieve thyroid-which can lead to constipation. I may also order x-ray studies, check for blood in the stool, or suggest a colonoscopy.

Once I have determined that the patient has "idiopathic" constipation-which basically means that there is no obvious underlying correctable cause( such as an underachieve thyroid, constipating medications, etc) I usually suggest some simple interventions-such as encouraging adequate dietary fiber, adequate fluid intake, and adequate physical activity-simple, natural measures that often work.

My next step is usually to consider Miralax(polyethylene glycol). This is a powder laxative, that is mixed with water. While it is not a "natural" substance, I believe it to be safe, and is generally effective. Some patients are able to take it on occasion "as needed", while others find that they need to use it on a regular basis.

If lifestyle changes and miralax are not getting the job done, I sometimes recommend a prescription laxative. The three prescription laxatives that I generally consider for my patients are: 1) Amitiza (lubiprostone) 2) Linzess(linaclotide) 3) Trulance (plecanitide)

Amitiza was approved by the Food and Drug Administration(FDA) in 2007. It is current FDA approved for the treatment of Chronic Idiopathic Constipation, Irritable Bowel Syndrome with Constipation, and Constipation Caused by Opioids. Nausea is the most common side effect of the medication-though there are other potential side effects that you should discuss with your doctor if this is prescribed to you. It is a twice per day medication. Nausea can be reduced by taking it with food and water.

Linzess was FDA approved in 2012. It is FDA approved for Chronic Idiopathic Constipation, and Irritable Bowel Syndrome with Constipation. Linzess is taken once daily. The most common side effect is diarrhea, though, again, there are other potential side effects that should be reviewed with the prescribing physician.

Finally, the most recent addition is Trulance, which was FDA approved in January of 2017. It is also a once daily product. It is FDA approved for Chronic Idiopathic Constipation. Like Linzess, the most common side effect is diarrhea.

I will share some thoughts on use of these medications from my experience with my patients. This is not intended as a comprehensive review of these products, nor should it be interpreted as specific advice. Every patient's situation is unique, and-as stated above-you should seek professional medical advice for your particular situation.

I feel that these medications are generally safe, generally well tolerated, and have a convenient dosing schedule. They don't work for everybody. On the other hand, sometimes they work too well! By that I mean that they can cause diarrhea. Sometimes the diarrhea can be severe, and even cause dangerous dehydration, requiring discontinuation of the medication. I usually caution patients to watch out for diarrhea, and even plan to stay close to their home for several days after starting the medication. Often times if diarrhea occurs initially, it may resolve after a few days. I encourage patients to "hang in there", drink plenty of fluids to stay hydrated, and if the initial diarrhea resolves, then they may be able to continue the medication. But, of course, if the diarrhea is severe or persistent the medication may need to be discontinued.

In addition to the above, it has been my experience that sometimes patients have an excellent response, but at some point lose the response and the medication stops working. My approach to those patients is usually to try another medication in place of the one that stopped working. However, at some point, I suggest re-starting the original medication, since often after a "drug holiday" the original medication may work once again. Other physicians may approach these medications differently.

While lifestyle and diet modifications are often adequate to treat constipation, the prescription products mentioned above have added significantly to our ability to help patients with constipation.

Peppermint Oil for IBS

It is not Colonoscopy Chronicles’ intention to provide specific medical advice to users of its blog, instead we provide users with information to help them better understand their health, diagnosed conditions, and the current approaches related to treatment, prevention, screening, and supportive care. Colonoscopy Chronicles urges users to consult with a qualified health care professional for diagnosis and answers to their personal medical questions.

Irritable Bowel Syndrome (IBS) is the most common gastrointestinal condition in America, affecting 15-20% of the adult population. The most common symptoms of IBS are abdominal pain, and changes in the bowel pattern,either constipation, diarrhea, or alternating constipation and diarrhea. Amazingly, our understanding of IBS is still very limited, and treatments have been less than satisfactory. 

While there have been several prescription drugs developed for IBS over the last several decades, these advances have been countered by the fact that several of the new medications that were released had to be withdrawn from the market due to safety concerns. This has left many patients searching for safer, more natural solutions for their IBS symptoms. Enter peppermint oil. Recognized for years as a remedy for digestive problems, peppermint oil seems to have found new life as a natural treatment for IBS.

There have been numerous scientific studies supporting the effectiveness of peppermint oil for pain and bowel dysfunction resulting from IBS. But what seems to have caused the renaissance in peppermint oil enthusiasm is the aggressive marketing of a new peppermint oil product-IBgard-by a company called IM Health Science. IBgard’s sleek packaging and marketing campaign seem to be working. But the product is not cheap. The directions say to take 1-2 capsules three times daily. A box of 48 capsules is $29.99. If you take 6 capsules a day, that box of 48 will last only 8 days.  While this seems a bit pricey, the good news is that there are other companies making similar products at a lower price point. For example, Pepogest by Nature’s Way costs $11.49 on the Walgreen’s website for a container of 60 capsules, which comes to a 20 days supply (if taken three times per day as directed).

