Colonoscopy Day

What is a colonoscopy?

Colonoscopy is the endoscopic examination of the large intestine, also known as the colon.

Why might my doctor refer me for a colonoscopy?

One of the most important reasons to have a colonoscopy is as prevention against colorectal cancer (CRC). Screening with colonoscopy starts for most people at age 50. Individuals with an increased risk for CRC due to a strong family history or specific medical conditions (e.g. ulcerative colitis, Crohn’s disease, hereditary polyposis syndromes) are recommended to start screening at an earlier age. Other reasons to undergo a colonoscopy include alterations in bowel habits, abdominal pain, blood in the stool, and iron-deficiency anemia.

What do I need to do before a colonoscopy?

We will provide you with detailed written instructions before the colonoscopy. These include both dietary modifications and a colon cleansing regimen. You should know that excellent bowel preparation is crucial for performing a high-quality colonoscopy. Additionally, you ought to inform your doctor about any allergies you have, or if you take medications which affect blood clotting, such as Pradaxa, Eliquis, Xarelto, warfarin, clopidogrel, heparin injections, or anti-inflammatory drugs. You may be told to discontinue some of them for a few days prior to the examination. 

How is a colonoscopy performed?

During the procedure you will remain sedated and experience no pain or discomfort. You will have no memory of the procedure afterwards. However, your vital signs will be under constant monitoring, including the blood pressure, heart rate, and oxygen saturation.

The gastroenterologist will then place a thin tube with a camera on the end into your anus and advance it past the different parts of the large intestine (Figures 1-3). This allows the examination of the internal lining (mucosa) of the colon. A small piece of tissue (biopsy) may also be taken to be further examined under a microscope.

Importantly, during colonoscopy we may remove any polyps (growths) that are identified (see endoscopic polypectomy). This has been shown to significantly reduce your risk for developing colon cancer in the future.

Are there any side effects of colonoscopy?

Colonoscopy is a very safe procedure, provided it is performed in a well organized endoscopic department with trained personnel. Extremely rare complications include bleeding following large polyp removal and tears in the wall of the bowel (perforation). These are usually dealt with endoscopically and only very rarely require surgery.

What happens after a colonoscopy?

Most people feel completely well once they recover from the sedation. You may feel slight bloating or mild abdominal pain, which will quickly improve with the passing of some gas. Once you have recovered fully from the effects of sedation, we will sit together so that we may discuss any findings and any therapy to be prescribed. In case polyps have been removed, we will recommend the appropriate timing for the next examination (usually in a few years), taking into account the results of the biopsy. 

If you have received sedative drugs you will not be allowed to drive for at least 6 hours. Eating and drinking is generally permitted about 30 minutes after the procedure.

What is videocapsule enteroscopy (VCE)?

VCE is a noninvasive technology that enables imaging of the small intestine. The capsule is the size and shape of a pill and contains a tiny camera (Figure 1). Following its ingestion, the capsule provides detailed images as it passes through the small intestine, offering complete visualization of the entire organ (Figure 2).

What are the indications of VCE?

The main indication is the evaluation of suspected small bowel bleeding (presenting either as visible bleeding or as iron deficiency anemia), following negative testing with gastroscopy and colonoscopy. Other indications include the diagnosis of suspected Crohn disease, small bowel tumors, hereditary polyposis syndromes and maybe celiac disease.

What is the procedure?

Patients should fast for at least 12 hours. Many doctors suggest polyethylene glycol preparation (similar to that given for colonoscopy) 16 hours before the procedure. The capsule is swallowed and sends images to a sensor that is fastened to the abdomen like a belt. The total duration of the examination is approximately 8 hours. After the first 4 hours the patient may eat a light meal. At the end of the procedure, the doctor examines the obtained video, while the capsule is expelled with the bowel movements.

What does the term polypectomy refer to?

Polypectomy refers to the removal of colon polyps during colonoscopy. It has been established that polypectomy decreases the risk for colorectal cancer.

How are colon polyps removed?

The polyps are removed during colonoscopy with a variety of techniques depending on polyp size, shape and location (Figures 1-3). During the procedure the patient remains sedated and experiences no pain or discomfort.

Are there any polypectomy-related complications?

Endoscopic polypectomy is definitely a safe procedure. Its most common complications are bleeding and perforation, occurring in approximately 1 in 1000 patients. Bleeding can be stopped immediately with hemostatic methods including application of clips, adrenaline injection and coagulation. Perforation may be managed either conservatively with intravenous fluids and antibiotics or surgically, taking into account several factors. 

Should the endoscopist be aware of my medications prior to polypectomy?

