Now, it's my great pleasure to introduce my partner and dear friend, Dr. Sumit Tiwani. Sumit joined Rockford Gastroenterology Associates in 2014. He received his combined bachelor's degree in the medical sciences and medical degree at Boston University. He completed his residency in internal medicine, fellowship in gastroenterology and hepatology, and an additional fellowship in advanced endoscopy at the Beth Israel Deaconess Medical Center and Harvard Medical School in Boston, Massachusetts. During his GI training, he served as chief fellow for the program. At the University of Illinois College of Medicine at Rockford, Dr. Tiwani holds the title of clinical assistant professor of medicine, director of gastroenterology curriculum, and serves on the medicine executive committee. Dr. Tiwani has a broad-based interest in digestive disease and endoscopy with special interest in liver, biliary, and pancreatic diseases, gastrointestinal oncology, and barotosophagus. He has advanced training in the therapeutic techniques of interventional endoscopy, including ERCP, endoscopic ultrasound, EMR, and RFA. Sumit's scientific research has been published in national and international journals. As we like to say in this course, Sumit, take it away. Thanks, Joe. Thank you to Joe and Sarah both for inviting me to talk to this conference. My talk this morning is on the basics of colonoscopy. We're going to have some overlap here with some of the topics that Dr. Martin has already touched on, but I have no disclosures. We'll start with a polling question first. Colonoscopy is the only screening test that can detect and remove polyps in the same setting, true or false? Excellent. The audience picked on this as the only screening test that can both detect and remove polyps, and we'll touch on that later in the talk. We have one more true or false question. Delayed post-polypectomy bleeding most commonly occurs between five to seven days. All right. Actually, the answer here is true, and we'll see that later in the complications section, but that delayed post-polypectomy bleeding window most commonly is about five to seven days after the procedure has been performed. Our objectives for the talk today, we're going to break down colonoscopy into different phases of the procedure. We're going to talk about the pre-procedure phase, the actual procedure itself, inter-procedure, and then post-procedure. We'll talk about patient selection, knowing complications and risks thereof, and then if we have a chance, we'll touch on artificial intelligence. Pre-procedure, before actually proceeding with a colonoscopy, it's important to consider the patient's indications for the procedure, their symptoms, whether the procedure is appropriate for the patient, and also what time frame are we trying to perform that procedure in. Timely scheduling is important. You want to consider, does the patient have acute or urgent symptoms, such as bleeding, weight loss? These are considered alarm symptoms. Or are they presenting, for evaluation, more chronic symptoms, such as chronic diarrhea? A lot of patients will present complaining with lifelong symptoms, and the urgency with which that colonoscopy may need to be done may be okay for a few weeks down the road, whereas somebody with more urgent symptoms, you might want to bring in within the next week or two to do their evaluation. So, it's important to consider the timeliness of that scheduling for the procedure, depending on the indication. Patient selection itself, so when a patient's presenting, will doing a colonoscopy actually affect the management of that patient? What do you anticipate potentially finding at the time of a colonoscopy that's going to affect the way you approach your management? Have you considered impaired treatment ahead of time? If they have symptoms that make you concerned most prominently for irritable bowel syndrome, might you try a trial of fiber or probiotics before considering a colonoscopy, particularly if there's no alarm symptoms right away? If they've failed impaired treatment, then that would be potentially an indication to proceed with the procedure as initially planned. Do you anticipate any therapeutic interventions? So, if they have a history of polyps or large polyps, do you anticipate needing a resection, endoscopic resection during the procedure? If they're presenting with rectal bleeding and they have a history of radiation to the prostate for prostate cancer, might you anticipate encountering radiation proctitis and anticipate needing to provide coagulation therapy during that procedure? If they have a history of bowel resection and they're presenting with symptoms that make you concerned about the possibility of a stretcher, might you anticipate a dilation? So, it's important to anticipate based off of the history and the symptoms what kinds of therapeutic interventions might be encountered or necessary during that colonoscopy. And colonoscopy can serve as an alternative for radiology. It's important to think that, to understand that CT scan can provide a lot of information, a lot of detail for many of the symptoms that patients will present with, but many times there are smaller things that the CT scan may not be able to pick up on. Even mucosal changes related to inflammatory bowel disease, early changes may not be picked up on CT scan and you're more likely to find those changes on a colonoscopy. So, again, thinking about the indications, are they presenting for a screening or surveillance procedure? Are they presenting with actual symptoms such as bleeding or weight loss, anemia? And do they have, what's their pre-procedure testing has shown? Do they have abnormal imaging? Do they have an abnormality on the CT scan that needs a close examination? Are you anticipating the need for diagnostics or therapeutic interventions during the colonoscopy? It's also important to consider what are the potential contraindications for the patient. So, it's important to assess against the benefits of the colonoscopy versus the risks. If somebody has multiple comorbidities, they're