My talk for this session is colonoscopy, the basics. I do not have any disclosures. First polling question, please, Eden. Colonoscopy is the only screening test that can detect and remove polyps in the same setting, true or false? Excellent. The answer is true. And we'll circle back to this tomorrow on my last talk of the day when we talk about the Nordic trial. So important piece of information. Delayed postpolypectomy bleeding most commonly occurs between five and seven days, true or false? All right, good chance to learn here. That five to seven day timeframe is the most common timeframe where we see postpolypectomy bleeding. It can occur shorter. It can occur as late as two to three weeks, but most typically in five to seven days, especially when some type of thermal therapy has been used. Thank you, Eden. My objectives today are to review the phases of colonoscopy, talk a little bit about patient selection. I'll only mildly have some repetitive information because I think sometimes it's important to hear something two or three times so we understand the importance of it, but we want to minimize overlap with other talks, talk about complications, and have a comment on artificial intelligence and what it can mean for who performs colonoscopy in the future. I won't discuss the mechanics of the endoscope. John had done that very nicely. Dr. Martin did that very nicely during his talk. And the mechanics are the same in the colonoscope, but the difference being the colonoscope is a longer scope. So pre-procedure, what is important for us? First, we want timely scheduling, and we want to be wise about choosing our patients. Timely scheduling, someone who has bleeding, someone who has weight loss, a little bit more important to get in and get in sooner than someone with chronic diarrhea. So let's, in our notes and in our discussions with our triage team, our nursing team, make sure we discuss timely scheduling when appropriate. Patient selection. Dr. Martin covered some of this. I do want to repeat it. Make sure that any time you choose a test, especially an invasive test like colonoscopy or any endoscopic procedure, understand that you're doing this because the results may change the patient management. If you don't see that patient management is going to change, then you should think long and hard about proceeding with an invasive procedure. When empiric therapy has failed is another reason we would proceed with colonoscopy if a therapeutic intervention is anticipated. For example, a diagnostic colonoscopy was done, a very large polyp was found, and we realize we need more time for that at a different location, perhaps the hospital to have different tools, then we would have that as a reason to proceed with colonoscopy and as an alternative to radiology. As with any test we order in endoscopy, we have to make sure we understand indications. Some of the more common indications we'll see for colonoscopy screening, someone's having their first evaluation for colon cancer screening or it's been 10 years since their last colonoscopy versus surveillance where the patient is coming back five years after having their first colonic adenoma. Lower GI bleeding, another indication that's very common. Abnormal imaging. We see a lot of referrals for abnormal imaging, especially CT imaging, so that's become a more common indication. Diarrhea, thinking about celiac as we, excuse me, microscopic colitis rather, as we work through the thought of diarrhea and then are we going to perform a therapeutic colonoscopy. Pre-procedure contraindications. As we think through proceeding with our procedure, we have to make sure that the benefits outweigh the risks. If we come to the conclusion that the risks outweigh the benefits, the patient is 80 years old, they've had some, let's say minimal lower GI bleeding, had a colonoscopy five years before, but now they're on oxygen. They had a recent diagnosis of, say, a bone marrow malignancy. Is it really worth proceeding with the exam to rule out perhaps a malignancy, which may be lower on our list with minimal rectal bleeding, as opposed to perhaps injuring the person if we move forward. If we cannot obtain informed consent in a non-urgent procedure, that is a contraindication. Known or suspected perforation, another one high on our list. Patients with fulminant colitis, we don't want to proceed with endoscopy because that could increase the risk of perforation. And one we sometimes, I think, overlook because we are overwhelmed with information from the EMR, make sure you review the labs, look for electrolyte abnormalities, especially acute electrolyte abnormalities, or a sudden change in their hemoglobin, although they came in for GI bleeding a couple of days ago, and maybe their hemoglobin looked good two days ago, and now we're preparing to do their colonoscopy, and all of a sudden that morning it's dropped three grams. So pay attention to your labs and make sure that we address any lab abnormalities prior to proceeding with the procedure. The next three slides are just quick recaps and reminders of stuff we've already heard. Clear liquids, very common diet for colonoscopy, but I'd like you to give thought to a low-residue diet in certain populations. There's good data on low-residue diets and how patients on low-residue diets have colon cleansing scores equal to that