So this actually, I think, brings us to our next Q&A session. We should have maybe about 10 minutes or so for Q&A. Maybe we do want to make sure we have adequate time for everybody to break for lunch as well. We do have a few questions that we can start with. I think there's one question. The first question is actually relevant to the previous talks. We'll come back to that in a second. But coming to the relevant questions for these talks, Dr. Martin and myself. First question is, can we diagnose ischemic colitis based on patient's symptoms with abdominal pain and rectal bleeding, or a colonoscopy should be completed first? This is a great question. I think there's variability in terms of how we practice. Ischemic colitis can be diagnosed in the right clinical situation with the right presentation and many times with imaging. So a patient with left-sided abdominal pain, rectal bleeding, diarrhea, and a typical pattern of ischemia on CT scan, you may be able to make that diagnosis right then and there without a colonoscopy or sigmoidoscopy. Personally, I tend to reserve endoscopic evaluation for those patients who may not be improving or when there's really other diagnostic consideration, you know, is inflammatory bowel disease in the consideration is pseudomembranous colitis from C. difficile consideration as opposed to ischemic colitis. But the majority of presentations, yes, you can pretty confidently make that diagnosis without colonoscopy. Next question, a patient had colonoscopy for history of colon polyps with seven-year recall. If he needs another colonoscopy in, let's say, four years for diarrhea and rectal bleeding, do we build a second scope as diagnostic or surveillance colonoscopy? So this gets to the importance of understanding the indication for the colonoscopy. A surveillance colonoscopy is essentially being done for follow-up of the previous history of colon polyps and in those patients who are presenting without symptoms, regularly scheduled, routinely scheduled surveillance colonoscopy without symptoms. In this case, you're doing a colonoscopy sooner than their recommended surveillance interval and even if it's after the recommended surveillance interval, if it's done for evaluation of certain symptoms, that should be a diagnostic colonoscopy. You're doing that not specifically to look for polyps, you're doing that for evaluation of their diarrhea and rectal bleeding. If you find polyps along the way, you may choose to remove those, but that colonoscopy indication is diagnostic. Next question, what specific recommendations or guidelines do you follow for determining the appropriate follow-up intervals after a colonoscopy considering factors like number, size, and type of polyps and individual risk factors? So there are actually some excellent guidelines. I think all three societies, ASGE, ACG, and the AGA published updated guidelines, I want to say in 2020, specifically detailing those considerations. It will come down to the numbers of polyps, size of polyps, the pathology involved, and whether any of the pathology was advanced polyps or not. And also considering family history and how that would affect the decision making around that. So that's the resource that I would recommend you seek out and there's very detailed guidelines there. Also understanding that there are differences potentially between adenomatous colon polyps and sessile serrated polyps as well. Next question, what is your normal practice if a patient presents for screening colonoscopy consult and there are no prior records of their past colonoscopy and the patient says they are due or the PCP sent them for one? Do you err on the side of caution and just do one? This is a great question. I will typically have that conversation with the patient about, you know, we would like to get your records. If we can get your records, we can make a specific recommendation based off of the findings on the previous colonoscopy. But understanding that a lot of times those, that procedure was performed elsewhere. Sometimes our patients may not even recall exactly where that procedure was if it's been 10 years or longer. And again, if it's depends on the indication, if it's a routine screening and it's been over 10 years and we can't track those down, or even if we can track those down, you know, is it an appropriate surveillance interval? If I have a patient that comes in and says that they had their colonoscopy, you know, five years ago, but in fact, it's only been two years, we may, once we have those records, contact them and say, you know, actually, you're not yet due. If you're not having symptoms, it's okay to wait a couple more years until the appropriate surveillance timeframe. But again, for symptoms, you may choose to still do the colonoscopy if they're presenting that way. Let's see, a couple more. Next question, how long does it take, how long does it typically take for the clips to be removed from the body post-procedure? Great question. So clips will typically fall off, as what I explained to patients, clips will typically fall off after a period of a couple of weeks. As the site is healing up. Now, that can vary. I've certainly done colonoscopies and upper endoscopies where clips were placed months or even years prior that are still present at the time. But the vast majority of the times these clips will naturally fall off within a few weeks of placement. I do advise patients that you don't need to be looking for them, you don't need to worry about