Well good morning. How was everyone's first day? That's good. Good. Did anyone do anything fun last night? Yeah? Who went into the city? Bunch of you guys. Good job. All right, well my name's Jennifer Jorgensen and I'm really happy to be here. I'm really happy that you guys are all here. I did this course probably about 14 years ago and thought it was great and have really enjoyed getting to meet a lot of you guys. So I thank the ASG for inviting me and I am going to talk about diagnostic colonoscopy. I have no disclosures. So we're going to start by talking about why we do diagnostic colonoscopy. We're going to talk about when not to do it, how to get the job done, and how to stay out of trouble. So there are three main indications for diagnostic colonoscopy, the most common being screening. We'll also talk about surveillance and doing patients for symptoms, signs and symptoms. So screening, as you all know, are asymptomatic patients, so no prior pathology, just doing it for screening for colon cancer. Just this last year, guidelines changed so that we now begin at the age of 45. And then for high-risk patients, we begin sometimes earlier than that, depending on what the risk factor is. Those are things like family history, genetic syndromes, inflammatory bowel disease, things like that. Once you've found a polyp or cancer in a patient, we then move on to surveillance colonoscopy. And those are done more frequently depending on the size of the polyp, the pathology of the polyp, those sorts of things. You'll become well-versed in this during your three years. And then we do it also sometimes for diagnosis of signs and symptoms. This is by no means an exhaustive list, but the most common indications are GI bleeding, both hematochesia and melana, especially if they've had a normal upper endoscopy, iron deficiency, anemia, diarrhea, and sometimes abnormal imaging of the colon, things like colitis or sometimes masses will be seen, things like that. So there are some reasons to not do a colonoscopy or at least to, you know, really think about whether it needs to be done. So if a patient has a perforated colon, there's very little reason to do a colonoscopy. You can make the perforation bigger. You can cause pneumoperitoneum, which can cause hemodynamic instability. So generally avoided in that situation. The next four indications, you can do a colonoscopy or at least a flexible stigmoidoscopy if it's necessary for diagnosis, but you just need to be really careful. Patients with acute diverticulitis, we typically like to wait four to eight weeks after the acute episode is over before we scope them to avoid perforation. The reason we do colonoscopy after an episode of acute diverticulitis is to make sure that there's not a mass or some other pathology that contributed to the diverticulitis. So if they've had a recent colonoscopy in the last year, sometimes we won't do a colonoscopy after an acute episode. And then with deep ulcerations, severe ischemia, and fulminant colitis, you just have to be very careful because there is increased risk of perforation because of the fragility of the colonic wall. So sometimes I'll do just a flex sig just to the point of the pathology, get my biopsies if that's what we're after for diagnosis, and then pursue a full colonoscopy after they've healed up if it's still indicated. Cardiopulmonary decompensation, you just have to weigh the risks and the benefits frequently in concert with your hospitalist or their primary care provider, sometimes even the cardiologist, to make sure that the indication and the benefits outweigh the risks. And then if they're not able to tolerate a bowel prep, it sort of depends on the indication. Certainly a screening colonoscopy, you want a very good bowel prep, so you wouldn't want to do that in a patient that isn't tolerating it well. But obviously there are some hospitalized patients that just really need a colonoscopy and may not have a great prep. Sometimes bleeding, you just have to clean more. Or if someone has very severe colitis, again, you can just do a couple of enemas or clean as you go and try and get the diagnosis. So patient-dependent. So now that we've talked about when we do a colonoscopy and when not to, usually we start with a very good perianal exam, and that's because you can find all sorts of interesting things when you look. So I was looking at my slides on the plane and I think the guy sitting next to me was like, oh my god, what is this woman looking at? Okay, so a couple of pictures here. The first one I think are probably prolapsed internal hemorrhoids. B, external hemorrhoids, probably thrombosed and bleeding a bit. C is early condyloma. So you can find all sorts of things, including signs of inflammatory bowel disease, those sorts of things. The digital rectal exam is also important. Make sure you have a very well lubricated glove. Do a full sweep of the anal canal to look for hemorrhoids, masses. And then in males, as long as you're there, you should probably do a prostate exam. Sometimes in the left lateral decubitus position, it can be hard to reach the prostate. You can have them pull their knees up towards their chest and that will improve your ability to reach the prostate. If you document a normal rectal exam on a male, it means that you didn't find