Colonoscopy

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Colonoscopy

Introduction

Equipment

Colonoscopy refers to the endoscopic

examination of the entire colon and rectum and often includes the

terminal ileum. Common activities performed during colonoscopy include

inspection, biopsy, photography, and video recording. The procedure is

technically challenging and requires considerable training and

experience. High-quality examinations require good clinical judgment,

anatomy and pathology recognition, technical skill in manipulating the

scope and performing biopsies, appropriate patient monitoring, and

well-maintained and clean equipment to ensure patient safety. Video

colonoscopes enable complete examinations of the entire colon in more

than 90% of examinations.

Most colorectal cancers appear to

develop from benign neoplastic (adenomatous) lesions. Americans of

average risk have a 6% lifetime risk of developing colon cancer.

Adenomas occur in about 30% of individuals at age 50 years and

55% at age 80 years. Several screening modalities are advocated

to detect early adenomas and cancer, including colonoscopy every 10

85% for polyps <1 cm in diameter and 95% for larger

polyps and cancers. The specificity for the examination approaches

mortality from colorectal cancer. Several analyses have suggested that a

single screening or repeated screenings every 10 years after age 50 may

be a cost-effective strategy. Despite increased insurance coverage for

colonoscopy screening, the feasibility of screening an entire population

has yet to be established.

of choice for patients with a positive fecal occult blood test (FOBT).

endoscopy. Patients with long-standing ulcerative colitis should undergo

colonoscopy with biopsy to examine for dysplasia beginning 8 years after

the development of pancolitis or 15 years after the development of

Colonoscopy is indicated for villous

adenomas of any size that are discovered during flexible sigmoidoscopy.

Distal tubular adenomas are not associated with an increase in proximal

adenomas, and some clinicians do not believe that colonoscopy is

required after removal of a small, distal tubular adenoma. Historically,

necessitating colonoscopic removal of the lesion and examination for

synchronous lesions. Some studies suggest that purely tubular lesions

>1 cm in diameter can be followed without immediate colonoscopy.

This strategy may be problematic, because a biopsy sample from within a

large lesion may fail to recognize the most significant pathology (i.e.,

missed villous or cancerous elements). Despite some contrary opinions,

colonoscopy is generally not indicated after the diagnosis of a

Average procedure times for experienced

endoscopists are about 10 minutes to reach the cecum and 30 minutes to

complete the entire procedure. Inadequate preparation is the most common

reason for prolonged or incomplete examinations. Most individuals in the

United States receive 3 to 4 L of a polyethylene glycol " based

electrolyte solution the day before the examination. Some studies have

suggested that longer procedures and greater discomfort occur in women

undergoing the procedure, possibly because of their anatomically longer

colons and greater sigmoid mobility. Older individuals may present

greater difficulty in reaching the cecum.

the administration of conscious sedation. Intravenous midazolam and meperidine have been the drugs most commonly

employed. Unfortunately, 15% of individuals receiving these two

medications are dissatisfied with their sedation. Propofol is an intravenous, short-acting sedative

used for the induction of general anesthesia. Propofol may provide superior sedation and more

rapid recovery, but its safety in office situations has not been

demonstrated. Studies have shown that the procedure can be performed in

selected individuals without sedation, with relatively high (70%

to 85%) rates of patients willing to undergo a similar procedure

again without sedation. Many physicians feel more comfortable with

routine administration of sedation to improve procedure acceptance among

morbidity from bleeding or colon perforation due to polypectomy. There

is a strong relationship between complication rates of diagnostic and

highest rates of these complications appear in the first 500

Colonoscopy can be safely learned only

with direct, one-on-one supervision by an experienced proctor or

preceptor. Debate exists about the number of procedures that trainees

need to perform to become competent in colonoscopy, and no scientific

data currently exists correlating the volume of colonoscopies performed

with acquisition of competence. Individual practitioners have varying

levels of manual dexterity and experience with flexible sigmoidoscopy

and can acquire skills at differing rates. Studies show that when

observable factors are used to determine technical competency in

colonoscopy (reach-the-cecum rate, time to complete procedure, and rate

of complications), family physicians, gastroenterologists, and general

surgeons are all comparable.

examination table in the left lateral position. Intravenous access

monitoring includes frequent vital signs, oximetry, and heart rhythm

(electrocardiographic) evaluation throughout the procedure. Flexible Sigmoidoscopy provides instruction for

scope insertion and examination techniques in the rectosigmoid

Step 1 View Original Step 1 View Original

Prior pelvic surgery may produce extensive adhesions in this area

through this area). Insert the scope only through visible lumen. The

wall of the descending (left) colon has a characteristic circular

appearance with encircling folds.

