ASGE Annual GI Advanced Practice Provider Course (Virtual) (Day One)

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This document outlines the essentials of colonoscopy, covering the pre-procedure, intra-procedure, and post-procedure phases, along with patient selection, complications, quality metrics, and emerging use of artificial intelligence (AI).

In the <strong>pre-procedure phase</strong>, appropriate indications include screening vs. surveillance, evaluation of lower GI bleeding, abnormal imaging, diarrhea, and therapeutic needs. Colonoscopy should be pursued when results are likely to change management, empiric treatment has failed, or endoscopic therapy is anticipated. Timing matters (e.g., urgent concerns like bleeding or weight loss vs. chronic symptoms). Contraindications include situations where risks outweigh benefits, inability to obtain consent for non-urgent procedures, suspected/known perforation, fulminant colitis, and acute electrolyte abnormalities. Preparation includes medication management (holding GLP-1 receptor agonists ~1 week per ASA guidance and SGLT2 inhibitors 3–4 days per ACC/ADA guidance; managing anticoagulants/antiplatelets), informed consent, sedation choice (moderate sedation vs. monitored anesthesia care), and bowel prep planning.

For <strong>bowel preparation</strong>, split dosing is emphasized (same-day acceptable for afternoon procedures). No single regimen is clearly superior; choices should consider comorbidities, safety, cost, ease, and prior prep adequacy. Hyperosmotic regimens should be avoided in patients prone to fluid overload or electrolyte issues, and “ultra-low-volume” preps are discouraged. Patients at risk for inadequate prep may benefit from navigation tools, low-residue diet for several days, clear liquids the day before, constipation treatment, promotility/simethicone, stopping constipating drugs temporarily, and high-volume prep.

In the <strong>intra-procedure phase</strong>, high-quality examination is assessed by cecal intubation, withdrawal time, and adenoma detection. Equipment selection (adult vs pediatric scopes) and therapeutic tools (snares, clips, cautery, APC, etc.) support biopsy, polypectomy, hemostasis, tattooing, dilation, and decompression.

<strong>Complications</strong> are uncommon; cardiopulmonary events (sedation-related) are most frequent. Bleeding can be immediate or delayed (often 5–7 days post-polypectomy) and treated endoscopically (epinephrine, clips, thermal therapy). Perforation may result from mechanical trauma, barotrauma, or electrocautery injury. Post-polypectomy electrocautery syndrome is also noted.

The <strong>post-procedure phase</strong> includes communicating findings, managing medications and non-polyp diagnoses, reviewing pathology, and setting appropriate surveillance intervals. Quality indicators include documentation of indication, adequate prep, cecal intubation (~95%), adenoma detection (~35%), and adverse event tracking. AI is discussed as a tool for real-time polyp detection/classification, though practical and financial challenges remain.

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Sumeet K. Tewani, MD, FASGE

Keywords

colonoscopy

bowel preparation split dosing

screening vs surveillance indications

contraindications perforation fulminant colitis

medication management GLP-1 SGLT2 anticoagulants

sedation moderate vs monitored anesthesia care

quality metrics cecal intubation adenoma detection withdrawal time

polypectomy and endoscopic hemostasis clips epinephrine thermal therapy

complications bleeding perforation post-polypectomy syndrome

artificial intelligence real-time polyp detection classification