Although it is a natural, and basically safe product, peppermint oil does have some safety issues. For example, due to the potential for decreased milk production, it should probably be used sparingly toward the end of pregnancy, and during breastfeeding. It is generally not advisable for children under seven. There is concern about causing low blood sugar in diabetics, and there has been a link to gallbladder inflammation. Finally, those with gastroesophageal reflux must be aware of the fact that peppermint oil can lower the pressure in the lower esophageal sphincter and cause aggravation of the acid reflux.

Despite these cautions, I am enthusiastic about the renewed interest in peppermint oil as an option for my IBS patients. I am hopeful that as our understanding about the underlying nature of IBS evolves, we will have more to offer our patients.

http://www.webmd.com/ibs/news/20081113/peppermint-oil-fiber-can-treat-ibs

https://umm.edu/health/medical/altmed/herb/peppermint

http://www.ncbi.nlm.nih.gov/pubmed/16121521

http://www.lalecheleague.org/nb/nbiss56-09p38.html

http://www.medicalnewstoday.com/articles/265214.php

Fecal DNA Testing: Passing Fancy or the Demise of Colonoscopy?

Fecal DNA Testing: Passing Fancy or the Demise of Colonoscopy?

For many years, there have been attempts to find easier and less expensive alternatives to colonoscopy as a means to screen for colorectal cancer. The stakes are quite high. There were an estimated 136,830 new cases of colorectal cancer in the United States in 2014, and 50,310 deaths from colorectal cancer in the same period.  The estimated 5 year survival is approximately 64.7%

As alarming as these statistics are, there has been a clear trend toward improvement since the advent of routine screening colonoscopy. Medicare began to pay for screening colonoscopies in “high risk” individuals in the 1980's and 1990’s and began coverage for average risk people in 2001.  Most analysts attribute the steady decrease in the rate of new cases and deaths from colorectal cancer to the more widespread acceptance of screening colonoscopy. In fact, it is estimated that if everyone age 50 (the recommended started point for most patients)and up were screened via colonoscopy, it would result in an 80% prevention of colon cancer, and a 60% reduction in deaths from colon cancer.

Despite these compelling facts, it is estimated that at least one in three Americans of the appropriate age(50-75)has not been tested for colorectal cancer, and therefore is needlessly at risk for this preventable problem. The reasons for this are multiple, and include inadequate public awareness, cost, inadequate access to medical resources, and fear of what some perceive to be an invasive medical procedure.

Current guidelines indicate that colonoscopy is the superior method for screening, since it effective for both early detection of colorectal cancer, as well as prevention(by detecting and removing pre-cancerous polyps). Average risk individuals are advised to have colonoscopy starting at age 50(45 for African Americans), then every 10 years if normal. For individuals who decline colonoscopy, yearly FIT(fecal immunochemical testing) is advised as an alternative.  This is a test that can detect tiny amounts of blood in the stool, which may indicate the presence of a colon tumor. While FIT is less invasive than colonoscopy(it involves submitting a scraping from a stool specimen), it is problematic in the sense that it is less likely to pick up cancers than colonoscopy, only detecting 79% of cancers.

To try and combat this lower rate of detection, researchers have combined the FIT test with a fecal DNA test, which can detect abnormal DNA in the stool, which has been shed by tumor cells in the colon.  The results were encouraging. The DNA test discovered 60 of the 65 cancers for an accuracy rate of approximately 92%.  The cost, according to Cologuard, by Exact Sciences Laboratories, is $599.

The role for fecal DNA testing remains to be seen. Like FIT, it is less likely to find colon cancers than colonoscopy. If it is utilized routinely to screen individuals, other issues such as the high false positive rate(meaning an abnormal stool test, when there is actually no tumor present), as well as the frequency with which such tests should be done, must be resolved.

Where does fecal DNA and FIT “fit” into my practice?(sorry-couldn’t help it!). I continue to recommend colonoscopy as the screening test of choice. It is hard for me to offer other tests as “first line”. Colonoscopy is the “gold standard” for accuracy, is well documented to save lives, and has withstood the test of time as en effective tool for detecting, and preventing colon cancer.

I offer fecal DNA testing and/or FIT as an alternate strategy for patients who refuse to undergo colonoscopy, or who-because of other serious medical conditions-may be poor candidates for colonoscopy. While cost and accuracy with fecal DNA testing remain a problem, it definitely represents an advance by offering another tool in the fight against colon cancer.

http://seer.cancer.gov/statfacts/html/colorect.html

http://content.healthaffairs.org/content/25/4/1153.full

http://www.hrsa.gov/quality/toolbox/measures/colorectalcancer/

http://www.cdc.gov/media/releases/2013/p1105-colorectal-cancer-screening.html

http://www.medscape.com/viewarticle/813850

http://gi.org/guideline/colorectal-cancer-screening/

http://www.cologuardtest.com/how-billing-works

Probiotics and Irritable Bowel Syndrome

It is not Colonoscopy Chronicles’ intention to provide specific medical advice to users of its blog, instead we provide users with information to help them better understand their health, diagnosed conditions, and the current approaches related to treatment, prevention, screening, and supportive care. Colonoscopy Chronicles urges users to consult with a qualified health care professional for diagnosis and answers to their personal medical questions.

