Preparing for a Colonoscopy

Podcast Transcript

Scott Steele: Butts & Guts, A Cleveland Clinic podcast, exploring your digestive and surgical health from end to end. Hi again everyone, and welcome to another episode of Butts & Guts. I'm your host, Scott Steele, colorectal surgeon and President of Main Campus here at the Cleveland Clinic in beautiful Cleveland, Ohio. And it's always nice to welcome back a guest and today I'm very pleased to have Dr. Christine Lee, a gastroenterologist in the Department of Gastroenterology, Hepatology and Nutrition here at the Cleveland Clinic. Christine, welcome back to Butts & Guts.

Christine Lee: Thank you. Happy to be here.

Scott Steele: Today we're going to talk about something that puts a lot of fear into people and that's how do you prepare for a colonoscopy. So, I know you've been on before, and before we jump right into preparing for a colonoscopy, give us again a little bit of your background. Where are you from, where did you train, and how did it come to the point that you're here at the Cleveland Clinic?

Christine Lee: Sure. I pretty much grew up and did all of my training here, right in the state of Ohio, with the exception of the GI Fellowship. I did that at the big state of Texas. I was active duty in the United States Air Force for 10 years until I joined the Cleveland Clinic family and I've been here since 2009, ever since.

Scott Steele: Fantastic. And thank you for your service. March is Colorectal Cancer Awareness Month, an awareness month that we are very passionate here about at Butts & Guts. And today we're going to discuss a little bit about what a patient can expect if they're going in for their colonoscopy screening, a screening that is used to detect and prevent colorectal cancer. To start, can you just touch again, what is a colonoscopy and why is it important for our newer listeners?

Christine Lee: Well, it's important because colon cancer is the third most common cancer in the United States, and unfortunately it's the second cancer causing death in the US, so it is really important to be screened. There are multiple modalities available for colon cancer screening. Colonoscopy is one of them. It is the gold standard for colon cancer prevention and so it is a very important test that one should seriously consider if you fall within the screening age bracket.

Scott Steele: Absolutely. It's something that can not only diagnose things but also can catch it at an early and even precancerous stage. So, can you walk us through the preparation process for a colonoscopy?

Christine Lee: The preparation process is what generally provides the biggest anxiety for patients, and it truly is the hardest part of the colonoscopy, but if you break it down into smaller manageable steps it's really doable and very manageable. The first step would be making sure you have the colonoscopy date and time that works with your schedule and having a driver, because of the anesthesia involved you will need a driver to help you drive home. Once that's factored, you want to just make sure you go through your health medical status and your prescriptions and see which ones need to be held, which ones can be maintained. And then if you take anything over the counter or health supplement wise, if it's not prescribed to you and it's not a necessity, it's generally safer just to hold those things for a week before your procedure, things like multivitamins or health supplements that you take/buy over the counter.

Secondly, about three days before you want to be on a low residual diet. A low residual diet being no nuts, no seeds, no dry fruit, no vegetables with peels, nuts, beans, those kinds of things. Anything that doesn't dissolve or completely liquefy can become a little bit of a problem during the colonoscopy. You want to avoid those for about three days prior to the procedure. One day before you're on a clear liquid diet, this is the time where you can have all the broth you want, vegetable broth, chicken broth, beef broth, any broth that you prefer. You do need some sustenance, so make sure you have plenty of the broth, Jell-o, homemade kinds always taste better than the ones you buy at the store. And then you have all the clear liquids, meaning anything you can pour into a glass and you can see through it, then it's a clear liquid diet. You can have Gatorade, water, white grape juice, apple juice, ginger ale, 7Up, Sprite, just any of those clear liquids that keep you well hydrated.

And then it comes down to the prep time. Now that can vary because there are many different prep options available in the market. It is just important that whatever prep that you chose, you sit down and read through the instructions prior to that date because you want to make sure you follow that instructions closely because it's important. The better the prep, the better your test. You want to give yourself the best foot forward and make sure that you get the highest quality evaluation. And to do that, you want to make sure you follow your prep instructions.

Scott Steele: Some patients have told me that their doctors tell them don't drink or eat anything red. Why is that?

Christine Lee: Sometimes some of the food coloring, the red, can be quite potent and it actually can adhere to the colonic wall and surprisingly it does sometimes look like blood. You don't want to confuse anybody or make your colonoscopy any harder than it needs to be so just simply avoid the food color red.

Scott Steele: That sounds good. And you mentioned this very briefly about going through with your doctor about what medications or supplements that you may be taking, but are there any medications or supplements that should be avoided?

