So, I don't have any disclosures. I would like to say thank you to the ASGE and the course directors for inviting me to talk on this topic because it's my favorite. This is honestly one of my favorite things that we get to do every day as gastroenterologists. There's a couple reasons, but for me, colonoscopy is an art. It starts with some basic concepts, which we'll talk about a little bit today, and honestly, your skill set is also an outgrowth of what we just heard about for upper endoscopy. But the true scope and breadth of your skills changes and evolves through your training and even into practice. And so, I think it's this art that grows with you through your practice. And even today for me, almost 10 years out from fellowship, I still encounter these colons where I'm just like, well, that was a doozy. And I have to pull out every trick I can think of to try to get the job done. So it's creative, it's humbling, and it's an art. Okay. So we're going to go through the indications for colonoscopy. So very broadly, you've got your cancer polyp indications and your symptom workup indications. So the cancer polyp indications fall into these two categories of screening, that's an asymptomatic person, and surveillance, a person that has a history of pathology in the colon. Use these terms. Start putting them into your presentation to your attending when you're presenting before the case starts, because you'll convey a ton of information with just a few words. It also helps you put your patient into a category that you can apply a guideline to, so you can start right away thinking about what follow-up might look like based on your findings. So your presentation would look like, 50-year-old female here for a first-time average risk screening colonoscopy. You just told me a ton of stuff with like three words. So start using this terminology early and get good at it. Diagnostic colonoscopy can be done for a variety of reasons, unexplained symptoms, lab abnormalities, GI bleeding, iron deficiency anemia, workup of IBD, or abnormal imaging. These are just a few. There are a few contraindications to colonoscopy. It's overall extremely safe. This is a list of some contraindications. You will be asked to scope a patient for every single one of these contraindications during your course of fellowship and your career, without a doubt. Perforated intestine is generally the one place where we have a hard stop. This should not be something that you automatically say yes to. Have a detailed discussion with your attending. The answer is most often no if there's a known perforation. These other contraindications are maybe more of an indication to rethink your procedural plan. So acute diverticulitis, if for some reason you need to go in and look before it's cooled off, you have a patient with IBD and known deep ulcerations but need a biopsy for CMV, ischemic colitis or fulminant colitis for IBD or C. diff, you may need to go in and take a look. You may need tissue. There may be a good enough reason to do a colonoscopy in these contraindicated scenarios. But you may modify your procedural plan and just do a flex sig, just get to the area of abnormality, take your biopsy, and get the heck out of there. And then, of course, there's the contraindications related to your patient. Cardiopulmonary issues affect all of our patients, on the inpatient service in particular. This is super important because, to me, this is the backbone of a lot of your thought process as a fellow, as a consultant. You need to be weighing the risk to your patient with the benefit to your patient in the context of the risk of the procedure and the benefit of the procedure. So if you have a high risk patient with a lot of comorbidities, this better be a high benefit procedure, right? If you're going in there to just take a couple pictures in somebody who's incredibly high risk, you need to have a good discussion to figure out if that's really the right thing to do. So cardiopulmonary assessment and assessing risk and benefit of the patient and the procedure is super, super important. And that's one thing you'll practice all throughout your practice or all throughout your training and your career. And then inability to tolerate bowel prep, obviously very common in the outpatient world, even more common in the inpatient setting. And then the question is why. If they have a bowel obstruction, they're definitely not going to tolerate the prep. So think about your procedural planning here as well. Is this something you can get to with enema prep and a limited lower scope like a FlexSig? But if you can't clean out the colon, it's very hard to do a complete colonoscopy. And you will be asked to do this. Enjoy. No. OK. So how do we start colonoscopy? Obviously, you're going to start from the outside and do a careful perianal exam. Your patients are usually sedated, so don't be scared to get in there and take a really good look. Just a little sidebar here. When you're doing your perianal exam and you actually find something and you want to describe it, there's not a clock face on the butt. So saying 12 o'clock, 6 o'clock doesn't translate to your surgical colleagues. It's anterior, posterior, left, right. So left anterior skin tag, posterior midline fissure. So anterior, posterior, left, right. Got it. Then you move on to your DRE. You're going to do a full finger exam of the anal canal, prostate exam if you're able to. And then you're going to get ready to insert the scope. And there's different ways to do it, directly inserting the scope, guiding it with your fingertip. But the common thread of all of this is that nobody likes to be stabbed in the butt. So just gentle, steady pressure, lots of lubrication. If your patient is awake or lightly sedated, be talking to them the whole time so that they know what to expect and you're not surprising them. When you position the scope on the gurney, you can either lay it flat on the bed, which I like to do, and especially when you don't have very