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Will it hurt? Will I be bloated afterward? What do I need to know about the prep? Colorectal surgeon James Church, MD, answers your top questions about having a colonoscopy and explains why they're so important for people over age 50.

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What to Expect From Your First Colonoscopy with Dr. James Church

Podcast Transcript

 Note: As of May 2021 the recommended age for a colonoscopy is now 45

Deanna Pogorelc:  Welcome to the Health Essentials Podcast brought to you by Cleveland Clinic. I'm your host, Deanna Pogorelc, recording here at Cleveland Clinic main campus with Dr. James Church. Dr. Church is a colorectal surgeon here at Cleveland Clinic and he's going to walk us through what to expect when having a colonoscopy, which is the best screening and prevention tool for colon cancer. So thanks for being here, Dr. Church. And to our listeners, please remember this is for informational purposes only and is not intended to replace your own physician's advice. So Dr. Church, according to the CDC, only about three and five adults in the US are up to date on their screening for colon cancer. So who does need a colonoscopy and why should they be having them?

Dr. Church:  Well, pretty much everybody needs a colonoscopy over the age of 50 if you're interested in not getting colorectal cancer. There is another big group of patients that need a colonoscopy and those are patients that have symptoms. So colonoscopy is the best way of checking out the lining of the colon for disease. So if you were to present with rectal bleeding, severe constipation, other symptoms, diarrhea that's not explained, then you need to find out why that's happening. And colonoscopy is the quickest, most accurate, and best way of finding that out. But if you take the symptomatic patients and put them aside, probably the biggest role for colonoscopy is preventing colorectal cancer.

Deanna Pogorelc:  Is it possible that someone could have the early signs of colon cancer but not have any symptoms?

Dr. Church:  Yes, and that's precisely why we emphasize colonoscopy. In fact, colonoscopy is really the only preventative test for cancer of any type. So for example, for breast cancer, we can't get in and take out the precancerous lesion. For other cancers, pancreatic cancer, we can't do that. In the colon, we can because every colorectal cancer comes from a precancerous polyp. And so if we get in there and take the polyps out, that patient is not going to get a cancer. Looking at it the other way, every patient I see in my office with a colon cancer didn't need to get that cancer. If they'd come and had a colonoscopy within the five years before I see them, they would have prevented that. And it's a tragedy.

Deanna Pogorelc:  So the general guideline is 50 if you don't have symptoms?

Dr. Church:  That's the average risk. And it's kind of dictated by the likely yield. So we could screen people under the age of 50. And as a matter of fact, young people are getting colorectal cancer more often. But the absolute numbers are very low. So it's not worth screening a million people and finding like three cancers.

Deanna Pogorelc:  Are there certain high risk groups, though, that might be more likely to be want to screen early?

Dr. Church:  Exactly. And that's really a key. And the commonest high risk group and the one that's easy to find out about is a family history of colorectal cancer or polyps or precancerous polyps. So the general rule of thumb is if you have a first degree relative, that's a parent or brother or sister or occasionally a child, with colon cancer, everyone else in the family needs to be screened 10 years younger than that person was or at age 50, whichever is the youngest.

Deanna Pogorelc:  Okay. So it seems that for people, sometimes the scariest part of a colonoscopy is the preparation part. So can you explain what needs to happen before the colonoscopy?

Dr. Church:  Well, I think people can work that out. Certainly we're not going to see in a thing if the colon is full of poop. So the poop needs to go. And the easiest way to do that is to wash it out. So there are a variety of ways of doing that. In fact, you would think there would be a perfect way by now because colonoscopy's been around since 1969 and the pharmaceutical companies have a great motivation to get the perfect prep because everyone would take it. But there isn't a perfect prep. There's a variety of them. Some involve drinking a lot, up to a gallon. Some involve drinking quite a bit less. None of them taste great despite the fact that various flavorings have been introduced. So it's a matter of sitting down with your doctor and working it out. And often patients will try one and it doesn't go very well for them. And then the next time, we'll try a different one. One of the issues is that they're reimbursed at different rates. So the cost of them to the patient will range from $5 to $135, which is a big difference. To me, having an easy prep is worth $130. But to other people, not so much.

