colonoscopy – Page 2 – Precision Digestive Care

A Gastroenterologist Cheats on the Colonoscopy Prep

Posted on March 12, 2018 - 2:59 pm by Frederick Gandolfo MD

I’ll just start out by letting you know that I had mixed feelings about posting this. Not because I’m embarrassed to publicly discuss my colonoscopy experience (weirdly enough, I am OK with that part), but because I don’t want to be responsible for people interpreting what I’m about to disclose far too liberally and ruining their pre-colonoscopy cleanout. So please read on, but don’t push the limits too much. Failing to achieve a good bowel prep will require you to repeat the exam and prep again, and nobody wants that to happen!

For the past year or so I have been having minor IBS-type symptoms on and off, mostly related to stress or periods of poor diet. As a gastroenterologist, I started getting into my own head and worrying that I had some rare or catastrophic disease (the availability heuristic is real!) Part of me knew that if the test was normal, I would probably feel better just with that knowledge alone. I’d also be lying if I said that I wasn’t just a little curious about the whole process too. I either talk to people about colonoscopies or perform them for most of my waking hours; shouldn’t I also have some first-hand experience to reference for my patients?

So I scheduled a colonoscopy and requested Suprep bowel prep. I choose Suprep because it is what I usually give out to patients…I’ve noticed that most people seem to complain the least about the taste of Suprep when compared to most other preps. That’s not to say that the other preps are inferior…I use them interchangeably. However, I wasn’t about to get two or three more colonoscopies just to test out all the preps, so the Suprep experience is what you get to hear about!

I was given the usual instructions for split-dose bowel prep: 1) Clear liquids only the entire day prior to the procedure; 2) Take the first dose of prep at 5 PM and the second dose of prep 5 hours before the procedure start time; 3) Nothing to eat or drink after the second dose of prep. Pretty standard stuff, these are the instructions I usually give to my patients. Following this will lead to a good or excellent bowel prep in the vast majority of people. But what if I told you that I did something different but still achieved an excellent clean-out?

toaster I cheated on the prep. I ate solid food the day before. Now before anybody gets too excited, I ate a very limited and small amount of food, but it made a huge difference in the ability to tolerate the entire process. The following is my “justification” for my cheating, other than the obvious reason of “I was hungry.” I wake up around 5:00 AM or earlier every day. I usually wake up starving and if I don’t eat something within an hour or so of waking I usually feel weak and like my head is spinning. I’ve been this way as far as I can remember, even back in elementary school. I had a long day ahead of me at work, and knew that without some calories in me I would crash in the mid-morning while doing procedures and not be able to function well. “It’s for the patients,” is what I told myself. I almost believed it, too!

So that morning I ate a good-sized bowl of plain vanilla yogurt (no toppings, nuts, fruit, etc.) I also had a few pieces of white toast with butter. We usually don’t have white bread in the house, but we were lucky to have an unseeded loaf of Italian bread from the night before that I toasted in the toaster and buttered up. For lunch, I had a huge gelato without any nuts or toppings. Throughout the day I drank black coffee and plenty of clear liquids.

ice cream I got home around 6PM that day (a little later that the recommended 5PM start time) and began drinking the prep. I mixed the first part of the prep with water as recommended and took a sip. Thinking that I’d be really slick, I used a straw to try and bypass my taste buds. “Not terrible,” I thought to myself, relieved that this process wasn’t going to be as bad as many patients made it sound. The prep tasted like a mixture of seawater, dish soap, and grape cough syrup…yum! A few sips later and I was rethinking this whole thing…the cumulative effect of drinking the prep made each sip taste grosser than the last. After drinking about one-quarter of the first 16 ounces of the stuff, I put the container in the fridge and took a 10-minute break to pace around the house and rethink my strategy.

Going back to the prep in the fridge, I took a few more sips through the straw. Why was it taking so long to drink this stuff? If this were water I could have drank the whole thing in five minutes. I think the straw is actually slowing the process down. I ditched the straw and was able to drink the prep much faster. A few gulps later I was half-way done with the first round. I put the container back in the fridge since the colder the prep was the less bad it tasted. It’s now about 6:20 PM and I suddenly felt a strange grumbling in my lower abdomen.

I was surprised at how fast this stuff works! I figured it would take an hour or so to have any effect, or at least give me some warning first. I was wrong on both counts! With 8 oz. of the nasty stuff down so-far, I was lucky that my bathroom was only a few steps away! Immediate watery diarrhea was the result. The thing I wasn’t expecting was the total lack of pain, cramps, or any discomfort whatsoever. It was as someone just opened the faucet, then closed it again. Magic!

