Colon Cancer Screening with Colonoscopy

Aka: Colon Cancer Screening with Colonoscopy, Colonoscopy, Home Medications Before Colonoscopy

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II. Efficacy

  1. Identifies up 94-98% of Colon Cancer
    1. Bressler (2007) Gastroenterology 132(1): 96-102 [PubMed]
  2. Identifies up to 98% of adenomatous polyps >1 cm (but only 74% <6mm)
    1. van Rijn (2006) Am J Gastroenterol 101(2): 343-50 [PubMed]
  3. Efficacious and reduces mortality
  4. Preferred over other Colon Cancer screening modalities
  5. Reference
    1. Mandel (1993) N Engl J Med 328:1365-9 [PubMed]
    2. Lieberman (2000) N Engl J Med 343:207-8 [PubMed]

III. Interpretation: Criteria for a high quality Colonoscopy

  1. Minimal fecal residue following colon preparation
  2. Colonoscopy reaches the cecum
  3. Withdrawal time from cecum to Rectum is 6 minutes or more
  4. Complete removal of identified polyps (not piecemeal excision)
  5. Rex (2002) Am J Gastroenterol 97:1296-1308 [PubMed]

IV. Adverse Effects

  1. Minor common adverse effects
    1. Adverse effects of preparation medications
    2. Adverse effects of sedation
  2. Serious common adverse effects
    1. Perforations: 1 in 500-3000
      1. Rectosigmoid: 66%
      2. Cecal: 13%
      3. Ascending Colon: 7%
      4. Transverse Colon: 7%
      5. Descending Colon: 7%
    2. Major Bleeding: 1-2 in 1000 (0.1 to 0.6%)
      1. Most common with biopsy or lesion excision
      2. May occur up to 2 weeks after Colonoscopy
    3. Post-polypectomy Syndrome
      1. Abdominal Pain, Leukocytosis, peritoneal inflammation without perforation
      2. Onset within 2 weeks of polypectomy
  3. Uncommon
    1. Splenic Trauma
    2. Vasovagal reaction
    3. Endocarditis
  4. Rare
    1. Sepsis

V. Findings: Polyps

  1. See Colonic Polyps

VI. Protocol: Home Medications Before Colonoscopy

  1. See Bowel Preparation
  2. No Antibiotic prophylaxis is needed in most cases
    1. Not indicated despite cardiac conditions, prosthetic joints, or vascular grafts
  3. Anticoagulants
    1. Low dose Aspirin and NSAIDS
      1. Typically may be continued for all endoscopic procedures
      2. However, local protocols vary, and some may require Aspirin and NSAIDs be stopped first
      3. However, stable patients on Dual Antiplatelet Therapy will typically have Aspirin continued, and other agent held
    2. Antiplatelet Agents (Clopidogrel, Prasugrel, Ticagrelor)
      1. Low risk of bleeding (e.g. routine Colonoscopy)
        1. These agents are stopped in most cases, but may be continued if higher thrombosis risk
        2. Dual Antiplatelet Therapy patients who are stable
          1. Constinue low dose Aspirin and hold the other antiplatelet agent as below
      2. High risk of bleeding
        1. Low risk of thrombosis
          1. Stop Clopidogrel or Prasugrel for 5-7 days
          2. Stop Ticagrelor for 3-5 days
        2. High risk of thrombosis (e.g. drug eluting stent placed in the last year)
          1. Delay procedure
      3. Restarting after procedure
        1. No polyps removed: May restart immediately
        2. Polyps removed: Restart 24 hours after procedure
    3. Warfarin
      1. Low risk of bleeding (e.g. routine Colonoscopy): May continue Warfarin
      2. High risk of bleeding
        1. Low risk of thrombosis: Stop Warfarin for 5 days before procedure
        2. High risk of thrombosis (e.g. Mechanical Heart Valve, VTE within 3 months)
          1. Delay procedure OR
          2. Warfarin bridging with Heparin stopped 4-6 hours before procedure
      3. Restarting after procedure
        1. No polyps removed: May restart immediately
        2. Polyps removed: Restart 12 hours after procedure
    4. Direct Oral Anticoagulants (DOACs, Apixaban, Rivaroxaban)
      1. Hold 1-2 before procedure (if normal Renal Function)
      2. Restarting after procedure
        1. No polyps removed: May restart immediately
        2. Polyps removed: Restart 48-72 hours after procedure
  4. Diabetes Medications
    1. Day prior to Colonoscopy
      1. Hold Sulfonylureas (e.g. Glipizide), Non-Sulfonylurea Insulin Secretagogues (e.g. Nateglinide)
      2. Consider decreasing evening premixed Insulin (e.g. 70/30) or Basal insulin by 50%
      3. Decrease Bolus Insulin by 50% (may use full Bolus Insulin dose if Carbohydrate Counting)
      4. May continue all other diabetes medications on day prior
    2. Day of Colonoscopy
      1. Consider giving partial Basal insulin dose on morning of procedure (esp. in Type I Diabetes Mellitus)
      2. Hold all other diabetes medications on the morning of procedure
  5. Other Medications
    1. Most other medications may be taken with a sip of water up to 3 hours before Colonoscopy