Two topics that are very hot in the world of Gastroenterology are: 1) Probiotics 2) Irritable Bowel Syndrome. How are they related? Irritable Bowel Syndrome, while it is the most common Gastrointestinal problem in America, is still not well understood. It is what we call a functional disorder of the bowel, meaning that you cannot see it on x-ray, endoscopy, or biopsy. Rather than a structural issue, it is more a disorder of how the bowel functions. My own view is that Irritable Bowel Syndrome (IBS) is probably multiple different disorders that we lump together under one name, essentially because we don't know any better at this point.

If you accept my position that IBS is probably multiple different disorders rather than a single entity, then   it follows that there may be multiple different mechanisms for the various disorders. One such mechanism is probably an imbalance in the normal bacterial flora of the gut. We all have billions of bacteria in the gut-principally in the colon. These bacteria live in a certain harmony and balance. One likely mechanism for bowel dysfunction is imbalance in the normal flora. Possible causes of such imbalance could include intestinal infections, antibiotics, and chemotherapy agents.

The idea of a probiotic is to add "good" bacteria to the gut, and rebalance the flora. I often recommend probiotics to patients with IBS. Since IBS is not always due to bacterial imbalance, it doesn't help everyone. It is not possible, in my opinion, to know up front who will benefit and who will not. However, probiotics are safe, easily accessible, and fairly inexpensive(although if you want to drop some serious cash on a probiotic, there are no shortage of expensive ones!!).

As far as which probiotic is best, there is really not a tremendous amount of data to help us. My own practice is to recommend a probiotic that contains lactobacillus acidophilus(most probiotics do contain this strain of bacteria). If someone is already taking a probiotic and not getting the results they hoped for, I often recommend switching to Florastor. Florastor, rather containing bacteria, contains a yeast called saccharomyces boulardii. I am not implying that Florastor is better than probiotics that contain bacteria, it is simply different, so if bacteria-containing probiotics don't work, try yeast-containing probiotics.

Colonoscopy Prep Can Be Fun!!

As we have discussed in previous posts, the preparation for a colonoscopy is one of the most vital, yet annoying, parts of the entire process.

Sometimes, however, we have to take these things with a little sense of humor!  I thought I would share this clever, and funny video with you. I hope you enjoy it, and use it to spread the word about colon cancer screening.

Kudos to Dr. David Rosenfeld for using his imagination!!

Hilarious Colonoscopy Prep Video

Irritable Bowel Syndrome

Irritable Bowel Syndrome

It is not Colonoscopy Chronicles’ intention to provide specific medical advice to users of its blog, instead we provide users with information to help them better understand their health, diagnosed conditions, and the current approaches related to treatment, prevention, screening, and supportive care. Colonoscopy Chronicles urges users to consult with a qualified health care professional for diagnosis and answers to their personal medical questions.

Tackling the topic of Irritable Bowel Syndrome(IBS) is ambitious, for many reasons. For one, it is the most common gastrointestinal disorder in America, affecting up to 10-15% of the population. Another reason it is a difficult topic to manage is the fact that IBS means different things to different people, including health care professionals. While there are well defined diagnostic criteria for IBS(Rome Criteria), not all healthcare providers utilize these criteria. To make matters even more dicey, IBS is what can be considered a "functional" disorder, meaning that it is a disorder of how the bowel functions rather that a structural abnormality.  What this means is that you can't see it with a scope, you can't see it with an x-ray, you can't detect it with a blood test(tho there is some excitement about a new blood test that might be promising), and you can't prove it via a biopsy. 

The elusive nature of the diagnosis sometimes creates the illusion that this is an imaginary illness. It is not. Patients with IBS sometimes get frustrated with healthcare providers, feeling that they are being treated as if the disorder is psychosomatic. Indeed, sometimes physicians do treat patients as if IBS is not a legitimate medical illness. I like to use the following analogy with patients: I explain IBS can be likened to migraine headaches, in the sense that you can't really demonstrate a migraine on an x-ray, blood test, or biopsy. Yet, we know that migraines are a legitimate disorder, and just because we can't see or touch them doesn't minimize the grief they cause. The same goes for IBS. 

