Colonoscopy.net.au

I have had a lot of request to do scopes on a Saturday morning. I will be doing a list at John Fawkner hospital this coming Saturday on August 27th.

I normally like to see all my patients beforehand so that full informed consent can be obtained. I can see my patients before hand at:

The Clinic Footscray (Wednesday) – Aug 17th and 24th
1st Floor, 91 Paisley Street, Footscray 3011 Tel: 9687 2271 Fax: 9689 6008

John Fawkner Private Hospital Consulting Rooms(Monday – Aug 22nd)
267 Moreland Road, Coburg 3058 Tel: 9385 2285

Caroline Springs Specialist Centre Suite 3-5, 224-226 Caroline Springs Blvd, Caroline Springs 3023 Tel: 8361 7655

Please bring along a referral from the general practitioner. (If you have seen me before, you would need a new referral if the last referral letter from your GP was more than 12 months old)

If it is not possible to come for a consult before hand or it is an urgent referral(ie acute bleeding from haemorrhoids) – please contact me directly through the rooms.

For more information about the procedures and the bowel preparation please see www.melbournesurgery.com

This is increasingly being used overseas.

Advantage:

Minimally invasive – all one needs to do is swallow the capsule with the camera

Unlike traditional colonoscopy – no need for sedation, less risks – main risk with capsule endoscopy is if the capsule is not passed in the setting of a narrowing of the bowel(ie stricture, tumour)

Disadvantages:

Less sensitive – ie more likely to miss polyps — this is because views are random depending on how the capsule is positioned as it moves through the colon. Hence if one has symptoms or positive faecal occult blood test, it is better to do a colonoscopy.

Also in Australia, the cost of this is not covered by Medicare

Many condition can cause rectal bleeding. It is important that you exclude a serious cause first by speaking to your doctor!  Risks symptoms for a more serious cause include having clots, blood being mixed with the stools, having lots of bleeding, bleeding frank blood, passage of mucus, increasing age(the older you are the higher your risk of bowel cancer), presence of anaemia and loss of weight

Causes include:

1. Bowel cancer – in particular a rectal cancer or cancer in the sigmoid colon

2. Polyps in the bowel – especially large ones in the rectum

3. Haemorroids – this is quite common but it is important to speak to your doctor about it and be examined throughly to exclude more serious cause

4. Inflammatory bowel disease eg proctitis, ulcerative colitis, Crohn’s disease

5. Anal fissure – usually there is a lot of pain when or after opening the bowels(but be warned : rectal cancer invading into the anal canal can also be painful)

6. Trauma to the perianal tissue

Lifetime risk of developing bowel cancer in Australia by the age of 85 years old:

1 in 10 men

1 in 14 women

Medial age at diagnosis: 70 years old

Risks in next 5 years:

30 year old person – 1 in 7000(less than the risks from a colonoscopy of perforation and serious bleeding)

40 year old person – 1 in 1200

50 year old person – 1 in 300

60 year old person – 1 in 100

70 year old person – 1in 65

80 year old person – 1 in 50

The risk is also greater for people with a family history of bowel cancer

Thank you so much for my Colonoscopy, now I know what you did!!

I know this is long but it is VERY VERY funny especially for those of us who are members of the “Colonoscopy Club”. If you can recall Billy Connolly’s sound effects version you will laugh even more!

Subject: Fwd: Colonoscopy Journal -
ABOUT THE WRITER……
Dave Barry is a Pulitzer Prize-winning humour columnist for the Miami Herald.

Colonoscopy Journal:

I called my friend Andy Sable, a gastroenterologist, to make an appointment for a colonoscopy.

A few days later, in his office, Andy showed me a colour diagram of the colon, a lengthy organ that appears to go all over the place, at one point passing briefly through   Minneapolis .

Then Andy explained the colonoscopy procedure to me in a thorough, reassuring and patient manner.

I nodded thoughtfully, but I didn’t really hear anything he said, because my brain was shrieking, ‘HE’S GOING TO STICK A TUBE 17,000 FEET UP YOUR BEHIND!’

I left Andy’s office with some written instructions, and a prescription for a product called ‘MoviPrep,’ which comes in a box large enough to hold a microwave oven.  I will discuss MoviPrep in detail later; for now suffice it to say that we must never allow it to fall into the hands of   America  ’s enemies.

I spent the next several days productively sitting around being nervous.

