Reasons for procedureIndications for colonoscopy include gastrointestinal hemorrhage, unexplained changes in bowel habit or suspicion of malignancy. Colonoscopies are often used to diagnose colon cancer, but are also frequently used to diagnose inflammatory bowel disease. In older patients (sometimes even younger ones) an unexplained drop in hematocrit (one sign of anemia) is an indication to do a colonoscopy, usually along with an esophagogastroduodenoscopy (EGD), even if no obvious blood has been seen in the stool (feces).Fecal occult blood is a quick test which can be done to test for microscopic traces of blood in the stool. A positive test is almost always an indication to do a colonoscopy. In most cases the positive result is just due to hemorrhoids; however, it can also be due to diverticulosis, inflammatory bowel disease (Crohn’s disease, ulcerative colitis), colon cancer, or polyps. Howeverince its development by Dr. Hiromi Shinya and Dr. William I. Wolff in the 1960s–polypectomy has become a routine part of colonoscopy, allowing for quick and simple removal of polyps without invasive surgery.Due to the high mortality associated with colon cancer and the high effectivity and low risks associated with colonoscopy, it is now becoming a routine screening test for people 50 years of age or older. Subsequent rescreenings are then scheduled based on the initial results found, with a five- or ten-year recall being common for colonoscopies that produce normal results. Patients with a family history of colon cancer are often first screened up to 10 years earlier.A study published in the New England Journal of Medicine (September 18, 2008) has found that among people who have had an initial colonoscopy that found no polyps, the risk of developing colorectal cancer within five years is extremely low. Therefore, there’s no need for those people to have another colonoscopy sooner than five years after the first screening. Procedure PreparationThe colon must be free of solid matter for the test to be performed properly. For one to three days, the patient is required to follow a low fiber or clear-liquid only diet. Examples of clear fluids are apple juice, chicken and/or beef broth or bouillon, lemon-lime soda, lemonade, sports drink, and water. It is very important that the patient remains hydrated. Orange juice, prune juice, and milk containing fibre should not be consumed, nor should liquids dyed red, purple, orange, or sometimes brown, however cola is allowed. In most cases, black coffee is allowed.The day before the colonoscopy, the patient is either given a laxative preparation (such as Bisacodyl, phospho soda, sodium picosulfate, or sodium phosphate and/or magnesium citrate) and large quantities of fluid or whole bowel irrigation is performed using a solution of polyethylene glycol and electrolytes. Often, the procedure involves both a pill-form laxative and a bowel irrigation preparation with the polyethylene glycol powder dissolved into any clear liquid, preferably a sports drink such as Gatorade or Powerade brand sports drinks which contain electrolytes.In this case, a typical procedure regimen then would be as follows: in the morning of the day before the procedure, a 238 mg bottle of polyethylene glycol powder should be poured into 64 oz. of the chosen clear liquid, which then should be mixed and refrigerated. Two (2) bisacodyl 5 mg tablets are taken 3 pm; at 5 pm, the patient starts drinking the mixture (approx. 8 oz. each 15-30 min. until finished); at 8 pm, take two (2) bisacodyl 5 mg tablets; continue drinking/hydrating into the evening until bedtime with clear permitted fluids. A common brand name of bisacodyl is Ducolax, and store brands are available. A common brand name of polyethylene glycol powder is MiraLax. It may be advisable to schedule the procedure early on a given day so the patient need not go without food and only limited fluids the morning of the procedure on top of having to go through the foregoing preparation procedures the preceding day.Since the goal of the preparation is to clear the colon of solid matter, the patient should plan to spend the day at home in comfortable surroundings with ready access to toilet facilities. The patient may also want to have at hand moist toilettes or a bidet for cleaning the