much scope in the patient, then you're not fighting gravity. You can hang the scope off the side of the bed, but when you're down into the rectum and most of the scope is outside of the patient, then you're kind of battling and the scope can fly out. It's not a good look. OK. Basic rules of colonoscopy, very similar to EGD. Don't advance the scope if you can't tell where you're going. So early days, you should be able to actually see the lumen, see where you're going. As you get better and have more experience, you'll be able to recognize how the wall of the colon changes and guides you towards a luminal view. But in general, don't push if you don't know where you're going. If you get lost, pull back. When you hand the scope to your attending, the first thing they'll do is pull the scope back. So pull back. And then even if you think you know where you're going and you can see the lumen, if you're getting resistance with advancing the scope, stop and troubleshoot. You don't want to push through resistance, at least until you know what you're doing. OK. You're going to use as little air as possible or CO2 in most cases, but as much as you need to get the lumen open. Keep the scope lubricated and pay attention to your patient's level of discomfort. In the context of using as little insufflation as possible but as much as you need, you can also add water immersion to the CO2 technique in order to get the lumen open. Sometimes that's helpful in the left side of the colon because if you're in the left side of the colon and you put a bunch of CO2 in there, gas rises into the right side of the colon. It can expand the right side of the colon like a little balloon, getting your destination even further away from you. It's pushing it away. If you use water in the left side of the colon, in some anatomic configurations, it actually sort of weights down the rectum and can straighten out a little bit that flexure out of the pelvis. So water immersion, especially on the left, can be really helpful. Anticipate that some of your cases may be more challenging. They all say females are more difficult. Maybe we are, but definitely there's a sharp turn in the pelvis in many female patients. You can have a more redundant colon. It is amazing to me how much colon can be packed into a very, very small person. Chronic constipation, where you can anticipate the lumen might be more dilated, making looping, which we'll talk about in a minute, a bigger problem. People with abdominal surgery and adhesive disease can give you that sort of fixed area of the colon where you're feeling resistance, lots of diverticulosis that can be difficult as well. And above all, especially if you're worried that it's going to be sort of a less typical colonoscopy, pay attention to your patient's level of discomfort. That can tell you something's not right and you need to troubleshoot. Start getting familiar with your anatomic landmarks, and we all know these, right? We're all doctors, so you know rectum, sigmoids, splenic flexure, transverse, hepatic, ascending cecum, TI. We all know these, but you're going to learn them from the inside. And so over the course of the next few months as you're doing colonoscopy, really key in on where you are, where you think you are in the colon. Be talking. Talk with your attending the whole time. I think I'm in the rectum. I think I'm in the sigmoid. I think I'm heading out of the sigmoid. And your attending will help you kind of learn to recognize these landmarks in the colon from the inside. This is a representative picture of the rectum. It's nice and open. You see this lacy, reticular, vascular pattern here. And then there's almost always a puddle. That's the gravity side. This is the antigravity side. And this, because the patient's lying on their left side, as you come around and back the scope out, this is almost always here. This puddle is a great practice puddle. This is where you're going to want to rotate your scope so that the suction port is at six o'clock. There is a clock face inside the colon for teaching purposes. And then you're going to dip the tip of the scope into the puddle and suction this out. This is a great place for early practice, for puddle positioning, and kind of being the master of the lumen. How do you rotate and make it go where you want it to go on the screen? This is a representative image of the transverse colon, which often has this kind of triangular shape to it. And it's a nice, long tube. You can almost imagine being like, echo, echo, right? That's the transverse. And then here's where you're going. The cecum IC valve is over here. Here's the AO down here. The TI is certainly something that you want to get good at looking at. And I'm not just saying that because I do IBD. You don't have to get in there for everybody. But during fellowship, you should certainly try, as long as your attending is willing to let you know everything's going well. The more you get into the TI, the easier it is to do and the faster you get at it. Some just basic tips. Having the cecum a little bit less insufflated, having some laxity in the wall is helpful. Starting to use your wheels. Oh, cool. This wasn't in my one at home. So yeah, so basically, what are they doing here? Sorry. Yeah. So basically, you put the scope in here. And then you're going to try to look in there. And you're going to deflect the tip of the scope. Here we go. And poke the tip of the scope into the end of the TI. If it'll work now. Did I mess it up? Sorry. Not sure. Is it? Yeah. Oh, there. and very, I love this, because you want to do really small movements with the tip of the scope, just like what you're seeing here. It's so tiny. And then it just kind of looks in between the edges of the valve and goes into the ileum, which is an awesome thing to do. The first couple times you do it, I highly recommend making up your own TI dance. It's very rewarding. And then as you're coming out and you're looking here at the cecum again, you can kind of see the