Thank you very much, and thank you to Drs. Byrne and Kowalski for inviting me to talk. This is my first time here at the course teaching, and it was six years ago, it seems, just like yesterday I was at this course as a first-year fellow. So thank you so much for having me. So today, I unfortunately don't have any disclosures yet, I'm too young of a faculty. Hopefully soon. We're going to go over colonoscopy, which can be probably the most daunting part of a first-year fellowship. I think the most daunting part of all training, I think, is third year of medical school, but I think colonoscopy is a very close second and can be a very, very humbling experience. We're going to go over what are the indications, what are the contraindications, and when we should not be doing colonoscopy, because that, too, is very, very important. Some techniques that we should be using when we're performing colonoscopy, and also troubleshooting so that we can hopefully reach the cecum with a short scope, which is ultimately the goal. So indications for colonoscopy. Most commonly, we're going to be seeing patients who are screening for colon cancer. Right now, the age to start in average risk patients is 45. Recently, a few years ago, it was lowered from 50. And you also have to pay attention to patients who are at higher risk, such as patients who have maybe IBD, family history, genetic, where they're going to want to start at an earlier age. Then you also want to think about if you're doing a surveillance colonoscopy. So a surveillance colonoscopy is somebody who has already had some sort of pathology in the past, whether that be your typical adenoma, whether they have IBD, is going to be a reason for a surveillance colonoscopy based on what their last colonoscopy showed or the disease state. And then we want to talk about diagnostic colonoscopy. So again, very common, especially when we're going to be on the inpatient services, but unexplained GI symptoms. And most commonly, we're going to be seeing a lot of patients with bleeding. That would be hematochesia or the ER consult for the positive FOBT, which we're all going to know and love, iron deficiency, anemia. And again, anytime someone has abnormal imaging in the colon, which can be very common as well too, is going to be an indication to undergo colonoscopy. I think it's also really important that we need to know about the contraindications to colonoscopy because what we ultimately want to do is do no harm. We want to do a colonoscopy that's going to ultimately provide benefit to our patients. And if we shouldn't be scoping up front, we should at least be telling our referring doc or our patient why we're not offering a colonoscopy at that point. So it seems very obvious, but if the patient has a perforation insufflation into the colon with either air or CO2 is obviously going to be very harmful and can cause pneumoperitoneum and decompensation. The next four are also commonly encountered as well too. Acute diverticulitis might be a reason that we want to think about doing a colonoscopy, but that can actually be a contraindication, be a very high risk for perforation. And so these are the patients that you're going to want to treat medically. And a couple of months after recovery, usually two months or so, is when you're going to actually want to bring them back and look for any signs of pathology. If they haven't had a recent screening or diagnostic colonoscopy prior to that episode. Patients who have really deep ulcerations, whether that be from very severe colitis, are at high risk for perforation. And we're not going to be wanting to go all the way around their colon, creating loops or pressure on these ulcerations that could also cause tears as well too. Patients who have severe ischemia. So quite commonly we're going to see patients in the ICU who likely have ischemic colitis after they've had shock, et cetera. Those patients are at very high risk for perforation. And again, if we want to do a colonoscopy or we're asked to do a colonoscopy, we should think more about flexible sigmoidoscopy, not creating any loops, not going very far, and getting a diagnosis with as short of a scope as possible and leaving the goal of getting to the cecum to the side in those patients. Cardiopulmonary decompensation. Again, your crashing patient should not undergo a colonoscopy. It seems really elementary to talk about, but this can be a very difficult discussion to sometimes have. But again, your patient has to be stable when we sedate them and undergo colonoscopy as well. And then lastly, patients who are not going to be able to tolerate the bowel prep, not going to be clear in the first place, didn't complete the prep or couldn't do it, that's going to be a contraindication to a successful colonoscopy and it's just going to be a sedation with a rectal examination and not a successful colonoscopy. So when we do finally start colonoscopy, the rectal exam and the perianal exam is going to be a very key integral part. So in box A, we actually see a patient