A sharp turn appears at the

splenic flexure. A bluish color of the vascular spleen may be

(with torquing) often is required to pass through the splenic

transverse colon is relatively straight. Another sharp angle exists

at the hepatic flexure. The hepatic flexure can be identified by the

bluish brown shadow of the liver seen through the colon wall.

The examiner may notice

transillumination through the left upper abdominal wall from the

endoscope light. The assistant can press down on the

patient 's right upper abdomen to facilitate the downward

deflection of the scope tip into the ascending (left) colon. The

ascending colon has a characteristic pattern of mucosal folds that

do not encircle the lumen completely.

Avoid the creation of loops

complications. Keep the instrument as straight (short) as possible.

Repeated short insertions and withdrawals and aspiration of air at

the flexures can pleat the colon wall onto the instrument. Abdominal

pressure by the assistant can eliminate loops in the transverse or

be challenging. The scope tip is advanced by pulling back on the

endoscope, causing paradoxical insertion. The scope tip is centered

in the lumen, and suction is applied to further advance the scope

through the colon. The ileocecal and appendiceal orifices may be

recognized when the cecum is reached. The appendiceal orifice

(shown) often appears on a "crow 's foot, " and

the three taeniae form a confluent fold leading to the orifice. In

the scope tip in the patient 's right lower quadrant through

the abdominal wall or seeing the light transilluminating through

abdominal wall can help to assure the endoscopist that the cecum has

necessary to confirm the scope 's location within the

Attempt to intubate the

ileocecal orifice, which often appears as a slit on the medial wall

3 cm above the pole (i.e., most proximal portion) of the ascending

colon. First, aspirate the fluid from the cecal pole. The ileocecal

orifice often is angled downward, and several attempts may be

required for intubation. Angle the scope tip toward the orifice, and

position the tip just past the orifice. Gently withdraw the scope

until the angled tip flattens the D-shaped mucosal fold.

visualizes the ileocecal orifice and the valve begins to open, the

instrument is straightened and advanced. Paradoxical advancement by

terminal ileal mucosa has a characteristic

withdrawal of the scope. Withdrawal must be slow, with careful

moved. Inspect behind every fold to ensure that hidden lesions are

few centimeters away. The electrocautery snare is inserted through

the biopsy channel. The snare sheath is positioned next to the

polyp, the wire loop is advanced over the polyp, and the wire loop

is slowly secured over the base of the polyp or pedicle. In order to

reduce the risk of performation, the scope tip is maneuvered so that

the snare loop is not touching the colon wall. Apply the

through the scope using the snare or grasping forceps. Larger polyps

can be removed by suctioning the polyp against the scope and

which have a narrower diameter than adult endoscopes.

Patients are usually monitored for 30

minutes after the procedure to make sure that they have recovered

completely from sedation. Someone must drive them home, but they can

resume a regular diet right away. They should be warned to contact their

provider immediately if they experience severe abdominal pain (not just

gas cramps); a firm, distended abdomen; vomiting; fever; or bleeding

Current Procedural Terminology (CPT)

codes listed here include the terminology "proximal to the

splenic flexure " in the code descriptor. However, for reporting

the intent to perform a full colonoscopy, use the colonoscopy codes

above with a -52 modifier to signify reduced services. In the office

setting, a tray charge can be billed (99070 or A4550) to help cover

View Large CPT Code Description 2008 AVERAGE 50th Percentile Fee Global Period 45378 Flexible colonoscopy with brushing, washing $1,041.00 0 45379 Flexible colonoscopy with removal of foreign body $1,238.00 0 45380 Flexible colonoscopy with one or more biopsies $1,143.00 0 45382 Flexible colonoscopy with bleeding control by

coagulator $1,371.00 0 45383 Flexible colonoscopy with ablation of tumors or polyps $1,389.00 0 45384 Flexible colonoscopy with tumor or polyp removal by hot

technique $1,491.00 0 CPT is a registered trademark of the American

Medical Association.2008 average 50th Percentile Fees are provided courtesy of 2008

MMH-SI 's copyrighted Physicians ' Fees and

Common ICD-9 Codes

View Large Abdominal mass 789.3 Anemia, unexplained 280.9 Iron deficiency anemia secondary to blood loss,

anemia 280.0 GI bleeding, acute 578.9 GI bleeding, occult 578.1 X-ray abnormality 793.4 Weight loss, severe 783.2 Benign neoplasm colon 211.3 Constipation, slow transit 564.01 Constipation, outlet dysfunction 564.02 Diverticulosis with blood 562.12 Rectal bleeding 569.3 Personal Hx CRCa V10.05 Family Hx CRCa V16.0 Ulcerative colitis 556.9 Rectal pain 569.42 Change in bowel habits 787.99 Personal Hx colon polyps V12.72 Abdominal mass 789.3 Anemia, unexplained 280.9 GI bleeding, acute 578.9 GI bleeding, occult 578.1 X-ray abnormality 793.4 Weight loss, severe 783.2

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Surg Laparosc Endosc Percutan

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Who should perform colonoscopy? How

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asymptomatic adults according to the distal colorectal

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discussion of issues and recommendations regarding

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et al., eds. Textbook of Primary Care

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The anatomical distribution of colorectal

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2000;51:33 " 36. [View Abstract] 21Simon JB.