I finished the rest of that evening’s prep over the following 20-30 minutes in between several other sprints to the bathroom. The prep was definitely easier to drink when cold straight out of the fridge. It was about 7PM and the bowel movements were coming fast and furious now. I also noticed that I was incredibly thirsty all of a sudden. I chugged 32 ounces of room temperature Gatorade in about five minutes flat. I wanted more, but only had tomorrow’s ration in the house. Therefore I drank a glass or two of water. By 9PM, all was quiet. I mixed tomorrow morning’s prep and put it in the fridge to chill overnight. I woke from sleep around 1AM for one more small bowel movement, but it was no big deal. I actually got decent sleep.

The next morning, I woke up at my usual time of 5AM. I drank 2 cups of black coffee as soon as I woke up. This was followed by another 16 oz. of Suprep over the next 45 minutes. I would gulp down about 4 oz. at a time, then rest for 10-15 minutes and repeat until done. This time, the bowel movements started immediately after taking the first bit of the prep and were mainly yellowish water. Another 32 oz. of Gatorade down the hatch and the process was complete. The last 2-3 bowel movements were literally clear water, like as clear as the water that comes out of the faucet. Cool, I did it!

Now would be a good time to talk about a study from a few years back. Thinking that improving the tolerance of the prep would remove one of the classic barriers for some people to do colonoscopy as well as decrease the number of broken appointments and inadequate preps, researchers randomized patients into two groups: One group received a clear liquid diet the entire day prior, and the other was able to eat a light breakfast and lunch with several food restrictions the day prior. Both groups then completed the standard bowel prep. The study showed exactly what we would expect: The people who starved all day were miserable, the people who ate a little were less miserable, and the quality of the bowel preps achieved were the same between the groups! The most interesting finding was that the group of patients who were restricted to only having clear liquids cancelled their appointments more than twice as frequently as the patients that were allowed to eat just a little. Hunger is a powerful force to compete with!

Now before you eat a bacon cheeseburger with fries, corn on the cob, and a salad the day before your colonoscopy, it’s very important to understand that these subjects (and yours truly) ate a very limited diet the day before the colonoscopy. Fibrous foods such as any fruits or vegetables are not allowed. Seeds, nuts, whole grains, fresh or dried herbs/seasonings, popcorn, and the like are definitely not allowed. Corn is probably the worst thing one can eat the day before having a colonoscopy!

no corn What kind of foods are OK to eat the day before the colonoscopy? Low residue foods (low roughage) are ideal; these are processed flours (white bread, etc.), white rice, pasta, yogurt, gelato, and related snacks, eggs, lean meats, and other foods. A light breakfast is fine. A light snack around lunch time is OK too, but after that it’s clear liquids only. That means “dinner” is clears only: You don’t want food and bowel prep in your stomach at the same time, trust me.

So back to the title of this article: A gastroenterologist cheats on the colonoscopy prep and wins! Did I really cheat? I guess not, since it seems that research backs up what I did! But did I win? Can you ever call getting a colonoscopy “winning?” I guess it depends on the findings. I did, however, have an excellent bowel prep!

What Causes Colon Polyps?

Posted on March 9, 2018 - 3:30 pm by Frederick Gandolfo MD

When it comes to colon cancer prevention, the polyp is the key player to know. Colon polyps, called adenomas, are precancerous growths originating from the inner lining of the colon wall. There are other types of polyps in the colon which are not considered precancerous, but for our purposes in this article we will consider the terms colon polyp and adenoma to be one and the same.

Polyps are important to know about because they are the precursors to colon cancer. That is, virtually all cases of colon cancer began many years earlier as a small polyp growing in the colon. For the average person, it takes many years for these small polyps to appear on the scene, which is why we don’t usually recommend colonoscopy until a person is 50 years old. However, it’s not totally uncommon to find significant-sized polyps in younger people in their 30s or 40s (and even in their 20s!) From the time a polyp starts growing, it is thought to take more than 10 years for the polyp to grow into cancer…and not all adenomatous polyps grow larger or turn into cancer at all. However, many polyps will continue to have cellular changes such as mutations that will promote growth of the polyp and eventually transformation into colon cancer.

By understanding what causes colon polyps, we can understand what causes colon cancer. Here are some risks factors for getting colon cancer/polyps that an individual cannot change:

Age: The risk tends to go up as one gets older.
Sex: Men seem to have a slightly higher chance of having polyps when compared to women.
Family history: A close relative with polyps or colon cancer makes your risk go higher.
Race: Black men and women have the highest risk of developing colon cancer.

