GIT J Club for better colonoscopy.

1. 2:
Ten tips for better, safer insertion.
AJG December 2012

2. 1. Anticipate altered sigmoid anatomy.
Acute recto-sigmoid angle:
Young women.
Elderly with stenosing Div dis.
Previous pelvic surgery(lower
abd
or pelvic as H/O abd
hysterectomy).
To overcome:
Not push forcibly.
Keep short scope, use torque
& rotation( clockwise).

3. 2. Never push against fixed resistance.
Force does not work in endoscopy.
Sp in IBD or radiation colitis.

4. 3. Maximize sensory feedback from the IT.
Hold the scope like pencil not like
tennis racket.

5. 4. Master the left colon.
2/3 of insertion time.
Reduce any loop before bypassing splenic flexture.
The most difficult segment during insertion.
Sigmoid colon accordion-like &its mesentry length is quite variable.
Can be short 25–30 cm with a straight scope in the cecum (at 65–70
cm of insertion). Or stretched to 70–80 cm.
Precise localization, by outside body scope length, is difficult when
looped, so mark polyps for finding it on withdrawal.
80% conventional alpha loop occurs because of the shape of the
pelvis& curved sacrum.

8. If this is not obvious, it can be approximated by assessing the amount of
scope inserted and the tension in the IT& applying knowledge
of the colonic anatomy to that point.
A resistance-free insertion through featureless colon to 80 cm with few
angulations suggests the formation of a large sigmoid loop. This will need to be
resolved before you attempt to advance to the right colon.
In contrast,a straight 50-cm scope at the splenic flexure with non-progression
on insertion suggests a mobile sigmoid or “high” splenic.Use of the stiffener or
specific pressure will control the problem.

10. Try not> 2 attempts, but go to the
next strategy.
Change to ped colonoscope or
gastroscope.

12. Try to enter ascending colon
with only 70–90 cm.
Often rotate clockwise into
the ascending with gentle
advancement & by
aspirating & gentle
backward/ forward
movements, proceed to the
cecum.
Brisk/forceful movements
Loss of one-to-one progress, means when is in the right colon
that redundant length of inserted will result in looping of the
endoscope requires withdrawal after relatively unfixed left colon.
the next corner&at the hepatic flexure
this can be simply completed by
clockwise torque, aspiration&
withdrawal into the ascending colon or
put the patient in half back or total
supine.

13. The site of flat lesions responsible for interval cancers.
It is inferior to ileocecal valve.
If difficulty is encountered, aspiration of air & counterclockwise
torque, hugging the medial wall of the ascending colon& working
gently backward & forward with 2-cm movements to insert
the tip of the colonoscope beyond the ileocecal valve.
Should touch the appendicular orifice for deep cecal intubation.

14. Cecum not reached within
20 mins or not half way in
10 mins:
Call the supervisor for
discussion or take over.
Consider benefit-risk ratio
for continuing attempt.
Quit & consider alternative
imagings.

15. At least half given on the morning of the examination.
No increase risk of aspiration pneumonia.
No increase in hesitancy..

16. Now FOR ALL.
Co2+ Propofol= Truly painless colonoscopy.
Decreases postprodeural distention pain.
Used specially when risk of pneumatic injury as in:
Colonoscopic decompression for acute colonic pseudoobstruction
Colonic stricture dilation
Stent placement
Severe colonic diverticular disease.

17. During insertion & aspirate water on
withdrawal to see details.
Useful for:
Unsedated colonoscopy
Redundant colon.

18. Allows simultaneous movement of the up/down control with left hand
& the right/left control with the right hand.
Can perform detailed therapeutic work.
Can be useful in passing complex turns in the sigmoid colon.

19. Major: bleeding, perforation.
Don’t forget: Aspiration( if hiccough be aware), splenic injury
(sedation increase looping & pull the spleno-colic ligament) .
Both increase by: sedation, supine & RL positioning.

20. For most diminutive & 1-2 cms polyps, cold
snare can be used.
No need for tenting or deflation & some of
normal mucosa can be reoved with the
polyp.

21. 50% of precan lesions is of the above lesions.
Needs:
Adequate luminal distention
Adequate cleanup of stool, mucus& bubbles
Adequate time
“Working the folds.”
Mucus cap on serrated polyps.

22. Screening colonoscopy is less preventive of CRC in
right colon BZ Flat,depressed & serrated lesions are
more.
So examine right colon twice sp if few or no lesions
are detected.
Use retroflexion or cap for folds inspection.

23. New snare for flat &
difficult to access polyps.
Spiral stents ( for flat ).
Ultrathin stents.
[Presented by]

24. Prophylactic cliping of large polypectomy defects. Specially for:
On anticoagulation or antiplatelet agent such as clopidogrel.
When a polyp in the ascending colon particularly hard to reach
When there is any question about a deeper injury during
polypectomy
When the patient has been referred from a remote area where there
is less endoscopic Expertise.
Postpolypectomy bleed or other complication might not be well
tolerated.

25. ANY QUESTIONS

26. THANKS