of people on clear liquids. These take motivated patients, perhaps better medically literate patients, and you may be able to convince that person to proceed with colonoscopy if they're thinking they couldn't do it because of the diet. So think about a low-residue diet. Sarah covered the anticoagulants and thionylparidines well. It's just a reminder we need to review our medications, not only anticoagulants, but also reviewing for sedatives, narcotics, certain psychiatric medications that could make it difficult, if not impossible, to state somebody with traditional sedation using fentanyl and Versed or make it more difficult for the anesthesiologist providing monitoring anesthesia care. Another one to look at is marijuana use in states where it's legal. That has become a real difficult challenge for sedation analgesia, even for the anesthesiologist using propofol. So make sure you review if there are medications where marijuana is legal. Make sure you review that as well. We heard about informed consent and bowel prep. My point on bowel prep is I like to show this slide or a slide similar. This is a Boston bowel prep score to the patients. You can have a little card or diagram, and on the left, I like to emphasize to them what a good prep looks like, in the middle what a pretty good prep looks like, and then not so good and really bad, and just tell them, I know it's difficult, I know the prep is not easy, but it's really important because the look that we get on the left could make all the difference literally between life and death depending on the prep, because sometimes it's difficult to get patients to come back when the prep is poor. And my only reminder about sedation assessment, many times you are the only person, only provider to see the patient before procedures. Make sure you look for worrisome signs or high risk signs for sedation and analgesia regardless if it's traditional or monitored anesthesia care. Look for neck anatomy and look for a history of radiation or any ENT surgeries. Look for a history of difficult intubations. Look at BMI, look at their comorbid disease, and as I said, look at their medications. Make sure you do a thorough assessment in your consultation as you prepare someone for endoscopy. Entry procedure, the goal of the endoscopist is very simple, and that is to perform a high quality exam. Why do you need to know at this point about what happens within the exam? Again, many times you are the provider that sees the patient, especially if you're operating independently in your clinic. In order to be the patient advocate, you have to understand all aspects of what we do in endoscopy. It's also a great way to get your patients to believe that you are practicing high quality medicine because you know all aspects of GI. Common questions you may get from the patients could surround the topics of sequel intubation rates, withdrawal times, adenoma detection rates. We'll come back to those in a slide on quality, but again, the more you know about these endoscopic procedures, the more qualified and the more confidence you'll endear in your patients. And then we'll finish up before we get into artificial intelligence with some comments and complications. Entry procedure, you can help your endoscopist collaborating physician by understanding the types of colonoscope. We have adult colonoscopes, we have pediatric colonoscopes, we have slim colonoscopes. And scope choice can become important. Some endoscopists specifically like to only use pediatric scopes even though they're only scoping adults. So to know that makes it easy in your scope selection sometimes if you're working that closely in the hospital with your physician collaborator. Body habitus, thin people, slender people who had multiple abdominal surgeries, more likely to have difficult anatomy because of adhesion. So those could be difficult procedures. And anyone who's had a previous difficult colonoscopy documented is something else you'd want to know about. So you can put that in your note so that the endoscopist can be better prepared for that colonoscopy. Devices, device terms that you'll hear, as Dr. Martin said, forceps. You'll see snares, baskets, injection needles, hemostatic devices, hemostatic sprays. Terms you'll see in the report that you could translate for your patients, especially as they're reading more of their reports. Tissue sampling or biopsying. Polypectomy. Many of the patients may not understand what a polypectomy is or means. Tattoo. We do that a lot for larger polyps. Endoscopist hemostasis that we use, APC, electrocautery, Irby units, another form of thermal therapy, and then hemostatic clips. You might see a reference to dilation of strictures. And on rare circumstances in hospitalized patients, we'll be using colonic decompression tubes. A couple pictures. Here's a small adenomatous polyp being removed with a snare and a little heat. You can see at the end of the snare a little white line. That is some thermal therapy. And that's maybe 10, a little bit bigger than 10 millimeter polyp. That's an angio-dysplasia. The device you see in the bottom quadrant of the picture is the catheter for argon plasma coagulation. So that's taking argon gas, converting it into a beam of energy, and it very nicely ablates that lesion and has very low risk of penetrating deeper into the colonic wall and