Colonoscopy

Is a medical exam which allows for the exploration of the lower part of the digestive tract made up of the Rectum, Sigmoid, descending colon, transverse colon, ascending colon, and the caecum.

What is a Colonoscopy used for?

A colonoscopy can be prescribed for various reasons and is becoming more frequently requested as a diagnostic exam. It is actually requested when a patient presents with the following:

• Blood in the faeces;
• Sudden weight loss without apparent reason;
• Presence of anaemia due to a lack of iron;
• Alterations of the colon and rectum during other examinations;
• Probability of the presence of ulcers, lesions, or celiac disease;
• Probability of the presence of intestinal polyps;
• The need to verify for the presence of colon cancer;

This exam also allows the specialist doctor to carry out surgical procedures such as the removal of polyps. By using instruments located within the endoscope, it is actually possible to take samples or perform small surgical procedures, block possible haemorrhaging or bleeding and finally perform emergency interventions. This procedure is especially important in patients who suffer from colorectal tumours.

Preparation for a colonoscopy

The preparation for colonoscopy requires a specific diet during the three days prior to the exam in addition to the taking of medications for the purging of the intestine. The preparation plan will be given to the patient directly by the specialist so that the patient will also receive specific indications where necessary.

The preparation phase is certainly very important, in that it allows for the proper exploration of the colon in optimal conditions.

Diet for a colonoscopy: what to eat and what not to eat?

As far as dietary restrictions, it is necessary to follow a diet without fibre three days prior to the examination. Here are some foods which can be eaten and others that must be avoided:

Foods to avoid:

• Fruit even dried and vegetables;
• Cereals and legumes;
• Smoothies and fresh squeezed juices;

Food that is permissible:

• Lean meat;
• fish;
• dairy and cheeses;
• eggs;

The morning of the exam and the day prior, a liquid diet must be followed so as to drink copious amounts of liquid except for milk and therefore decrease the intake of solid foods. Finally, in the six hours prior to the colonoscopy it is not permitted to eat solid foods.

Laxative drugs for the preparation: when and how to use them?

Laxative drugs for the preparation of a colonoscopy must be taken the day before the exam. Here is the procedure that must be followed:

• The laxative drug prescribed by the specialist is to be dissolved in water according to directions. It is to be taken the morning or the afternoon before the examination. Often it must be repeated twice that time in order to have the best results;
• There is no need to take purge liquids or enemas unless otherwise prescribed;
• Taking a laxative drug can decrease the absorption of other medications;
• Some laxative drugs are contraindicated in patients who suffer from favism;

What to do if you take medication?

In case the patient takes medications, it is important to let the specialist know. It is particularly important if the patient is taking anticoagulants or aspirin so that the specialist can evaluate whether to continue or to modify the treatment with these medications.

How to avoid the classic preparation: Colon Wash

It is now possible to have a colonoscopy done while avoiding the classic pre-procedure preparation. It is actually possible to book, at CertisMed centres that provide this technique, a procedure called Colon Wash. A Colon Wash means that the patient doesn’t need to take laxative drugs or purge drink prior to the procedure.

By using an innovative new machine, the patient will undergo a thorough colon cleanse. The wash is painless, fast and safe. With the Colon Wash it is sufficient to show up at the centre about an hour before the scheduled colonoscopy, saving time and inconvenience.

How is it done?

Procedure

A colonoscopy can last anywhere from 20 to 60 minutes. Colonoscopy is normally done in an outpatient situation even if sedation is requested.

The patient is asked to lie down on their left side. In this position the medical professional will then located the vein into which a sedative will be administered, at the same time, the patient’s vital signs, blood pressure, heart rate, blood oxygen levels, will be constantly monitored. When the patient is asleep, the doctor will proceed by carefully inserting the endoscopy into the anus and will guide it into the rectum and then on to the colon. During the colonoscopy the doctor will be able to thoroughly examine the mucosa and the walls of the intestine, and they can also painlessly remove fragments of the mucosa for further histological testing. During the examination, air is blown into the intestine so that the doctor can get a better visual.

A colonoscopy is known to be an invasive and painful test which may often require sedation. The exam, if performed following specific protocol and therefore using sedatives, will cause less discomfort or be completely painless for the patient. A colonoscopy done under sedation can be performed using various methods:

• Conscious sedation: requires the use of analgesic and hypnotic medications. The patient, even if sedated, remains conscious:
• Deep sedation or anaesthesia: is obviously much stronger than the previously mentioned conscious sedation, a colonoscopy under deep sedation can only be performed by an anaesthesiologist, who will be present throughout the entire procedure. This sedation will be done using a constant flow of the drug allowing for a deeper relaxation for the patient. For this reason the procedure is also called colonoscopy under anaesthesia;
• Colonoscopy without anaesthesia: as already noted, colonoscopies are test which cause pain, especially in patients who are more sensitive. It is therefore not recommended to undergo the exam without sedation, unless more modern, less invasive methods are used, such as robotic colonoscopy.