Anticoagulants, antiplatelets and anti-inflammatory drugs are of special interest. The gastroenterologist may also ask for blood tests prior to the procedure or even discuss with other doctors (e.g. cardiologists) regarding coagulation issues for each individual patient.

What happens after I have polyps removed?

In the vast majority of cases the patient returns back home and their everyday activities after polypectomy. You might need to have a colonoscopy every few years to look for new polyps. Also, if the polyps you had removed were of the precancerous type, people in your family might need to be checked for polyps and colon cancer, too.

What does the term Endoscopic Retrograde Cholangiopancreatography (ERCP) refer to?

ERCP is an examination used for the diagnosis and treatment of biliary and pancreatic diseases.  It has been developed in the 1980’s and has dramatically decreased the need for major open surgical interventions.

How is it performed;

During ERCP the patient remains under deep sedation and feels no pain or discomfort. The endoscope is advanced through the mouth, esophagus and stomach into the duodenum and reaches an area called ampulla of Vater, where both bile and pancreatic ducts drain (Figure 1).  A small plastic tube (cannula) is passed through the endoscope into the opening of the bile duct, dye is injected, and X-ray pictures are taken. Subsequently, a small cut in the duodenal wall is made so that the endoscopist can perform a variety of therapeutic interventions (stone extraction, stent placement etc.) according to the diagnosis (Figure 2).

ERCP indications

Obstructive jaundice
Choledocholithiasis (stones in common bile duct)
Malignancies of the pancreas or biliary tract (cytology and stent placement)
Benign biliary strictures
Acute lithiasic pancreatitis (with co-existing cholangitis)
Biliary tract trauma (iatrogenic or not)

Are there any complications?

ERCP can be accompanied by complications like pancreatitis, bleeding and perforation, the two latter being extremely rare (<1%). Pancreatitis (inflammation of the pancreas) is the most frequent complication, occurring in about 5 to 7 percent of people undergoing ERCP. When it occurs, it is usually mild, causing abdominal pain and nausea, which resolve after a few days in the hospital. Rarely pancreatitis may be more severe.

A variety of endoscopic and pharmaceutical methods exist to decrease the incidence of post-ERCP pancreatitis. Mandatory parameters include careful patient selection and an adequately trained endoscopist. In the USA training in ERCP is provided additionally to the standard gastroenterology program (i.e. fellowship in advanced endoscopy). Dr. Scotiniotis has received such training in the University of Pennsylvania, Philadelphia, while Dr. Sioulas has obtained a similar experience in the University Hospital of Hamburg, Germany.

What is Endoscopic Ultrasound (EUS)?

ΕUS is an examination that combines endoscopy and ultrasound. In that way we are able to examine deeper parts of the esophageal, gastric or bowel wall as well as the surrounding tissues (mediastinum, pancreas, biliary system, lymph nodes, etc.).

How is it performed?

The patient is under sedation and feels no pain or discomfort. The procedure is accomplished with a specialized flexible endoscope and lasts approximately 30 minutes. Afterwards, the patient returns home.

What are the indications for EUS?

1. Diseases of the pancreas and biliary tract:
   EUS enables detailed examination of the pancreas and extrahepatic biliary tract. It may clarify lesions that are found in other examinations like CT and MRI or even diagnose extremely small lesions (sized 5-10mm) that can not be identified otherwise (Figure 1). It is also very useful for the assessment of pancreatic cystic lesions.

2. Staging of esophageal, gastric and rectal cancer:
   EUS is a very precise tool for the staging of esophageal, gastric and rectal cancer. Furthermore, in the preoperative setting EUS can identify those patients that are eligible for neoadjuvant chemotherapy (i.e. chemotherapy prior to surgery).
3. Submucosal lesions of the gastrointestinal wall:

EUS enables examination of the deeper layers of the gastrointestinal wall. Accordingly, submucosal lesions can be assessed to guide further management. Surrounding tissues and vessels (e.g.varices) can be also evaluated.

What is EUS-FNA?

EUS-guided Fine Needle Aspiration (EUS-FNA) is the acquisition of tissue from tumors or fluid from cysts through thin needles under EUS guidance.  It has been shown that EUS-FNA contributes significantly in the diagnosis of various abdominal masses and the correct characterization of cysts (e.g. pancreatic cysts) (Figure 2).

A few EUS-FNA performing centers exist in our country. Our experience involves more than 1500 patients referred to us from all over Greece. The examination is painless and extremely safe (pancreatitis in only 0.6% of the cases). According to the results of internal audit our sensitivity for diagnosing malignancy reaches 95%, being within the recommended international standards.