running the risk of thermal burn or thermal injury, which we'll talk about, and perforation. Some complications. The good news overall, Dr. Martin commented on this in his talk on upper endoscopy as it relates to sedation. The risk of any serious complication tends to be low in colonoscopy. Cardiopulmonary complications are the most common and mostly related to sedation risk. So again, another reason to make sure we understand our patients and their sedation risk profile, especially if you're using traditional sedation analgesia when an anesthesiologist is not involved. Reducing the risk of sedation complications, again, appropriate anesthesia risk assessment, appropriate management of high-risk patients by the anesthesia service. So if you do use or your group uses traditional sedation and you think an anesthesiologist needs to be involved, don't hesitate to ask the anesthesia service to get involved if you think it's going to be a safer outcome and path for your patients. And always appropriate pre-sedation monitoring, intra-sedation monitoring, and post-sedation monitoring. Some complications. We can see immediate post-polypectomy bleeding. This can occur with cold snare removal, a little less common with hot snare removal, but we can see it. You will see notation in the reports of epinephrine injection. So we inject epinephrine through a catheter, typically in a 1 to 10,000 solution. You'll see hemostatic clips. You might even see the term over-the-scope clips. These are larger over-the-scope clips that can help us with certain bleeding and defect in endoscopy, and there is thermal therapy. Perforation is something none of us want to have happen, but it does occur. There have been causes of perforation prior to the use of CO2. So prior to our use of CO2 to insufflate the colon, we were using air, and you ran a small risk of mechanical or barotrauma, I'm sorry, or barotrauma. Now that we're using CO2, we see less barotrauma. There's always the risk of mechanical trauma. Mechanical trauma tends to occur more at flexures, so the splenic flexure, the hepatic flexure, it tends to occur more frequently in patients who have difficult anatomy, perhaps lots of intradominal adhesions changing the anatomy of the colon and changing angles of the colon that could increase the risk of mechanical trauma, and less likely would a perforation occur from electrocortis injury, but it does occur. Here's a post-polypectomy bleed. This was an immediate post-polypectomy bleed. You can see kind of central bottom of the slide, the stalk of the polyp. You see these two shiny objects at about midnight and four o'clock. Those are clips, and it took a third clip, dead center, to get this to stop bleeding. The bleeding occurs because a vascular structure, an arterial, small arterial vascular structure has been breached, and it did not stop, was not stopped by cortary therapy. That is what we don't want to see. That is a perforation. Some perforations can be closed endoscopically. Others, unfortunately, need to go to surgery. The circle shows the perforation itself, and if you look into the perforation, you see this yellow color with some cascading red lines. The yellow color is adipose tissue and the serosal surface with some vascular structures on the surface. So that's something none of us want to see. Post-procedure, again, many times you are the primary person disseminating the findings to the patients. Another reason why you need to be intimately knowledgeable about what happens during endoscopy, have a good understanding about the different medications that can be used, ranging from the complex biological agents of IBD to the very simple agents that could be used for hemorrhoids. Understand the pathology terminology and be able to translate that into very common language for your patients. So understand adenoma, hyperplastic polyp, and other terminology such as non-polyp path that you may see related to IBD or microscopic colitis. And make sure you understand and get our patients in surveillance programs if they have adenomas following the appropriate guidelines. Some quality indicators that are important for you to know, and because many of our patients now are asking questions, they're becoming very knowledgeable. A lot of this is in the lay press, some of it's not accurate, so you want to be the accurate transmitters of information. Most of your practices, if not all, will participate in a quality database project, so you should have good access to the numbers. Overall, the goal for adenoma detection rate, it's greater than 20% in women, greater than 30% in men, and overall 25%. In the United States right now, we're at about a 40% overall adenoma detection rate, which is really high, and many groups are north of 40%, so that's very encouraging. And when you do speak about adenoma detection rate with your patients, if they ask, I would not speak about individual physicians. I would reference the overall group rate. That could start some controversy or difficulties within the practice. You might put yourself in a bit of a pickle by pointing out a physician who maybe has 35% adenoma detection rate when everybody else is above 42%. So speak about the group rate and understand what the group rate is. Sequel intubation rate should be greater than 95%. Most high-functioning practices are 98% or above. Post-polypectomy