Deanna Pogorelc:  So they need to be fasting also in addition to doing the prep?

Dr. Church:  Yes. The prepping is a little tricky in that once you've cleaned the colon out, you only have so much time before it's going to start getting dirty again, even if you don't eat anything. So the timing of the prep has to go with the timing of the colonoscopy. So if your appointment is in the early morning, you can take all the prep the night before and then you go to sleep and then you come and you have your test done and then you go and get breakfast. If your exam is done a little later in the day, like around lunchtime, you can take half the prep the night before and half the next morning. Then get the exam and then go and get lunch. If your exam is in the afternoon, you can take it all that same morning. So you can have clear liquids, like soft diet the day before, drink your prep for breakfast, go to the office, have the exam, and then go and have dinner.

Deanna Pogorelc:  Okay. So you don't necessarily have to take multiple days off work or something to have a colonoscopy?

Dr. Church:  No, generally not.

Deanna Pogorelc:  So on the actual day, can you talk a little bit about what the procedure is like when they come into the office? They're coming into an office, right? It's not a surgery, they're just having a procedure. And what is it like the day of?

Dr. Church:  Well, there's a variety of settings that can be done in. So commonly, it's done in an endoscopy suite and that's really purely outpatient. Sometimes if more advanced procedures are going to be done, it's in an advanced endoscopy center, which is kind of halfway between an endoscopy suite and an operating room. And general anesthetic can be given in a place like that, whereas it's not usually given in an endoscopy suite. And then sometimes it's done in the operating room itself. It's the same procedure, but the setting depends on previous experience. So for example, if the exam was extremely painful and you want to be put to sleep completely, you can't really do it in the endoscopy offices. It has to be in an advanced suite or the operating room. So we have a variety of locations and contexts that it can be done. And generally, that's a discussion between you and your doctor. For the first one ever, most patients have a comfortable experience, so most patients it's done in the endoscopy suite, which is really no muss, no fuss. You go in there half an hour before, it takes about half an hour, maybe a little less. You wait half an hour to recover and then you go home.

Deanna Pogorelc:  And then it's performed by a physician, a specialist?

Dr. Church:  Yes. A lot of big hospitals are teaching hospitals. And so trainees, with the patient's consent, can have a role in the exam. It's just, again, down to the doctor that you have.

Deanna Pogorelc:  Sure. And then will they be sedated? You mentioned some people might have a general anesthetic, but most people won't.

Dr. Church:  Well when you realize what has to happen ... So your colon is about six or seven feet long and we want to look at all of that six and seven feet. And so to do that, we have to get a scope around that six and seven feet and it's not straight. So if you imagine what your tummy is like, that six feet has to fit inside that tummy. And some tummies are pretty small and so it has to coil up. And putting the scope around the coils can stretch the colon and cause pain. That's where most of the pain comes from.

Dr. Church:  So some people are born with a nice straight colon and my children could do the colonoscopy it's so easy. It just goes in and out and the patient thinks, "Oh, has it started yet?" And we say it's done. Others, it might take me two hours to try and get around and we have to give high doses of sedation and pain medicine and it's very difficult. Very difficult colons may be about three in a hundred. In fact, of a hundred patients that come for a colonoscopy, sometimes we can't get to the end in one or two out of that hundred just because the colon is so difficult to examine. So the odds are low that that's going to happen to any one particular patient. And that shouldn't stop people from coming in and having a try. And in general, it's going to go very well.

Deanna Pogorelc:  Sure. And then so you're just looking for those precancerous lesions?

Dr. Church:  Yes. So that's why it's important to have a nice clean colon. Of a hundred precancerous lesions only one is going to turn to cancer. And in general, if they are very small, it's going to take 10 years for that to happen. But we can't tell which one is going to turn. And so we take out everything. So probably we're doing a lot of unnecessary removal of polyps, but it's better to do it that way and then you catch everything. In general, the bigger a polyp is, the closer it is to cancer just because it means it's been there longer.

