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Medical Forum / General / General / February 2006Colonoscopy prep question for Howard
Howard, I just went to a new general surgeon today (the only one left), since all the rest of them where I live (including my last general surgeon, who just did a hemorrhoidectomy on me last August) formed one group and dropped my insurance (blue cross). I have been to over 75 doctors in my life and do not like most of them, and this will help explain why. I am quite familiar with medicine, and the human anatomy, and prescription drugs, and have been studying medicine for 15 years. I have many medical problems and have a specialist for every part of my body. Basic reason for visit to general surgeon was to request a colonoscopy, since I have been having a lot of rectal/perineal pain, along with my other problems. My last colonoscopies were in 2002 and 1995 respectively. Didn't want my gastro (old school) to do colonoscopy since he insists on doing the prep in the hospital just before the procedure (no way, I go 40-50 times and have to have my privacy, to clean myself etc). I have had many EGD's in my life (currently yearly). Anyway I introduced myself to the surgeon, and tried to explain some of my medical problems and history and he agreed to do the colonoscopy, and I asked him if I could try the saline solution instead of the colyte (polyethylene glycol) and he said okay. My last colonoscopy was with the fleet phosho soda (bad stuff) and that tore me up so bad their was no way I could take it a second time just before the procedure. Okay are you ready for this. The surgeon's girl came in to schedule me, and give me the instructions, and I took a quick look at them and said something must be wrong, and that the requirement to be on a liquid diet for *two days* prior to the procedure must be wrong and that it was only one day for my last two colonoscopies, and I never heard of such a thing. That is utter cruelty and in IMO incompetence, but of course I didn't say anything about the incompetence. I told her it was not humane to go two days without eating, and that can't be right, so she went and asked the doctor to confirm, and came back and said that was his method. So I told her I would like to ask him about it. He came back and tried to justify the two day liquid diet (even though I told him my last two colonoscopies were not like that - ie light breakfast the day before and start the liquid diet at noon time). He said that's the way he has been doing it for the last twenty years, and I knew this was wrong. I have never heard of such a thing, and googled it when I got home, and everything said start the liquid diet at breakfast, or noon, the day prior to the procedure *not two days before* . Howard, what the hell is going on here. That is insanity (cruelty) to ask someone to go two days on liquids only, and not eat anything. There is no way I will do it, but just won't tell him. I will start the liquid diet the day before and drink a bottle of citrate of magnesia at 10:00 (which is powerful stuff in itself), and then do the saline solution (six-500 cc bottles) per the instructions and I guarantee you I will be excreting pure liquid, and it will tear me up. There is no way I am going to go two days with out eating (which would actually be closer to 2-1/2 days by the time the procedure is over and I get home). That would be absurd, and I can't believe this doctor asks his patients to do that, especially the elderly. Like I said, I checked my last colonoscopies, and they were both day before liquid diets [plus the cleanser(s) of course], and I got the same thing when I googled it. Is this doctor being too conservative here (I figure he's in his mid fifties). I'm sure he's a fine surgeon, but I don't think he knows what he's doing on the colonoscopy prep - ie way too conservative. Please comment. BTW Howard, I asked you a long time ago (over a year) if you were a general surgeon, and you never answered me. Thanks...Pete > Howard, > [quoted text clipped - 60 lines] > (over a year) if you were a general surgeon, and you never answered me. > Thanks...Pete I'm a General Surgeon. I primarily specialize in laparoendoscopic surgery, but I do the whole gamut. I've done more that 10,000 colonoscopies. There are a lot of ways to prep the colon for colonoscopy, none of them very pleasant. Most people will say that the colonoscopy itself is a piece of cake compared to the prep. I don't feel quite as strongly as you do about the prep your surgeon is recommending, but I agree with you that two days of clear liquids is unnecessary. The approach you are planning is probably exactly what I'd do too, if he were going to scope me. I think that should be completely adequate. HMc >> Howard, >> [quoted text clipped - 68 lines] > them very pleasant. Most people will say that the colonoscopy itself > is a piece of cake compared to the