Another feature of IBS that presents a challenge is the fact that, despite its prevalence, it is poorly understood. This lack of  understanding about some of the most basic features of IBS, such as what causes it, leads to a number of unfortunate consequences. For one, when the medical establishment doesn't understand a disease entity, and has challenges treating it, there is a tendency to pawn it off as a psychosomatic disorder, or to try to avoid seeing such patients, whom they may perceive as a nuisance. A second unfortunate consequence is that IBS patients become prey to charlatans who hawk unproven, useless, and costly remedies, that waste their time and money. It is understandable, however, that patients look outside the mainstream when they feel that their needs are not being met. 

In reality, IBS is probably not a single illness, but rather a multitude of different disorders that we lump together under a single banner, because we currently don't know any better. The different individual disorders probably each have a separate underlying cause, and thus should probably be treated differently. The state of the art, however, is such that currently it is difficult to really distinguish between these "variations" of IBS. I truly believe that one day we will be able to pinpoint the type of functional gastrointestinal disorder a patient has(versus lumping them together under the IBS umbrella), and focus our treatment in a much more effective manner. There is definitely progress being made.

This series will outline some of the variants of IBS that are currently recognized, as well as the current state of the art as far as treatment goes. Along the way I will interject my observations and personal experiences, having cared for IBS patients for over 25 years. I hope you find it helpful and meaningful for yourself or someone you care about.

Affordable Care Act?

September 30, 2013 will probably not go down as a hugely memorable day in history. Yet, it represents   a pretty momentous confluence of events. On the one hand, there is the threat of an impending government shutdown based on partisan squabbling predicated on the defunding of the Affordable Care Act, or Obamacare, as it is widely known. We are on the brink of ......well, brinksmanship.

On the other hand, we are also on the brink of the inauguration of Health Exchanges-one of the cornerstones of the Affordable Care Act. The Exchanges represent a pretty grandiose social experiment. The goals of the Exchanges seem pretty laudable: reduce insurance premiums, allow those with preexisting conditions to get coverage, allow small businesses and families to have the same kind of leverage with insurers that large employers have.

There are many unknowns as to how, in fact, this will play out. And people should probably use a great deal of caution before chucking whatever plan they currently have. One of the gigantic question marks about the exchanges is a very practical one-how much will the insurance plans offered cost the consumer, and will that actually represent a savings over their current plan?

The fact that patients with pre-existing conditions must be allowed to purchase insurance on the exchange leads me to believe that insurance premiums are bound to go up rather than down. Obviously, if an insurer has a pool of insured people that are highly likely to use a large amount of medical services, they have to charge more to mitigate this risk.  In addition,somehow insurers must pay for the  laundry list of services that must be included for plans offered on the exchanges, such as prescription drug coverage and wellness services, somehow that must be paid for.

It is estimated that only a small portion  of the population will be using the exchanges. If you have existing insurance through your employer, you are only eligible for the exchange if your portion of the premium is over 9.5% of your income. Furthermore, Medicare recipients are not eligible. Further reducing the eligible pool of participants in the Exchanges, is that some states have elected to opt out of creating Exchanges. Those states who do not have an exchange will have a federally run exchange starting in 2014.  The exchanges will probably be applicable to only about 20 million people-more or less.

If you do not currently have health insurance, and you are eligible for the Exchange and you fail to purchase insurance, you will be fined $95. This fine will gradually escalate to $695 over the next few years.

So how will insurers try to keep down the cost of insurance plans offered on the exchanges? Physicians are very fearful that their reimbursement for work done under the auspices of insurance plans offered on the Exchange plans will go way down. One physician organization indicated that reimbursement was a low as 70% below more conventional insurance plans.

Colonoscopy Conspiracy?

Colonoscopy Conspiracy??

Don't get me wrong-I am not a conspiracy theorist....I am not one of those folks who is convinced that 9/11 was a government plot, or that the moon landings were a hoax. And, deep down, I really don't think that our government is really conspiring to phase out screening colonoscopy by trying to turn public opinion against it through the media. But.......you never know!!

I must confess, however, that my mind did start to wander about such possibilities when I happened to read two articles in large circulation newspapers(large circulation newspapers-that sounds like an oxymoron these days) that maligned colonoscopy. And interestingly, they were published only about 1 month apart. Coincidence? Maybe. Newspapers acting as a shill for government agenda-ie trying to curtail Medicare spending by convincing readers that colonoscopy is an unnecessary ripoff? Maybe.

If you are interested, one article was in the New York Times on June 2 of this year, while the other was in the Washington Post on July 20th of this year. I have attached the links below.

