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?’

DAY BEFORE TEST

Have a light breakfast(but do not have any grain bread or anything with seeds in it)

12:00 Noon

Have a light lunch – (eg soup, sandwich). YOU MUST NOT EAT AFTER THIS

3:00 pm

Start taking the COLOCAPS BALANCE

Swallow down 5 capsules with a glass of clear fluids(eg water, black tea or coffee without mild, cordials, strained fruit juices without pulps, jelly, clear soup)

If morning procedure,

Continue taking 5 capsules every 15min until all 65 capsules have been taken

If afternoon procedure,

Continue doing these until there are 20 capsules left.

Leave 20 capsules to take on the morning of the test – every 15 minutely from 7am until 8am. You can continue to have clear non-alcoholic fluids up to 4 hours prior to the procedure

DAY BEFORE TEST

Have a light breakfast(but do not have any grain bread or anything with seeds in it)

Dissolve GLYCOPREP in ONE litre of water and place in fridge

12:00 Noon

Have a light lunch – (eg soup, sandwich). YOU MUST NOT EAT AFTER THIS

3:00 pm

Start drinking the GLYCOPREP solution – drink 1 glass every 15 minutes. (Slow down if nauseaous)

5:00 pm

Mix 1 sachet PICOPREP with water and drink. Drink at least 1 litre of clear fluids(eg water, black tea or coffee without mild, cordials, strained fruit juices without pulps, jelly, clear soup) over the next 2 hours

7:00pm

Mix 1 sachet PICOPREP with water and drink. Drink at least 1 litre of clear fluids over the next 2 hours

DAY OF TEST

Morning examination – Do not eat or drink anything. Take usual medication with sip of wter.

Afternoon examination – Drink lots of clear fluids up to 4 hours before procedure.

Causes include:
1. Perianal skin tags – these are benign. If they are causing problems(ie difficulty wiping clean after bowel action), then they can be removed
2. Haemorrhoids – especially third or fourth degree ones which prolapses out. These may be too big to band and may need formal haemorrhoidectomy
3. Perianal haematoma – this is painful and due to a ruptured blood vessel in the area causing a clot to form

4. Other Soft tissue lesions – eg cyst, lipoma, benign tumours such as hidradenoma

5. Anal cancer – this is rare, the lump is usually hard and may be associated with bleeding

6. Rectal polyp prolapsing out!

7. Rectal prolapse – this causes a large lump in the area. Surgical repair is usually indicated.

The best thing to do is to see a doctor about this and have this assessed properly.

Just the other day, my theatre nurse was saying “this whipper snapper is having a double banger this arvo”.  I could see that my registrar(who is an international medical graduate) had no idea what she was talking about. I sort of had to guess what a whipper snapper is…

Anyway, a double banger(also called a top & tail or top & bottom) is a gastroscopy and colonoscopy.

Whipper snapper – I am told that this is a term we refer to someone who is younger. But in this case, we were referring to a “young” elderly man!

To all the medical students and doctors taking the AMC exams who may be reading this, don’t worry – this will should not come out in your exams! Imagine getting a question like this in “layman’s terms” – “Please discuss with this whipper snapper who has family history of  bowel cancer the pros and cons of doing a double banger”

Oh.. and by the way, “arvo” means afternoon – learnt that years ago, when my colleague told me he was taking the “arvo” off and handing over the pager to me.

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

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.

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)

In smaller country public hospitals, the waiting list is thankfully shorter.  This is only fair as country patients  do not usually have access to a local private endoscopy centre(where one can pay a small centre fee to have the endoscopy with the endoscopist fees’ bulk billed to Medicare)

The benefits of banding compared to surgery to excise the haemorrhoids are that: 1. It is relatively painless(if the rubber bands are placed high above the anal canal) 2. It does not require any more anaesthesia than the one for the colonoscopy.

It is a relatively quick procedure to perform. A short proctoscope is inserted. The rubber band is loaded onto the suction bander. The haemorrhoids is sucked up onto the suction head and the rubber band is then applied. This rubber band strangulates the neck of the haemorrhoid. This is then repeated on the other haemorrhoids seen.

Complications are uncommon. Sometimes they may be discomfort or feeling or an urge to go to the toilet after the procedure. Occassionally, if the haemorrhoids is large, it can be painful. Bleeding and blood clots may be notice when the haemorrhoids sloughs off over the next 2 weeks.(If there is severe bleeding one should see a doctor immediately – patients on blood thinners and with liver problems are at higher risk of bleeding)