Then, on the day before my colonoscopy, I began my preparation.  In accordance with my instructions, I didn’t eat any solid food that day; all I had was chicken broth, which is basically water, only with less flavour.

Then, in the evening, I took the MoviPrep.  You mix two packets of powder together in a one-litre plastic jug, then you fill it with lukewarm water. (For those unfamiliar with the metric system, a litre is about 32 gallons). Then you have to drink the whole jug.  This takes about an hour, because MoviPrep tastes – and here I am being kind – like a mixture of goat spit and urinal cleanser, with just a hint of lemon..

The instructions for MoviPrep, clearly written by somebody with a great sense of humour, state that after you drink it, ‘a loose, watery bowel movement may result.’

This is kind of like saying that after you jump off your roof, you may experience contact with the ground.

MoviPrep is a nuclear laxative. I don’t want to be too graphic, here, but, have you ever seen a space-shuttle launch?  This is pretty much the MoviPrep experience, with you as the shuttle. There are times when you wish the commode had a seat belt.  You spend several hours pretty much confined to the bathroom, spurting violently.  You eliminate everything.  And then, when you figure you must be totally empty, you have to drink another litre of MoviPrep, at which point, as far as I can tell, your bowels travel into the future and start eliminating food that you have not even eaten yet.

After an action-packed evening, I finally got to sleep.

The next morning my wife drove me to the clinic. I was very nervous.  Not only was I worried about the procedure, but I had been experiencing occasional return bouts of MoviPrep spurtage.  I was thinking, ‘What if I spurt on Andy?’  How do you apologize to a friend for something like that? Flowers would not be enough.

At the clinic I had to sign many forms acknowledging that I understood and totally agreed with whatever the heck the forms said. Then they led me to a room full of other colonoscopy people, where I went inside a little curtained space and took off my clothes and put on one of those hospital garments designed by sadist perverts, the kind that, when you put it on, makes you feel even more naked than when you are actually naked..

Then a nurse named Eddie put a little needle in a vein in my left hand.  Ordinarily I would have fainted, but Eddie was very good, and I was already lying down.  Eddie also told me that some people put vodka in their MoviPrep.
At first I was ticked off that I hadn’t thought of this, but then I pondered what would happen if you got yourself too tipsy to make it to the bathroom, so you were staggering around in full Fire Hose Mode.  You would have no choice but to burn your house.

When everything was ready, Eddie wheeled me into the procedure room, where Andy was waiting with a nurse and an anaesthetist.  I did not see the 17,000-foot tube, but I knew Andy had it hidden around there somewhere..  I was seriously nervous at this point.

Andy had me roll over on my left side, and the anaesthetist began hooking something up to the needle in my hand.

There was music playing in the room, and I realised that the song was ‘Dancing Queen’ by ABBA.  I remarked to Andy that, of all the songs that could be playing during this particular procedure, ‘Dancing Queen’ had to be the least appropriate.

‘You want me to turn it up?’ said Andy, from somewhere behind me.

‘Ha ha,’ I said.  And then it was time, the moment I had been dreading for more than a decade.  If you are squeamish, prepare yourself, because I am going to tell you, in explicit detail, exactly what it was like.

I have no idea.  Really.  I slept through it.  One moment, ABBA was yelling ‘Dancing Queen, feel the beat of the tambourine,’ and the next moment, I was back in the other room, waking up in a very mellow mood.

Andy was looking down at me and asking me how I felt.  I felt excellent.  I felt even more excellent when Andy told me that IT was all over, and that my colon had passed with flying colours. I have never been prouder of an internal organ.

On the subject of Colonoscopies…
Colonoscopies are no joke, but these comments during the exam were quite humorous…. A physician claimed that the following are actual comments made by his patients (predominately male) while he was performing their colonoscopies:

1. ‘Take it easy, Doc. You’re boldly going where no man has gone before!’

2. ‘Are we there yet? Are we there yet? Are we there yet?’

3. ‘You know, in   Arkansas , we’re now legally married.’

4. ‘Hey! Now I know how a Muppet feels!’

5. ‘Hey Doc, let me know if you find my dignity.’
6. ‘God, now I know why I am not gay.’

And the best one of all:
7.. ‘Could you write a note for my wife saying that my head is not up there?’