New York Times

Washington Post


Let's start with the New York Times article. The article is entitled: The $2.7 Trillion Medical Bill, with the subtitle:Colonoscopies Explain Why the US Leads the World in Health Expenditures.  Really?? Is it that simple? When the article starts out with that title, you know it isn't designed to present a balanced approach to the topic. The article goes on to discuss some anecdotal cases of patients who were stuck with some ridiculously exorbitant bills for their routine colonoscopy, and decries the overall cost of colonoscopy, quoting a figure of $10 billion per year in the US.  It goes on to quote Dr. Gilbert Welch, a Dartmouth professor as saying, “We’ve defaulted to by far the most expensive option, without much if any data to support it,” when discussing colonoscopy versus other screening tests for colon cancer.  The article failed to mention the fact that Dr. Welch has pretty much made his living over the last 20 years by bashing any attempts to achieve early detection of disease through screening tests. Hmmm, I wonder if he would discourage his mother or father from getting a screening colonoscopy. But, I digress. Oh, one more thing, Dr. Welch-there actually is plenty of data to support it.

Anyhow, the article flashes eye catching highlights, like patients who got staggering bills of over $9000 for a colonoscopy. You have to dig a little deeper into the article, however to find that Medicare paid, on average, $531 for a colonoscopy in 2011. ( By the way-of this total, the physician's professional fee for performing the colonoscopy is approximately $220) Is this really why we lead the world in health care expenditures?

Let's move on to the Washington Post article. This one is another doozy. It is entitled, "How a Secretive Panel Uses Data That Distort Doctors' Pay". The article goes on to describe how an American Medical Association panel, supposedly behind closed doors, hatches a diabolical scheme to tilt the Medicare reimbursement process in the favor of physicians. They cite the case of colonoscopy, the Relative Value Unit(RVU)-which is the basic currency of Medicare reimbursement, is based on 75 minutes of physician time. The article then goes on to question how this can possibly be valid if some physicians are performing 12 or more colonoscopies in a day, i.e. there just aren't enough hours in a day How can colonoscopy reimbursement possibly be based on 75 minutes of physician time when the procedure often takes only 20 minutes or so, etc, etc. Like the New York Times article, it sounds like another example of how colonoscopy is a ripoff being perpetrated by the evil empire of medicine. 

These articles were very disturbing to me, and they should bother you as well. Colon cancer is the number three cancer killer in America. There are approximately 150,000 new cases of colorectal cancer diagnosed per year in the United States, and approximately 55,000 deaths per year. While there are other less expensive, less invasive tests to screen for colorectal cancer, colonoscopy is the only one that offers both early detection, as well as prevention(by way of detecting and removing precancerous growths). Screening colonoscopy has been shown to reduce deaths from colorectal cancer.

Sensationalist headlines blaming colonoscopy for America's healthcare woes, and portraying it as some elaborate scam only serve to discourage those who might be on the fence about getting a screening colonoscopy which might save their life. As a physician who performs colonoscopy, if the American Medical Association is distorting data to provide me windfall profits for performing a colonoscopy, then they are doing a poor job of it. As I mentioned above, the professional fee from Medicare for performing a colonoscopy is about $220. While the procedure may take only 20-30 minutes to perform, that is only the tip of the iceberg in terms of the man hours that are involved. The performing physician also routinely reviews the patient's medical record prior to performing the colonoscopy, speaks to the patient and family in the recovery area following the procedure, tracks down and evaluates results of any biopsies performed during the procedure, communicates those results to the patient, along with any further actions based on those results, and indicates when-if any-followup exam should be performed, and documents all of the above.  So is the RVU for colonoscopy based on 75 minutes of time really a distortion? If anything, it may be an underestimate.

Hemorrhoid Treatment

                                                   Hemorrhoid Treatment-Part 2

It is not Colonoscopy Chronicles’ intention to provide specific medical advice to users of its blog, instead we provide users with information to help them better understand their health, diagnosed conditions, and the current approaches related to treatment, prevention, screening, and supportive care. Colonoscopy Chronicles urges users to consult with a qualified health care professional for diagnosis and answers to their personal medical questions.


In our last post, we discussed treatment of hemorrhoids. As I indicated, I am a strong proponent of hemorrhoid banding in those patients in whom it is appropriate to treat their internal hemorrhoids. The technique I use involves the CRH System for hemorrhoid banding. The company that makes the equipment has a fairly helpful website that describes the equipment and the technique in some detail.http://www.crhsystem.com/

Having been involved in banding hemorrhoids for almost 25 years, I have found the CRH System the best one for my patients. First of all it is safe. Like any medical intervention, hemorrhoid banding has potential complications. The most common "complication" is the one that patients are usually the most concerned about-pain. Patient's, quite understandably, are worried about how painful the procedure will be. And in fact, with some techniques there can be a significant chance of pain after the procedure(32% in on published series from 2005). However, using the CRH system, the risk of significant pain after the procedure is less than 1% !!

I do not promise my patients that the technique is totally painless-since I would rather underpromise and overdeliver. I counsel them to expect a mild pressure-like sensation, or a slight pinching, which usually resolves within a few hours. Usually no intervention is necessary for such monir discomfort, however, I encourage patients to use Tylenol(acetominophen), or Advil(ibuprofen) as needed-as long as they are not allergic to those medications of have no other medical contra-indication. I always find it gratifying when we finish the procedure, and patients look at me in disbelief, and say"Is that it?


