I'm going to move on to discussing colonoscopy. Some of what is in my talk has already actually been covered by Dr. Martin's excellent talks already, so that should make this go hopefully a little bit faster, we have some time to catch up. I have no disclosures. So I'll start with two polling questions. The first question here is, colonoscopy is the only screening test that can detect and remove polyps in the same setting. True or false? Excellent. So as compared, we'll talk about the comparison between colonoscopy and other screening tests, but colonoscopy really allows you to remove those polyps as opposed to most of the others that are just meant for detection. I think maybe those that answered false may have been considering sigmoidoscopy as the alternative. Polling question number two, delayed post-polypectomy bleeding most commonly occurs between five and seven days. True or false? Good. A little bit more of a split here, but that five to seven days post-polypectomy is the most common timeframe for delayed post-polypectomy bleeding. Delayed post-polypectomy bleeding would be during the first 24 hours or so after the procedure, but that delayed timeframe is usually about five to seven days and we'll cover that as well. So the objectives of this talk are to discuss the phases of colonoscopy, patient selection, understand some complications and the potential role of artificial intelligence. We'll touch on each of these. So I like to think about breaking up the colonoscopy into three different phases, pre-procedure, intra-procedure and post-procedure. The pre-procedure phase has a lot to do with the decision making around the colonoscopy. Is this considering the indication for the colonoscopy, timing of the colonoscopy, making sure you're choosing your patients or selecting the patient appropriately. It's important to consider is this patient presenting for their colonoscopy for a reason for screening or surveillance due to a personal history of polyps or is it for evaluation of certain symptoms such as lower GI bleeding? Is it for evaluation of abnormal imaging, previously abnormal CT scan? Are you intending to do any therapeutic intervention? For instance, have they been identified previously to have a large polyp that was not addressed at the index colonoscopy and now they're referred for endoscopic mucosal resection or endoscopic submucosal dissection of a large polyp. So those are important considerations when we're talking about the indication. The timing of scheduling also is important depending on what symptoms and what the indication is. For instance, symptoms like bleeding or weight loss may make the procedure more urgent whereas evaluation of chronic diarrhea may not be quite as urgent. In patients who are presenting with an event of acute diverticulitis or ischemic colitis and need a colonoscopy for her follow-up afterwards, is it important to delay the colonoscopy by several weeks to allow resolution of the acute inflammatory event? Many times we'll delay those for six weeks beyond the initial presentation for that surveillance. When you're selecting your patient, it's important to consider will the findings or will the anticipated findings on the procedure change the management for that patient? Have we already tried empiric management and has that provided any benefit or results for the patient in terms of, for instance, evaluation of constipation? Are we going to try some over-the-counter methods earlier before considering a colonoscopy? And is there any therapeutic intervention that's anticipated, that endoscopic mucosal resection of a large colon polyp? Is this a patient who's had surgery before and may have an anastomotic stricture that we're anticipating dilating? Are we anticipating biopsies? Is that going to be relevant to our patient's course moving forward? So these are all important in the selection of the patients and also understanding that there are certain indications where a colonoscopy is more important or better indicated and better in evaluating certain symptoms as compared to radiology, for instance, a CT scan. It's also important to weigh the contraindications to colonoscopy. When do those risks outweigh the benefits? Is it an emergent procedure or is it a non-emergent, non-urgent procedure and what's your ability to obtain consent for that patient? Is that patient able to consent for themselves or do they have a healthcare surrogate or power of attorney that need to be in contact with or in touch with? Is there a concern for perforation? That would be a contraindication to performing colonoscopy in the setting of that concern or fulminant colitis, for instance, patients with severe ulcerative colitis or toxic megacolon from severe C. difficile infection. Other considerations, particularly when we're discussing bowel preparations, are there acute electrolyte abnormalities that need to be addressed or corrected? What is the risk of further exacerbating those electrolyte abnormalities by bowel prep? And also, what are those risks involved in terms of providing sedation or anesthesia to our patients? In preparation, Dr. Martin has already touched on a number of these considerations for patients who need a clear liquid diet versus for a screening or surveillance patient who does not have any symptoms, when is a low residue diet the day before a reasonable option? Or for patients who have had difficulty with bowel prep with just one day of a clear liquid diet ahead of time, how early do you have them transition to a low residue diet? How far ahead of the procedure do you do that? Periprocedural medication management, we talked about anticoagulants and antiplatelet agents. The recent guidelines with regards to GLP-1 medications and SGLT-2 medications, the GLP-1s, the ASA guidelines, my understanding is that these are being revisited already, but for the last year or so, the recommendation is that these have been held for one week before colonoscopy. SGLT-2 inhibitors, the recommendation is to hold these for approximately three days before colonoscopy, and that's because of a concern that these may trigger an exacerbation in diabetic patients. And then, as Dr. Martin already discussed, the informed consent process, considerations with regards to moderate sedation versus MAC anesthesia, and bowel prep considerations for our patients. This is a diagram of the Boston Bowel Prep score, and this is something we evaluate during our colonoscopies. It's broken up into the three different sections of the colon, the left colon, the transverse colon, and the right colon, and they're graded on a score of zero to three for each segment. Acceptable