who likely has prolapsed internal hemorrhoids, but this could also be rectal varices as well too if they have cirrhosis. In B, we're going to see thrombose external hemorrhoids, and in C, we can see condyloma as well, a part of our perianal exam well. Some docs actually prefer to do this with the light on in the room when they actually start the case, but your white light from your endoscope should be enough to do a very careful examination before you insert your colonoscopy. The next part, we're actually going to do a digital rectal exam before we insert the colonoscope and we want to do a full 360-degree sweep of the anal canal looking for any masses, anything that's reachable as well. And in males, we're going to want to do a prostate exam as well. I won't lie, I'm guilty of not always doing a prostate exam in my patients, but it is something that we should be doing as well too, palpating for nodules before we insert the endoscope. And what we're also going to get from our digital rectal exam is the angle at which the scope should be inserted. So the angle at which our finger is inserted into the rectum is the angle at which the scope should enter into the rectum as well too. And so having that angle in mind when you insert the scope afterwards is super, super important as well. So in this picture, they actually use the finger to kind of guide in. I don't personally do that. I use the rectal examination to kind of guide where I'm going to be going as well too. You're usually pulling back on the gluteal fold with your left hand and inserting with your right. What you really want to do is make sure that you can get a full view. I think most trainees have had the accidental intubation in the female patient. And colposcopy is not something that we want to be billing for or doing. I don't consent for that either. We did one about two weeks ago, our second year fellow. But I said, why don't you pull back and reinsert? It was a little awkward for a few minutes, but we got through it. So what I call the scope dance is a really important part of starting the scope as well too. So you're going to drop the bed rail down. And then what you have to do is usually you have to get that scope from the hanging position to the bed and get set up. And that can be a very awkward transition sometimes. But eventually what you're going to want to do is lay the scope flat on the bed with no loops in it. And also the part that attaches from where the dials are back to the processor has to have no loops in it as well too. Once that's all straight, you're going to be setting yourself up for a much more successful scope. And I think we're going to hear more about ergonomics in terms of the bed height as well too. Some people scope with the scope flat on the bed to allow it to not have to hold onto it. Some people will argue that hanging over the bed is more successful. And the reason is, is that a lot of people will scope with their left hand as well too. Torquing can also get you 360 degree views, which can be very helpful as well too. And it's a little bit more difficult to use that technique if your scope is flat on the bed. But at the same time, hanging over the scope of the bed, you cannot lose sight of the scope and it cannot fall on the ground. So most trainees start out with it flat on the bed. But I would encourage you to try both because both have their advantages and disadvantages. So it seems simple. But if you remember these three basic views, you're going to be a rock star in the endoscopy suite as a first year. So we don't want to advance the scope without being able to see where we're going. So if we don't see the lumen, we're not going to continue to insert. When in doubt and if we're wondering what we're looking at or any question whatsoever, we're going to want to pull the scope back. That's never going to hurt the patient. So advancing blindly without knowing where we're going can cause harm. And then lastly, if there's significant resistance, you feel like you're pushing up against a brick wall, we're not going to advance the scope. If you remember all these three things, you're going to really decrease your risk of ever having a perforation, which I think is everybody's goal is to never cause a perforation. But these are the things that you're going to remember throughout your endoscopy. In terms of insufflation, a lot of places are now offering CO2. Some are still using air. But CO2 has been shown to have, it dissipates better, absorbs better, and the patients oftentimes have much less discomfort afterwards. But remember that air and CO2 can cause pain and discomfort after the endoscopy. Barotrauma is also something that's of concern as well too. So use what you need, not anymore. And remember if you're using air to always withdraw air on your way out after you've examined a full segment. You want to try to lubricate the entire scope and you're going to want to use a lot of lubricant, especially on the end of the scope when you insert. If you feel like your scope is sticking as you