space between the AO and dipping the tip of the scope in between the folds of the IC valve, and then boom, you're inside the ileum, and that's what it looks like. Cool, that's neat. All right, so as you're advancing the scope, you're seeing the inside of the lumen. It may have areas of diverticulosis, where you're like, I don't know, is that a tick? Is that the lumen? Am I going the right way? Take your time, ask your attending, listen to your attending, we're there to help you, and use the folds to kind of direct you the right way, not the wrong way. All right, so we're going to talk for a minute about loop formation, which you heard a little bit about on EGD. So again, a lot of the skills that you learn for EGD translate to colon, and you learn them on EGD first, because you just do, it's a simpler, shorter scope. So loop formation, you can see is when you're trying to advance the scope, but instead of going forward, it's bowing out the side of the colon, and what you see on the screen is that paradoxical motion. So you're pushing the scope in, but you're going in, I don't know, two, five centimeters, and the scope tip on your screen is not, it might even be going backwards, or paradoxical motion. So that's a loop, and it's kind of like, if you're taking a stiff object, like a pencil, and sticking it into a floppy object, like a sock, you're going to push, and you're going to get looping, and this floppy object is going to move out of the way, and the scope is not going to go straight. So this is like you spend, I don't know, the first, at least six months of fellowship being like, I think I feel a loop, I think I feel a loop, I think I feel a loop. That's the learning process here. There are different types of loop. Some of them are more complicated to deal with than others, but they all feel kind of the same, with that idea of loss of one-to-one, paradoxical motion, your patient may not be super comfortable, you may start to feel a little bit of resistance, those are all signs that you've got a loop coming on. And there are some predictable areas where you're more likely to loop, so unlikely to loop in the rectum, but once you start getting out of the rectum and into the sigmoid, here's your floppy sock, and you're sticking your pencil in there, right, the scope's trying to go through, but it's got this turn to make, and it's floppy, so as the scope is trying to go forward, it's actually bowing out down here, so sigmoid is a common area, your flexures and transverse, and then getting down into the cecum can loop as well. So loop reduction is all about pulling back the scope, usually with a little bit of torque, and that whole idea is that as you loop, then you torque, pull, and it's straightening that wall of the colon so that the scope now goes straight instead of bowing out to the side. So that's why that's in bold, pull back to straighten. So what if you do that, and then you try again, and you're still looping, and each time you go in, the loop comes back? That's when you reach for some help from your team, so abdominal pressure is usually given by your tech or whatever assistant's in the room with you. It should be used strategically. Your tech may be buff, they may not be buff, but it's a lot of work to push on a belly for extended periods of time, so you want to use your pressure really strategically. Basically you straighten out your scope, then we're going to go over the different places where you have your assistant push, but they basically hold the wall of the belly, supplementing that tensile strength of the wall of the colon to keep it straight, and then the scope can go forward instead of making that turn and bowing out to the side. So if you're really low in the colon, you don't have much scope in, you're sort of at that rectosigmoid turn, suprapubic pressure, you're in a little further left lower quadrant, you're in a little further like around splenic flexure or into transverse, then the mid-abdomen, and then you can also have pressure at the flexures. This is kind of what that looks like. So here's the scope going in, here's that first turn, and you can totally visualize this, right? Like you're pushing this direction, you want the scope to go this direction, but it's not, it's going this direction. That's where your pressure comes into place. The hand comes here, pushes on this, allowing the scope to go straight. This is another example in the left lower quadrant. So you're going to pull back. You don't, pushing when a loop is, or putting pressure when a loop is already in there is less effective than getting the loop out, than using the pressure to prevent it from forming in the first place. And then again, sort of as you advance the scope even further, you know, you can, this is a smaller person, you could even put your whole hand over the entire abdomen and support the whole abdominal wall. Okay, so this is just a little tip. Sometimes you get all the way to the hepatic flexure and you're like, I'm doing awesome. I'm so close at the hepatic flexure and you can't get the scope to go around the hepatic flexure. It keeps closing, the folds are stuck together, it keeps looping. One thing you can do is take your patient's shoulders and kind of just adjust them a little bit more supine. It opens up the rib cage, it opens up the hepatic flexure, and that can sometimes help the scope go on and make that final turn into the home stretch. All right, once you're there and everything's nice and straight and you've done what you want to do and you're in the cecum, then you need to start the real work. You want to clean the colon. This should be very intentional. You're looking while you're washing, you're suctioning out the fluid in a strategic way, and that goes back to what I was saying about practicing on that rectal puddle. That's the same technique you're going to use, it's just more complicated in the cecum because you have more scope in the patient. You want to get your puddles to six o'clock, be efficient, get them