Dr. Church:  And you haven't asked this question but it's kind of a natural follow on that polyps grow because the genes controlling the rate of growth of cells have a mutation. So these genes are kind of the break on the cell growth. So cells need to grow but they need to grow in a controlled way. And when you take that break off, the cells start to grow faster than they should. And then what happens is another gene gets mutated and then the cells grow even faster. And then a third gene gets mutated and each of these mutations happens over three or four years. Cells grow even faster. And then they start the buildup. And then you can see them, that's a polyp. And if they continue to grow faster, at some stage, they'll get the ability to invade. And that's when they become a cancer. So the bigger the polyps are, the more mutations have happened and the closer they are to a cancer.

Deanna Pogorelc:  But you can remove them easily during the colonoscopy?

Dr. Church:  Yeah. So the ease of removal depends on how big they are. I've taken out polyps that have been two or three inches in size. This kind of opens up even another can of worms in that different endoscopists feel comfortable taking off polyps of different sizes. So somebody may see a polyp that's an inch and they say, "Oh, I can't take that off. You have to go to surgery." Whereas, if that patient came to see me, I would think, "Oh, I can easily take that off. You don't need to go to surgery." So one tip is that if you're advised by your doctor, "Go and see a surgeon," get a second opinion. It's worth it because surgery is a big deal. Whereas, taking off a polyp is not nearly such a big deal.

Deanna Pogorelc:  Okay. So what about after the colonoscopy? How will someone feel afterwards?

Dr. Church:  Well, it depends on how much sedation they had. So normally, my practice is I just give a sedative, which is called Versed. It's like Valium. So normally when it goes in, it's like the patient had like a double martini. So they're relaxed, they always smile. They say, "Oh, what did you give me?" And then sometimes they tell me their secrets. But I work on the theory that it's always easy to give a little more if you need to rather than give too much. And you hear bad stories about people being over-sedated so that's not good. Some doctors will give some narcotic as well, which I try and avoid that because narcotics can cause people to vomit. And the combination of a sedative and a narcotic can really depress people's breathing, especially more elderly patients. So people have worked it out. Others like to give Propofol. And that's really spread through the country now as a way of putting people completely to sleep. So it's a balance.

Dr. Church:  And then to get back on this one colonoscopist is not like the other, some people cause more pain than others. So I've seen patients where other doctors haven't been able to complete the exam and I've been able to. Or patients have had a really bad experience and they come and see me and then they're very happy. So another tip for the patient is finding out what sort of rating your doctor has as a colonoscopist to the best that you can. You can look for reviews online, you can talk to other patients that might have seen him. You can talk to your own doctor and say, "What do you know about Dr. Johns? Is he any good? Would you go to him yourself? Would you send your mom to him?" And find the best technical colonoscopist and the most accurate diagnostic. Because getting into the colon is one thing, but seeing the polyps is another. And one of our quality indicators for colonoscopy is the ability to detect polyps. And it's not the same for each colonoscopist. And you don't want to have a colonoscopy be told, "Oh, it was normal," but it wasn't normal.

Deanna Pogorelc:  Right. So what will those results look like to the patient? How long does it take to get results in? And what does that look like?

Dr. Church:  So a male age 50 has a 30% chance of having a pre-malignant polyp, and a female has a 20% chance. So if you're in that 70% or 80% with a normal colon, then that's great. You get the results straight away. So you go to the patient and say, "Good news, everything's normal. See you in 10 years." So this would be for the average risk patient. There may be other things going on. You may see some diverticular disease. And then you explain that that's very common, especially as you get older. It doesn't mean you've got diverticulitis, it just means the pockets are there. Sometimes patients may have irritable bowel and you can see that and then advise the patient about diets to eat and ways to deal with that. Sometimes they have hemorrhoids and there's nothing like a colonoscopy bowel prep to make the hemorrhoids flare up. So you can discuss that with the patient. But the main reason you're doing it is screening. And so you can reassure them.