However, roughly half of all cases of colon cancer (and by extension, colon polyps) are a result of modifiable risk factors. These are the things that you can control. If we know what these risk factors are, maybe we can make better choices for ourselves and our families. The following is a list of the known risk factors for developing colon cancer/polyps:

- Alcohol: Alcohol use is closely tied to colon cancer risk. Unfortunately, even for “social” drinkers, the risk goes up by about 10% if you only drink less than 1 drink per day. If you have 2-4 drinks per day, the risk increases by 23%!

alcohol

- Red meat: Beef, veal, lamb and pork (despite the advertisements) are considered red meats. Regular consumption of about 100 grams of red meat per day (about the amount found in 2 regular-sized McDonald’s hamburgers) can increase the risk of colorectal cancer by 17%. I like the idea of “everything in moderation” so let’s aim to only eat red meat about once per week.
- Processed meat: This seems to be a real bad one…processed meat is often also red meat and is defined as meat that has been salted, cured, smoked, fermented, or treated with other processes to improve flavor or preserve the meat. Processed meat is bacon, sausages, hot dogs, cured ham, etc. The risk of colorectal cancer goes up by 18% for those who eat just 50 grams per day of processed meat (this is half the amount of red meat needed for the same risk).

processed meat

- Lack of dietary fiber: Eating fiber is good for your colon for many reasons, and transmits a decreased risk of colon cancer as well. An extra 10 grams of fiber in the diet can drop colon cancer risk by 10%, but don’t stop there: Men should get 38 grams of fiber per day, and women are recommended to eat 25 grams per day. An apple has about 4 grams of fiber in it, so that’s a lot of apples to eat every day! Alternatively, you should eat a variety of plant-based foods and take in fiber with each meal and snack.

apples

- Smoking: This seems obvious. Smoking causes all kinds of cancer. It also increases the risk of colon polyps and colorectal cancer. Smoking is not a great way to stay healthy.
- Obesity: Being overweight or obese increases the risk of colon cancer. This is independent of physical activity. That is, the excess weight itself seems to be tied to cancer risk, likely due to changes in inflammatory and growth signaling molecules, among other factors.
- Lack of exercise: Interestingly, staying physically active can reduce the risk of colon cancer by a whopping 25%! The minimum amount of exercise recommended for this purpose is about 2.5 hours per week of moderate exercise, or 75 minutes per week of intense exercise, but more is better. Again, the reasons for this are somewhat unclear but likely rooted in positive changes in insulin resistance, growth factors, inflammatory factors, and who knows what other things that are modified by exercise. We weren’t born to sit around, going from couch to car to chair and back again…we were born to move, so do something active on a regular basis!

marathon

Coffee: Well this should really read “lack of coffee” because coffee seems to be somewhat protective against developing polyps and colon cancer! There are not many high-quality studies on this topic, but what is out there suggests a 25% decrease in colorectal cancer with coffee consumption, possibly due to the antioxidants found in coffee.
Calcium: This is controversial. On one hand it seems that high consumption of dairy products like milk is associated with a lower risk of colorectal cancer. At best, supplementing calcium seems to have no effect on cancer risk for better or worse. However a very recent study suggests an increased risk of adenomatous polyps from taking both calcium and vitamin D supplements in combination, so more research will be needed to figure out the exact role of calcium, vitamin D, and the combination of both for colon cancer prevention.

And let’s not forget the final factor that leads to colon polyps and cancer in many individuals:

Bad luck: Unfortunately some people just have bad luck. We doctors don’t understand everything! This is why it’s still important to get screened for colorectal cancer at the appropriate age even if you don’t have any family history or symptoms, and are a thin, non-smoking, vegan, fitness-guru teetotaler!

March is Colorectal Cancer Awareness Month

Posted on March 1, 2018 - 3:23 pm by Frederick Gandolfo MD

It’s March, which means it’s Colorectal Cancer Awareness Month!

Preventing colon cancer is one of the most important things that we gastroenterologists get to do. Even if you’re not particularly interested in colon cancer, there will still be some interesting stuff for you to read this here as I will cover a little bit about nutrition, exercise, and healthy lifestyle choices as they relate to colon cancer prevention. I also look forward to sharing a somewhat humorous and true story about bowel prep from the perspective of a patient, and that patient is me!

First, I’d like to review some basic facts about colorectal cancer for any new readers out there:

What is colorectal cancer?

Cancer, in general, is when your own cells develop DNA mutations and eventually stop obeying the normal control signals from the body that function to tell the cells when to stop dividing and where not to grow (obviously this is a gross oversimplification). These rebellious cancer cells multiply and form a tumor, which is just a mass of cancerous cells. Tumors can grow into other organs and cause damage, blockages, bleeding, and other types of badness. The cells inside the tumor can also spread through the bloodstream or lymphatic system and land in other locations in the body, a process known as metastasis.

Colorectal cancer is when this process happens in the colon (or the rectum, which is the end portion of the colon). The cells that transform into the typical type of colon cancer originate from the inner lining of the colon and turn into a type of cancer called adenocarcinoma.