anus. A soothing salve such as petroleum jelly applied after cleaning the anus will improve patient comfort.The patient may be asked to skip aspirin and aspirin-like products such as salicylate, ibuprofen, and similar medications for up to ten days before the procedure to avoid the risk of bleeding if a polypectomy is performed during the procedure. A blood test may be performed before the procedure. The investigationDuring the procedure the patient is often given sedation intravenously, employing agents such as fentanyl or midazolam. Although meperidine (Demerol) may be used as an alternative to fentanyl, the concern of seizures has relegated this agent to second choice for sedation behind the combination of fentanyl and midazolam. The average person will receive a combination of these two drugs, usually between 25 to 100 g IV fentanyl and 14 mg IV midazolam. Sedation practices vary between practitioners and nations; in some clinics in Norway, sedation is rarely administered.Some endoscopists are experimenting with, or routinely use, alternative or additional methods such as nitrous oxide and propofol, which have advantages and disadvantages relating to recovery time (particularly the duration of amnesia after the procedure is complete), patient experience, and the degree of supervision needed for safe administration. This sedation is called “twilight anesthesia.” For some patients it is not fully effective, so they are indeed awake for the procedure and can watch the inside of their colon on the colour monitor. Substituting propofol for midazolam, which gives the patient quicker recovery, is gaining wider use, but requires closer monitoring of respiration.A meta-analysis found that playing music improves patient tolerability of the procedure.The first step is usually a digital rectal examination, to examine the tone of the sphincter and to determine if preparation has been adequate. The endoscope is then passed through the anus up the rectum, the colon (sigmoid, descending, transverse and ascending colon, the cecum), and ultimately the terminal ileum. The endoscope has a movable tip and multiple channels for instrumentation, air, suction and light. The bowel is occasionally insufflated with air to maximize visibility. Biopsies are frequently taken for histology.In most experienced hands, the endoscope is advanced to the junction of where the colon and small bowel join up (cecum) in under 10 minutes in 95% of cases. Due to tight turns and redundancy in areas of the colon that are not “fixed”, loops may form in which advancement of the endoscope creates a “bowing” effect that causes the tip to actually retract. These loops often result in discomfort due to stretching of the colon and its associated mesentery. Manoeuvres to “reduce” or remove the loop include pulling the endoscope backwards while torquing the instrument. Alternatively, body position changes and abdominal support from external hand pressure can often “straighten” the endoscope to allow the scope to move forward. In a minority of patients, looping is often cited as a cause for an incomplete examination. Usage of alternative instruments leading to completion of the examination has been investigated, including use of pediatric colonoscope, push enteroscope and upper GI endoscope variants.For screening purposes, a closer visual inspection is then often performed upon withdrawal of the endoscope over the course of 20 to 25 minutes. Lawsuits over missed cancerous lesions have recently prompted some institutions to better document withdrawal time as rapid withdrawal times may be a source of potential medical legal liability. This is often a real concern in clinical settings where high caseloads could provide financial incentive to complete colonoscopies as quickly as possible.Suspicious lesions may be cauterized, treated with laser light or cut with an electric wire for purposes of biopsy or complete removal polypectomy. Medication can be injected, e.g. to control bleeding lesions. On average, the procedure takes 2030 minutes, depending on the indication and findings. With multiple polypectomies or biopsies, procedure times may be longer. As mentioned above, anatomic considerations may also affect procedure times.After the procedure, some recovery time is usually allowed to let the