The drugs used to deep or conscious sedation are chosen based on the specific clinical characteristics of each individual patient, such as weight, age, and chronic pathologies.

Colonoscopy with Videocapsule

It is possible to perform a colonoscopy using a videocapsule. Here are the characteristics of this method:

Procedure: is an exam that is performed thanks to a pill that is swallowed with a bit of water. The pill contains a high definition camera which records the path that it follows. The endoscopic videocapsule is an examination created to analyse the intestine but not for the colon.

Sedation: not necessary.

Preparation: the same as for a traditional colonoscopy.

The endoscopic videocapsule can only be used to complete information that were not noted previously or that were not available during the conventional or robotic colonoscopy. The pill will be expulsed by the patient in a natural manner. This test is only for diagnostic purposes.

Virtual Colonoscopy

A virtual colonoscopy is an exam can be done in conjunction with a traditional or robotic colonoscopy. Here are the characteristics:

Procedure: It is really a CAT scan, by using powerful software, it reproduces the whole colon. The patient must therefore lie down on the scanner. The medical professional will then start the procedure so as to produce high definition images.

Sedation: not necessary.

Preparation: The same as for a traditional colonoscopy. A contrast medium will most likely be necessary.

It is a completely painless examination, but it allows for the virtual visualization of the inside of the colon. A virtual colonoscopy is also suggested in case a traditional colonoscopy is inconclusive, due to, for example a blockage.

Robotic Colonoscopy

A robotic colonoscopy is used as an alternative to or in addition to a traditional colonoscopy. In a robotic colonoscopy, instead of using a traditional flexible probe which is pushed by the medical professional, it uses a disposable robot with autonomous traction that is remotely commanded using a joystick.

The disposable probe, in addition to being safer than a traditional colonoscopy, which is sterilized after each procedure, totally eliminates the risk of perforation, thanks to its structure, completely flexible and with a very delicate movement.

A colonoscopy with a remotely controlled flexible endoscope is generally considered painless and not very invasive from the patient’s point of view.

Preparation: The same as for a traditional colonoscopy, unless a colon wash is performed;

Sedation: not necessary;

Procedure: The exam is the same a traditional colonoscopy and is done in an out-patient situation; the patient lies down on their side. The robotic colonoscopy generally takes longer than a traditional colonoscopy and can last anywhere from 30 to 60 minutes. During the robotic colonoscopy, the patient is completely awake and can interact with the doctor. Finally, a robotic colonoscopy just like a traditional exam, allows for operative procedures, such as biopsies, and the removal of polyps (polypectomy).

Colonoscopy and pain

Is a Colonoscopy painful?  

A colonoscopy is considered an uncomfortable and potentially painful exam. The pain is caused by the endoscopic probe that in order to reach the last part of the colon, it has to be manually pushed. This pushing causes the probe to hit the walls of the colon, causing pain. Also the injection of air during the procedure can cause further pain and cramping, caused by the stretching of the intestinal walls needed to guarantee excellent vision of the intestinal walls.

For all of these reasons sedation is recommended, allowing the patient to relax making them feel calmer. The lack of proper sedation will without a doubt interfere with the procedure.

Will I have pain after the colonoscopy?

After having a colonoscopy, especially if an operative procedure such as the removal of polyps is necessary during the exam, there will be pain and discomfort in the 24 hours after the procedure. The most common symptoms after the examination are the following:

• Feeling of intestinal bloating;
• Cramps;
• Quick, sharp pain, especially in the area of the intestine where tissue was removed;

The above mentioned symptoms can be stronger in patients that have a lower pain threshold. If the symptoms become too strong or do not go away quickly, it is advised to consult a doctor.

Colonoscopy with biopsy

A colonoscopy, whether it’s robotic or traditional, is a test that not only examines but also allows for operative procedures to be performed. The most common operative procedures are biopsies and polypectomies, the first is done in order to remove portions of tissue that will later be analysed in a lab so as to confirm the presence of possible pathologies, and the second is used to extract masses called polyps that can develop on the intestinal walls

What are polyps?

