Esophagogastroduodenoscopy and Colonoscopy

Professional Society Guidelines for Colonoscopy and EGD

A number of professional societies have developed guidelines for colonoscopy and EGD, including the American Cancer Society (www.cancer.org), the American Gastroenterological Association (www.gastro.org), the American Society for Gastrointestinal Endoscopy (www.asge.org), and the National Comprehensive Cancer Network (www.nccn.org). 

Potential Complications Associated with Colonoscopy and EGD Although complications rarely occur with colonoscopy and EGD, they can be potentially life-threatening when they do occur. About 1 complication occurs for every 1,000 EGD procedures, and the overall serious adverse event rate is about 2.9 per 1,000 colonoscopy procedures. The risk of some complications may be higher with colonoscopy if it is performed for an indication other than screening.

Potential EGD Complications  With diagnostic EGD, cardiopulmonary adverse events range from minor incidents, such as changes in oxygen saturation or heart rate, to signifi cant events, such as aspiration pneumonia, respiratory arrest, myocardial infarction, stroke, and shock. 

Patient-related risk factors for these adverse events include pre-existing cardiopulmonary disease, advanced age, American Society of Anesthesiologists class III or higher, and increased modifi ed Goldman score. Procedure-related risk factors for hypoxemia include diffi culty with intubating the esophagus, prolonged procedure, and patient in the prone position.

Infectious adverse events that may occur with diagnostic EGD include transient bacteremia and infectious endocarditis. These result from either the procedure itself or failure to follow guidelines for the reprocessing and use of endoscopic devices and accessories. Bleeding and perforation may also occur during diagnostic EGD. 

Clinically signifi cant bleeding is rare, and may be  morelikely in individuals with thrombocytopenia and/or coagulopathy. Perforation is associated with a mortality rate that ranges from 2% to 35%. Early identifi cation and expeditious management of a perforation have been shown to decrease associated morbidity and mortality.

Factors that increase risk for perforation include the presence of anterior cervical osteophytes, Zenker’s diverticulum, esophageal stricture, malignancies of the upper GI tract, and duodenal diverticula. Complications of endoscopic interventions include perforation, hemorrhage, bacteremia, postprocedure pain, and aspiration. Risks associated with foreign body retrieval include superfi cial mucosal laceration, GI hemorrhage, and perforation.

Risk factors for perforation include removal of sharp, irregular objects, delay greater than 24 to 48 hours to endoscopic intervention, and history of repeated intentional foreign body ingestion. Percutaneous endoscopic enteral access may result in aspiration, bleeding, injury to internal organs, perforation, “buried bumper syndrome,” prolonged ileus, wound infection, necrotizing fasciitis, or even death. 

Potential complications of endoluminal therapy include bleeding, chest pain, abdominal pain, dysphagia, odynophagia, dyspepsia, nausea, esophageal ulcer formation, and esophageal stricture formation.

There are a number of contraindications for EGD. Absolute contraindications include possible perforation, medically unstable patients, and unwilling patients. Relative contraindications include anticoagulation, pharyngeal diverticulum, and head and neck surgery.

ABOUT COLONOSCOPY & EGD:

A colonoscopy is a procedure your doctor will perform to examine the lining of your colon (large intestine). The doctor will insert a flexible tube into the rectum and through the colon, looking for abnormalities. 

An EGD is a procedure your doctor will perform to examine the lining of your esophagus, stomach and duodenum (first section of small intestine). The doctor will insert a flexible tube into your mouth, down your esophagus, into the stomach and small bowel looking for abnormalities. 

Prior to the procedures, you will be given anesthesia through an IV. Following the procedure, you will be groggy for a few hours and therefore, should not schedule anything else for the remainder of the day. 

You are NOT allowed to drive for the remainder of the day.  It is recommended to have a person who is over the age of 18 to stay with you for 6-8 hours after your procedure.

WHAT TO BRING AND DO PRIOR TO PROCEDURE:

• Please bring your PHOTO ID and INSURANCE CARD.

• Please bring a list of your current medications (including non-prescription) and allergies.

• YOU MUST HAVE A DRIVER 18 YEARS OF AGE OR OLDER WHO WILL ACCEPT  RESPONSIBILITY AND DRIVE YOU HOME. They will need to be within a 15 minute driving  distance of our facility. 

They will be notified when your procedure is over and MUST be  present at the time of discharge to receive instructions and teaching. You are NOT allowed to  take a bus, taxi, Access a Ride, walk home, etc. If you do not have a ride your  procedure will be cancelled or rescheduled.