prep. Absolutely...especially now that they put you to sleep with propofil :-) . > I don't feel quite as strongly as you do about the prep your surgeon > is recommending, but I agree with you that two days of clear liquids [quoted text clipped - 3 lines] > > HMc Thanks Howard...I was hoping you would agree. I have pics of all my procedures and the 1995 colonoscopy was perfectly clear except for a little light green jello which is normal :-). The 2002 one wasn't as good (and I knew it wouldn't be) because I couldn't handle the fleet phospho soda in the early AM, after just tearing myself up with it the night before (it was unbelievable). My gastro told me they weren't using it anymore where I live. I don't know - it was only one group of gastros that used it I believe. Anyway thanks again for your answer. I feel more reassured now. Take care...Pete > Absolutely...especially now that they put you to sleep with propofil :-) . It's been a while since I've had a colonoscopy, mostly because I have the true paradoxical reaction to Versed (it wakes me up and keeps me awake) and my problem was finally found to be very mild inflammation in the small intestine, where a colonoscope wouldn't reach anyway. In case one is suggested again, is propofil preferred over Versed now?  Signature"Did Father shoot him? I will eat Grandfather for dinner." - Helen Keller, on learning of the death of her grandfather >> Absolutely...especially now that they put you to sleep with propofil :-) >> . [quoted text clipped - 4 lines] > the small intestine, where a colonoscope wouldn't reach anyway. In case > one is suggested again, is propofil preferred over Versed now? Most common meds used in intravenous conscious sedation, as for endoscopy, would be Versed, plus either Demerol or Fentanyl. If, for whatever reason those don't work for a particular patient, then Propofol as a continuous drip, is used. Usually, Propofol requires an anesthetist or anesthesiologist since monitoring is quite critical. HMc >>> Absolutely...especially now that they put you to sleep with >>> propofil :-) . [quoted text clipped - 13 lines] > > HMc Howard...I had the conscious sedation in the 90's, but it seems that all the gastro's have gone to the propofol at the endoscopy and surgical centers nowadays, so now you get an additional bill from the anesthesiologist (who has to talk to you and be nearby, even though an anesthetist does the administration of the drug). My current gastro uses Versed for my EKG's and saves you the extra bill (he's from the old school and says the anesthesiologist is overkill - I agree but the propofol is good stuff - quick acting, quick recovery and no hangover). When my gastro does my EKG's he has the nurse give 100 mg of demerol first, and then knocks me out with the Versed, and believe me there is no consciousness (even though it is referred to as conscious sedation). And it lasts a lot longer than the propofol, and more hangover, so he must use a good amount. When I had the conscious sedation in the 90's, I was partially awake during the procedures, and did not go unconscious. It seems a shame that they have gotten away from the conscious sedation where the gastro could inject Versed or whatever into your IV, without an anesthesiologist and anesthetist being required, and the additional bill, etc. I suspect it's all related to insurance, and someone didn't wake up once, or some horseshit like that...Pete >>>> Absolutely...especially now that they put you to sleep with >>>> propofil :-) . [quoted text clipped - 36 lines] > etc. I suspect it's all related to insurance, and someone didn't wake up > once, or some horseshit like that...Pete I'm sure it varies from region to region, but doing colonoscopy under propofol is uncommon. There's cerainly no monetary advantage to doing so, nor is there any advantage to the patient from a discomfort standpoint (assuming the IVCS is done properly). In my case, my daily volume of colonoscopies is such (in addition to my surgical schedule and office schedule) that the time involved in getting anesthetists involved for endoscopy is prohibitive (I would need three anesthetists just for colonocopies). The only time we use an anesthetist/Propofol is if the patient has in the past required an excessive amount of Versed and/or narcotic, or if we reach a certain level of administered IVCS and haven't achieved satisfactory sedation and comfort. I don't get to collect any more money for administering the IVCS, but it's cheaper for the patient, safer, and makes for a much more efficient outpatient unit. HMc >>>>> Absolutely...especially now that they put you to sleep with >>>>> propofil :-) . [quoted text clipped - 51 lines] > it's cheaper for the patient, safer, and makes for a much more > efficient outpatient unit. I totally agree Howard. Hell, I live in a relatively small "redneck" community in northwestern Maryland, and they have basically gone