sedative wear off. Outpatient recovery time can take an estimate of 3060 minutes. Most facilities require that patients have a person with them to help them home afterwards (again, depending on the sedation method used).One very common aftereffect from the procedure is a bout of flatulence and minor wind pain caused by air insufflation into the colon during the procedure.An advantage of colonoscopy over x-ray imaging or other, less invasive tests, is the ability to perform therapeutic interventions during the test. A polyp is a growth of excess of tissue that can develop into cancer. If a polyp is found, for example, it can be removed by one of several techniques. A snare device can be placed around a polyp for removal. Even if the polyp is flat on the surface it can often be removed. For example, the following shows a polyp removed in stages:Polyp is identifiedA sterile solution is injected under the polyp to lift it away from deeper tissues.A portion of the polyp is now removed.The polyp is fully removed. Ultrasound duodenography and ultrasound colonographyDuodenography and colonography are performed like a standard abdominal examination using B-mode and color flow Doppler ultrasonography using a low frequency transducer for example a 2.5 MHz and a high frequency transducer for example a 7.5 MHz probe. Detailed examination of duodenal walls and folds, colonic walls and haustra was performed using a 7.5 MHz probe. Deeply located abdominal structures were examined using 2.5 MHz probe. All ultrasound examinations are performed after overnight fasting (for at least 16 hours) using standard scanning procedure. Subjects are examined with and without water contrast. Water contrast imaging is performed by having adult subjects take at least one liter of water prior to examination. Patients are examined in the supine, left posterior oblique, and left lateral decubitus positions using the intercostal and subcostal approaches. The liver, gall bladder, spleen, pancreas, duodenum, colon, and kidneys are routinely evaluated in all patients. With patient lying supine, the examination of the duodenum with high frequency ultrasound duodenography is performed with 7.5 MHz probe placed in the right upper abdomen, and central epigastric successively; for high frequency ultrasound colonography, the ascending colon, is examined with starting point usually midway of an imaginary line running from the iliac crest to the umbilicus and proceeding cephalid through the right mid abdomen; for the descending colon, the examination begins from the left upper abdomen proceeding caudally and traversing the left mid abdomen and left lower abdomen, terminating at the sigmoid colon in the lower pelvic region. Color flow Doppler sonography is used to examine the localization of lesions in relation to vessels. All measurements of diameter and wall thickness are performed with built-in software. Measurements are taken between peristaltic waves .The abdominal quadrants scanned in the order.The duodenal tri-band wall with folds of Kerckring, showing floaters with water contrast.A high resolution view of colonic haustration. RisksThis procedure has a low (0.35%) risk of serious complications.The most serious complication generally is a tear or hole in the lining of the colon called a gastrointestinal perforation, which is life-threatening and requires immediate major surgery for repair; however, the rate of perforation is less than 1 in 2000 colonoscopies.Bleeding complications may be treated immediately during the procedure by cauterization via the instrument. Delayed bleeding may also occur at the site of polyp removal up to a week after the procedure and a repeat procedure can then be performed to treat the bleeding site. Even more rarely, splenic rupture can occur after colonoscopy because of adhesions between the colon and the spleen.As with any procedure involving anaesthesia, other complications would include cardiopulmonary complications such as a temporary drop in blood pressure, and oxygen saturation usually the result of overmedication, and are easily reversed. In rare cases, more serious cardiopulmonary events such as a heart attack, stroke, or even death may occur; these are extremely rare except in critically ill patients with multiple risk factors.Oral sodium phosphates