them. They should not cause, should not typically cause any symptoms as they traverse into the stool. What are your thoughts, next question, what are your thoughts on virtual colonoscopy? So virtual colonoscopy refers to CT colonography. And Dr. Martin, by the way, jump in at any time if you have specific thoughts that I'm not addressing too. But CT colonography is basically an alternative to colonoscopy for screening purposes. Virtual colonoscopy is not widely available in our region where I practice. So it's it doesn't typically come up very often as an alternative for our patients. In the patients that have come in for a discussion regarding virtual colonoscopy, I usually do explain to them that it's it's meant for a screening. I do explain the process that involves CAT scan. So there are considerations there in terms of sure it may may not be as invasive, but patients still have to do a bowel preparation. Patients still do have insufflation of the colon with carbon dioxide or air to to better identify those polyps. It does not allow for intervention. There are, you know, concerns with regards to radiation exposure because it's CAT scan related and management of incidental findings and what the approach might be. So I have that open conversation. One of the important things to think about when you're when you're talking to your patients about what they're again, going back, what are their expectations? What are what are their thoughts? And a lot of it is shared decision making after having that conversation with them. And a lot of times these patients will will err on the side of what's more readily available and understanding the risks and benefits and the alternatives of virtual colonoscopy versus standard colonoscopy. Yes. I mean, you know, just to add to that, I think it's become largely unavailable is the bottom line. There is only there are only a few radiology groups historically and, you know, about 15 years, 20 years ago that ever expressed any interest in that modality. And, you know, just just like you're busy and your schedules are full, there's are two. And they have other things that don't have alternatives to to CT or MR that they need to get on their schedule. So they were never that enthusiastic about using cross-sectional imaging to replace diagnostic colonoscopy. The other thing that I think is pretty much squelched it is that there are better non-invasive ways to look for adenomatous polyps like Cologuard. And so once that came along, I think this pretty much went out the door. CT colography is very expensive, too, and very few insurance companies were willing to pay for that. And then, of course, they need, as Dr. Tawani said, they need a colonoscopy if you find anything. And sometimes what it was seeing was stool. So it's not a particularly specific way to look for these things either. Great points, Dr. Martin, thank you. I think two more questions and then we can break. Pause there. So how do you approach young patients who do not have alarm features adamantly requesting a colonoscopy? That is a tough conversation to have with patients, particularly if there aren't any strong indications to perform the colonoscopy. Sometimes it helps even to say that we're going to consider a colonoscopy. We have a few things that we may try first. You know, I think, for instance, in a patient who younger patient who may be presenting with typical IBS symptoms, I do kind of counsel them that, you know, that they don't have any specific alarm features. There are other there are considerations for which we might consider colonoscopy. But I also want to focus on trying to get you feeling better as well. And we're going to let's try this, you know, probiotic or fiber or other intervention first. And if that doesn't work or if you do develop worsening symptoms, maybe we will consider that colonoscopy down the road. Those are kind of interventions that I try to try to refocus them a lot of times. Sometimes they'll they'll actually say, oh, but I had blood once or I had something once to make you say, OK, then then then maybe we'll consider the colonoscopy. But usually I try to redirect them and try to try to encourage them to consider some therapeutic interventions along the way and keep that in your back pocket for subsequent testing. I don't know if you have any other pearls on that, Dr. Martin. I think that's that's pretty much as you described it to me, nothing to add there. All right. If you're two questions, OK, if you're planning a repeat colonoscopy for a patient with UC to potentially change therapy due to inadequate response, how long do you typically wait to perform colonoscopy if they are flaring? I think that's a great question clinically for even our inflammatory bowel disease colleagues and talks as well. You know, sometimes there is a utility in doing a flexible sigmoidoscopy to assess the severity of the disease, to obtain the biopsies, rule out alternative reasons depending on the therapy that they're on, for instance, doing biopsies to assess for CMV colitis. Even in the midst of a flare, a flexible sigmoidoscopy, and again, if somebody is in a is in the setting of a flare, I may choose not to do a full colonoscopy, but just that flexible sigmoidoscopy to reduce that risk of of complications. If they are flaring and you've already got them on treatment for their flare in terms of the timing of of doing a colonoscopy, if you're doing it for surveillance reasons, ideally you want them to be out of that flare