COLONOSCOPY

Preparation for the procedure

When a decision is made to perform a colonoscopy, you will be prescribed medication to clear the bowels out prior to your procedure. The dose, timing and instructions for use will be made clear to you during a pre-assessment appointment and you will be given a copy of these instructions in print.

Details of what you may eat or drink in the run-up to the procedure will be clear. The medication is usually taken on the afternoon before your procedure. It will result in frequent bowel evacuations later that evening (and possibly through the night) but by the morning your bowel will probably be empty. Do not worry if some liquid waste is still being passed on the day of your procedure: the procedure can still go ahead and the fluid can usually be suctioned away during the procedure if necessary.

Bowel cleansing can result in quite a substantial loss of fluid, so it is important that you drink sufficient fluid up until the time that you are instructed to stop drinking. Patients who are frail, diabetic, suffering with heart problems or kidney problems or incontinence, or who have a colostomy, or those who live alone and have no transport, may be better off having their bowel cleansing as an in-patient. This need will be identified and agreed with you when you see your surgeon.

What happens on the day?

You will be “admitted” to the surgical unit by the duty nurse and you will be changed into hospital clothing that is suitable for the procedure. Your surgeon will discuss the procedure with you and together you will sign a consent form. Thereafter you will be taken into the operating theatre and monitors to keep an eye on your blood pressure, pulse rate and oxygenation will be attached to your arm. You will be given Oxygen via your nose. A cannula is inserted into a vein on the back of your hand through which, should you want them, medications can be administered. These can be Midazolam (a sedative to reduce anxiety) and Fentanyl (a morphine-based painkiller) or a combination of the two. Some patients elect not to have one or even both of these drugs.

Once you are ready for us to proceed, the colonoscopy commences. Generous lubrication is applied and the procedure should be over within 20-30 minutes. Patients often expect to be unconscious, but this is not the case: you should be calm or mildly drowsy. You may wish to even watch the procedure on the television monitor. Throughout the procedure you will be engaged in conversation (unless you don’t wish to chat) and a nurse will keep an eye on your vital signs. You may be asked at times to change your position. We may even assist the colonoscope to negotiate bends in the colon by pressing on your tummy with a hand.

Your surgeon may need to take samples from your bowel. These small samples are taken without you being aware of us doing this i.e. it is totally painless to have a sample taken. Your gut cannot feel heat, cold, sharp or dull pain. It can only feel stretch or distension (which it really doesn’t like) which arises from gas filling it or the colonoscope pressing against it. Some biopsies are termed “hot biopsies”: don’t panic, you won’t feel any heat or pain or shock, it simply refers to the application of electrical current to the biopsy forceps. Should we encounter any polyps, these can often be removed through the colonoscope by placing a wire noose around them to snare them off. Once again, you cannot feel this happening. To facilitate this removal of polyps, it is sometimes necessary to inject fluid beneath them, or to tattoo some ink into the adjacent bowel lining to show a future colonoscopist where the polyps used to be. Yet again, you cannot feel this injection happening. We retrieve the polyps in a small net placed through the colonoscope.

After the procedure you will return to a small private room. You may be inclined to have a brief nap if you were given Midazolam or Fentanyl. One of the pleasant side-effects of Midazolam is that it might give you amnesia of events that occurred. Patients often presume that they were unconscious, but it is merely a case of them forgetting that they were actually awake and chatting to us! This tendency to forget things, and the general effect of the drugs, wears off quickly. Your surgeon will discuss what was seen and done during the colonoscopy with you once they are confident that you won’t forget what they will say. Plans will be agreed for the future ongoing care e.g. review in outpatients or further tests or discharge for good etc. You will be offered a drink and a snack. The nurse will provide you with a letter for your GP and she will reiterate the advice given to you. Once we are happy that you are steady on your feet and that your vital signs are normal, you will be released. If you have had Midazolam or Fentanyl, you will need to have a relative or friend escort you back home as you may not drive.

The entire visit should last approximately 2-3 hours. All pathology reports will be communicated to you and to your GP, either by letter or when you are reviewed or both. These take a minimum of 7 working days to come back from the pathologist.

What are the risks of colonoscopy?