Bernal JC, Enguix M, López García J, García Romero J, Trullenque Peris R. Rubber-band ligation for hemorrhoids in a colorectal unit. A prospective study. Rev Esp Enferm Dig. 2005/01;97[1]:38-45

O'Reagan PJ. Disposable devices and a minimally invasive technique for rubber band ligation of hemorrhoids. Dis Colon Rectum 1999; 42(5): 683-5.

Hemorrhoids It is not Colonoscopy Chronicles’ intention to provide specific medical advice to users of its blog, instead we provide users with information to help them better understand their health, diagnosed conditions, and the current approaches related to treatment, prevention, screening, and supportive care. Colonoscopy Chronicles urges users to consult with a qualified health care professional for diagnosis and answers to their personal medical questions. One of the most common findings at the time of colonoscopy is that of hemorrhoids. While it may seem like a simple topic, I believe that hemorrhoids are highly misunderstood! Let’s start by discussing what hemorrhoids are. They are simply engorged veins near the anal opening. Misunderstanding number one is that many patients are under the impression that it is mandatory to treat and/or remove all hemorrhoids. That is not true. Since hemorrhoids are really not linked to an increased risk of colorectal cancer, and do not necessarily lead to anything more sinister, there is no reason that hemorrhoids automatically need to be treated or removed. I tell patients that the main reason to be aggressive with hemorrhoids is if they are causing significant symptoms. Most people with hemorrhoids do not have symptoms. Those who do have symptoms must decide if the symptoms are bothersome enough to warrant doing something about them. That is really “in the eye of the beholder”. How much a patient is willing to put up with varies from person to person. The second major misunderstanding regarding hemorrhoids is “If it hurts down there, it must be hemorrhoids”. The fact is, that hemorrhoids can certainly cause discomfort. However what patients perceive as pain from hemorrhoids is often from other causes. For example, an anal fissure-which is a small cut in the skin at the anal opening-can cause severe anal discomfort. Likewise, irritation of the skin right around the anus, from eczema, dermatitis, or yeast infections can cause discomfort . Taking a good history of the patients symptoms and doing a good physical examination are critical to diagnosing the source of a patient’s symptoms. While it seems self evident, an accurate diagnosis is critical in providing the proper care for a patient with pain in the anal/rectal area. I have seen all too many patients who were treated for hemorrhoids-sometimes even surgically, when the underlying source of their symptoms was not actually their hemorrhoids. In addition to discomfort, hemorrhoids can also bleed. This bleeding is often minor, and does not necessarily mandate aggressive treatment. On the other hands sometimes the bleeding is persistent and severe enough to warrant intervention. Examples of this are when the bleeding leads to frequent soiling of clothing, or is extensive enough to cause the patient to become anemic. It is important that what is perceived as hemorrhoidal bleeding is not from something more sinister such as a malignant tumor of the colon or rectum. Evaluation with colonoscopy may be necessary in order to rule out tumors or other lesions as a source of the bleeding. Once it has been determined that hemorrhoids are the source of a patient’s problems, then next issue is how to treat them. Bleeding, in my opinion, is best treated with either band ligation or surgical hemorrhoidectomy. I favor trying band ligation first, since it is less invasive, and generally well tolerated and effective. The technique I use employs the O’Regan hemorrhoid banding equipment made by CRH. (www.crhsystem.com)