any prosthetic nodules. So if you're not able to reach it, just document a normal perianal exam and leave it off or say that you weren't able to completely evaluate the prostate. Prostate. I have found a few nodules over the years, so it's worth doing, I think. Just a word to the wise, if you feel an anterior mass in a female, consider that they might have a tampon in. It really kind of freaked me out the first time I felt that. I thought she had a mass and it was just a tampon, so good for her. All right, anal intubation. This is another fun picture. There's a couple of ways to go about doing it. I tend to use picture three. I have a double glove on my right hand, well-lubricated finger. I do my rectal exam. I leave my finger in place and then with my left hand, I use the scope or my finger to guide the scope through the anal canal. It works very well for me. There's obviously other ways to do it. If someone has a very stenotic anal canal, it can be difficult and method one works better. We were also talking about this at the faculty lunch yesterday and none of us really understand what two is. One of my colleagues calls it the sneak attack. I'm not sure what that one is, but anyway, try your method. Figure out what works for you and you'll do a good job. Okay, so once the scope is in place, you have a couple of options. You can lay the scope on the bed as on the left picture. That's what I like to do. I like that method for a couple of reasons. It stabilizes the scope so it's not likely to come out. It also lets me know if I'm getting a loop in there because sometimes it'll twist as you're getting real loopy. It also takes some of the pressure off my left hand. After a day of scoping, you can get kind of tired holding that scope and it does take some of the weight off. Some people like to have the scope hanging over the side of the bed. If you do that method, you'll usually need to kind of brace the scope between your body and the bed to prevent it from falling out early in the exam when you don't have a lot of scope in the patient. So, try both of those methods. See what works for you. Okay, and this picture was shown yesterday, but I'm showing it again because I think it's really important. We spend a lot of our time scoping and it's really easy to get ergonomic related injuries. So, make sure that your screen is not too high. If your screen is too high, you're going to spend your day like this and your back and your neck are going to pay for it. Make sure that the bed is adjusted so that you're in a really neutral, comfortable position. No one ever told me this in fellowship. It's kind of a, I don't know, a newer recognition and I scoped a lot because I'm short, I think, with my arms up here and that does take a task on your shoulders. It's important to make sure that your scopes are well maintained. If you're finding that your scope dials, if you're turning your dial a lot and it's not responsive, it's time to have those dials tightened up. But the downside to that is a lot of times when they first come back, they're a little bit too tight and then you're really working to turn the dials. So, it's best to kind of try and keep them, you know, with that one-to-one motion. You'll see that this woman is standing on a mat and I think that's also really important. If you stand on a cushioned mat, it really helps your legs and your back. And a lot of people benefit from compression hose, too, to help support their legs. And if you can, this is hard, especially as a fellow, to take breaks because you're always behind. But it is nice to take a break, at least at lunchtime. So, these are pretty basic rules of colonoscopy, but if you stick to them, it'll keep you out of trouble. So, if you can't see where you're going, do not advance the scope. Seems intuitive, but you will be tempted at times to sort of slip around blind corners and things like that. Just be very careful. It's much better to have the view of the lumen in view. If you are finding that you're not having a good view, like you're getting a lot of pink or red, it's usually because you're pushed up against mucosa. And if you just pull back a little bit, it'll usually bring things into view for you, and you can adjust and move forward. And then, if you're feeling a lot of resistance, do not advance the scope. Use as little air as possible and as much as needed. I think that's sage advice. CO2 is nice. Hopefully, most places are using that. It's better for patient discomfort. Water is also beneficial. I find that sometimes in tight sigmoids, if I fill the lumen with water, it can help me get through those tight turns a little bit easier. You do want to keep the scope really lubricated. Sometimes, if you're towards the end of the scope and you're feeling resistance, it can actually just be because the scope has gotten dried out and there can be resistance at the anal canal. So just keep that in mind. And then, always pay attention to the patient's level of discomfort. If they're really uncomfortable, either they have really bad IBS or you're putting a lupin. And I feel like I can tell if someone has IBS by how they respond to my colonoscopy. Because some patients, it's interesting. You barely move the scope and they're screaming. And other patients, you put a lupin this big and they're