Not uncommonly, an abdominal CT scan report may say there is thickening of the bowel wall in particular the rectum. The differentials here include:

1. normal bowel wall – perhaps the muscles the wall were contracted at the time of the scan

2. Rectal cancer in particular a circumferential tumour – therefore the next investigation from this is usually a colonoscopy

3. Inflammatory bowel disease, diverticular disease – but one would also see the diverticula etc

An elderly patient was referred with rectal bleeding thought to be from haemorrhoids(The patient has just had colonoscopy <2 years ago by a gastroenterologist which showed only haemorrhoids and was otherwise reported as normal) The patient’s bleeding had not really settled at all since the previous colonoscopy and the patient’s bleeding was attributed to the haemorrhoids reported in the colonoscopy. The patient was referred recently for the haemorrhoidal bleeding and a colonoscopy was performed. A low rectal cancer measuring about 5cm was found(the cancer was arising from a tubulovillous adenoma, located just above the anal canal, the tumour can be felt on rectal examination – mobile, T2 on MRI). Fortunately, this could be treated with a transanal excision of the rectal cancer and the patient recovered quickly from the surgery.

The points to learn from here is that :

1. One should not always assume any rectal bleeding is due to haemorrhoids- especially if this persist despite treatment of the haemorrhoids. (If haemorrhoids have been bleeding up to the colonoscopy, it would be a good idea to band them at the end of the colonoscopy) If symptoms persist, reinvestigate or refer on.

2. A rectal examination is still useful even in the 21st century- As Norman Browse’s book on Symptoms and Signs of Surgical Diseases says “”Every patient with a rectal complaint should have a rectal examination”". This still holds true today. Be thankful that there are gloves these days – I have heard in the past in places where gloves were not easily available, doctors used to put soap into their fingernails before doing the rectal examination. ( A good tip is to double glove the hand doing the rectal examination – that way you can throw away the top glove after the rectal exam before doing anything else)

3. On colonoscopy, care must be taken to look carefully at the anal canal and what is just above. Sometimes faeculent fluid can obscure the view – this should be sucked out. A J manouvre at the end in the rectum is also useful. In fact during my training, I remembered one of my mentors telling me how he heard about a case of a low rectal cancer being missed during a colonoscopydue to too rapid an insertion.

By right, being an investigation, there really should not be such a long wait for a colonoscopy. After all, one of the main reason the test is being done is to exclude a bowel cancer.

Why should a public patient wait for such a long time for an investigation? Does anyone have to wait more than 4 weeks for a blood test or any Xray?

Currently there are so many patients on public waiting lists all over Australia.  Mathematically, I cannot see how this would get any shorter if the current situation persist. In fact, it will only get longer as the population ages, more and more people leave private insurance and hospital budgets become tighter.  Also in public hospitals, the throughtput is much less than in  a private endoscopy centre for a number of reasons including:

1. Hospital bureaucracy slowing turnover of patients

2. Working culture

3. Need for trainee anaesthetists and surgeons/gastroenterlogists to learn hands on

4. Financial model in public hospitals do not given any incentives for the hospital to do more scopes(they would go over budget, they can only have a certain percentage of patients are day cases, and only do a certain number of scopes a year) nor do they give incentives for specialists(paid by the hour on a rate far less than what one gets privately, often moral is low due to hospital bureaucracy, most are staying on only out of a duty to care for their patients and to teach the trainees) to increase throughput

Hence in the public hospitals, the average colonoscopes booked to a half day list(with registrars) may be about 6-7 while privately one can have 8-10 cases on a half day list.(Some private centres do even more than that – but doing  a colonoscopy too quickly is also not good as polyps may be missed.  Ideally, 30min should be allocated for each colonoscopy procedure to allow time to have a careful look on withdrawing the colonoscopy)

Frail lady in her eighties presented to her GP with change of bowel action.

Colonoscopy shows 5cm low rectal tumour.

Transanal excision performed – ie surgery via anal canal to resect the tumour alone, not needing a laparotomy.

Histology: Rectal adenoma

How long is it before someone would present with bowel cancer?

This varies from person to person – these days, the sooner one brings this to the doctors attention, the sooner this can be looked at.

Recently a patient in the 70s who has been on holidays travelling around Australia presented to his local GP complaining of a change of bowel action. He was investigated and found to be severely anaemic. He was sent to the Emergency department as he has had increasing difficulty opening his bowels.

On examination, he was found to have a low rectal cancer on rectal examination. Further investigations showed that he has lung metastates.

He went on to have a resection and permanent stoma.