on antiplatelet therapy or anticoagulation, are they acutely ill with electrolyte abnormalities? Are you seeing this patient as an inpatient? It's important to consider what are the risks of the whole process, risks of the procedure itself, but also the risks of sedation, risks of anesthesia, risks of bowel preparation for those patients. The patients that you're not able to get consent for, if it's not an emergency procedure, what is the process to obtaining consent for those patients? Defining the appropriate healthcare surrogate or power of attorney. If a patient has a known perforation or a suspected perforation, that would be a contraindication to insufflating air and spit pollen to perform a colonoscopy. In the presence of fulminant colitis, such as severe ulcerative colitis or C. difficile colitis, the risks of colonoscopy would significantly outweigh the benefits of that exam. And again, in the setting of acute electrolyte abnormalities, the risks of the procedure, risks of sedation, risks of bowel prep all need to be considered. And now we're preparing the patient for the colonoscopy. And before we actually embark on the procedure itself, we want to think about the bowel preparation, sedation, and informed consent, as Dr. Martin has already touched on. Some of the things to consider, is this patient appropriate for a clear liquid diet before the procedure, the day before, as part of their preparation? Might they be more reasonable to have a low residue diet? Somebody who has no GI symptoms is presenting for a routine screening or surveillance. They don't have any disease contraindications. They don't have underlying constipation. Low residue diet may improve the patient's satisfaction and may improve patient's compliance with follow-up. A lot of people fear the procedure itself, but it's clear liquid diet that they end up quoting as the more difficult portion of a clear liquid diet in the bowel prep, as opposed to the procedure itself. So trying to accommodate and allowing low residue diet the day before may improve satisfaction and follow-up. It's important to consider the medications that they're on and how you might need to adjust or hold those prior to the procedure, any anti-coagulation and anti-platelet agents, particularly if we're considering or anticipating any therapeutic interventions. It's important to have a discussion with the patient and share decision-making, both with the patient and the prescribing provider, whether that's the primary care doctor or the cardiologist or other relevant specialists, as to is it appropriate to hold those medications how long to hold these agents as well. Newer medications that you may have heard of recently in terms of recommendations from our anesthesia colleagues or endocrine and cardiology colleagues, GLP-1 receptor agonists, such as Ozempic and Wigovy, Monjaro. The Anesthesia Society has recommended that we hold these for about a week before colonoscopy. I know that's a point of controversy right now. The GA has said that maybe we don't need to follow that very strictly, particularly if patients don't have any symptoms. But this is worth investigating or understanding your colonoscopist, your anoscopist and their relationship with their anesthesia colleagues about their recommendations before procedures. The same with the SGLT-2 inhibitors. The American Diabetes Association and American College of Cardiology have both recommended holding these three to four days before surgery. And this is in anticipation that dehydration, given an NPO status or prep for surgery, increases the risk of vasodosis with these medications. So, it might be worth considering holding these for a few days before bowel prep for colonoscopy. Again, no clear guidelines at this point from the GI Society, but something to consider in discussions with the prescribed providers. This is an example of the Boston Bowel Prep score. So, this is one of several scoring systems that are used during colonoscopy to grade the bowel prep. Previously, we used to use terms like excellent, good, fair, poor, and inadequate. But over time, we've become more structured in the way we should define our bowel prep. We break it down into the scores of the left colon, the transverse colon, and the right colon. And scores range from zero to three. Both two and three would be considered adequate, whereas one, which is four, or zero, which is basically unprepped, are considered inadequate preps. And you grade each segment of the colon as you add up the sum. If you have a sum of six or greater, that would be considered an adequate bowel prep for the procedure in somebody with an intact colon. But keep in mind also that if you have any segment that's less than two, so if you have a colonoscopy where the left colon is a three, the transverse colon is a two, and the right colon is a one, even though that sum is six, that right colon really had an inadequate prep, and that's a patient where you would want to consider bringing them back sooner than later with additional bowel prep or extended bowel prep to properly evaluate the right colon. So you'll see this more standardized on colonoscopy reports. Now we get to the actual procedure itself. Important pieces of consideration during the procedure is you want to make sure you're performing a high-quality exam. Take your time to examine each fold behind each flexure. Make sure you're getting an adequate view, washing any residual debris or mucus or bubbles as we saw in Dr. Martin's video. Make sure you're not missing any small polyps or lesions. You also want to understand what are the quality indicators of colonoscopy and understand how to achieve those quality indicators. Sequel intubation rates should be greater than 95%. Withdrawal times should be certainly at least six minutes, and that seems to be getting longer and longer in terms of the recommendations. Maybe an optimal time is closer to nine or ten minutes of a withdrawal. Adenoma detection rates, we'll touch on that towards the end, and also understand the complication rates of the providers that are performing