for bowel preparation prior to colonoscopy carry a risk of acute renal failure under the form of phosphate nephropathy.On very rare occasions, intracolonic explosion may occur.High frequency ultrasound duodenography and colonography carry no risks associated with the procedures. ResultsA recent study published in the Annals of Internal Medicine implies that colonoscopy screening prevents approximately two thirds of the deaths due to colorectal cancers on the left side of the colon, and is not associated with a significant reduction in deaths from right-sided disease. This study examined people with colon cancer diagnosed between 1996 and 2001 in Ontario who died of colon cancer by 2003, and hence studied colonoscopies done in the early to mid 1990s. (Since the procedure continues to evolve, more recent colonoscopies may be more effective). The summary result, according to table 3 of the report, show approximately a 37% reduction in the death rate from colorectal cancer, with a significantly lower reduction in death for “incomplete” colonoscopies. See alsoAnal probeBow and arrow signRectal examinationSigmoidoscopyPolypectomyVirtual colonoscopy References^ Sivak, Jr., Michael V. (2004-12). “Polypectomy: Looking Back”. Gastrointestinal Endoscopy 60 (6): 977982. doi:10.1016/S0016-5107(04)02380-6. ISSN 1097-6779. PMID 15605015. http://linkinghub.elsevier.com/retrieve/pii/S0016510704023806. ^ http://www.cancer.org/docroot/ped/content/ped_2_3x_acs_cancer_detection_guidelines_36.asp^ Rex, Douglas K.; Bond,John H.; Winawer,Sidney; Levin,Theodore R.; Burt,Randall W.; Johnson,David A.; Kirk,Lynne M.; Litlin,Scott; Lieberman,David A.; Waye,Jerome D.; Church,James; Marshall,John B.; Riddell,Robert H. (June 2002). “Quality in the technical performance of colonoscopy and the continuous quality improvement process for colonoscopy: recommendations of the U.S. Multi-Society Task Force on Colorectal Cancer”. The American Journal of Gastroenterology 97 (6): 12961308. doi:10.1111/j.1572-0241.2002.05812.x. ISSN 0002-9270. PMID 12094842. ^ Gmperiale, Thomas F., Glowinski, Elizabeth A., Lin-Cooper, Ching, Larkin, Gregory N., Rogge, James D., Ransohoff, David F. (2008). “Five-Year Risk of Colorectal Neoplasia after Negative Screening Colonoscopy.”. N Engl J Med 359 (12): 12181224. doi:10.1056/NEJMoa0803597. PMID 18799558. http://content.nejm.org/cgi/content/abstract/359/12/1218. Retrieved 2008-09-17. ^ No Need to Repeat Colonoscopy Until 5 Years After First Screening Newswise, Retrieved on September 17, 2008.^ Waye, Jerome D.; Rex, Douglas K.; Williams, Christopher Beverley (2003). Colonoscopy: principles and practice. Wiley-Blackwell. pp. 210211. ISBN 1405114495. ^ Decker, Joe (15 November 2006). “Preparation: Diet” (Blog). Colonoscopy Blog. Blogger.com. http://colonoscopyblog.blogspot.com/2006/11/details-of-preparation.html. Retrieved 2007-06-12. ^ “Colyte/Trilyte Colonoscopy Preparation” (PDF). Palo Alto Medical Foundation. June 2006. http://www.pamf.org/gastroenterology/ColyteColon.pdf. Retrieved 2007-06-12. ^ Bretthauer, M; Hoff G, Severinsen H, Erga J, Sugar J, Huppertz-Hauss G (20 May 2004). “[Systematic quality control programme for colonoscopy in an endoscopy centre in Norway]” (in Norwegian) (Abstract). Tidsskrift for den Norske laegeforening 124 (10): 14021405. ISSN 0029-2001. PMID 15195182. ^ The article PMID 20514160 was cited here, but this UID appears to be incorrect.^ Rikshospitalet University Hospital (April 2006). “Clinical Trial: Nitrous Oxide for Analgesia During Colonoscopy”. ClinicalTrials.gov. http://www.clinicaltrials.gov/ct/show/NCT00318825. Retrieved 2007-06-12. ^ Forbes, GM; Collins BJ (March 2000). “Nitrous oxide for colonoscopy: a randomized controlled study”. Gastrointestinal Endoscopy 51 (3): 271277. doi:10.1016/S0016-5107(00)70354-3. PMID 10699770. ^ Clarke, Anthony C; Louise Chiragakis, Lybus C Hillman and Graham L Kaye (18 February 2002). “Sedation for endoscopy: the safe use of propofol by general practitioner sedationists”. Medical Journal of Australia 176 (4): 158161. PMID 11913915. http://www.mja.com.au/public/issues/176_04_180202/cla10751.html. Retrieved 2007-06-12. ^ Bechtold, ML.; Puli, SR.; Othman, MO.; Bartalos, CR.; Marshall, JB.; Roy, PK. (Jan 2009). “Effect of music on patients undergoing colonoscopy: a meta-analysis of randomized controlled trials.”