Christine Lee: Certain things like iron can actually stain the colonic walls dark, and there are certain over-the-counter medicine that decrease the effectiveness of your bowel prep such as Imodium or Lomotil. You want to make sure you're not taking anything that's unnecessary or that can counteract the effects of the bowel prep.

Scott Steele: I know there's a lot of preps out there and we're not here to discuss one versus another. Some are pills and some are drinking lots of liquid and less liquid and all sorts of things. But what are some of the more common misconceptions about the colonoscopy prep?

Christine Lee: One of the misconceptions about the colonoscopy prep is that you can't eat anything and it's just so arduous that it's impossible to complete. A lot of the bowel prep options that are available have different nuances so it is important that you are involved in the decision-making. What's right for you may not be right for your neighbor. Depending on your anatomy, if you've had surgical alterations of your anatomy or your other medication needs, it's important to sit down and discuss with your ordering provider and find the right prep that best suits your needs.

Scott Steele: I've had patients say to me, "You know what? I'm not taking a prep. I'm just not going to eat or drink anything for two weeks." What do you tell them?

Christine Lee: Oh, that is actually the worst thing you could do for yourself, because when you eat nothing at all, then your body goes into starvation mode and it just clamps down everything you already have. Even the stool, it'll just hold onto everything to just be able to suck out every last calorie your body can absorb and thereby making the bowel prep quality less effective. So, you really want to keep things flowing so taking in a lot of broth, Jell-o, all the clear liquids, just keep things flowing to keep it moving actually will improve the quality of your bowel prep. Not eating anything at all actually makes it worse so we encourage a lot of oral intake for nutrition, hydration and just electrolyte repletion.

Scott Steele: I've had some patients also tell me that, "I can't take a bowel prep, I just can't take it. Doesn't matter." Do you tend to find that there's probably one bowel prep out there that patients can take or what do you tell that particular patient?

Christine Lee: Everybody has different needs. For those particular patients that feel that it's too much volume and they just can't tolerate the entire prep, the best option is actually modifying the time, so you start early. If you can't do it all because it's too much, then break it up. You can start, what, a day and a half early. You can start 12 hours earlier, you can start 16 hours earlier. That way you can break it down into smaller portions, allowing yourself more time to complete. That way you have four hours, six hours in between your portions of the bowel prep. As long as you complete it, that's the key. A lot of times people think less is more, but it really isn't the case here because you really need to have that colon flushed out and cleaned out for the best quality test. If you feel not confident that you can complete the whole entire volume, then just start earlier, you can start 12 hours earlier, 16 hours earlier. That way you have ample time to rest in between your sessions.

Scott Steele: How can patients manage any discomfort or anxiety related to the preparation?

Christine Lee: I think the biggest anxiety is not knowing. If you can make an appointment with your ordering provider, sit down with them and talk about what to expect. They can relieve a lot of your anxiety by just letting you know what's going to happen and answering any questions that you may have. Oftentimes even during the procedure, patients come in quite nervous and anxious. If you just let them know, "Hey, listen, I'm going to talk every step of the way and tell you what's going to happen before it happens," that alone relieves great deal of their anxiety. The most anxiety provoking is just not knowing and feeling that they have no control. If you just let them know what's going to happen so they have less ambiguity of what's going to happen next, and let them know they are in control, you can let them know you're the boss. If you say you need more sedation, we can give you more sedation. If you say, "Hey, I want to quit," you can quit. But just arming them with information is very helpful.

Scott Steele: What do you say to the patient who comes to you on the morning of and says, "Dr. Lee, I promise you I took my whole prep, but I've still got a little bit of yellow that's coming out of me."

Christine Lee: Generally that will be the last push. And in our endoscopy we actually have flushing capabilities with water irrigation. Majority of the time it's still very effective where we can go in and let them know, "Hey, that's just the last final push, so most likely you'll be fine." Rarely do we go in and if it is just not compatible for the endoscopy, we may have to reschedule you for another time.

Scott Steele: Okay. Now they've made it through the prep. What should patients expect on the day of the procedure?

Christine Lee: On the day of the procedure, I just tell them, "Hey, listen, this is the finish line. Once you get your body to our facility, we'll take over from there. That's the easiest part. Our nursing staff will take you in, they'll settle you to your bed, make you very comfortable. The anesthesia will make sure that you're not in any discomfort. We take care of you. That's the point where you just lay and be comfortable as you can and we'll take care of the rest."

Scott Steele: How long does the procedure typically take and what is that recovery process like?