completely and well controlled in order to get your surveillance biopsies. But if you're trying to make therapeutic decisions, then basically getting an assessment of the of the activity of the disease is really the most important factor in changing those therapies. So I wouldn't necessarily wait. I think that getting the data from a flex sig for UC particularly is helpful in making your decision, in your decision making process. All right, last one, and we'll break for lunch. How do you balance patient preference to have EDD colon performed together versus practice preference to do them separate? We actually, practice wise, we do try to perform them together when possible. We try to encourage our patients to if they can. Some patients, for instance, they have a lot of upper GI symptoms and you do have concerns about their ability to tolerate their prep. And and in that case, it may be reasonable to do the upper GI evaluation first, try to improve their symptoms or address that portion and have them return for the colonoscopy. But if they if they may be able to tolerate the procedures together, then we would actually encourage them to consider that. And it does and it does reduce, you know, the need for a second second visit, second round of sedation, second appointment where they would need a driver. So those are all reasons to help them kind of consider coming in together to perform or to have both the endoscopy and the colonoscopy together. Yeah, I think it's a pretty rare thing, right, where it would be better for the patient to separate them. That's a pretty unusual circumstance because of everything you said, Sameed, it's usually not to the patient's benefit to do them separately. Right. Yeah. I just wanted to call to your attention that there is actually a question that got placed in the webinar chat. Do you think we have a minute to address it? Because I think it's a good question. And the question is, do you use any risk benefit tools for patients with polyp history over 80 years old? It's a good question. Yes, definitely. Right. Do you? I'll repeat it. Do you use any risk to benefit tools for patients with a polyp history who are over 80 years old? I'm not aware of any tools. It's a conversation and looking at their overall medical history and what you think about their the prognosis of their overall lifetime ahead of them. Don't. Isn't that right? Yeah, that's absolutely correct. It's all individualized. You know, the the most of the guidelines would say, you know, you can continue screening colonoscopies up to the age of 85, but above 75 is where you want to individual or you want to more more seriously consider individualization of that decision making. So a lot of it will go down to what is the personal what is their personal history? What is their personal risk in terms of colon polyps and colon cancer? Have they had a significant polyp burden and needed very frequent colonoscopy? Have they had significant advanced polyps? And what's their other health? What are their medical comorbidities and what are the risks of putting them through colonoscopy? And again, not just the procedure, but the risks of holding anticoagulation, the risks of the bowel preparation process. Are they able to manage their bowel movements? Are they able to manage that on their own at home? Are there other considerations where you need to consider their support at home in terms of their tolerability? What are their risks with related to sedation and anesthesia? So it's very individualized when you're talking about that population. I think that, you know, the challenges that in this day of open access endoscopy, we're not usually the ones that are involved in that conversation a priori. And so there's a referring doctor whose conversation or not with the patient has led to them already prepping and being in front of you. This is an example here of a patient who has a polyp history and is over 80 and they show up in your office and they're already prepped. That's a little different situation. Right, Sameen? That is. That is a difficult situation as part of our screening process with our open access. You know, patients that are over the age of 75, they do get flagged to a provider to review first. And some of those patients in reviewing their referral may still be appropriate for that open access. Some of those patients will have them come in to have an office visit either with the provider or even one of our APPs to have that conversation to them because they may, their primary care, their referring provider may not have had a detailed conversation about, you know, the risks and benefits of the colonoscopy in their personal situation. So that's how our practice manages and tries to avoid the open access for 75 and over. Makes sense. I mean, you know, obviously there are some 80 year olds who are healthier than many 50 year olds and that and a family history that also agrees with that would probably, you know, make it air on one side rather than the other. So it is, as Dr. Tiwani is saying, it's all about the patient history and physical. It's all about your dialogue with them and taking into account the patient's wishes and desires after they've been educated, along with discussing the risks, potential benefits and otherwise with them. All right. Thank you so much, Dr. Martin, Dr. Tiwani for those great talks and question and answers.

ischemic colitis

colonoscopy practices

diagnostic imaging

gastroenterology guidelines

personalized screening