2000;163:1277 " 1278. [View Abstract] 22Sipe BW, Rex DK, Latinovich D,

outpatient colonoscopy: administration by nurses supervised

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Fee and Coding Guide. Duluth,

• Conscious sedation drugs and equipment
• Colonoscope and video monitoring equipment
• Biopsy forceps, snare, electrosurgical generator

Indications

• Evaluation of a radiographic abnormality
• Screening of asymptomatic individuals for colon neoplasia or cancer
• Evaluation of unexplained gastrointestinal bleeding
• Positive FOBT
• Unexplained iron-deficiency anemia
• Examination for a synchronous colon neoplastic lesion when a lesion is found in the rectosigmoid
• Surveillance or follow-up study after removal of a prior neoplastic lesion
• Suspected inflammatory bowel disease or surveillance for previously diagnosed inflammatory bowel disease
• Evaluation of symptoms suggestive of significant colon disease (e.g., chronic diarrhea, weight loss, abdominal or pelvic pain)
• Therapeutic procedures (e.g., polyp removal, foreign body removal)

Contraindications (Relative)

• Fulminant colitis
• Acute diverticulitis
• Hemodynamically unstable patient
• Recent (<3 months) myocardial infarction
• Recent (<1 week) bowel surgery
• Uncooperative patient
• Coagulopathy or bleeding diathesis
• Known or suspected perforation
• When the procedure results will not produce a change in management

The Procedure

• PITFALL: Sliding the scope along the colon wall (i.e., slide-by technique) is not advocated, as this technique may result in perforation at the rectosigmoid junction.

• PITFALL: Colonic explosion has occurred in individuals undergoing electrosurgical polypectomy. Explosion of intraluminal methane gas is unlikely if the colon has been adequately prepped.

• PITFALL: Reinsertion of the scope may be needed if the scope has to be withdrawn to remove a large polyp. The polyp may obscure the scope tip, making adequate visualization of the colon wall during withdrawal difficult.
• PITFALL: Occasionally, polyps fall away or are mishandled, or a large number must be removed. Unretrieved polyps can be recovered after the procedure. Patients may strain to move them out of the colon, or added bowel prep solution (i.e., polyethylene glycol solution or phosphate enema) can be administered through the scope to induce evacuation. The fluid is filtered so that the polyps can be recovered for histologic examination.
• PITFALL: Suspected perforation after polypectomy necessitates hospital observation and evaluation.

Complications

• Perforation: 1 to 2 per 1,000 procedures (studies from diagnostic colonoscopies only, however)
• Bleeding following polypectomy
• Adverse reaction from sedatives such as respiratory depression, allergic reaction, or cardiac dysrhythmia

Pediatric Considerations

Postprocedure Instructions

Coding Information and Supply Sources

• Recommendations for endoscope cleaning appear in Appendix K: Recommendations for Endoscope Disinfection
• Complete endoscopy equipment such as endoscopes, light sources, video endoscopy monitors, cleaning and disinfection aids, and mouthpieces are available from the following manufacturers: Olympus Corporation, Center Valley, PA (http://www.olympusamerica.com) Pentax Precision Instrument Corporation, Montvale, NJ (http://www.pentaxmedical.com)
• Intravenous materials (e.g., intracaths, normal saline solution, intravenous tubing) can be obtained from local hospitals or surgical supply houses.
• Propofol (1% Diprivan) injection is available from AstraZeneca, Wilmington, DE (http://www.astrazeneca-us.com). Meperidine (Demerol) injection is available from Wyeth-Lederle (http://www.wyeth.com). Midazolam (Versed) injection is available from Roche, Nutley, NJ (http://www.roche.com).
• Guidelines for monitoring patients receiving conscious sedation appear in Procedural (Conscious) Sedation.

Olympus
Corporation, Center Valley, PA (http://www.olympusamerica.com)

Pentax Precision
Instrument Corporation, Montvale, NJ (http://www.pentaxmedical.com)

Bibliography