General Information

General Information

Why the Excitement?

News reports say the Ontario government may cut anaesthesia-assisted colonoscopy. Some reports say "It is unthinkable to have a colonoscopy without sedation,” and others just call it a "freakout.” If you're about to have a colonoscopy, how will this matter to you? First, read the stories here and here.

The best question is, "how many doctors will be at my colonoscopy?" One or two? After these changes, the answer will almost always be one. Before these changes, the answer was usually one, but sometimes two. It’s not a big issue most of the time.

If there is one doctor, then this is the endoscopist. He or she is usually a general surgeon, like me, or a gastroenterologist. This is the person who advances the colonoscope through the bowel, takes out polyps and makes diagnoses based on what they see in the colon. If there is just one doctor, then this is also the person who bears responsibility for the patient’s comfort and sedation. The sedative medications are usually given by a registered nurse, who works under the direct supervision of this doctor.

If two doctors are present at colonoscopy, then the second doctor replaces the registered nurse. Before you get the impression that this is just a doctor doing a nurse's work, the second doctor is an anesthesiologist who is skilled at putting people to sleep and waking them up again. They have skills in keeping people comfortable during full-on surgery that is much more invasive and pain-inducing than colonoscopy. They are skilled at hooking people up to ventilators and at keeping patients comfortably sedated in the intensive care unit, sometimes for weeks at a time. They have a skill set that goes far beyond what’s needed for colonoscopy sedation. Having one of these doctors present is much like using a printing press to write a word when a ballpoint pen will do.

Yet, sometimes it is helpful to have that second doctor. The anesthesiologist can use a medication called propofol, that in Ontario the endoscopist is not allowed to use. Propofol can be more dangerous and so an anesthesiologist needs to be at the bedside. Propofol often results in patients being completely asleep during their procedure and waking up a bit faster after it. The risk of sedation is small whether propofol is used, or whether the nurse and endoscopist are giving sedation with midazolam and fentanyl. With propofol however, the risk of breathing complications is a bit higher. Otherwise, the two approaches are not significantly different.

The one exception is patients who don’t sedate well with midazolam and fentanyl. Typically these are people who may have high anxiety, or who take anti-anxiety medication, or who have chronic pain and need long-term narcotics. For them, propofol usually works better. For their sake, I hope that OHIP would continue to provide funding on an exceptional basis. For everyone else, midazolam and fentanyl tend to work just fine when given by an experienced endoscopist and registered nurse working together.

I didn’t yet mention unsedated colonoscopy. This too can be had if someone really wants it. But it’s not for everyone. Some people have a short and straight bowel and moving a colonoscope through them is relatively pain-free. Some people experience less discomfort than others. Maybe a person is really curious to see inside themselves. Whatever the reason, unsedated colonoscopy is possible. About 10% of my patients choose not to have sedation. Even so, if someone starts their colonoscopy without sedation, it’s always possible to add sedation partway through to keep the proceedings civilized.

Let’s hope the civilized proceedings don’t stop at the endoscopy suite but extend all the way to Queens’ Park.

This article is written by Dr. Mark Reimer. He is a general surgeon and medical director of The Reimer Clinic. He has performed about 12,000 colonoscopies in a decade of practice. Outside of his medical work, Dr. Reimer manages a home care company called Freiheit Care Inc.

Most cancers develop on the inner lining of the large bowel from gland-type polyps. Polyps are flat lesions, like a pitcher's mound on a baseball diamond, or as pedunculated lesions like a mushroom. Some polyps are harmless and others grow to become cancerous. The pathway from normal mucosa, through a polyp stage to a cancer can take about ten years. Some cancers are more aggressive.

Colon Cancer Facts
What is colorectal cancer?

Colon cancer is 90% curable if caught early -- if caught late, it is 90% fatal. Colon cancer is the second leading cause of cancer death in North America. In 2017 the Canadian Cancer Society estimates that 26,800 Canadians were diagnosed with colorectal cancer and 9,400 of us died from it. Put another way, 1 in 13 men and 1 in 16 women will be diagnosed with colorectal cancer. That's the bad news. Thankfully, with screening this cancer can be prevented or diagnosed early on when it is still curable.

What are the signs of colorectal cancer?

Often, there are none. Colon cancer may lie hidden in the body until it is large. By then, it is often too advanced to cure. Common signs and symptoms include:

  • blood in your stool

  • a change in your bowel habits

  • abdominal discomfort, cramps, gas pains

  • a feeling of not being able to empty all of your stool during a bowel movement

  • weight loss and fatigue

  • a mass that can be felt on abdominal or rectal examination

What are the risk factors?
  • age over 50 (age over 45 if African-American)

  • a family history of colon cancer

  • a personal history of polyps

  • inherited disorders that predispose to cancer (FAP and HNPCC)

  • inflammatory bowel disease like Crohn's disease or ulcerative colitis

  • red meat and processed meat consumption

  • alcohol

  • obesity

  • sedentary lifestyle

  • diabetes
  • smoking

  • prior abdominal radiation therapy

Several options exist to help keep you safe from colon cancer. The recommended choices are colonoscopy, the fecal occult blood test and flexible sigmoidoscopy.

Colonoscopy may be the best test for you. It reduces the risk of death from left-sided cancer by 60-70%. It also protects the right side of the colon. It is the "preferred" screening test for colorectal cancer prevention according to the American College of Gastroenterology. The benefits of colonoscopy are that it is widely available, it examines the entire colon, it allows for single-session diagnosis and treatment, and it need not be uncomfortable when sedation is used.

The stool for blood test (also called the FOBT test) requires that several stool samples be sent for analysis to determine if blood is in the stool. In a study in the New England Journal of Medicine, the FOBT test identified only 23.9% of patients who had an advanced pre-cancerous lesion or cancer as determined by a colonoscopy performed right after the FOBT test. This test needs to be repeated every one or two years. It reduces death from colon cancer by 15-33% and is better than no screening at all. It is cheap and safe and easy to do. Colonoscopy is better at preventing colon cancer. The Asia Pacific consensus recommendations for colorectal cancer screening suggest that this test is appropriate for use in resource-limited countries.

Other options include flexible sigmoidoscopy, which is a colonoscopy that stops half-way through the colon. In combination with the FOBT test, it overlooks advanced colonic neoplasia (lesions at risk for colon cancer) in 24% of people. Colon cancers are distributed about equally throughout the entire colon. Flexible sigmoidoscopy + FOBT is an improvement over FOBT alone and over flexible sigmoidoscopy alone. Colon cancer rates are increasing in the right colon, a region seen by colonoscopy but not by flexible sigmoidoscopy.

CT colonography involves taking images of the colon with a series of x-rays. It compares favorably to colonoscopy and is an accepted screening option for colon cancer. Funding for it is somewhat limited and other options such as colonoscopy or stool testing are more commonly used.   This test requires a bowel preparation and if lesions suspicious for polyps are found, it may result in a recommendation for a follow-up colonoscopy. This test is suggested to be performed every five years for screening and it is an important option for patients who decline colonoscopy.

For further reading, the American College of Surgeons provides a patient information brochure that compares and contrasts available screening options. The Ontario Association of Gastroenterology comments on the Canadian Task Force on Preventative Care recommendations for colon cancer screening, saying "Colonoscopy is probably the best colon cancer screening test".