go in, you're going to want to just stop, pause, ask for more lubricant if you've used it. But really having the patient be comfortable is ultimately what's most important. So you're going to use a lot of lubricant as well too. And then the last one is I think really important, especially if you're using conscious sedation, which I think is important. If you get the chance to train on conscious sedation, I think it really teaches you of loop technique, really making sure that you're keeping a straight scope as well too. And oftentimes knowing what you're doing wrong is if the patient becomes more uncomfortable. With propofol, your patient's in a much more deep state and they're not going to be able to grimace as much or really let you know that they're having a lot of discomfort. And then you're also going to want to anticipate difficult cases. Females tend to have a much more tortuous colon that can be more difficult, it can be more redundant. Younger patients especially and anyone who's had abdominal surgery or adhesions or hysterectomies can be very, very difficult as well too. So you're going to want to anticipate maybe using pressure early. Some patients you're going to want to select a pediatric colonoscope. And what I often recommend too is if the patient's had a colonoscopy before, that's noted to be difficult. Take a look at the last colonoscopy note, see what that endoscopist used and that will kind of guide you as to what you might need to anticipate as you start your endoscopy. So we want to think about the landmarks as well too as we're going around and withdrawing. And identifying these is going to be integral not only for our photo documentation but also kind of knowing where we should be applying pressure and taking biopsies, et cetera. So the rectum is what we're going to see right after we immediately insert the scope. So if we pull back, we're going to be able to see the dentate line leading into the rectum. And then you can see the three folds of the rectum as well looking down forward. Once we've reached about 15 centimeters in, we are then at the rectosigmoid junction and then beyond that you're in the sigmoid as well. The transverse colon kind of has a characteristic triangular appearance to it. And this can commonly let you know that you're in the transverse colon. And then finally the Holy Grail, the ultimate adrenaline rush as a first-year fellow is when you see the cecum in the IC valve and you can yell out, seek him. I will tell you that it still feels good to yell, seek him, in the room, even today. And I actually have somebody who claps when I get there, one of my techs, and it makes you feel good. I don't know what it is. But maybe it means I rarely reach it, I'm not very good. But nonetheless, it makes you feel good to hit the seek him and take this picture. But identifying this is super important, not only for your photo documentation, but knowing that you've actually done a complete colonoscopy as well, too. But getting there is important, but the way that we get there, short scope as well, too, because if you get here, you're contorted, your scope stiffener dial is basically at the dentate line, that's not really gonna be a successful colonoscopy in terms of doing what we need to do, which is actually the examination afterwards. TI intubation, not often, not always needed, especially in screening colonoscopies, but I use this a lot, especially if there's ever a funny-looking appendix or you're wondering if there's a lot of diverticular disease if you've got the right photo, but what you're gonna wanna do is really deflate the air that you've put in, and that will allow the IC valve to open up more. Some people use two different techniques. One is, you can kinda look like in that last picture, if we were to look, we would've been able to go right into the terminal ileum without difficulty. But some people use a deflection technique, which is, you identify the appendiceal orifice, and patients use, or we use what's called the bow and arrow sign. So if you imagine the appendiceal orifice kinda being a crescent shape, you imagine that as being a bow and arrow, and if you were to fire an arrow from that bow, that will point you towards the ileocecal valve. So if you're ever in doubt of where your IC valve, or if you have no idea, what you're gonna wanna do is identify the appendiceal orifice, and the bow and arrow should point towards where the IC valve is, and some people can intubate with a blind technique, or at least it will tell you the right direction as to where you need to go. Landmarks for lumen are really important, especially in patients who have a lot of diverticular disease. This can be very tricky to navigate through the sigmoid colon, especially if they have a particular burden of diverticuli. I think what I recommend doing is water immersion, especially on the left side of the colon. This will keep the colon shorter, and be a little bit easier to identify exactly where you need to go. One other technique I do recommend, and probably