Christine Lee: The procedure typically takes about 25 to 30 minutes, but we always tell patients to plan on being with us about two to three hours on the safer side. And the reason for that is when you come in and check in, there's a lot of paperwork that needs to be done. They have to put an IV in your arm, you may need to produce a urine sample for a pregnancy test, depending. And then just getting the monitors hooked up and then just getting you acquainted with the staff that's going to be in your procedure room. And also the consent process, you want to talk to your provider before you start the procedure. And that's all before even the procedure starts. The procedure itself, like I said, is about 25 to 30 minutes, and then the recovery time varies greatly. Some people, they're ready and recovered within five minutes. Some people may need a lot longer. It all depends on how well you recover from feeling a little bit sleepy or waking up from your nap. When you combine all of those, the safest thing is to just schedule about two to three hours.

Scott Steele: What are the most common findings that are found during a colonoscopy and what do they mean?

Christine Lee: Most common things that we find are called polyps, but those are basically abnormal growths. These are benign until they're not, so you want to find them at the early stages. You want to get those polyps before they turn into malignancy. These are abnormal growths, they're easier to remove when they're small. When we find them, we don't just take pictures, we remove them. By removing them we really changed that trajectory now removing any chance that that polyp will turn into anything more dangerous down the road. Other than polyps, we often find structural alterations or variations on the patient. Some people may have diverticulosis, they may have redundant colon, they may have excessively tortuous sigmoid colon. And a lot of those, even though that wasn't the intent for the colonoscopy, can be very helpful for the patient because once they know, they know how to better manage it so that they don't continue that process, thereby minimizing their risk of going to develop diverticulitis or sigmoid volvulus, things like that. It's always better to have things evaluated so you know what's going on inside your body.

Scott Steele: How should patients interpret their results and what are the next steps if something abnormal is found?

Christine Lee: Interpreting, I would encourage the patient to interpret those with a medical professional, whether it's the ordering provider or the provider that performed the procedure. Oftentimes in the procedure report, it's required that we use medical terminology that may not be as readily knowledgeable by the patient in layman's terms. It's just important to interpret that with the right professional that can adequately explain that to you. Now, if anything is abnormal and it is found, it is strongly recommended that you seek a medical appointment with whether a GI physician or GI provider that can not only explain that abnormality further, but recommend or come up with a plan of care for you and the necessary follow-up that you might need.

Scott Steele: What's on the horizon as far as innovations in colonoscopies or colon cancer screenings?

Christine Lee: Oh, this is an exciting time. We already have some stool DNA testing that continues to improve every year. On the horizon there are some blood tests that's coming down the pipeline that hopefully will make it a lot easier for other patients to access. And who knows, with AI, anything can happen.

Scott Steele: That's fantastic. And so, now, it's time for our quick hitter. It's a chance to get to know our guests a little bit better. First of all, what was your first car?

Christine Lee: Oh, that would be... I'm dating myself now. It would be a 1969 Cutler Supreme Oldsmobile.

Scott Steele: Fantastic. When you were a kid, or even now, what was your favorite cartoon or cartoon character?

Christine Lee: My favorite cartoon? I didn't watch too much cartoons, but the only cartoon that comes to mind would be Tom and Jerry.

Scott Steele: Fantastic. What is your favorite dessert?

Christine Lee: That would have to be tiramisu.

Scott Steele: And finally, do you have a hidden talent that you can tell us about?

Christine Lee: My hidden talent? Well, if I told you it wouldn't be hidden anymore, so I'm not sure if I should disclose, but I am known to be pretty good at masquerading catered food and pawning that off as my own home-cooked meal.

Scott Steele: That is absolutely fantastic. Give us a final take home message for our listeners.

Christine Lee: Colon cancer, it can be really devastating to not just the person but their family. There is an excellent modality of screening and it's not as arduous or difficult as one I have talked about. Just break it down, make it simple, it's easy. It's the best thing you can do for yourself and your family.

Scott Steele: Fantastic. And so to learn more about colonoscopies or to schedule a screening here at the Cleveland Clinic or at a Cleveland Clinic location near to you, please visit clevelandclinic.org/colonoscopy. Again, that's clevelandclinic.org/colonoscopy. You can also call the Cleveland Clinic Digestive Disease Institute at 216.444.7000. That's 216.444.7000. Dr. Lee, thanks so much for joining us on Butts & Guts.

Christine Lee: Thank you so much.

Scott Steele: That wraps things up here at Cleveland Clinic. Until next time, thanks for listening to Butts & Guts.