to propofol at the endoscopy centers. I guess the pharma company (AztraZeneca) must get together with the gastro's and they all vote - lol . The local gastro's (most of them) own shares in the latest endoscopy center here (and it was formed by them). Take care...Pete > >> Absolutely...especially now that they put you to sleep with propofil :-) > >> . [quoted text clipped - 10 lines] > drip, is used. Usually, Propofol requires an anesthetist or anesthesiologist > since monitoring is quite critical. Thanks for the information. Sounds as though if one is thought necessary for me again, 'virtual' colonoscopy may be the way to go (I have a bad habit of not breathing well under a general) or for me to just start running the other way. Signature"Did Father shoot him? I will eat Grandfather for dinner." - Helen Keller, on learning of the death of her grandfather >> Most common meds used in intravenous conscious sedation, as for >> endoscopy, [quoted text clipped - 8 lines] > habit of not breathing well under a general) or for me to just start > running the other way. General anesthesia implies NO breathing. All reflexes are suppressed, including the drive to breathe and the key job of the anesthetist is to make certain that the patient is still breathing and addressing that if necessary. Sometimes it requires manual ventilation if the patient gets too deep. Propofol is very short-acting, so if that happens, the drip is turned off and the patient "awakened" to the point where he/she is breathing on their own again. IVCS implies sedation, pain management, and amnesia, but the patient's reflexes, including breathing, are intact. Propofol is somewhere in between and that line between too much Propofol (no breathing) and not enough (inadequate sedation) is a fine one. Thus, use of Propofol usually requires an anesthetist experienced in controlling the drip rate and walking that fine line between too much and not enough. The very tricky, close monitoring requires experience and can't (shouldn't) be done by anyone who has any other job to do during the procedure. Obviously, the use of Propofol is kind of a big deal with more risks, more expense, more hassle. HMc Virtual colonoscopy - promising technique in some circumstances, but it's not there yet from a sensitivity/specificity standpoint. And it doesn't relieve the patient of the colon prep. > >> Most common meds used in intravenous conscious sedation, as for > >> endoscopy, [quoted text clipped - 13 lines] > certain that the patient is still breathing and addressing that if > necessary. Well, of course; I didn't want to bore anyone with a long organ-recital of my problems under general anesthesia so I went for mildly amusing instead. As I failed, I'll go for the recital say that I have mixed apnea and asthma and 'buck' (per anesthesiologists) when induced. I am said to be a pleasant and compliant patient when awake, but a real bitch when unconscious. > Obviously, the use of > Propofol is kind of a big deal with more risks, more expense, more hassle. > > Virtual colonoscopy - promising technique in some circumstances, but it's > not there yet from a sensitivity/specificity standpoint. And it doesn't > relieve the patient of the colon prep. While the prep is unpleasant, it's *nothing* compared to going through a colonoscopy without any effective sedation, as I have done three times. I understand that it's not terrific for polyp detection, but I have never been subjected to one for that reason. At least now my paradoxical reaction to Versed is known and it won't be tried again. Thanks again! I hope it's a very long time before this information comes in handy. Signature"Did Father shoot him? I will eat Grandfather for dinner." - Helen Keller, on learning of the death of her grandfather >> >> Most common meds used in intravenous conscious sedation, as for >> >> endoscopy, [quoted text clipped - 41 lines] > Thanks again! I hope it's a very long time before this information comes > in handy. I didn't mean to scare you off from IVCS. Propofol is the ideal mechanism for a patient like you. It should have been used on your *second* colonoscopy. That you went through that 3 times is very unfortunate. HMc > "REP" <rep@inanna.com> wrote in message > > While the prep is unpleasant, it's *nothing* compared to going through a > > colonoscopy without any effective sedation, as I have done three times. [quoted text clipped - 8 lines] > for a patient like you. It should have been used on your *second* > colonoscopy. That you went through that 3 times is very unfortunate. And a kidney biopsy. Well, remember what Nietzsche said... (just waiting for someone to respond, "Du gehst zu Frauen? Vergiss die Peitsche nicht!" No, that's not what I had in mind.) Signature"Did Father shoot him? I will eat Grandfather for dinner." - Helen Keller, on learning of the death of her grandfather
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