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