bleeding rates are about 1 in 500 to 1 in 1,000. That's delayed post-polypectomy bleeding, and thankfully, the perforation rate is very low. So those are quality indicators for not only physicians to understand, but URAPP colleagues. Post-polypectomy bleeding, as I said, most commonly occurs within five to seven days, and that's delayed post-polypectomy bleeding. Many times it stops on its own, but many times we end up, unfortunately, proceeding with a second colonoscopy. It is safe to administer a PrEP in these patients, so please know that. It is safe to administer a PrEP, and we should administer a PrEP to make sure we can easily find the site of bleeding. So that, again, is five to seven days, and most of this is handled with mechanical therapy, with clips through the scope, less likely more thermal therapy, which caused the initial injury. Perforation we talked about. And the third one I want to talk about is post-polypectomy electrocautery syndrome, or a transmural burn. We don't see this very often, but sometimes when we use thermal therapy, there is a burn that goes deeper than that initial layer or that second layer of the colon. Patients get a cirricitis, meaning there's a little weeping of fluid and maybe even a tiny microperf that is sealed with a little fluid collection. There's no overt perforation. Patients present with significant discomfort, abdominal discomfort, many times have an elevated Y count. Some antibiotics, IV fluids, pain management, and they do very, very well. All right, let's just end with a little bit about artificial intelligence. We have now seen many studies over the last three years on artificial intelligence-assisted decision support systems. So these systems are helping identify, detect, and classify colorectal polyps, specifically adenomas, adenomas versus hyperplastic polyps, sessile serrated polyps. So they're really, they can be a bit of a game changer for certain populations of endoscopies. However, we still don't quite understand the real-time value of artificial intelligence in routine colonoscopy for those groups. And I'm sure every physician on this panel is north of 40% in their adenoma detection rates. But what the value is in high performers, high value performers, that's a real question. And this is, there are some real financial challenges to organizations of all types of how we're going to fund this and how are we going to pay this. We certainly can't lose money on this. Why is it important to you, the APP? One, again, you want to be knowledgeable about everything in colonoscopy and about colonoscopy. So you'll see articles about it. But there's a second reason. I'll start off with a quote. I'm a huge fan of history, American history, world history. And I do enjoy reading about Winston Churchill. And this quote, if we open a quarrel between past and present, we shall find we have lost the future. I am a very proactive or try to be a proactive thinker. And we do have a significant problem in GI. The gastroenterologist shortage is very real. I think an accurate number is probably about 2,600 gastroenterologists short. Older gastroenterologists are retiring, younger other gastroenterologists are retiring at an early age. We are not seeing an increase in fellowships. So I think this problem is going to grow. Not many new fellowships are being started. So now we have the GIAPP gastroenterologist clinic team, whether you operate independently or with a physician. We have the GIAPP hospitalist team. There's no doubt in my mind that we are going to see the GIAPP endoscopy team, endoscopist team. What will that mean? I'm not clear, but there'll be a different role for that APP. And I do believe at some point we will have the APP endoscopist. And I think AI, if it does occur, or I should say when it occurs, it will be AI that brings us forward. I can envision a day where maybe in two rooms are dedicated to the APP endoscopist, a physician therapeutic endoscopist is overviewing, looking at some monitors, AI detects some polyps, and it's detected and confirmed that that should be removed. And then the endoscopist comes in that room. That's just me trying to think proactively and thinking about our future. Our volume of patients isn't going away. We're going to remain very busy and we have to figure out a way forward of dealing with our physician shortage. So just something to think about. We touched on it this morning. I think it's a very fun concept to toss around. Pearls, important. It's important to think about the phases of colonoscopy and understand as much about colonoscopy as you can, because many times you are the only one disseminating information about the procedure. Understand the importance of patient selection, timely selection, doing procedures only if it's going to change the outcome or management of the patient. Understand our complications. And again, I'll say one last time, will the procedure change management and outcome? That has to be our guiding principle of any procedure. And I think we have a very exciting future ahead in endoscopy with AI. And I am very interested to see what the GI APP endoscopy team will look like. Thank you. And with that, I will pass it on.

colonoscopy basics

complications

artificial intelligence in colonoscopy

quality indicators in colonoscopy

patient selection

future role of AI in endoscopy