these procedures, also taking into consideration the types of diagnostic or therapeutic maneuvers that are being done. During the procedure, we have various types of colonoscopes that we can consider using. The general types are the adult colonoscopes, which are a little bit wider and stiffer, as compared with pediatric colonoscopes, which are a little thinner and more flexible. Certain manufacturers also have hybrid scopes, which sits somewhere in between. There's also super slim scopes, which may be useful for patients that have known strictures, so it's important to consider the type of colonoscope you want to use. Scope choice is dictated by a number of different factors. Personal preference for the endoscopist, the patient's body habitus, knowing the previous history and previous attempts at colonoscopy, did that patient have a difficult colonoscopy previously, and what were the reasons for the difficult colonoscopy? Was it looping in a long and tortuous colon, or was it sharp angulation in the flexures of the sigmoid colon? That will influence your decision as to what scope you choose for the procedure. You should also understand the different devices and accessories that are available for your use for these procedures. Forceps are rarely used for diagnostic, for biopsy, but the stairs are used for polypectomy, injection needles for injecting into the submucosal space. This can be used for lifting of polyps prior to resection. This can be used for administration of medication, such as epinephrine, if you're trying to treat a post-polypectomy bleed, or injection of a tattoo, carbon black or Indian ink, to tattoo an area of polyp, sorry, an area of the colon, either after a complex polypectomy for future reference and surveillance, or if you've made a diagnosis of a cancer, to facilitate identification during an operation by your surgeons. So you have various needles, you also have various hemostatic devices as well available. The most commonly performed procedure during a colonoscopy is biopsy, and polypectomy. Those are far away the two most common. Tissue sampling, meaning biopsies, so any abnormality that you might identify if you're looking at, say, an area of the colon that appears inflamed, or ulcerated, or even if you're doing random sampling when you're assessing a patient for microscopic colitis, a tissue sampling is polypectomy. This is, of course, for any screening and surveillance colonoscopy, but even for any diagnostic colonoscopy, if you encounter a polyp, you can perform a polypectomy in that same setting many times. And I mentioned tattooing for future reference, surveillance, or for identification during an operation. Endoscopic hemostasis, we have quite an armamentarium of devices that can be used depending on what we're trying to treat. APC is argon plasma coagulation. This is a type of non-contact coagulation that can be used particularly for treating AVMs and radiation proctitis. Electrocautery devices, so you can use snares with electrocautery-enhanced currents to allow a hot polypectomy as opposed to a full-snare polypectomy. Irby is the name of the most commonly used electrosurgical generator to provide those currents to allow APC and hot snare. Then you have hemostatic clips, which are endoscopically placed through the scope clips to treat bleeding lesions. We'll see a picture of that in a moment. We can use balloons through the scope to dilate strictures. We can place decompression tubes through a colonoscope in patients in the hospital with valvulose or pseudo-obstruction. We can place stem sterile colonoscopy for palliation or for bridge to surgery in patients with nearly obstructing or completely obstructing colon cancer. There's a number of therapeutic maneuvers that can be done. This is an example of a polypectomy. You see the white portion is the snare. The snare is actually closed around the base of that polyp. Once you have it secure, just closing that snare through the base will allow that polypectomy to be complete. You can use electrosurgery if needed to provide more clottery. Clottery will reduce the risk of immediate bleeding, but that does carry a risk of delayed bleeding, particularly in those patients with antiplatelets and anticoagulation. This is an example of an AVM. What you see in the bottom right corner is the tip of the device that provides APC. APC, like I said earlier, is non-contact, so keeping the device just off the mucosa will allow the argon gas to carry the current to the mucosa and clotterize this vessel. You have to consider complications, the complications that can be encountered during a colonoscopy. As Dr. Martin mentioned with upper endoscopy, the risk of serious complications with colonoscopy is also very low. The most commonly encountered complication or risk is related to sedation, and that is cardiopulmonary risks or maybe transient hypoxia, but also it's important to consider other risk factors, particularly in the setting of patients who have other medical comorbidities, so it's important to have a proper pre-procedure understanding of their anesthesia risk. You may want to consider those patients that are at elevated risk to have anesthesia support, so MAC anesthesia or deep anesthesia, with the assistance of our anesthesia colleagues, as opposed to conscious sedation. You want to make sure they have appropriate monitoring before, during, and after the procedure, continuous monitoring of their pulse, blood pressure, oxygen saturation as well. Other most commonly encountered complications from colonoscopy would be, would include, post-follow-up ectomy bleeding and perforation. When you encounter post-follow-up ectomy bleeding immediately, there are a number of things that we can do. We can inject epinephrine to the area to provide tamponade, maybe something as a constrictive effect to allow control of that bleeding. Hemostatic clips can be used to provide a mechanical closure, and then thermal therapy or coagulation. Perforation can occur for various reasons. Mechanical trauma, so as we're passing the colonoscope towards the cecum, if there's