• You should plan on being at the hospital for approximately 2 - 3 hours.

• Read prep instructions THOROUGHLY.

• 6 HOURS PRIOR TO CHECK IN TIME STOP EVEN WATER. NOTHING BY MOUTH.

If you need to cancel or reschedule your appointment, you MUST do so 3 business days prior to your appointment date or a cancellation fee may be assessed.

PLEASE CHECK IN AT REGISTRATION DESK WHEN YOU ARRIVE AT THE HOSPITAL

You are scheduled for a procedure called a EGD/Colonoscopy on (date and time) at Togus VAMC

PRIOR TO YOUR PROCEDURE DATE

One week (7 days) prior to procedure date

1.-Stop taking iron or a multivitamin with iron supplements, herbs, and supplements including ginkgo and fiber

2.-Stop eating corn, beans, tomatoes, seeded fruit (raspberries, kiwi, strawberries)

3.-Stop taking Aspirin

4.-Call the nurses in the Endoscopy unit if you take Coumadin, Jantoven (Warfarin), Plavix (clopidogrel), Aggrenox (aspirin/dipyridamole), Insulin, or any oral diabetic medications (metformin,glipizide, glyburide).

5.-CALL THE ENDOSCOPY SUITE (623-8411 ext 5014) IF YOU HAVE NOT RECEIVED THE MEDICATIONS TO COMPLETE THE PREP AS LISTED BELOW

6.-ARRANGE FOR A DRIVER, YOU WILL NOT BE ABLE TO DRIVE HOME AFTER YOUR PROCEDURE DUE TO THE MEDICATIONS WE WILL GIVE YOU FOR THE PROCEDURE see additional information below.

7.-Call (207)623-8411 ext 5014 to confirm that you are coming to your appointment, you may leave a message any time of day, please leave your last name, last 4 numbers of social security number, appointment date and time, and phone number to contact you if needed. If you have a question that needs to be answered we will call you back if not we will not call you back, consider your appointment confirmed.

2 DAYS BEFORE YOUR PROCEDURE

1. Stop all fiber supplements (Metamucil,Psyllium Fibercon, calcium polycarbophil, Citrucel, methylcellulose)

2. Take 2 Bisacodyl tablets in the morning and 2 tablets in the evening

3. Start Low Residual Diet starting with breakfast

 a. Low fiber cereal

 b. White bread/ toast

 c. Plain crackers

 d. Skinless potatoes

 e. Turkey

 f. Chicken

 g. Fish

 h. Applesauce

 i. Bananas

 j. Rice

 k. Canned fruit without seeds and skins

 l. Cooked/ canned vegetables without seeds

4. Foods to avoid

 a. Corn in any form including popcorn

 b. Raw vegetables

 c. Raw fruit

 d. Any food with seeds

 e. Whole wheat cereal

 f. Whole wheat bread

 g. Raisins

 h. Ice cream with nuts

 i. Dried fruit

 j. Nuts

 k. Granola

 l. Brown rice

1 DAY BEFORE YOUR PROCEDURE

Start clear liquid diet(No Solid Food TODAY) starting with breakfast. Clear liquid diet includes:

--coffee (no creamers, can use sugar)

--tea

--soda (Ginger Ale, Pepsi/Coke, Sprite/7 Up, Mountain Dew, root beer)

--jello (No red flavors)

--juices (No red flavors)

--popsicles (No red flavors)

--broth only (chicken, beef, vegetable)

--Gatorade (No red flavors)

--water

--drink mixes for water such as Crystal Light, Kool-Aid, (No red flavors)

COLON PREP:

1. At 8am mix Golytely (PEG-3350/ELECTROLYTES PWDR) with water and place in refrigerator

2. From 4pm to 7pm drink contents of jug, 8 ounces every 10-15 minutes until 3 quarts of the Golytely (PEG-3350/ELECTROLYTES PWDR) has been consumed. Drink as slowly as needed, DO NOT ADD ICE.

3. Take 4 Bisacodyl tablets by mouth at bedtime Drink plenty of liquids throughout the day to avoid becoming dehydrated Failure to correctly do your prep as stated above may result in your procedure needing to be rescheduled.

DAY OF PROCEDURE

1. 4 Hours prior to your procedure time drink remaining quart of Golytely (PEG-3350/ELECTROLYTES PWDR) over 1 hour 8oz. every 15 minutes.