How does colorectal cancer happen?

Colorectal cancer occurs when a precancerous polyp (known as an adenoma) forms inside the colon and slowly accumulates additional genetic mutations, causing the polyp to grow larger and act more aggressively, eventually invading into the muscle layer of the colon wall and becoming full-blown cancer. We think this process takes about 10-20 years to occur, which is a very important fact when it comes to colorectal cancer prevention. This long sequence, from adenoma to cancer, is the reason why screening can prevent colon cancer—we can intervene during the long precancerous stage and change the natural history of the disease. Stated more simply, we can remove the precancerous polyp before it actually turns into colon cancer, therefore preventing colon cancer from developing at all!

How do we prevent colon cancer?

All professional gastrointestinal societies recommend starting to screen most people for colorectal cancer starting at fifty years old. However, true prevention really starts many years before most people have to worry about getting a colonoscopy! Diet, exercise, and many lifestyle choices can increase or decrease the risk of developing colorectal cancer. We will cover this important topic in more detail later this month.

As far as screening goes, there are various tests available to look for both colorectal cancer and adenomatous polyps. I have covered these topics in more detail in past articles, so I will invite new readers to peruse the links below for more info:

However, if you are in a hurry and don’t want to read those older articles, we can boil down the testing recommendations for most individuals as follows: To prevent colorectal cancer, the average-risk man or woman should have a colonoscopy starting at age 50, and then every 10 years thereafter, until about 75-85 years of age. If polyps are found, they are removed during the colonoscopy, and the next exam is scheduled sooner than 10 years later.

colon cancer awareness

Can young people get colon cancer?

Most cases of colon cancer are diagnosed in people in their late sixties and early seventies, with rectal cancer being diagnosed somewhat earlier (early sixties). The good news is that colorectal cancer rates in the over-fifty population are on the decline! This may be due to several factors such as the increase in effective colorectal cancer screening programs and a decline in the popularity of smoking. However, new data is showing that the rate of colorectal cancer in young people is actually on the rise! Although it is still relatively rare, the rate of colorectal cancer is increasing in the 30- and 40-year-old age group.

We are not quite sure why colorectal cancer is increasingly developing in the younger population. Various theories exist, including the influence of obesity, inactivity, food additives, poor diet, and even antibiotic exposure. All we can conclude at this point in time is that symptoms that could be consistent with colorectal cancer should not be ignored just because a patient is relatively young.

Well, that about wraps up the basics on colorectal cancer. I am going to hit this topic from all angles this month, so be sure to keep reading!

For a quick reference on colorectal cancer, see the American Cancer Society’s publication Colorectal cancer facts and figures 2017-2019.

Think Twice Before Large Colonic Polyp Surgery

Posted on May 12, 2017 - 4:17 pm by Frederick Gandolfo MD

Large colonic polyps used to be managed by a surgeon, similar to how colon cancer is still managed…cut it out and hope for the best. However, it is clear that when possible, these large non-cancerous polyps are more safely removed using advanced endoscopic techniques, such as endoscopic mucosal resection (EMR). Despite excellent safety data on endoscopic removal of large polyps, there is still a reluctance by many physicians to send their patients for EMR. Why wouldn’t a fellow endoscopist sent their patients for a procedure that is as effective, safer, with no significant recovery time, and far less expensive when compared to surgery? I’m not entirely sure…maybe there is unfamiliarity with the technique among many physicians, or perhaps there is ignorance about the actual risks of surgery. Or maybe (just maybe) sending a patient for surgery is a gastroenterologists way of protecting his or her delicate ego…as in, “If I can’t remove it than it can’t be done by anyone with a scope!”

The truth is, it’s all about the positioning of the polyp. Is the polyp in a place that is able to be approached by the scope in the right position to facilitate removal? Sometimes the biggest polyps are easy to remove because they’re in an ideal location. Other times, a relatively small lesion proves impossible to remove because it is just at a bad angle and can’t be made better no matter how the endoscopist tries to reposition things.

Here is a recent case of a large polyp resected using standard EMR technique. As always, the patient should be followed up closely to make sure the resection was complete.

A-C: Large tubular adenoma in rectum. D: After resection, large vessel visible at base. E: After coagulation of vessel using hot forceps. F: After clip placement.

When compared to surgery, which carries a 14% risk of a major postoperative event (e.g.: need for colostomy, major infection, anastomotic leak, need for reoperation, cardiovascular event, blood clot, etc.) and a 1-in-140 risk of death in 30 days (which rises to 3% in the over-80 patient age group), endoscopic polypectomy is much safer. The most common risks of endoscopic removal of large polyps includes bleeding (6.5%), perforation (1.5%), need for emergency surgery (1%), and a 1-in-1250 risk of death.