Diverticulosis

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. So, you've had your colonoscopy, and now your doctor tells you that you have diverticulosis. You nod your head knowingly, since your doctor acts as if you should know exactly what that means, as she speeds on to her discussion about your hemorrhoids. But in reality, you really don't know what that means, and by now, it's too late to ask her. The recovery room nurse hands you a slick brochure telling you all about diverticulosis. You tell your friends at the health club the next day that they found diverticulosis, and suddenly your hearing stories about nuts, seeds, popcorn, Aunt Sally's ruptured colon, antibiotics, and now your head is swimming. After all, you just came her for a good workout and now your ready to check into the Mayo Clinic. Help!! Well-Doctor Mike is here to give you the Baby Boomer's Underground Guide to Diverticulosis. Stick with me, kid, you'll be fine! I am going to try and distill twenty three years of experience as a Gastroenterologist into a few paragraphs about diverticulosis-so please realize that this is not a comprehensive review of the topic. Rather, I am going to tell you the exact same thing that I tell my patients, what I consider the basics about diverticulosis.So here goes............ First of all,when the colonoscopy is over and we are reviewing the results, if diverticulosis is present, I let the patient know. I explain that it is a common finding-that probably at least 60-70% of people get diverticulosis. However, the good news is that the vast majority-perhaps 95% or so-will never experience any problems related to their diverticulosis. I go on to explain that diverticulae are little pouches in the colon,and while they are extremely common, we don't exactly know what causes them. There are many theories, most relating to the amount of dietary fiber we eat,but they are probably genetic to some extent, since they tend to run in families. I also explain that while the vast majority of people do not develop problems from the diverticulosis, the two major complications are diverticulitis, and bleeding. I explain that diverticulitis occurs when the pouches become infected. This leads to abdominal pain that is usually in the left lower part of the abdomen, and sometimes in the middle af the abdomen, below the navel. Other associated symptoms can include fever, or constipation. I advise patients to be aware of those type of symptoms and to seek medical attention right away if they occur, since they might need antibiotics to combat the diverticulitis. I explain that the bleeding associated with diverticulosis is usually painless, and sudden in onset. The bleeding is usually fairly severe when it occurs. Again, I advise patients to seek medical attention immediately if they have suspected diverticular bleeding. Finally, I explain to them that for years we advised patients to avoid nuts, seeds, and popcorn, on the theory that those particles are undigestible, and can get lodged in the diverticular pockets and cause diverticulitis. It seemed like a logical instruction-but the problem is, that it turned out that there was really no good evidence that ingesting nuts, seeds, and popcorn had anything to do with diverticulitis. Therefore, I currently do not restrict those items in my patients with diverticulosis, but rather just suggest a general high fiber diet. And that, my friends, is my "Readers Digest" version of diverticulosis. Naturally, this is a very simplified version of a very complicated topic. I did not touch on some of the less common, but very serious complications of diverticulitis, such as perforations, abscesses, or obstructions which may require surgical intervention. I also did not touch on those who have frequent, recurrent episodes of diverticulitis that may require elective surgery. But remember, these serious complications are not common. But because they may be fairly dramatic,even though they are not common, they get a lot of notoriety.

Removing Polyps With Snare

Snare Polypectomy We have discussed the use of the biopsy forceps to remove polyps. That technique is generally limited to the removal of smaller polyps-usually less than 5 millimeters. Larger polyps are generally removed using the snare technique. Just like the use of biopsy forceps, snares can be "hot" or "cold"-meaning that electrocautery is used or not used. A snare is basically a wire lasso that is placed around a polyp, then tightened around the polyp tissue to cut off the polyp.

Generally, the cold snare technique is limited to smaller polyps. The hot snare technique-ie the use of electrocautery-is employed in the removal of larger polyps since the cautery provides hemostasis(bleeding control) by essentially sealing off small blood vessels the may be severed during the removal of the polyp. Because polyps come in various shapes and sizes, the snare technique is adjusted based on the polyp. Let me give you an example. Some polyps are "pedunculated", meaning they grow on a stalk-almost like a cherry on a stem.

To remove such a polyp, the snare is placed around the polyp, and the stalk is severed by tightening the snare and at the same time using electrocautery current through the wire. The diagram below shows a good representation of a snare polypectomy of a pedunculated polyp.

Once the polyp has been removed with this technique, there is usually a small burn mark on the wall of the colon, as seen below(the small whitish area).

Polyp Removal Techniques The last post on this blog discussed some of the commonly encountered types of polyps. One of the goals of colonoscopy is to detect potentially pre-cancerous polyp-the distinct advantage of colonoscopy(versus imaging studies such as lower gi x-rays, or so called "virtual" colonoscopy is the ability to not only detect polyps, but to remove them at the same time. There are several techniques that are used by gastroenterologists. The choice of technique may depend on the size and shape of the polyp, as well as the experience, training, and comfort-level of the physician performing the procedure with the various techniques. I will try not to bore you technical details of each approach, but rather, I hope to give you a general idea of each so that if you or a loved one has a polyp removed you can have an idea of what exactly that meant. FORCEPS POLYPECTOMY Forceps are basically like a tiny set of tweezers. They are on the tip of a long wire-type device that we slide down the biopsy channel of the scope, and they emerge from an opening in the tip of the scope while it is in the colon. The assistant can open the forceps, then the physician positions the forceps over the polyp, then the assistanrt closes the forceps, thus grasping the polyp. The physician then basically just pluckes the polyp off the wall of the colon. Forceps can be "cold" or "hot". In the case of a cold forceps, there is no electric cautery involved, whereas in a hot forceps polypectomy, monopolar cautery is used. The advantage of cautery is that it can prevent bleeding, and can help destroy any redsidual polyp tissue on the colon wall that was not grasped with the forceps. The disadvantage is that sometimes the polyp tissue is destroyed by the cautery and difficult for the pathologist

The Underground Guide to Polyp Removal!

How Are Polyps Removed?


We talked a little bit about colon polyps in our last post. Many patients are curious as to exactly how polyps are removed during colonoscopy. Today we will discuss that very topic. To be honest with you, the techniques we have for removing polyps during a colonoscopy are pretty amazing!

