A routine colonoscopy could save your life

Last week, as time for her colonoscopy drew near, Barbara Cockman just wanted to get it over with.

Having a colonoscopy is sort of like going to the dentist: No one looks forward to it, but the consequences of not doing it can be far worse than the test itself.

Cockman had had a colonoscopy 10 years earlier, so she knew she would be guzzling liquids and running to the restroom the day before. And she expected that the procedure itself would be short and painless, which it was. She also knows that having her colon examined for polyps or other irregularities is one of the most important things she can do for her health.

A colonoscopy is a test used to look for signs of colon cancer, one of the most frequently diagnosed cancers in the United States. Experts at the National Cancer Institute estimated that nearly 150,000 people would receive a diagnosis of colon cancer in 2008, and that nearly 50,000 people would die of colon cancer.

Early detection by colonoscopy is one of the most useful tools doctors can use against colon cancer.

Who should get them? And when?

Everyone should have a screening colonoscopy when they reach age 50, even if they feel great, said Dr. Ken Koch, a gastroenterologist. Colon cancer becomes more common as people grow older.

"We all should have a screening colonoscopy to be sure that there's no little polyps lurking or even a cancer we don't feel lurking in the colon," he said. The colon is a big organ with muscles that can relax, he said. "You could grow a pretty good-sized tumor in there and never feel it until it's almost too late."

People who have a first-degree relative - a parent, a sibling or a child - who has had colon cancer, should have a screening test at age 40.

Symptoms that could be attributed to colon cancer, such as blood in the stool, warrant having a colonoscopy, Koch said. Colon tumors can also cause vague abdominal pain that can occur in several different places, and such pain in a patient over 50 could be cause for a colonoscopy to help determine what is causing it.

Although constipation and diarrhea are common conditions, a change in bowel habits could be a sign of a colon tumor, Koch said. If a person over 50 who has always had good digestive health starts having constant constipation or diarrhea, a colonoscopy would be in order to rule out a tumor.

Cockman underwent her second colonoscopy last week to coincide with her 70th birthday. Her first, 10 years ago, came out of necessity when a physical showed some irregularities.

"I was really nervous then," she said. That colonoscopy turned out fine. She felt apprehensive about last week's test, she said, but when her brother-in-law discovered that he had colon cancer, she knew she had to go through with it.

Patients must prepare for the test by taking powerful laxatives to clear out their colons, a process known as "the prep." The prep is important, Koch said, because the doctor performing the test needs to be able to see all of the lining - the mucosa - of the colon. Polyps, which can become cancerous, develop in the mucosa.

"Everybody gets very concerned and anxious about the prep," Koch said. "In my experience, maybe half of the patients say 'It really wasn't as bad as I thought it was going to be.' One or two people really hated the whole idea and the experience."

Cleaning out the colon involves drinking a preparation - "All that gook," Cockman said - that will cause frequent bowel movements the day before the procedure. It is wise to plan to stay at home and near a restroom that day. Patients will be restricted to a clear, mostly liquid diet. Patients can drink tea, coffee, broth and diet sodas. Plain gelatin is allowed, but nothing red that could look like blood.

"I push Gatorade a lot," Koch said. He advises his patients to drink plenty of liquids to avoid becoming dehydrated.

On the day of the procedure, patients come into the hospital or doctor's office, get their vital signs checked and have an IV started. Their doctors explain the risks - bleeding or perforation - and the benefits of the procedure. Patients will be sedated and should remain comfortable during the procedure. They most likely will not remember it.

Cockman, whose colonoscopy was performed by Dr. Robert Holmes of Piedmont Gastroenterology Specialists, remembers nurses and assistants laughing and joking with her before her sedation took hold.

"The whole thing was just so easygoing," she said. She has no memory of the procedure.
Doctors begin a colonoscopy by performing a rectal exam. The next step is inserting a flexible tube with a light and a small camera on its end, a colonoscope, into the rectum and passing it slowly through the colon. Images from the camera appear on a video screen. Puffs of air from the tube distend the colon to make viewing better. After the tube has gone throughout the colon, the doctor slowly withdraws it, once again, checking every kink and corner for polyps.

"If you take seven minutes or more as you back out of the colon, you will find the most polyps," Koch said. He takes 10.

If a polyp shows up during the colonoscopy, doctors can remove it by passing an instrument through the colonoscope. They can also remove and biopsy suspicious tissue. Holmes found and removed two polyps during Cockman's procedure, and the polyps will be biopsied. She expects to have results back within a week.

As doctors reach the end of the exam, they return to the rectum, turn the scope around to look for hemorrhoids and exam the end of the rectum.

Once the exam is over, patients are taken to a recovery area, where they may remain for 30 minutes to an hour. Once they wake up, they may be offered crackers and something to drink.

"When patients feel as good as when they arrived, they are discharged to go home," Koch said. Because they have been under sedation, patients must have drivers.

"You cannot call a taxi; you cannot get on the bus; you can't walk home," he said. The sedating drugs may cause lingering sleepiness or affect thinking, he said. He recommends that his patients take it easy for the rest of the day.

"Certainly by the next day, folks are fine."

Cockman felt nausea in the car on the way home.

"I thought that I would just feel so well I could go out to an early dinner," she said. "I went home, and I was sacked out until the next morning."

Some doctors are using a new procedure, a virtual colonoscopy, to screen for colon cancer. In that procedure, a CT scan is taken of the abdomen, which involves taking many cross-sectional images, Koch said. The images are put together with software to reconstruct an image of the colon so that a radiologist can "virtually drive through the colon looking for polyps or tumors," Koch said.

The advantages of the virtual colonoscopy are that patients don't have to be sedated and don't need IVs, Koch said. The disadvantage is that the procedure can miss small polyps, making it less accurate than the traditional colonoscopy. And people undergoing a virtual colonoscopy still must go through the prep. Virtual colonoscopy is being done for screening at Wake Forest University Baptist Medical Center, Koch said, but the procedure is not covered by insurance.

"Time will tell where virtual colonoscopy fits into screening," Koch said. "If you have pain, blood in the stool or anemia, you need more than screening."

Cockman is a big proponent of colonoscopy.

"I feel that every living person should have a colonoscopy by the time you're 50," she said. "It's a lifesaver."

Janice Gaston can be reached at 727-7364 or at jgaston@wsjournal.com.

For more information on colonoscopies, check these Web sites: www.mayoclinic.com/health/colonoscopy/CO00009
or http://digestive.niddk.nih.gov/ddiseases/pubs/colonoscopy