lower endoscopy usual pracctice

[laurentrilli]

I'm trying to get a handle on how different endo departments deal with colonoscopy patients who request an drug-free exam. Our hospital's endo department has a lot of differing opinions on the matter. One doc said its an uncomfortable but better/safer exam..ie: the endoscopist has to go slow and the patient can feel pain before getting perforated (which is a big safety factor). Another doc in the same department says an unsedated patient makes them rush to minimize the patient's pain so unsedated is a bad idea. I know that a lot of patients prefer deep sedation with propofol because the exam is basically pain-free; some patients report discomfort with the usual midazolam/fentanyl combination. So it seems to me that the risk of perforation is increased with a deeper degree of sedation since the patient can't feel when the scope is looped; from the standpointof safety it would seem that the safest exam would be drug-free, followed by midazolam/fentanyl and propofol would be the least safe (the reverse order of most patients preference). I would appreciate anyone's comments. Thanks.

[CrohnieToo]

The degree of discomfort or pain a patient encounters is DIRECTLY RELATED to the SKILL of the person conducting the scope procedure and to the degree of disease involvement or stricturing of the colon. The pain tolerance of a patient is also a factor. I have a neighbor who finds tweezing chin hairs too painful who prefers to shave her chin!!!!

The number of procedures a doctor has done has little bearing on their skill if those procedures have all been done w/the patients being sedated. W/that sedation there is no need for the doctor to bother developing any skill in doing the scope. Generally the faster the doctor is doing the scope, the less skillful he/she is.

[brillohead, ADN, RN]

I had a scope done with no sedation for a few different reasons, including the fact that I didn't have a driver (and they wouldn't do it if my driver wasn't present for the entire procedure) and also that there is a chance of sedation affecting (worsening) depression symptoms. Plus I just was really interested and wanted to be able to watch the thing myself!

Honestly, I can't understand what the big deal is. If you've ever had a stomach virus, you've been in WAY more pain than a scope causes!

I don't think it's really that there IS so much pain so much as the fact that everyone is so uptight (afraid) about the fact that there MIGHT be pain, combined with the fear that people have over having something stuck "up there" in the first place. (Men in particular.... what sissies!!!!)

My gastro has done several other folks without sedation, at the patient's request. She even has a couple patients who request no sedation for their upper scopes! Sorry, I've had that particular test about a half-dozen times in the past fifteen years, and I really don't know if I could handle the gag reflex thing (I've woken up "during" a few times (pneumatic dilations of the LES are quite violent in nature), and it was pretty scary).

However, if they were able to hook up a separate monitor on the other side of me so I could observe the test, I just might give it a try. I'm weird that way, though... I refused to even have "a little something to take the edge off" for my arthroscopic knee surgery because I wanted to watch and remember the whole thing, plus I wanted to be able to talk to the surgeon and ask questions during the procedure.

[angelrun1]

as a patient i prefered having midazolam/fentanyl...which helps anxiety and minimizes the pain. I have had several pts request no medication or minimal meds. it does depend on the pt. if the pt is fighting the procedure because of pain or anxiety that makes it more difficult to do the procedure BUT the pt must be able to respond to commands. i would not want to be giving propofol for a procedure. unless u are talking about venting them.

[brillohead, ADN, RN]

Just wanted to clarify, too, that when I had mine unmedicated, I was NOT in an inflamed state. I'm sure that inflammation would have made a big difference in the amount of pain I experienced.

For the Average Joe just having a regular old look-see, though, the prep is by far the worst of the deal.

[oncall24/7]

All very interesting comments. Having worked anesthesia as both a nurse and as an anesthesiologist, I always assumed that patients naturally wanted to be (or think that they were) "out" for the procedure. Most GI docs use enough (often too much midazolam) to prevent much memory of the procedure; but a fair number of patients do not think that this amnesia is a good thing. I have done a surprizing number of cases where the patient requests nothing of just standby fentanyl; it's harder for the endoscopist because it slows them down but most of the pain associated with colonoscopy is due to anatomy partly, but mostly due to operator skill. A fairly large number of older patients have no ride home and it bothers me when they are given the choice: sedation with a ride home or no test for you. A third option is an unsedated exam and the can drive home or take public transportation. A fair number of colonoscopies are incomplete due to tortuous colons even when done under sedation; but at least it's a partial exam. I just had one unsedated and it wasn't too bad.

[WondeR.N.]

As a patient with IBS, I can say that I never could have endured a scope without propofol. I had a baby without a single molecule of anything--not even Tylenol--so I can deal with pain. However, I think a patient who is experiencing any symptoms going into the scope would be playing with fire by trying it without any meds. Intense pain during the procedure could cause involuntary movement that could result in a perforation. Even after an uncomplicated procedure by a great GI doc, I was in horrible pain for hours after it--I can't imagine what I would have gone through during it. However, for an asymptomatic patient just having a routine "look-see," no meds might be doable.

[WondeR.N.]

I should clarify that while the procedure itself was uncomplicated, I was quite inflamed. Not sure if I made that clear.

[CrohnieToo]

Did you mean that you have IBD? IBD is inflammatory bowel disease which could be ulcertive colitis or Crohn's colitis which is Crohn's disease found in the colon or Crohn's disease which can appear anywhere from the mouth to the orifice.

IBS is irritable bowel syndrome and to the best of my knowledge there is NO INFLAMMATION w/IBS. If you were told IBS I would question the doctor AND the Dx!

[WondeR.N.]

I have IBS along with an autoimmune issue--hence the inflammation. Although, recent research is suggesting that there actually is inflammation in "regular" IBS, as well.

[WondeR.N.]

Ah...CrohnieToo, I just noticed your username. I've actually been keeping my fingers crossed that this recently developed IBS isn't the beginnings of Crohn's, b/c my mom has it. We'll see...

[CrohnieToo]

I understand. But that is why I questioned the IBS and inflammation. Personally, I would NOT accept an IBS Dx. I would be insisting on a pill camera endoscopy. They don't call the small intestine "the dark continent" for nothing.

Altho THE most common area for Crohn's to be first discovered is in the terminal ileum at or near the ileocecal valve, that is not always the case. Mine first struck in the mid-ileum. Thank God I was at Mayo Clinic w/my husband when I flared so badly because back in 1976 not too many local doctors would have ever recognized and been able to Dx Crohn's disease. His Mayo doctor STRONGLY suggested that I go thru the Clinic as well and thank God I listened to him and did so!!

I'm sorry you are having so much difficulty and very sorry to learn your mom has Crohn's disease. We don't know of anyone else in my family who has any form of IBD or intestinal problems. Evidently I'm just the "odd man out".