VII. Management: Suspected colonoscopic perforation

  1. Indications for immediate laparotomy
    1. Peritoneal signs
    2. Unreliable patient or comorbid conditions
    3. Large defect
    4. Poor Bowel Preparation
  2. Evaluation of stable, reliable patient
    1. Step 1: Obtain upright abdominal XRay
      1. Laparotomy for Free air
    2. Step 2: Obtain CT Abdomen
      1. Laparotomy for large perforation
    3. Step 3: Observe
      1. Indications
        1. Negative upright Abdomen
        2. Negative CT or contained perforation on CT
      2. Conservative protocol
        1. Patient kept NPO on Intravenous Fluids
        2. Prophylactic Antibiotics
        3. Serial exams, XRays, and White Blood Cell Count
      3. Laparotomy Indications
        1. Clinical deterioration
        2. Increased White Blood Cell Count

VIII. References

  1. (2022) Presc Lett 29(5): 27
  2. Kavic (2001) Am J Surg 181:319-32 [PubMed]
  3. Wilkins (2018) Am Fam Physician 97(10): 658-65 [PubMed]

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Related Studies

Ontology: colonoscopy (C0009378)

Definition (MSHCZE) Endoskopické vyšetření, terapie nebo operace na luminální straně tračníku.
Definition (MEDLINEPLUS)

Colonoscopy is a procedure that lets your doctor look inside your entire large intestine. It uses an instrument called a colonoscope, or scope for short. Scopes have a tiny camera attached to a long, thin tube. The procedure lets your doctor see things such as inflamed tissue, abnormal growths, and ulcers.

Your doctor may recommend a colonoscopy:

  • To look for early signs of cancer in the colon and rectum. It may part of a routine screening, which usually starts at age 50.
  • To look for causes of unexplained changes in bowel habits
  • To evaluate symptoms like abdominal pain, rectal bleeding, and weight loss

Your doctor can also remove polyps from your colon during a colonoscopy.

You need to be on a clear liquid diet for 1 to 3 days before the colonoscopy. During the procedure, you receive medicines to keep you relaxed.

NIH: National Institute of Diabetes and Digestive and Kidney Diseases
Definition (NCI_NCI-GLOSS) Examination of the inside of the colon using a colonoscope, inserted into the rectum. A colonoscope is a thin, tube-like instrument with a light and a lens for viewing. It may also have a tool to remove tissue to be checked under a microscope for signs of disease.
Definition (NCI) Endoscopic examination of the luminal surface of the colon.
Definition (MSH) Endoscopic examination, therapy or surgery of the luminal surface of the colon.
Concepts Diagnostic Procedure (T060)
MSH D003113
ICD9 45.23
SnomedCT 271997005, 142496001, 73761001, 359590001
CPT 1007622
LNC LP6191-3, LA15380-1
English Colonoscopies, Colonoscopy, Endoscopic examination colon, colon endoscopy, colonoscopy procedures, colonoscopy procedure, colonoscopies, colonoscopy (treatment), Endoscopy Procedures on the Rectum, Endoscopic examination of colon, Colonoscopy (procedure), Endoscopy of colon, Colonoscopy, NOS, Endoscopy of colon, NOS, Colonoscopy [Ambiguous], colonoscopy
Italian Colonscopia con endoscopio flessibile, Colonscopia
Swedish Koloskopi
Japanese ｹｯﾁｮｳﾅｲｼｷｮｳｹﾝｻ, 大腸内視鏡下手術, 大腸内視鏡検査, 結腸内視鏡検査, 内視鏡下手術-結腸, 内視鏡下手術-大腸, 内視鏡検査-大腸, 結腸鏡検査, 結腸スコープ法, 内視鏡検査-結腸, 大腸内視鏡法, 結腸鏡下手術
Czech kolonoskopie, koloskopie, Koloskopie
Finnish Koolonintähystys
Russian KOLONOSKOPIIA, КОЛОНОСКОПИЯ
Croatian Not Translated[Colonoscopy]
Polish Wziernikowanie okrężnicy, Kolonoskopia
Hungarian Kolonoszkópia
Norwegian Koloskopi
Spanish colonoscopia (procedimiento), colonoscopia, endoscopia del colon, Colonoscopia
Portuguese Coloscopia, Colonoscopia
Dutch coloscopie, Colonoscopie
German Kolonoskopie, Koloskopie
French Coloscopie
Derived from the NIH UMLS (Unified Medical Language System)

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