most advanced endoscopists use in the first place, is to put a cap on. I've found that a clear cap on the end of the scope in a patient with severe diverticular disease can actually help guide you through the sigmoid a lot easier, or wherever the diverticular disease is as well. And then the all-famous loop formation, the reason that colonoscopy is so difficult, because if it was just scoping a lead pipe, it would be not so difficult. What we're actually scoping through is kind of like a sock, it's very, it goes in one direction, and you're trying to go left, and you're going right, and it can be very, very difficult. So here it's showing us paradoxical motion. This is when we're going further and further and making a bigger, bigger loop. What's actually happening is you're inserting the scope, and the tip is actually coming back in the wrong direction. So that's a paradoxical motion. So what we need to do for that is pull back, first of all, rule number one is always pull back. And then two is we want to kind of figure out where our loop is being formed, and use abdominal pressure to prevent that loop from occurring as we reinsert the scope. So in terms of the types of loops, people like to talk about the different types, and there's nomenclature for them. Unless you're using a scope guide, which is kind of rare, I don't find the nomenclature as helpful to me as I find just knowing that I'm putting a loop in, and that I need to do something different, and how to get that out is more important. So some areas of the colon are more movable than others. Particularly the sigmoid, the transverse, and the cecum can be more mobile, but the transverse and the sigmoid are where we tend to run into more difficulty, and less so in the retroperitoneal areas. So loop reduction is gonna be an important technique, and we're gonna work on this in the lab as well, too. What you're actually gonna want to do is you're gonna pull back, and usually what you're gonna do is you're gonna turn in a clockwise fashion. If you are pulling in the wrong, if you are torquing in the wrong direction, you're gonna feel it, because that loop is gonna get actually bigger. Try the other direction as well, too, but usually it's a pullback with a clockwise torque, and that loop is gonna straighten out, and your scope is gonna straighten out, and sometimes you're actually gonna go farther. Your scope is gonna go farther as you pull back as well. We talked about pulling back to straighten. As we're forming loops, the goal is to not form them in the first place, and what we're gonna want to use is abdominal pressure, and this is really gonna help the scope stay straight, push back against the loop formation, and allow us to get to the cecum with a shorter scope. So this slide kind of goes over based on where you are at in terms of distance from the anal verge as to where you want to start putting pressure. Usually I kind of go through an algorithm. If you've identified where you are, I start to push in those areas, but again, shorter, you're gonna want to start with suprapubic pressure, or left lower quadrant, and then move on. Some people use left mid-abdomen. I find that oftentimes patients will also have a very redundant sigmoid, which means right lower quadrant pressure will actually really work, but I think it's important to kind of talk back and forth with the people in the room, your techs or nurses who are providing pressure and say, hey, let's push here, and it's a talk back and forth, not just push pressure and hold it for 10 minutes while I try to figure out what the heck I'm doing. It's a constant talk back and forth, and I usually ask my tech or nurse, do you feel my scope? And if it's not working, I say, okay, stop your pressure there, and we're gonna go to another spot, and it's a constant discussion back and forth. And when I first started out, I thought that asking for pressure was kind of like asking a sign of failure, or maybe I was making somebody else do work, but I think of everybody in that room, they really wanna get you to the C-cum, they really wanna help you, so the more that you're willing to ask for help, they're more willing to give it, and if you guys would think of that as a team, I think it's really, really important. This is showing the areas where you're gonna wanna apply pressure. Usually your patient's more so in the left lateral cubitus position, but again, this is where you're gonna wanna start with pressure, usually in the suprapubic region left lower quadrant. This is showing left lower quadrant pressure as well, too, to kind of stop an alpha loop from being formed in the sigmoid. And again, pulling back, reducing and torquing, and then going on after that pressure. And once you've made it past that area, then you wanna tell whoever is applying pressure that they can let go, and see if your scope remains stable. What you don't wanna do is fatigue anybody in the room with you. You wanna ask for pressure when you need it, but also when you don't need it, stop with the pressure as