As with any medical procedure, colonoscopy is not without risk. Thankfully these risks are mostly highly unlikely to occur and they are mostly not serious (with one exception). The risks can be classified into the following categories:

1. Preparation for the procedure – Bowel cleansing can lead to dehydration. Dehydration will cause headaches, but if severe enough, it can even lead to low blood pressure causing dizziness, light headedness or fainting. In extreme cases, your kidney function can become compromised, especially if you already have a degree of kidney failure. Prolonged diarrhoea can also lead to a flushing out of minerals (electrolytes), so if you already have electrolyte deficiency this can worsen and lead to disturbance to the function of several organs, most notably the heart. Modern cleansing agents often allow you to eat until shortly before your procedure, so getting a low blood sugar level (hypoglycaemia) is unlikely unless you are a diabetic or have a hormonal problem related to glucose.

2. Sedatives and painkillers – Excessive doses, or unusual sensitivity on the patient’s part, can lead to disruption to breathing, blood pressure or circulation. With the doses used nowadays, this is extremely unlikely to occur. You will be monitored closely and should these things come to pass, a reversal agent is immediately on hand and the effects can be rapidly reversed within minutes. Allergic reactions to these drugs are extremely rare.

3. Colonoscopy itself – Taking a small sample biopsy and removing polyps are, by their nature, going to traumatise tissue. However, bleeding from these sites is usually trivial and it is extremely rare to bleed heavily unless you have taken anti-coagulants without informing us of this. Even if you bleed, this can be controlled through the colonoscope in almost every case. A tiny wound in the bowel lining does not usually become infected, despite the presence of billions of bacteria, as the bowel’s immune system has evolved to deal with transgression of the bacteria. Should this rare event occur, simple antibiotics alone should remedy the situation. It is not natural to insert an object into the bowels, even a flexible one, and neither is it natural to apply heat to the bowel to burn off a polyp. Excessive application of heat, excessive insufflation of gas and excessive force by the surgeon can all lead to perforation (puncture) of the colon. For a straightforward diagnostic procedure, this risk across all UK units (trainees, nurse endoscopists, non-consultants and consultants) is approximately 1:1000. For therapeutic procedures in which large polyps are removed, early tumours are removed or narrowings are dilated, the risk is as high as 1:250. You will be pleased to know that this complication has never happened to one of my patients

.FLEXIBLE SIGMOIDOSCOPY

This is a limited colon and rectal inspection using a colonoscope. No preparatory diet is needed and no full bowel cleansing is necessary. However, the rectum and lower colon do need to be evacuated to allow adequate visualisation of these areas. An enema is needed for this. The enema can either be self-administered by you at home (with clear instructions provided) or it can be administered by a nurse once you arrive in the surgical unit. It usually causes an urge to evacuate within minutes. Each room has en-suite facilities for you to use. It is unusual to require a second enema. You will sign a consent form, change and then go through to the operating theatre.

The procedure does not require any sedative or pain relief. Only minimal monitoring will be required. After applying lubrication, the procedure gets underway and it is usually over within 15 minutes. For a description of what might be done during the procedure, read the section on colonoscopy above. The risks for a purely diagnostic procedure are 10-fold lower than with colonoscopy, but risks of the flexible sigmoidoscope usage are identical to therapeutic colonoscopy usage.

After the procedure is completed, you will have a chat with your surgeon, you will be offered a drink and a snack and you will be free to go once any paperwork is completed. The overall turnaround time is about 1-2 hours.

                            OGD                         

      Oesophagogastroduodenoscopy     

                    or “gastroscopy”                

Preparation for the procedure

Clear verbal and written instructions will be provided during your consultation or at a pre-assessment appointment. This will include information on what you may eat or drink prior to the procedure and when to stop oral intake. Unless you have diabetes or unusual dietary or digestive problems, this should be straightforward. Though you might experience some hunger pangs, a few hours of starvation is easy and safe.

What happens on the day?

You will be “admitted” to the surgical unit by the duty nurse and you will only be changed into hospital clothing that is suitable for the procedure if you want to do this – you can wear your own clothes if you prefer this, but ensure that your sleeves are short. Your surgeon will discuss the procedure with you and together you will sign a consent form. This will include a discussion on whether to have local anaesthetic spray in your mouth or a sedative (see below). Thereafter you will be taken into the operating theatre.

If you choose the local anaesthetic spray, this is administered (a bit like a breath freshening spray) and this quickly numbs your mouth and the back of your throat. If you have chosen to have sedation, monitors to keep an eye on your blood pressure, pulse rate and oxygenation will be attached to your arm. You will be given Oxygen via your nose. A cannula is inserted into a vein on the back of your hand through which a sedative called Midazolam (to reduce anxiety) can be administered. A dental guard is inserted for you to bite down onto to, both to protect your teeth and to prevent your teeth damaging the telescope.

