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Did You Say Colon ...?

January 18, 2007 By:
Frank Rosci, JE Feature
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Dr. Harvey Guttmann, president of Gastrointestinal Associates

A colonoscopy is one of the most highly recommended medical tests today and, perhaps, one of the least understood and most feared by men and women alike.

But people shouldn't be hesitant or afraid to have the test, medical professionals agree, since the days of discomfort, doubt and danger often associated with it are long gone. And, first and foremost, it saves lives.

"It used to be, 25 to 30 years ago -- when colonoscopies began to become more popular -- that the procedure was very complicated," acknowledges Harvey Guttmann, M.D., chief of gastroenterology at Abington Memorial Hospital and president of Gastrointestinal Associates in Jenkintown. "Two doctors were needed often back then -- one to hold the instrument, the other to direct it. The instrument itself, called a colonoscope, about 5 feet long, while flexible, was stiffer than the one in use today.

"It had fiber optics inside to light the colon, and a physician would look into the scope as you would with a telescope. And pain control wasn't good at that time," continues Guttmann, who is also president of the Delaware Valley Society of Gastrointestinal Endoscopy.

"There was a two-day prep years ago, and the procedure could only be done after a barium enema was given; instruments to remove polyps were in their very early stage. All in all, the procedure was successful only about 75 to 80 percent of the time. So, those days were the truly prehistoric ones of colonoscopy. The safety, efficacy, comfort and technology are far better today, with a success rate of 95 percent."

Indeed, today, it's a totally different examination, done on an out-patient basis most of the time in hospitals but in surgical centers as well, and performed almost without exception by one physician. "The test focuses on the stable, relatively healthy patient in a complete and comprehensive way as a cancer screen to check the overall health of the colon and also symptoms, such as rectal bleeding," notes Guttmann.

While patients may fear the very idea of the test and be concerned about being uncomfortable, the situation has been improved dramatically. "Patients drink two quarts of a cleansing solution, a much more pleasant-tasting liquid than the gallon of the old-style cleansing solution. Adding to patient comfort, for certain patient populations, at least, is the use of pills instead of liquid.

"Patients are also more effectively sedated; the scope is thinner and much more flexible, which means a gradation of flexibility can be created, important to comfort and safety since the colon is 3 feet to 4 feet long, and has many twists and turns," explains the doctor. "As for patient safety, the entire procedure is carefully monitored, including [the use of] EKG machines, oxygen-saturation assessments and blood-pressure devices; optics are better," with procedures done on "people as old as 100."

And the risk of injury -- of perforating the colon -- is low, he points out, happening to just 1 in 1,000 people.

Within the next five to 10 years, there will be options other than a standard colonoscopy, such as stool blood tests and other non-invasive tests, including virtual colonoscopy. More technically advanced methods of screening the colon should be available as well, including the use of different wave lengths of light -- similar to those used in night-vision technology -- that will allow a clearer view inside the colon.

Also in the works: HD colonoscopy -- coming into use now -- that identifies flat polyps, says Guttmann.

But it all depends on how accurate these options will be, so, until then, he adds, the very best way is the existing way.

Recent recommendations in a New England Journal of Medicine article suggest a colonoscopist spend at least six minutes inside the colon looking for polyps.

"Looking at the colon from its beginning to its end is critically important," says Guttmann. "That takes about five to 10 minutes, while most of the looking, which is shown on a screen via a lighted video chip inside the instrument, is done as the doctor withdraws the instrument."

Once sedation wears off, a patient will feel well again in a matter of hours, he says; the nausea and vomiting that used to be part of the experience is "almost unheard of today."

Unless there is a family history of colon cancer, a patient's first colonoscopy should be at age 50. For those with a family history, the first test should be at 40 or younger, says Guttmann. Six in 100 people run the risk of contracting colon cancer in their lifetime, while 12 percent to 15 percent of those with a family history of the disease do, he concludes.

Just the Facts, Please!

When it comes to allaying patients' fears about having the procedure,Mitchell Conn, M.D., MBA, associate professor of medicine at ThomasJefferson University Hospital, where he is director of endoscopic training,says that he just tells patients the facts.

"A colonoscopy has always been safe -- and is safer than ever today -- and is necessary because colon cancer is a very common cancer that affects about 7 percent of the U.S. population, with the risk greatest for people over 50, a risk that increases as someone ages," he explains. "The test is a unique form of screening, and is very important since it can diagnose and also help to prevent cancer by removing polyps."

In that sense, the test differs from a mammogram and PSA (a prostate test), which can only used as a diagnostic test, he says.

There is nothing to fear, Conn attests, since the equipment is safer and mechanically better. Even if polyps are found, they are generally benign, he notes.

Patients should seek an experienced colonoscopist, he advises, adding that an experienced colonoscopist who has performed many procedures may be technically better at identifying pathology and treating polyps.

In time, less invasive tests will become more commonplace, he says, as long as they're accurate. In the realm of science fiction vs. science fact, a capsule endoscope that a patient would swallow is in development, but for now a colonoscopy is the legitimate "gold standard" for screenings, says the doctor.

He credits some celebrities -- notably TV-news anchor Katie Couric, who had the test done on camera -- with encouraging people to schedule it: "The so-called 'Katie Couric effect' has gotten many, many people to have the test."

At Drexel University's College of Medicine, David Stein, M.D., assistant professor and chief of the division of colorectal surgery, relies on a mix of humor and realism to reassure patients.

"It's the whole bowel thing -- preparing for the test, cleaning out the colon -- that scares most people. The test itself is the easy part. I ask patients what's better, preparing for the test or getting cancer? Their own answer works to calm most of them," he explains.

"It's especially important that Ashkenazi Jews, who have a high incidence of inflammatory bowel disease or ulcerative colitis, and even Crohn's Disease, be screened," he adds.

For more information, log on to: www.coloncancerfoundation.org.

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