Dr. Church:  If there is a polyp, then you tell them, "Well, I took a polyp off and it looked pretty much to me like a precancerous polyp or it didn't." Whatever it looks like, you can tell. "And I took it out. We'll send it off to the lab. We'll get the biopsy back in two or three days. And then I'll write to you or you can see it on my chart. And we'll recommend the interval for the next colonoscopy." So any precancerous polyp means at least back in five years. So not 10 years, but five years.

Dr. Church:  If there are multiple polyps, we may need to come back quicker. It just means your colon's a little bit more at risk. So you can look at a colon like a garden and polyps are weeds. Some gardens don't produce any weeds, others are producing weeds all the time. You got to get the weeds out so you have to come back quickly before they get too big. And then if you see a polyp that you don't like the look of, it might be a cancer, and you can still take it out, that might be all that's necessary. But you'd wait for the path. And usually we'll put in a little tattoo so we know where that was. And then if it's a cancer and the patient needs surgery, the surgeon will know exactly what part of the colon to take out.

Dr. Church:  So sometimes it's actually a cancer and you can't take it out. And those are the discussions that you don't like to have because oftentimes the patients, it's just natural to be anxious when you go for a colonoscopy because what are they going to find? And then this is the worst dream come true. But if it's asymptomatic, if it's found on screening, almost always at early stage, almost always it's curable. And the way surgery is done these days with minimally invasive techniques, it's nothing to be scared of now. It's hardly any incisions, there's not much pain. Taking out a section of colon, you have a normal quality of life and you've saved your life by having the colonoscopy and having the cancer found. So it's all good really.

Deanna Pogorelc:  Yeah. So you've made a great case for having a colonoscopy, but if someone, for whatever reason, just is still hesitant to do it, are there any other options for colon cancer screening?

Dr. Church:  Well, like we said, colonoscopy is the only preventative technique because it's the only technique that you can remove polyps. There are other ways of screening the colon and they involve stool tests. The most accurate stool test is a relatively recent test looking at DNA in the stool, the DNA that comes from these precancerous cells or cancer cells. It's quite accurate. Its sensitivity, which means if there are a hundred cancers, it'll find 92 of them. That's almost as good as colonoscopy. And it will even find, oh, at least half of the precancerous polyps, the big precancerous polyps, the important ones. So it's not as good as colonoscopy because a positive DNA test of the stool means you need a colonoscopy. But a negative one means that you probably don't. And then you would repeat the DNA test later, like about three years later. The stool tests that look at blood aren't as accurate as the DNA. There's even a blood test now for circulating cancer DNA in the blood, but the sensitivity of that, there's out of a hundred cancers it'll only find 62. So it's significantly less. It's almost like tossing a coin. But it's available. It's a commercial test. Your doctor should know about it.

Deanna Pogorelc:  Great. Well is there anything else you want to let our listeners know about colonoscopy before we wrap up?

Dr. Church:  Well, just to say that I've had four myself. So the first two I did with no sedation at all because I didn't want to miss any work. And it is possible to do it with no sedation. You have to have a friendly colon though. And some patients prefer that. Some patients are more scared of being sedated than they are for the exam, but you have to get a very skillful colonoscopist and then probably arrange for somebody to come with you in case you would need sedation. The ability to do that is determined that the first exam, and then we know what your colon's like. And if it goes really smoothly and there's no pain at all, then the next time, you just show up on your way to work, get the colonoscopy, and go to work.

Deanna Pogorelc:  Well, thank you so much for being here with us. And to learn more, please visit clevelandclinic.org/colonoscopy. And for more interviews with our Cleveland Clinic experts, subscribe to this podcast or check out Butts and Guts, which is a Cleveland Clinic podcast focused on digestive health. For more health tips, news, and information, follow @Clevelandclinic, all one word, on Facebook, Twitter, and Instagram. And thanks for joining us.

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