Intestinal polyps are formed in the mucosa of the intestine, above all in the colon and in the rectum. The majority of these neoformations are benign in origin; however they need to be monitored so as to avoid future complications. Thanks to a colonoscopy it’s possible to identify potential neoformations, very frequent in people over the age of 60 and especially for those who had a family history of tumours of the colon. There are different types of polyps:

• Peduncular polyps: stick out from the mucosa and have a peduncula.
• Sessile polyps: do not have a peduncula and can be difficult to remove.
• Polyposis: is a genetic defect and is characterized by the presence of over 100 polyps.
• Hyperplastic and inflammatory Polyps: are often identified in conjunction with other pathologies (Crohn’s disease, diverticulitis and colitis), but fortunately they are benign in nature.
• Neoplastic and adenomatous Polyps: are polyps that present themselves with histologic characteristics in a more or less advanced stage of development.

How is a polypectomy performed?

Once the polyp that is to be removed is identified, the technique requires the polyp to be cut at the base of the peduncula, thanks to the use of a specific scalpel in the shape of a loop.

Not all polyps are peduncle; those that are sessile for example, completely adhere themselves to the walls of the gut and in this case it may be necessary to remove them piece by piece, repeating the colonoscopy in different occasions. When the polyp is very big or doesn’t have a peduncula, the doctor can decide to inject a vasoconstrictive drug at the base of the polyp, which reduces the risk of haemorrhaging.

Regardless of the polypectomy technique used, after the removal of the entire polyp or of its fragments, the material is sent to a laboratory for a histological analysis; examining the characteristics of the polyp, the specialist anatomy pathologist can then establish is further tests and/or operations will be needed or not. Fortunately, only in a limited number of cases, for example, does the test discover the presence of tumour cells at the base of the polyp or the peduncula; in such cases a polypectomy cannot be considered conclusive and it may be necessary to have surgery in order to remove part of the colon where the polyp was located.

The Biopsy

It’s useful above all when there are inflammations present or to analyse tissues that are not homogenous. With a biopsy, the specialist can remove samples of tissue and organic matter by using miniaturized surgical pincers, and which will then be sent to the laboratory for analysis.

Colonoscopy and risks

What are the risks of a Colonoscopy?

Just like any medical exam, colonoscopies also have risks.

The possibility of incurring risks is almost non-existent, provided that the patient choses specialised centres with skilled professionals. A colonoscopy therefore, can be considered a safe test. Here are the types of risks of a colonoscopy:

• Risk of perforating the intestine: the reasons can be multiple, for example a perforation can be caused by excessive force on the part of the medical professional with the instrument, or an improper operative procedure;
• Risk of bacterial contamination: as is known, in the traditional technique the colonoscope is sterilized after each exam. Improper sterilization can increase such a risk;
• Risk of haemorrhaging: in specific situations, that is to say when the patient has inherent problems of blood coagulation; it can be particularly risky during a colonoscopy to perform operative procedures such as the removal of polyps.

Side Effects

In rare cases, after a colonoscopy, some patients make complain of the following problems:

• Diarrhoea;
• Constipation;
• Minor bleeding during the first bowel movement, especially if biopsies or polypectomies were performed during the exam;
• Abdominal pain and cramps, abdominal bloating.
• Bloating and flatulence are fairly common in the post-exam phase as a necessary consequence of the air blown into the intestine to improve vision through the probe.

If the exam is performed under sedation, the patients may complain of feeling light headed or of fatigue, in some cases they may be nauseous. These disturbances, normally, go away in the 24 hours following the exam; if not then the patient must contact their doctor.

After the colonoscopy: diet

To avoid certain recurring disturbances (like constipation and diarrhoea) it is generally advised to pay close attention to diet after a colonoscopy. The patient must remember that after the exam, the intestine is fundamentally lacking some of the substances which allow for proper functioning (ex. Bacterial flora and protective mucous). This happens because the preparation for the colonoscopy aims at cleansing the digestive tract, to permit the specialist to better explore the colon with the probe.

Examples of foods that should be avoided after a colonoscopy:

• Alcohol;
• Coffee;
• Fatty foods;
• Overly rich foods;
• Spices (it is preferable to avoid sausages etc.);

Examples of foods that can be eaten after a colonoscopy:

• Well-cooked legumes;
• Fruits and vegetables;
• Pan cooked veal (fried of grilled may cause disturbances to the intestine);
• Yogurt;
• Water and mineral salts (it is recommended to drink small amounts but often);

After the exam it is normally recommended that the patient rehydrates themselves by absorbing liquids gradually and frequently. In the same way it is recommended that foods making up a normal diet be reintroduced gradually in the days following the exam.