like, hmm. But anyway. All right. And then, there are a few patients that are just difficult. And there's not much you can do about it except anticipate that it might be difficult. Females, don't let your male colleagues, women, tell you that females are not harder. I do. My practice, I'm one of the few women in my practice. And so, most of my schedule are women, which is fine with me. But they are harder. And they do sometimes take a little bit longer. Young and thin patients tend to be a little bit more difficult. Patients who have had abdominal surgery. And of course, diverticulosis poses an important challenge. And we'll talk a little bit more about that in a minute. Okay. So, everyone kind of knows the anatomy of the colon, I am sure. But when you're on the inside of it, it can be a little bit hard to tell where you are. When you're in the rectum, you pretty much know you're in the rectum. And when you're in the cecum, there are very reliable landmarks. But everything in between is a little bit iffy. So, we'll go through some clues. So, the rectum, pretty easy to know that you're there. You just got in there. It's got a wide lumen. It's got increased vascularity. It's got the three valves. Most rectums are about 12 to 15 centimeters. Varies a little bit because most anal canals are between 2 and 4 centimeters. The reason it's important to know if you're in the rectum versus the sigmoid is mostly for colon cancer. Because rectal cancers and colon cancers are treated differently. So, try and be precise. Most surgeons will repeat with a rigid scope just to get a more precise measurement. And of course, we use MRI for staging. So, that helps as well. But do try to be precise in your measurements. And then after the rectum, of course, you go through a couple of turns in the sigmoid colon. When you get into that straight part, you're probably in the descending colon. But it's hard to tell the difference. The splenic and hepatic fluxes are The transverse colon tends to be more triangular. And sometimes you can see the light transluminating through the abdominal wall. And that can give you a clue. But again, not 100% reliable. So, the next time you're really sure about where you are is when you reach the cecum. And you know you're in the cecum because of two things. The transverse colon and the hepatic flux. So, the transverse colon is a little bit more triangular. The hepatic flexure, especially if it's deflated or just really tight, can look like the cecum. So, make sure that you identify both the appendiceal orifice and the IC valve to be sure. Pop into the TI if you're not sure. That definitely proves things. So, TI intubation. It's not always necessary. But when it is, it's a good idea to do it. That definitely proves things. So, TI intubation. It's not always necessary. But when it is necessary, those tend to be the most difficult ones to get into. So, patients with stenotic valves because of Crohn's disease and things like that. So, especially early on, get used to colonoscopy. But once you start getting really good at getting to the cecum, I highly encourage you to try and get into every TI, even if it's normal, just for practice. One of the best tips is to deflate the cecum. If you deflate the cecum, instead of the IC valve kind of pointing away from you, it'll become more horizontal and it'll be easier for you to catch it with the tip of your scope. If you can't find where the orifice is, you can use the bow and arrow sign. The bow is created by the appendiceal orifice. So, it's kind of that curvature. And then if you can imagine the arrow going through it, it should point to the IC valve. And then I sometimes find putting water in the cecum is helpful. Or as you get a glimpse of the opening to the ileum, you can also insufflate water and that'll help open it up and make it easier to get in. So, that's one of the tougher things with colonoscopy, but just practice and you'll get good at it. So, we're going to talk about loops next. Let's see. Oh, that's showing the colon or the cecum deflating. There you go. Oh, no. Landmarks. Sorry. Okay. So, sometimes it can be hard to know if you're in the lumen or if you're in the diverticulum or which way the lumen is going. So, these are a couple of tricks that you can use to help you know which way the lumen is. So, in the top left picture, that's a patient with a lot of diverticuli. And sometimes those diverticuli can look just like the lumen of the colon. Just be really careful in those areas. Use very small movements forward and backward, left and right. If you get the tip of your scope in a diverticulum, you're going to know it pretty quickly because it's going to be a dead end. You're going to want to aim for the darker area. So, if you're shining your light in a diverticulum, that light is going to reflect back on you and you're going to know that it's not the lumen. So, just pull back a little bit, look around, and go for the darkest part of the colon, and that's usually going to be the lumen. And then a couple of other landmarks that can help you, the tinea and then the folds. You should be going perpendicular to the folds. Okay. Loop formation. This is the bane of every first-year fellow's existence. He's showing how a loop forms. So, you're pushing the scope in and rather than the tip