or adequate prep is a two or three in each segment, so a total of six, although also keep in mind that you may have one segment that's three, another segment that's two, and a third segment that's one, and even though that total is six, that segment that was graded as one is still considered an inadequate prep. So this is a nice way to standardize our evaluation of preps. Leading more into the intra-procedure phase, so now we've decided that it is time to proceed with the colonoscopy for our patient. It's important to make sure you're performing a high-quality exam and track a lot of the quality indicators for colonoscopy, and these are all things that we track, and most divisions should be tracking for their gastroenterologists, their endoscopists. What are sequel intubation rates? What are withdrawal times? How much time are we spending actually evaluating the colon? Our adenoma detection rate, and how many patients that are presenting for their screening and surveillance procedures, are we actually detecting adenomas in those patients? How frequently does that occur? And then also tracking our complication rates to make sure that we are doing our procedures in a safe manner for our patients. Considerations when we're doing colonoscopy, we have to consider the different types of colonoscopes available. Most manufacturers have an adult version and a pediatric version. There are some manufacturers that offer a hybrid type colonoscope, which is basically in between those two options. There are also super slim versions as well. So understanding what colonoscopes are available in your GI lab, and then the decision as to which one to use comes down to a lot of different factors, mostly endoscopist preference. But considerations for those that do use both or use various types would be considerations, for instance, the patient's body habitus, have they had a previous difficult colonoscopy and what was the difficult factor? Is it angulation or is it looping in a long tortuous colon that will affect the endoscopist scope choice? And then it's important as an endoscopist to understand the various devices that we have at our armamentarium and at our availability to use during our procedures for the various interventions that might be performed. Scenarios for biopsies, scenarios for polypectomy, if we do have to manage bleeding or perform tattoo in the indication where we've removed a large polyp or we've identified a cancer, what's the role of or how do we use injection needles to perform that tattoo? Electrocauterine clips are very important in the management of post polypectomy bleeding, whether it's immediate or delayed, and also with those advanced techniques of endoscopic mucosal resection and endoscopic submucosal dissection. I mentioned these diagnostic and therapeutic maneuvers already. Biopsy or tissue sampling, polypectomy, tattoo, as I already mentioned in the previous slide, but endoscopic hemostasis, so when a patient is presenting with lower GI bleeding, whether it's post polypectomy bleeding or another etiology, what are the various devices we can use to manage that bleeding? As I mentioned previously, in a patient with an anastomotic stricture from previous surgery, are we anticipating dilation of that stricture and how will that affect our approach to the patient? In patients who are in the hospital with colonic pseudo-obstruction or a sigmoid volvulus, is there a role for decompression tube placement during colonoscopy? This is a picture example of a polypectomy. The white that you see at the very bottom of the screen is the snare. The snare itself is actually closed around the base of that polyp. This is right before the actual polypectomy excision of that polyp. I don't believe that I think this is a picture, not a video, but this is an example of an AVM, very similar to one of the images that Dr. Martin showed on previous endoscopy. This is something that if we're doing this colonoscopy for a patient with bleeding or anemia, we would consider argon plasma coagulation to treat the AVM and radiation associated vascular actasia, also known as radiation proctitis. You'll see many of these scattered in the rectum as a result of radiation therapy, most commonly for prostate cancer. Again, you can use argon plasma coagulation to treat this, to treat bleeding. Understanding the complications, again, the risk of serious complication, colonoscopy is very low, similar rates to those of upper endoscopy. Most commonly, the complications that we do see are related to sedation, and those are cardiopulmonary complications related to hypoxia, bradycardia. There are ways to reduce the risk of those sedation complications is recognizing in that pre-procedure phase or intra-procedure phase what's our appropriate anesthesia risk assessment ahead of time. In those patients that are high risk, when do we involve our anesthesia colleagues to perform those patients under MAC anesthesia or monitored anesthesia care as opposed to moderate sedation, and intra-procedure and pre-procedure and post-procedure monitoring. Management of complications, so I mentioned immediate post-polypectomy bleeding. The majority of this we recognize at the time of the colonoscopy, so we've done the polypectomy already and there's persistent bleeding from the polypectomy site. Options may include injection of epinephrine, using hemostatic clips for mechanical force to close the polypectomy defect. Thermal therapy may have a role as well with direct coagulation, particularly for oozing vessels at the base of a polypectomy site. It's also important to recognize that perforation may happen and that can happen as a result of mechanical trauma, passing the scope through a difficult sigmoid colon, barotrauma from insufflating too much air or adding additional pressure, and then electrocautery injury at the time of polypectomy or treatment. These are all the potential reasons that a perforation could occur. Recognizing perforations and trying to manage those perforations, so we now have many endoscopic tools that we can use, including clips, to manage these when they are recognized immediately. Here's an example of post-polypectomy bleeding. So the polypectomy site is kind of in the center of the screen there. You see actually two clips that have been deployed already on the polypectomy site in an effort to try to manage the bleeding. This appears like there may be more clips coming. And then this is the appearance of a perforation site that was recognized at a colonoscopy. Again, we may be able to use clips to try to close this defect during the colonoscopy if it's recognized immediately. It's