Once you are ready for us to proceed, the gastroscopy commences. Lubrication is applied to the telescope and it is inserted into the mouth. The procedure should be over within 5-10 minutes. Patients often expect to be unconscious with a sedative, but this is not the case: you should be calm or mildly drowsy. Throughout the procedure you will be given advice and reassurance by a nurse who will also keep an eye on your vital signs. There is a natural tendency to gag on anything that touches the back of your mouth: this is minimised or eliminated by local anaesthetic spray, but not by sedation. Despite having a gastroscope down your gullet, you WILL be able to breathe, but you won’t be able to speak. When the tube is ready to enter your gullet (oesophagus), you will be asked to swallow. This helps to let the gastroscope through the valve at the top of the gullet that stops acid or stomach juices coming back up. Once it is through this obstacle, the hardest part is over.

The stomach and duodenum are entered in sequence and then carefully inspected in reverse sequence. You may feel very bloated, but you won’t feel any pain. You will often belch and occasionally when doing this you will have some moisture in your mouth. The nurse will suction this away so do not fear that it will go down the “wrong way” into your lungs. It is important that you stay calm and that you focus on slow steady breathing.

Your surgeon may need to take samples from your gut. These small samples are taken without you being aware of us doing this i.e. it is totally painless to have a sample taken. Your gut cannot feel heat, cold, sharp or dull pain. It can only feel stretch or distension (which it really doesn’t like) which arises from gas filling it or the gastroscope stretching. Besides, your stomach is used to distending with food, so it is extremely unlikely that the gas distension would hurt.

Some biopsies are termed “hot biopsies”: don’t panic, you won’t feel any heat or pain or shock, it simply refers to the application of electrical current to the biopsy forceps. Should we encounter any polyps, these can often be removed through the gastroscope by placing a wire noose around them to snare them off. Once again, you cannot feel this happening. To facilitate this removal of polyps, it is sometimes necessary to inject fluid beneath them, or to tattoo some ink into the adjacent gut lining to show a future surgeon where the polyps used to be. Yet again, you cannot feel this injection happening. We retrieve the polyps in a small net placed through the gastroscope.

Photographs can be taken to serve as a permanent record in your notes or to facilitate explanation of abnormalities to you afterwards. Sometimes biopsies will have been taken to test for the presence of bacteria in your stomach: these biopsies produce results in 24 hours and the endoscopy nurse or your surgeon will let you know if bacteria are present by phone call or letter. All other pathology reports will be communicated to you and to your GP, either by letter or when you are reviewed or both. These take a minimum of 7 working days to come back from the pathologist.

After the procedure you will return to a small private room. You may be inclined to have a brief nap if you were given Midazolam. One of the pleasant side-effects of Midazolam is that it might give you amnesia of events that occurred. Patients often presume that they were unconscious, but it is merely a case of them forgetting that they were actually awake and chatting to us! This tendency to forget things, and the general effect of the drugs, wears off quickly. Your surgeon will discuss what was seen and done during the procedure with you once they are confident that you won’t forget what they will say. Plans will be agreed for the future ongoing care e.g. review in outpatients or further tests or discharge for good etc.

You will be offered a drink and a snack. This depends on whether you had a sedative or whether you had throat spray: you must have regained sensation after throat spray (usually 30-60 minutes) or come round from the effects of the sedative. The nurse will provide you with a letter for your GP and she will reiterate the advice given to you. Once we are happy that you are steady on your feet and that your vital signs are normal, you will be released. If you have had Midazolam, you will need to have a relative or friend escort you back home as you may not drive. The entire visit should last approximately 1-2 hours.

Throat Spray or Sedation?

Sedation with Midazolam reduces anxiety levels, it doesn’t “knock you out” or render you unconscious and oblivious to what is happening to you. It doesn’t switch off your gag reflex, so you will tend to retch quite a bit and be more aware of the gastroscope in your throat. It does make you a little drowsy or woozy, which may leave you a little disoriented and experiencing a surreal environment. It does keep you a bit more relaxed and it might give you complete amnesia about your procedure. These effects all wear off within about 45 minutes.

