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)

Also it is important to avoid food with seeds in the few days preceeding the colonoscopy. Small seeds are a nightmare to the endoscopist as they become stuck in the suction channel of the scope when the faeculent fluid is sucked out!

Other things that have been seen during a colonoscopy include: pill granules,  vegetable material …and even a fruit sticker  stuck on the wall of the bowel!

Also the bowel preparation work best when one drinks plenty of fluids in order to “wash” out all the faeces in the colon. So remember to take lots of drinks when taking the bowel prep! (But avoid alcohol or coffee !)