out of there, look under them, look behind the folds. Retroflexing is very important. You want to make note and document your prep quality, obviously anything else that you find. I always think about this kind of like if you were on the SWAT team and you get called into some hot scenario and you're with your gun and you're at the door and you're like, the kitchen's clear, behind back of the couch is clear, the closet's clear, right? You're doing the same thing in the colon. Think about what you're doing. Behind the IC valve is clear, AO is clear, right colon's clear. You won't miss stuff if you're thinking about it the whole time. And then retroflexing, here's an example of retroflexing in the rectum. So you're going to pull all the way back until you see the dentate line, then you know you're at the end, and then you advance the scope a little bit into the rectum so you have nice free space, and then you're going to flip both of your wheels and the scope will go all the way back, and then you can look at the inside of the bottom of the rectum, the anal verge. This is really important. This is one of those skills early on in fellowship that you're like, man, I'm having a great retroflexion day. It's awesome. And then the next day you're like, I've lost it. My mojo is gone. It's very humbling, but this is important to practice and get good at. If your patient is lightly sedated or coming out of sedation at this point, this is also a good way to really assess your patient's comfort. You can do this in an awake patient once you're good at it. So saying all that, it's sort of the end of the colonoscopy. It's a skill that comes and goes, but it's a good skill, an important one, and one that you'll obviously do with each colonoscopy. The very beginning of GI fellowship, your first few colonoscopies, you're like, I got to the CECM. You're going to be texting your co-fellow, CECM, you're going to be texting your co-fellow from the year ahead of you, I just got in the TI, right? Super fun. But if you get into the CECM and you get into the TI in your first six months of fellowship, it's probably an accident. Sorry. The point of this is actually learning all of these little tiny skills and building them together into a complete colonoscopy toolkit. So if you think about it, and I'm going to apologize to the Utah fellows because you'll hear me say this a bunch during the year, but think about your favorite movie that's like a sports movie or a dance movie or a superhero movie, like the main character does not come out and do the thing in the first scene, right? There's always this incredible training montage where they learn how to do whatever, learn this superpower, do X, Y, or Z, and then at the very end, they do the thing. So this is you guys, this is your superpower, and you got to learn each piece of it and get really good at each piece of it. So as I'm teaching at the very beginning of the year, if you're getting your puddles in six o'clock, I'm so happy. That's exactly what you need to be doing. I do not care if you get to the CECM, because if you do, it's an accident. In summary, you want to review your procedural indications, the risks and benefits of your procedure, make sure you understand what you're doing and why, and that it's safe or reasonably safe for the outcome that you're expecting, the information you're expecting to get from your procedure. Assess your patient's position, your position, be comfortable, start thinking about ergonomics early. That is such a true statement that the older you get, the more important ergonomics become. Almost everybody gets an overuse injury at some point, so take care of yourself. Then think about scope insertion by using a combination of water immersion, especially on the left, and minimal CO2, but as much as you need to see where you're going. Don't be afraid to change the position of your body or your patient's body if you think that's going to help facilitate successful completion of the procedure. Abdominal pressure should be used thoughtfully, ideally before the loop is in or after you've taken the loop out to prevent it from coming back. Most techs don't like to give pressure for longer than, I'd say, 30 seconds. It feels like a really long time when you're pushing on somebody. So think about it in little chunks of thoughtful, purposeful time. And then reduce your loops, reduce more. You're going to spend a lot of time learning about loops. As you withdraw, your views matter. Clean the mucosa. Make a mental map of what you've seen and what you haven't seen. Be a SWAT team. Clear the colon. Look behind the folds. Your exam is only as good as what you see and what you do, so be thorough. And then don't forget about retroflexion. You'll start out practicing it in the rectum. A lot of us also do it in the right colon, so as you get better, that same skill set translates to the next step in your procedural skills. Take your time. Be methodical. Just like on the EGD, you're going to have your set routine that you do, and a lot of it's going to be dictated by where you are in the colon. So learning that anatomy, being comfortable with where you are is very important. And that's all I got. Thanks. Okay. There's a question from the virtual audience. It just came through. It says, when scoping early on as a fellow, there's a lot of hesitation to ask for abdominal pressure and position changes because you get blame getting stuck to your technique rather than the patient's position. Any advice about this? I mean, I think that, you know, learning when to use pressure is part of the first phases of fellowship. So your attending should be there helping you know when pressure is going to be helpful and when it's not. We all use it. It's important in terms of reducing the risk of loop formation and stretching the side of the colon. So I think it's part of your technique, really.

colonoscopy

gastroenterologist

procedural techniques

anatomical landmarks

ergonomic considerations

abdominal pressure