important to also know that immediate closure of this perforation is not necessarily going to be complete management. So these patients, if this is a routine screening colonoscopy where this occurred, this patient will need to be admitted, managed with bowel rest, antibiotics. It would be important to involve our surgery colleagues in case this was an incomplete closure as well. So recognizing and appropriate early management of complications. In the post-procedure phase, everything's gone well. You've completed the colonoscopy. Now the patient's in recovery. Again, go out and meet your patient for discharge, explain to the patient what we found, what we did. I like to explain, again, what we found, what we did. Also explain or set an expectation for when they may get pathology results and why one might call, one might receive a phone call. For instance, if there's something urgent that we are anticipating an intervention based off the pathology results versus less urgent decision-making from polyp and timing of surveillance. Is that going to be three years, seven years, 10 years? And what the expectation might be for the patient. In the immediate setting, if we've made a diagnosis of rectal bleeding related to hemorrhoids or inflammatory bowel disease, we may make some medication recommendations and medication prescriptions right then and there versus in other times we may wait and see depending on what those pathology results show. So setting those expectations and setting the expectation of a surveillance program for patients with polypectomy. Quality indicators for colonoscopy, again, range through the different phases of colonoscopy. So it's important to participate in a good quality database project. This is something that we do in our unit here. Having appropriate documentation of the indication for the procedure and adequate bowel preparation for the procedure during your intra-procedure phase. What are the sequel intubation rates? What are the adenoma detection rates? There's a sessile serrated lesion detection rate, withdrawal times, all that I mentioned or touched on previously. There are benchmarks for what we should be striving to achieve for all of our units, all the endoscopists. And the post-procedure phase, appropriate selection of timing for the surveillance or screening interval depending on the findings at the colonoscopy and tracking and reporting of our adverse events. Post-polypectomy bleeding is expected at a low rate of 1 in 500 to 1 in 1,000. And should be less than 0.1% for our screening patients. So understanding those benchmarks, understanding those and tracking your own rates for reporting reasons is important. So we talked about post-polypectomy bleeding. The typical time for delayed post-polypectomy bleeding is in that five to seven day range. The idea behind this is that in the early stage the coagulation will occur and the patient will develop a clot on that site. And usually around the six, seven day time frame is when that clot will fall off the site and may expose or allow recurrent bleeding to occur. Recognizing perforation, recognizing post-polypectomy electrocautery syndrome, so this is a patient for instance who we had a, we used electrocautery for a polypectomy, the patient was doing well in the PACU recovery and goes home and comes back or calls in with pain, fever, a lot of times they'll have this polypectomy syndrome which is not a perforation but probably some transmural burn from that electrocautery that's led to some cirrhosal inflammation and if they've already gone home they may need to come back into the emergency department for a CAT scan and labs. They may be managed well with just antibiotics but it's important to recognize that possibility in the post-procedure time frame. Artificial intelligence, there's a lot of excitement around artificial intelligence and its implications in GI and various forms of clinical practice throughout. One of the biggest areas where artificial intelligence has made a lot of progress in GI is with its application in colonoscopy. There's several different, there's at least a few different decision support systems that have been developed and are available for GI labs now. These basically help in the detection and classification of colorectal polyps. There's the CADX and CADE forms which are important for detecting polyps and then also classifying those polyps for instance as adenomas versus hyperplastic polyps. This is not something that we've yet implemented in our lab but I know that there's a lot of interest in this and I suspect a lot of labs are exploring adding this to their labs if not already there. There are some considerations for if your lab is considering this. What is the additional benefit in terms of the real-time value? Are we identifying polyps that your endoscopist has not already identified? Are those polyps important polyps? For instance, are we identifying more hyperplastic polyps or more adenomas or both and how is that affecting procedure time? How is that affecting surveillance intervals? How is that affecting the patient's overall plan moving forward? Those are important pieces that need to be further clarified. But there's a lot of good data supporting the use of artificial intelligence. And then for private or independent practitioners and independent labs, there are of course financial considerations for adding this or implementing this in your lab. It's a very, very exciting field and exciting addition to colonoscopy looking forward. So Pearls, as we wrap this up, is understanding the phases of colonoscopy, the pre-procedure phase as that differs from the intra-procedure and post-procedure phases, understanding the importance of appropriate patient selection for our procedures or the appropriate indications, management of peri-procedural medications, choosing appropriate sedation when we're considering moderate sedation versus MAC anesthesia support, recognizing the risks of complications including immediate or delayed post-polypectomy bleeding and perforation when you're making the decision as to performing the procedure, will the procedure change management, what are your anticipated therapeutic interventions? Are we doing this to plan biopsies, perform a therapeutic polypectomy? Are we doing this to dilate an anastomotic stricter or is this for screening and surveillance and understanding the implications there? And then the future of adding artificial intelligence to colonoscopy is bright. I'm excited for the upcoming changes. Thank you.

colonoscopy

polyp detection

procedure phases

patient considerations

artificial intelligence

complications