. Dig Dis Sci 54 (1): 19-24. doi:10.1007/s10620-008-0312-0. PMID 18483858. ^ Lichtenstein, Gary R.; Peter D. Park, William B. Long, Gregory G. Ginsberg, Michael L. Kochman (18 August 1998). “Use of a Push Enteroscope Improves Ability to Perform Total Colonoscopy in Previously Unsuccessful Attempts at Colonoscopy in Adult Patients”. The American Journal of Gastroenterology 94 (1): 187. doi:10.1111/j.1572-0241.1999.00794.x. PMID 9934753.  Note:Single use PDF copy provided free by Blackwell Publishing for purposes of Wikipedia content enrichment.^ Barclay RL, Vicari JJ, Doughty AS, et al. (2006). Colonoscopic withdrawal times and adenoma detection during screening colonoscopy. 355. pp. 253341. ^ Njemanze, P. C., Njemanze J., Skelton A., Akudo A., Akagha O., Chukwu A. A., Peters C., Maduka O. (2008). High-frequency ultrasound imaging of the duodenum and colon in patients with symptomatic giardiasis in comparison to amebiasis and health subjects. Journal of Gastroenterology and Hepatology, Vol 23, No. 7 (2), e34-e42.^ “Colonoscopy Risks”. January 16, 2008. http://ibdcrohns.about.com/od/colonoscopy/p/colonoscopy.htm. Retrieved 2008-07-18. ^ J. A. Dominitz, et al., American Society for Gastrointestinal Endoscopy, “Complications of Colonsocopy”, Gastrointestinal Endoscopy, Vol 57, No. 4, 2003, pp. 441-445^ Lien YH (September 2008). “Is bowel preparation before colonoscopy a risky business for the kidney?”. Nat Clin Pract Nephrol 4 (11): 606. doi:10.1038/ncpneph0939. PMID 18797448. ^ N.N. Baxter, M.A. Goldwasser, L.F. Paszat, R. Saskin, D.R. Urbach, and L. Rabeneck, “Association of Colonoscopy and Death from Colorectal Cancer: A Population-Based, Caseontrol Study,” Annals of Internal Medicine, Volume 150 Issue 1, 6 January 2009 article; (see also summary version, Effectiveness of Colonoscopy for Prevention of Mortality From Colorectal Cancer accessed December 22, 2009)^ “Real-world colonoscopy benefit seen more limited”. Reuters. December 16, 2008. http://uk.reuters.com/article/healthNewsMolt/idUKTRE4BF6LJ20081216?pageNumber=1&virtualBrandChannel=0.  External linksLearnColoRectalSurgery.com – Colonoscopy picturesColonoscopy. Based on public-domain NIH Publication No. 02-4331, dated February 2002.Patient Education Brochures. American Society for Gastrointestinal Endoscopy informationv  d  eDigestive system surgical and other procedures (ICD-9-CM V3 42-54)Digestive tractUpper GI tractSGs/EsophagusSialography  EsophagectomyStomachGastrostomy (Percutaneous endoscopic gastrostomy)  Gastrectomy (Billroth I, Billroth II, Roux-en-Y)  Bariatric surgery (Gastric bypass surgery, Adjustable gastric band, Sleeve gastrectomy, Vertical banded gastroplasty surgery)  Gastroenterostomy  Hill repair  Nissen fundoplication  GastropexyImagingEndoscopy: EsophagogastroduodenoscopyUpper gastrointestinal seriesLower GI tractSmall bowelBariatric surgery (Duodenal switch, Jejunoileal bypass)  Jejunostomy  Ileostomy  Partial ileal bypass surgeryLarge bowelColectomy  Colostomy  Appendicectomy  Hartmann’s operationRectumLower anterior resection  Abdominoperineal resectionAnusAnal sphincterotomy  Lateral internal sphincterotomyImagingEndoscopy: Colonoscopy (Virtual)  Proctoscopy  Sigmoidoscopy  Enteroscopy  Capsule endoscopyTransrectal ultrasonography  Enteroclysis  Small bowel follow-through  Abdominal ultrasonography  Lower gastrointestinal seriesAccessoryLiverHepatectomy  Liver transplantation  Artificial extracorporeal liver support (Liver dialysis, Bioartificial liver devices)Gallbladder, bile ductCholangiography (Endoscopic retrograde cholangiopancreatography, Percutaneous transhepatic cholangiography, Magnetic resonance cholangiopancreatography)  Cholecystectomy  Cholecystography  HIDA scanPancreasPancreatectomy  Pancreaticoduodenectomy  Pancreas transplantation  Puestow procedure  Frey’s procedureAbdominopelvicPeritoneumParacentesis  Intraperitoneal injectionHerniaHerniorrhaphy  MacEwen’s operationOtherLaparotomydigestive system navs: anat of tract,glands,perit,diaphragm/physio/dev, noncongen/congen/congen of d+w/neoplasia, symptoms+signs/eponymous, proc Categories: Diagnostic gastroenterology | Medical tests | Endoscopy

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Colonoscopy

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