advancing, it's just forming this big loop causing the patient discomfort. This is just a cartoon depiction. And then in real life, it sort of makes me nervous how much scope he's putting in this patient. He's putting almost the whole scope in and you can see that instead of going forward, it's coming back. So, that's what's called paradoxical motion. So, the first step with loops is, you know, recognizing that you're forming a loop. So, you're always forming a loop. Every time you go around a corner, you're forming a loop. So, every time you go around a corner, you should try and reduce that loop. Certainly, if you're seeing paradoxical motion, you're introducing a loop. But if you're not getting that one-to-one transmission of scope in to tip moving forward, you're also getting a loop. It's hard sometimes in the beginning to detect that, especially if you're getting, you know, a little bit less than one-to-one. You can kind of slowly introduce a loop and it can sneak up on you. So, just assume you're forming a loop and around every corner, you're going to want to reduce. And we'll talk about how to reduce. So, these are the many different types of loops that you can form. And they're all treated pretty much the same. For the most part, you're going to want to torque the scope and pull backwards. And usually, you're going to torque clockwise. Every once in a while, a loop will encourage you to torque counterclockwise. And you'll be able to tell the difference because you're going to want to try and have the view of the lumen or the lumen in view. The reason for that is as you pull back, sometimes the scope will actually go forward as you reduce the loop. And you don't want it to go forward if you're not facing the lumen. So, this is a little anatomy reminder because it'll help you know where your loops are forming. So, it's good to predict where you're forming loops. As you probably remember, the ascending and descending colon are retroperitoneal. So, they're tacked down a little bit. And you're not likely to form any loops there. But the sigmoid colon and the transverse colon are prime for loop forming. If your assistant can feel where the loop was, then that's a good place to put pressure. But if they can't, then you can use this anatomy to sort of predict where the loop might be forming so that you can at least give them some advice on how to help you out. Some of it is just trial and error, though. So, this is a depiction of loop reduction by pulling back. And this is loop reduction by torquing. Torquing often helps straighten the colon so that when you try again, you don't reform it. And then this is showing what one-to-one transmission looks like. So, as he pulls back the scope, he pulls back. When he pushes in the scope, it goes forward. So, after you've reduced a loop, if you have that one-to-one transmission, you know that your loop has been reduced. And you can try again. If you try again, and the colon has been straightened out, you might have good luck and be able to just proceed. But a lot of times, the same loop will just keep reforming, reforming, reforming. And that's when you're going to need some assistance. So, we'll talk about pull back to straighten. It's really the most important thing you'll do in colonoscopy. And you'll want to do it frequently. Even when you think you've reduced your loop, a lot of times you haven't. So, just constantly be pulling back and torquing. Okay. So, this is about abdominal pressure. So, there's a couple of things that you can do. One thing that I like to do early on if I'm developing a sigmoid loop is I just have the patient kind of roll more towards their belly. That puts a little bit of pressure on their left lower quadrant. And sometimes that can be enough, especially in obese patients where the assistants have a hard time, you know, finding where to put pressure. And then this table talks about, you know, if you're in certain areas where you might start with pressure. So, we're going to go through each of these in turn. And you'll have these slides. So, one of the earliest places that a loop will form is that first sigmoid curve. So, you can tell by the x-ray that it's kind of the loop is going to be forming up towards their umbilicus. And so, you're going to have your assistant hopefully wearing a glove put their hand right at the umbilicus and kind of push down towards the pelvis. And then the second curve in the sigmoid is usually going to be more towards the patient's left. So, if you have your assistant start on the kind of left lower quadrant and again push up towards the umbilicus, that can be helpful. You will note they're not giving a lot of pressure. You know, sometimes your assistants are in there like, you know, really pushing. And sometimes, you know, with obese patients you have to do that. But really it's finding the right place and just giving a little bit of support so that that loop is basically hitting their hand and not reforming. Okay. And then this one is when they have a splenic loop. You do have to be careful if you have a big loop at the spleen because you can cause splenic damage. It's not common, but it can happen. So, having your patient or your assistant kind of give pressure in more the left upper quadrant and pushing down can be helpful. And then this was a