The vast majority of polyps are removed using:
1) Biopsy forceps- “cold” versus “hot”
2) Snare-“cold” versus “hot”

Biopsy forceps can be “cold” meaning that there is no electric current passing through the forceps, or they may be “hot” in which case monopolar electric current is transmitted to the tissue through the forceps. Polyps appropriate for removal with a biopsy forceps are usually quite small-up to 3 millimeters for a cold forceps and up to 4 mm for a hot forceps.

The forceps is really a tiny set of “tweezers” on a long wire that can be passed down a long hollow channel in the colonoscopy. The tweezers can be opened and closed by the technician assisting the colonoscopist. When a tiny polyp is identified, the forceps is slid down the scope, and the polyp is grasped with the open jaws of the tweezers which are then closed. If “hot” forceps are used, an electric current is passed through the forceps to obliterate the tissue, then the polyp is “plucked” off the wall of the colon with the forceps. The polyp tissue is then retrieved and sent to the pathology laboratory. If “cold” forceps are used, the polyp is grasped and plucked off the wall of the colon without any electric current.

Here is what a biopsy forceps looks like:

Here is the "business end" of a biopsy forceps:

Here is a polyp being removed with a "hot" biopsy forceps. Note the the polyp tissue is whitish color-the result of "blanching" of the tissue from the electric current:

Next time we will discuss the snare technique for polyp removal-so stay tuned!!

Colon Polyps- A Primer

It is not Colonoscopy Chronicles’ intention to provide specific medical advice to users of its blog, instead we provide users with information to help them better understand their health, diagnosed conditions, and the current approaches related to treatment, prevention, screening, and supportive care. Colonoscopy Chronicles urges users to consult with a qualified health care professional for diagnosis and answers to their personal medical questions.





Colon Polyps Part I

As a practicing Gastroenterologist, one of the most common situations that arises relates to the question of colon polyps. Polyps of the colon are extremely important! Therefore my mission today is to try to debunk some of the misconceptions regarding colon polyps, and give a clear understanding of this common condition.

First off, what exactly is a polyp? A colorectal polyp is a fleshy growth lining the wall of the colon or rectum. There are a variety of types of polyps, but I will confine my discussion to the two major types. Adenomatous polyps are the most important type, because they are the principal precursor of colorectal cancer. The other type of polyps are hyperplastic polyps. The vast majority of those are small and insignificant, although as I will discuss later there is a small subset of hyperplastic polyps that do have the potential to become cancerous.
Since adenomatous polyps are the main precursor of colorectal cancer, I will focus most of our attention on them. Just to give you an idea about the magnitude of this problem, consider the fact that in the United States alone in 2010, there were 142,570 cases of colorectal cancer diagnosed(4th leading cause of cancer in the US) and 51,370 deaths from colorectal cancer(2nd leading cause of cancer death). There is a 6% lifetime chance of the average American developing colorectal cancer.The appalling part of these statistics in my opinion is that I believe those numbers are far higher than they need to be. Why? Because if precancerous polyps can be identified and removed, we can effectively reduce the risk of colorectal cancer, and in turn the risk of dying of the disease. We, as a society, are doing a much better job of getting this message out. Since colonoscopy was recognized as an effective screening method, and routine screening colonoscopy began to be covered by Medicare, the death rate from colon colorectal cancer has gradually edged down. However, sadly, only about 50% of Americans of the proper age(50 years and up) is getting routine colorectal cancer screening.
So why aren’t we shouting this from a mountaintop and having everyone checked for polyps? Good question. It is a huge public health problem, and like many things, there are a variety of opinions on how to best screen people for colorectal cancer and colorectal polyps. I could spend hours reviewing the different strategies that have been proposed. Let me just summarize by saying that in my opinion, there is no doubt that colonoscopy is the best screening test to look for colon polyps and cancer. But if you have the time and interest, feel free to look at the conclusions of the U.S. Preventative Services Task Force-which goes into great detail about the various options. http://www.uspreventiveservicestaskforce.org/uspstf/uspscolo.htm
So what are the odds that your routine screening colonoscopy will show adenomatous polyps? It is estimated that approximately 25% of Americans at the age of 50 will have polyps on a routine screening exam. The chances of having polyps increases with age. These polyps come in a variety of shapes and sizes. When it comes to polyps, size does matter. In generally, larger polyps are more likely to harbor cancer cells than smaller polyps. As far as shape goes, they may grow on a stem, almost like a cherry(pedunculated polyps) or they may grow fairly flat, more like moss on a tree(sessile polyps). These differences in polyp shape can have important implications as far as the techniques used to remove them.

Pedunculated Polyp

Sessile Polyp



Not only do adenomatous polyps vary in the their size and shape, they also vary in the way they look when examined under a microscope. By that, I mean that the polyps can be categorized as tubular adenomas, tubulovillous adenomas, and villous adenomas. Of these, the more villous component, the higher the risk of cancer transformation. Fortunately, about 80% of polyps are tubular adenomas.
Next time we will discuss the management of polyps including methods for removal, safety of removal, and subsequent followup.