This is very important. Once finished nothing to eat or drink.

2. DO NOT TAKE DIABETIC PILLS OR INSULIN. CHECK YOUR BLOOD SUGAR.

3. Take your blood pressure medication 2 hours prior to your procedure time

4. Check in on 5 South Endoscopy Unit 30 minutes prior to your appointment time.

5. Your DRIVER must check in with you

You will NOT be able to drive the same day of your procedure. WE REQUIRE TO SEE YOUR DRIVER BEFORE AND AFTER THE PROCEDURE. Failure to provide proof of a driver will result in the cancellation of your procedure. 

If transportation is a problem for you, please contact DAV (207) 623-8411 extension 5790 to see if they will be able to help with transportation arrangements.

Please give us plenty of notice if you are unable to keep this appointment so another veteran can have your spot. For questions or concerns, please call (207)623-8411 or toll free (877)421-8263 extension 5014 to speak to one of the Endoscopy Nurses.

Complications of Colonoscopy & EGD

Executive Summary

Gastroenterologists perform colonoscopy and EGD to visualize the digestive tract. Esophagogastroduodenoscopy, which is used to visualize the upper gastrointestinal (GI) tract, involves introducing a small fl exible endoscope through the mouth and advancing it through the pharynx, esophagus, stomach and duodenum. 

For colonoscopy, which is used to visualize the two main parts of the large intestine (i.e., colon and rectum), a long fl exible colonoscope is inserted through the rectum and advanced and maneuvered into the colon.

The level of sedation required to perform colonoscopy or EGD successfully may range from minimal sedation to general anesthesia. Patient age, health status, concurrent medications, preprocedural anxiety, and pain tolerance infl uence the level of sedation required.

Procedural variables include the degree of invasiveness, the level of procedure-related discomfort, the need for the patient to lie relatively motionless, and the duration of examination. Diagnostic and uncomplicated, therapeutic upper endoscopy and colonoscopy are successfully performed with moderate sedation. 

Most patients receive conscious sedation with benzodiazepines and narcotics. Although anesthesiologist-monitored sedation, with or without propofol, is recommended only for high-risk patients, propofol sedation is sometimes given unnecessarily to low-risk patients who request it in order to be totally unconscious during the procedure. 

The use of anesthesia services for colonoscopy and EGD has doubled in recent years, with the majority of services delivered to low-risk patients. This trend is projected to continue.

Potential Colonoscopy Complications 

As with EGD, colonoscopy also carries risk of cardiopulmonary complications that range from minor fl uctuations in oxygen saturation or heart rate, to signifi cant complications such as respiratory arrest, cardiac arrhythmias, myocardial infarction, and shock. 

Risk for these complications increases with advanced age, higher American Society of Anesthesiologists Physical Status Classifi cation System scores, and presence of comorbidities. Colonic perforation may result from mechanical forces against the bowel wall or barotrauma, or as a direct result of therapeutic procedures. In addition, risk for perforation may increase when colonoscopy is performed by an endoscopist with low procedure volume.

Although hemorrhage is most often associated with polypectomy, it can also occur during diagnostic colonoscopy. Potential risk factors for postpolypectomy bleeding include polyp size, number of polyps removed, recent warfarin therapy, polyp histology, and patient comorbidities. 

Other potential colonoscopy complications include postpolypectomy electrocoagulation syndrome, gas explosion, abdominal pain or discomfort, and even mortality. Miscellaneous complications include splenic rupture, acute appendicitis, diverticulitis, subcutaneous emphysema, and tearing of mesenteric vessels with intraabdominal hemorrhage.

Absolute contraindications for colonoscopy include a competent patient who is unwilling to give consent, an uncooperative patient in whom consent has been given but in whom adequate sedation cannot be achieved, toxic megacolon, fulminant colitis, and known free colonic perforation. 

Relative contraindications for colonoscopy include: acute diverticulitis; very large abdominal aortic aneurysms (particularly if asymptomatic); patients who are immediately postoperative; patients who have had a recent myocardial infarction or pulmonary embolism, or are currently hemodynamically unstable; and pregnancy (defer colonoscopy in most cases if the indication does not require immediate resolution).

Monitoring Performance Outcomes for Colonoscopy and EGD Insurance companies often base coverage decisions on guidelines set forth by the American Cancer Society (ACS), the American Gastroenterological Association (AGA), the American Society for Gastrointestinal Endoscopy (ASGE), and the National Comprehensive Cancer Network (NCCN). Thorough physician documentation is critical for reimbursement of colonoscopy and EGD.