well. It's better for the patient, and it's better for everybody else. Usually if you're a little bit further, you're in the transverse colon, 35 to 50, and mid-abdominal pressure can help as well, too. Sometimes I ask for transverse pressure, but again, talking back and forth and saying, let's try transverse, let me know if you feel my scope, et cetera, really, really will help you be more successful. If there is difficulty getting past the hepatic flexure, sometimes I call this the false cecum, where it actually can look like the cecum, but it's collapsed, or it's not opening up, and you think you're there, but you're really not. What you wanna do is actually have the patient's shoulders rotated back, and that can actually, almost like they're going to a supine position, this can actually allow the hepatic flexure to open up, and easier to see where you're going as well, too. In terms of once you've made it there, then we actually have to think about endoscope withdrawal, and again, we wanna be there with a short scope so that as we withdraw and we identify pathologies such as polyps, we can actually maneuver our scope to get where we need to be. So the first thing is making sure we clean the colon. We wanna flush it out, suction up, anything that can suck through the scope, so that we can actually visualize the mucosa and small polyps. We wanna check behind every fold. Some people use a clear cap to do this. I'm sitting in a room with a bunch of advanced endoscopists. Of course they're gonna use a cap, or some sort of assistive device such as an endocuff as well, too. This can really help you peer behind a lot of folds as well. And then prep quality is also really important to note, because if your prep quality is not adequate, it's not gonna pass as a screening colonoscopy. I encourage you to use a scoring system when you do endoscopy. I would recommend learning the Boston bowel prep score, which is actually a validated score. It's a score that we use after we clean each segment of the colon, the right, the transverse, and the left. It's out of three. And just know that what we're looking at right now is a three, meaning we can visualize all the mucosa. Nothing but solid stool is a zero, and then one and two in between. But any segment that's a one or less is an inadequate prep, or any score that's less than six on the Boston score is an inadequate prep, and the patient actually needs to have another repeat endoscopy. And finally, retroflexion. This is gonna be done, some people do learn to retroflex in the right, particularly in the cecum, but all patients should have a retroflexion in the rectum. What you're gonna wanna do is pull back to the dentate line prior to advancing the endoscope, and you're gonna wanna find a wall or basically a ramp to put your scope advance into, and as you advance, you're gonna dial back with your big dial so that you curve and almost do a back flip with your scope. What can really assist that as well too is if you use your small dial to torque further, then you can really look back on your scope, do a 360 degree view, take a picture, look for any hemorrhoids, other polyps as well too, and do a complete examination at the end of the scope. So in summary, you wanna make sure that you, these are a little bit different than what we had earlier, but nonetheless, you wanna make sure you're doing the right indication for the right procedure, you wanna make sure that whether it's a screening diagnostic or surveillance colonoscopy, make sure that you pay attention to the patient's body position, make sure you kind of anticipate where the loops are being formed and asking for pressure sometimes in multiple different places. Water immersion is really important, especially on the left side of the colon. This prevents barrel trauma on the right side of the colon because that's where a lot of the air will enter into. And again, don't push against any fixed, don't push against any fixed resistance, pull back when in doubt, and always make sure that you visualize the lumen before you advance. And then lastly, I also, off the slide, I think it's really important when I talked about teamwork in the room to really get to know everybody that you're working with, whether that be your, not your attending necessarily, but know the techs, know the nurses, know the CRNAs, know the person who takes the garbage out because if you know their names, you show them that you care about them and you show them that you're there to learn from them, it creates a really good respect in the room. And I really feel like once you've done that, people really wanna help those fellows who have taken an interest in them. And I think if you show that you care about everybody in the room and really try to get to know them, they're gonna really wanna help you and they know how hard this is. And they're gonna definitely make sure that you're more successful. And with that, I thank you for your attention. Thank you.

colonoscopy

indications

contraindications

screening

diagnostic

techniques