nice article that gave a lot of tips, but one of their tips was if you're having trouble getting past the hepatic flexor, sometimes just an easy maneuver is to rotate their shoulders back without fully putting them in the supine position. And that can help you get around the hepatic flexor. And then the last area that gives me a lot of trouble still is sometimes you're right at the IC valve and you just can't get those last, you know, two centimeters to look behind the valve and get a really good look in the cecum. So, deflating the cecum can help. Sometimes you can literally just suck your way into the cecum. If that doesn't help, abdominal pressure or it sometimes helps to put the patient fully supine with their knees up and that'll just pop you right in. It's a little bit of effort to do that in a sedated patient. So, I usually try other things first before I do that. All right. So, we've made it to the cecum. So, now we get to withdraw and that's when we really take the time to look very closely for polyps. So, this video is just showing how he's going back and forth, looking behind every fold, using his dials to look right, left, cleaning very well, especially in the right colon. You're going to want to clean, clean, clean because those desacerated lesions can be really tricky to find. So, be very meticulous. I think this video goes on for a long time. All right. And then there happened some small studies that show that doing two passes through the right colon not only increases your ADR by almost 20%, but also increases your detections of SSLs by about 10%. And you can do this either in forward view twice or you can retroflex in the cecum and pull back in the retroflex. And then finally, after you've examined the entire colon, you get to the rectum. And this video is showing how to retroflex. So, he's pulling back until he sees the dentate line. And then as he inserts, he's going to dial down with his big dial all the way, pushing a little bit more gently. Sometimes you have to also add the right colon. So, he's pulling back until he sees the dentate also add the right left button, pushing a little bit more, and then it'll come into view. So, you can get a pretty good view of the rectum in just the forward view. But I think most people still do retroflexion. I know I do. I have one partner who doesn't because of the potential risk of perforation. I find that I've never had that happen. Most people haven't, but it has been reported. You do have to be careful. You don't want to be forceful. And there are certain situations where I won't retroflex. So, patients that have severe colitis, if someone's had a low anterior resection, I usually don't. And sometimes people just have a very small rectal vault and I'll try a couple of times and it just doesn't feel right. I don't push it on those patients. I just get a really good view in the forward view. All right. So, in summary, make sure you know why you're doing the colonoscopy. If you ever have a complication and you don't have a good indication, that's not a good combination. So, just make sure you have a good indication. Make sure the patient understands why you're doing it, what the risks are, and what the benefits are. Always be aware of your scope position using your landmarks. If you're in the sigmoid colon and you have 100 centimeters of scope in, you've got a loop. So, those are things to pay attention to. Usually, you can make it to the cecum in anywhere between 60 and 90 centimeters in most patients. Make sure the patient's comfortable. If they're not, like I said, they have a rip-roaring IBS or you've got a loop in and probably have a loop in. And be aware of your body position for your own health and protection. Always assume that you have a loop. So, reduce those loops. If you think you've reduced it, try again. If you keep putting in the same loop, you can use the techniques of water immersion, position changes, and abdominal pressure to help you out. And then when you're drawing, just make sure that you're very meticulous about cleaning the mucosa. Be very thorough. Look behind every fold. Go back and forth multiple times. Consider going through the right colon twice. Use both of your hands to navigate, to look all the way around and behind every fold. And take your time and be methodical. And that's it. Have fun. All right. Are there any questions? I want to make one comment. When you mentioned about the retroflexion, Dr. Jorgensen's right. Sometimes, if it just can't be done because of stiffness or whatnot, our patient's prior surgery is very difficult. Sometimes, though, if they haven't had any surgeries and you're having a very difficult time and you just don't feel comfortable, you can use actually just a standard upper endoscope. You can ask the person to switch. It's very flimsy. It's very easy. And retroflex is very nice. And you look like a pro. You're like, look at how easy this is. Pretending it's like you just started another scope. So, probably in your first year, that's not going to happen. But once you're out and you're having a difficult time retroflexing the rectum, the upper endoscope actually is another tool you can use. Any other questions? All right. Thank you.

diagnostic colonoscopy

screening

surveillance

symptoms

perforated colon

intubate anal canal