significant looping at an angle, such as in the sigmoid colon or one of the fletchers, then it could be mechanical trauma during the loop formation. Barotrauma can occur if you're applying a significant amount of pressure to the abdomen or forward pressure as you're trying to push the scope forward. And then electrocautory injury, particularly if we're taking out a large polyp, that electrocautory injury can lead to a perforation or post-follow-up ectomy syndrome. So this is an example of what appears to be post-follow-up ectomy bleeding. You can see two clips in this picture that applied to the polypectomy site in order to try to control that bleeding. And this is an example of a perforation that you might encounter. And this is something that, with some of our tools, we may be able to close endoscopically, but it's also important to understand that if you encounter this, whether you try to close this endoscopically or not, this is a patient that you need to talk to post-procedure and should be admitted and have surgical colleagues assess the patient in case of a peritonitis. These patients will be on antibiotics post-procedure and be hospitalized even after closure. So post-procedure, so now we've completed the procedure. We've done our interventions or done our biopsies and polypectomies. Now we have to think about how are we going to inform our patients of those findings. Most commonly we'll do that immediately post-procedure, but many times those patients may not recall the findings. So it's important to have appropriate documentation of the post-procedure findings and access afterwards. So if the patient needs to call later and have access to your triage nurse or somebody in the department who can relay those findings again to the patient. We can rely on some family members, but family members may not always be the most reliable either. And then what if you found abnormalities during the procedure? You might want to make some medication changes right away. You may want to wait on pathology results. Do you have a mechanism in place for appropriate follow-up of those pathology results? Will you have that patient return to clinic to review those results before starting medications? And for those patients who are coming for screening and surveillance colonoscopies and the only therapeutic intervention you did was polypectomy, you should have a surveillance program built in. So based off of the polyps, the size of the polyps, and the pathology that's resulted, you have a plan in terms of what's the appropriate surveillance interval, whether that be three years, five years, seven years or longer, depending on the pathology. Coming back to those quality indicators, now it's important to consider participating in a good database for tracking your quality, tracking your quality numbers. Adenoma detection rates, they're national benchmarks that have been published. Overall, adenoma detection rates of greater than 25% in your initial screening colonoscopies. For men, that should be higher, greater than 30%. And for women, that's a little bit, national benchmark is 20%. You'll see many practices will have rates much higher than that, but these are the nationally published benchmarks. You want to make sure that you're achieving those benchmarks. Sequentivation rate greater than 95% and very low complication rates and post-polypectomy bleeding rates of 1 in 500 to 1 in 1,000 and similar for perforation. Those complications, again, post-polypectomy bleeding. So immediate post-polypectomy bleeding is identified immediately during the colonoscopy or within the first 24 hours. Post-polypectomy bleeding is more common when we use clotting-enhanced polypectomy. And the most common timeframe for that is five to seven days after the procedure. Those patients may present to the hospital with significant bleeding and maybe getting the history that they just recently had a colonoscopy will guide your treatment. Recognizing perforation, whether that's identified immediately during the colonoscopy or in their presentation immediately afterwards, if they're in significant pain in that post-procedure recovery area, think about the possibility of perforation. And then post-polypectomy syndrome, patients may present with acute onset of pain or fever within 24 hours or so of the procedure. Many times they'll present to the emergency room. Imaging may not show any evidence of perforation, may show some localized thickening, particularly in an area where you're treated with a polypectomy or coagulation therapy for treatments. And those patients would benefit potentially from antibiotic therapy and an observation. In the interest of time, I'll skip over artificial intelligence other than say that this is the new kid on the block. Very exciting. There's a lot of interest, particularly in colonoscopy in terms of using artificial intelligence, both for the identification or detection of colon polyps and for diagnostic purposes in terms of differentiating the pathology. So, identifying adenomas as opposed to hyperplastic polyps or other lesions. Obviously, there are financial challenges potentially. This is a very new technology, but very exciting technology nonetheless. So, it's important to think about the various phases of colonoscopy. It helps to think of the pre-procedure, intra-procedure, and post-procedure phases and what you want to consider in each of those phases. Particularly with patient selection, whether it's sedation, pre-procedure, medication changes, what's the appropriateness of the procedure, timeliness of the procedure, and the presenting symptoms. It's important to recognize complications, what the risks of those complications are, and how to manage those. Will the procedure change your management for your patient? How will it affect subsequent management and subsequent treatments? And participate in a quality database to track your quality measures. And then AI is the new kid. A very exciting future for colonoscopy. Thank you.

Dr. Sumit Tiwani

colonoscopy

pre-procedure

intra-procedure

post-procedure

adenoma detection rates