According to the ASGE/ACG Taskforce on Quality in Endoscopy, quality indicators for EGD and  colonoscopy include proper indication, informed consent, and risk stratifi cation. In addition to aff ecting reimbursement, incomplete documentation can also aff ect patient outcomes and may increase risk of liability and malpractice claims. Complications arising from procedures and unplanned operations and admissions are important factors to review in order to assess patient outcomes. 

However, it is important to consider the nature and extent of the surgery being performed. Privileging is a process that recognizes that a physician is both qualifi ed and competent. It defi nes a physician’s scope of practice and the clinical services he or she may provide, and it is based on demonstrated competence and is a datadriven process.

Physician privileging involves gathering information with which to decide the types of care, treatment, and services or procedures that a practitioner will be authorized to perform in a specifi c setting (e.g., hospital), taking into consideration setting-specifi c characteristics, such as adequacy of the facilities, equipment, and number and type of qualifi ed support personnel and resources. Other criteria that determine the practitioner’s qualifi cations include the  physician’s education, training (residency and/or fellowship), and clinical experience (number of procedures performed with satisfactory outcomes).

Statements on principles and methods of privileging and credentialing for endoscopy and colonoscopy have been developed by the ASGE, the Society of American Gastrointestinal and Endoscopic Surgeons (SAGES), and the American Society of Colorectal Surgeons (ASCS). In addition, the Multisociety Sedation Curriculum for Gastrointestinal Endoscopy (MSCGE) covers best practices in procedure sedation training based on published data and expert consensus.

Privileging requires qualifi ed and objective physician-controlled peer review, utilizing criteria that have been established through common legal, professional, and administrative practices, endorsed by a formal consensus process, and that are publicly available. 

These criteria must be directly related to quality of patient care, and documented physician performance should be measured against these criteria. Peer review decisions must be fair and without confl icts of interest and have dated detailed documentation, and should be confi dential and protected.

Hospitals with a history or pattern of retaining or contracting with incompetent and low-quality providers may be subject to potential legal liability for any injuries to patients, exclusion from federal and state health benefi t program participation, loss of commercial contracts, and loss of accreditation by healthcare standards organizations.

Complications of Colonoscopy & EGD

EGD, colonoscopy, and polypectomy are safe and are associated with very low risk, when performed by physicians who have been specially trained and are experienced in these endoscopic procedures.

One possible complication is perforation, in which a tear through the wall of the bowel may allow leakage of intestinal fluids. This complication usually requires surgery, but may be managed with antibiotics and intravenous fluids, in selected cases.

Bleeding may occur from the site of biopsy or polyp removal. It is usually minor and stops on its own or can be controlled by cauterization (application of electrical current) through the endoscope. Rarely, transfusions or surgery may be required.

Localized irritation of the vein may occur at the site of medication injection. A tender lump develops and may remain for several weeks to several months, but goes away eventually. Other risks include drug reactions and complications from unrelated diseases, such as heart attack or stroke.

Do I need to do anything special to prepare? 

There will be dietary restrictions and/or prep instructions provided by your physician in preparation for your procedure. You may be asked to modify your regular medication schedule. For an EGD (Esophagogastroduodenoscopy), your stomach must be empty. You will have a period of fasting determined by your physician. 

For a Colonoscopy, your colon needs to be empty of waste material. Your physician will prescribe a bowel cleansing preparation. A clear liquid diet will need to be followed as directed in the prep instructions provided by your physician. If you have not received the pre-procedure instructions three days prior to your scheduled procedure date, please call your physician.

What will happen during the procedure? 

Our team of healthcare providers will prepare you for your procedure. You will have an opportunity to visit with your anesthesia provider and GI physician to answer questions prior to your procedure. In the procedure room an anesthesia provider will position you comfortably and give you medications known as, MAC anesthesia through an IV, to cause relaxation and sedation. 

This will cause you to fall asleep but you can breathe on your own and will wake up quickly. Based on your individual procedure and medical history you and your GI physician may determine to use an anesthetic known as moderate sedation (twilight sedation) or even no sedation at all, as appropriate. Generally you will be in the procedure area for 90 minutes. You may feel bloated and gassy from air introduced into your system during the exam. 

You should be able to eat normally afterwards unless we instruct you otherwise. Medications given during your procedure will require you to have a responsible person to receive instructions and drive you home.