Local anaesthetic throat spray is a topical numbing agent which acts a bit like a very powerful throat lozenge. It blocks the sensation of nerve endings that widely populate your mouth and throat, nerves which ordinarily protect you from letting things go into your lungs by mistake and which help to co-ordinate chewing and moving food from your mouth into your gullet. You will be alert and fully in control of your faculties, but you will tend to gag much less and tolerate the presence of the gastroscope in your digestive system a bit better.

The issue of how quickly you can eat is not usually seen as crucial by most patients, but for some the issues of transport are relevant matters to consider. Some patients like to be awake, in control and hate retching: they opt for throat spray. Others don’t mind gagging, but welcome the easing of their anxiety and hope that they have no unpleasant memories: these patients opt for sedation. In my experience, most new patients opt for the throat spray and the majority of patients who have experience of both methods would prefer throat spray. That would be my preference too if I was on the receiving end of a gastroscopy.

What are the risks of gastroscopy?

As with any medical procedure, gastroscopy is not without risk. Thankfully these risks are highly unlikely to occur and they are mostly not serious (with one or two exceptions). The risks can be classified into the following categories:

1. Preparation for the procedure – Starvation is a nuisance, but it should not cause you harm. Dehydration might arise if you didn’t drink much the day before. Only mild depletion of fluid occurs in the interval from starvation until you are drinking again. This might cause headaches. A low blood sugar level (hypoglycaemia) is unlikely unless you are a diabetic or have a hormonal problem related to glucose. This will be discussed with you in advance of the procedure.

2.  Sedatives – Excessive doses, or unusual sensitivity on the patient’s part, can lead to disruption to breathing, blood pressure or circulation. With the doses used nowadays, this is extremely unlikely to occur. You will be monitored closely and should these things come to pass, a reversal agent is immediately on hand and the effects can be rapidly reversed within minutes. Allergic reactions to these drugs are extremely rare.

3.  Gastroscopy itself – It is not natural to insert an inedible object into the upper digestive system, even a flexible one, and neither is it natural to apply heat to the gut to burn off a polyp. The mouth guard should protect your lips and teeth from injury, but loose teeth or crowns can be dislodged rarely.

Aspiration (anything other than gas entering the airways) can occur since the valve at the top of the gullet is held open by the gastroscope: it is for this reason that you are asked to keep your stomach empty for a gastroscopy. However, whether with or without throat spray, you can cough up anything that goes down into your lungs, so you should not suffer the side-effect of aspiration pneumonia. 

Taking a small sample biopsy and removing polyps are, by their nature, going to traumatise tissue. However, bleeding from these sites is usually trivial and it is extremely rare to bleed heavily unless you have taken anti-coagulants without informing us of this. Even if you bleed, this can be controlled through the gastroscope in almost every case.

A tiny wound in the gut lining does not usually become infected, despite the presence of billions of bacteria, as the gut’s immune system has evolved to deal with transgression of the bacteria. Should this rare event occur, simple antibiotics alone should remedy the situation.

Excessive application of heat, excessive insufflation of gas and excessive force by the surgeon can all lead to perforation (puncture) of the gut. For a straightforward diagnostic procedure, this risk across all UK units (trainees, nurse endoscopists, non-consultants and consultants) is approximately 1:10000. For therapeutic procedures in which large polyps are removed, early tumours are removed or narrowings are dilated, the risk is approximately 1:250. You will be pleased to know that this complication has never happened to one of my patients. 

GETTING IN TOUCH IF YOU NEED HELP

 

You will be given clear instructions on how to quickly summons help whilst on the ward. If you should need to stay overnight, a Resident Medical Officer (RMO) is resident in the hospital to attend to you in the first instance. This doctor is able to deal with many emergency situations, as are the well qualified resident nursing staff. If necessary, Mr Bradford will be called both for advice and to attend - he is on-call for you at all times until you are discharged and he can be at your bedside within just a few minutes in an emergency.

Once at home you have access to medical advice in several ways:

1. Call the hospital to speak to the nurse on duty and/or the RMO

2. Call your local GP surgery (during hours)

3. Call the Out of Hours GP service (after hours)

4. Call the emergency services (999) or attend your nearest A&E services

As a general rule, unless it is an emergency rather call the hospital in the first instance for advice on who is best placed to attend to your needs. We have a low threshold for having a quick look ourselves if we are concerned that a complication might have arisen: usually it is a false alarm. If either your GP or the hospital staff feel that Mr Bradford needs to be contacted about you, they will track him down. In the event that your problem has arisen some days later, and Mr Bradford is away, you might have to default to the NHS services for assistance.