Reader Question: The Dreaded Colonoscopy

Dear Doctor Steve: My brother had colon cancer at age 45.My doctor wants me to have a colonoscopy (I’m 47), but the thought of it just creeps me out. Is there any way I can get out of it? — Goatweed

Dear Goatweed, if indeed that is your real name:

Colonoscopy is a relatively simple procedure, actually. Taking a four-foot fiber optic tube, the colonoscopist looks at every inch of your large intestine, starting from the rectum and finishing in the first part of the colon, called the cecum. (By the way, do you know the definition of a colonoscope? It’s a 4 foot tube with an asshole at both ends! HAW! HAW! That’s what we call “gastrointestinal humor” in the medical business.) It’s a procedure that is ideal for screening for colon cancer, polyps (which can turn into cancer), and other conditions. Given that you have a family history of colon cancer, you’d be a great candidate to “ride the rocket.”

Now, all of this sounds uncomfortable, so take heart from the fact that you won’t feel a thing. You’ll be asleep during the whole procedure—or at least goofy enough that you won’t remember it when it’s over.

The doctor who does your colonoscopy will put in an IV in your arm before the procedure. Just before starting the colonoscopy, a nurse will give you an injection of some medication (often a tranquilizer called Versed and fentanyl, a very nice narcotic); fight it as you might, within a minute or less you’ll be under. It’s a very light anaesthesia (also called “conscious sedation” because you’re kind of conscious, but really quite sedated) and you won’t need life support or anything like that. You’ll continue to breathe normally and the colonoscopist can do his or her thing without the burden of you nattering on about how uncomfortable it all is.

Now here’s the great part…although you’re only in light sedation, one of the effects of the Versed is to make you forget everything that happens while you are affected by it. On top of that, it’s very short acting. So the way it seems to you is this: you lay down on your side, they give you the medication, you blink your eyes…and it’s over. Most people wake up and swear the staff is fooling them, that they never actually did the procedure—that’s how incredible the anesthesia is. There is no sensation of time passing, no pain, no discomfort, and no feeling that anything was even done to you. It’s pretty perfect.

After it’s over, you’ll feel rather normal, but you’re really not. You can’t drive because your reflexes are off, and you probably can’t do any meaningful work. Just let someone drive you home and take it easy. Watch a movie that you can afford to forget later (because you might), visit a website that’s meaningless to you, play a stupid video game, or just hang out for the day. Enjoy it. You don’t get that many days in your life that you have to relax and aren’t actually sick or otherwise indisposed.

Now, having said all this, it sounds like the colonoscopy is a pretty decent experience. The procedure itself actually is pretty great, just as I described above. There is a real downside to it however, but it happens the day or so before the colonoscopy. This is the dreaded bowel prep.

You see, to get a good look at your intestines, the colonoscopist needs a nice, clean bowel. A colon full of disgusting contents will clog up the fiber optics and prevent a good exam. You want the doctor to be able to see every inch of colon to make sure you don’t have any polyps or worse, so following the prep instructions is a must.

Different doctors use different bowel preps; I prefer the “Fleet’s PhosphoSoda” method, myself. In this version, you go on a “clear liquid” diet for 24 hours, and then drink 3 ounces of the most gawd-awful salty-citrus tasting stuff mixed in your favorite beverage (which just makes it worse, to me). It is so salty and crazy tasting that it’ll make you shudder as you drink it. Just down it quick and get it over with. Before an hour has passed, you’ll have the most incredible case of diarrhea, so make sure you’re at home and ready for it. In other words, don’t drink this stuff and then go shopping for ties at the mall—you’ll regret it. This is manly diarrhea…it emerges with a force heretofore unknown in your experience. And it keeps coming and coming, as this PhosphoSoda stuff rolls through your bowels like a tsunami, dragging everything with it in its path.

About six hours later, you get to drink the stuff again just for good measure. Here comes the diarrhea again, but this time you’ll notice a very bizarre effect. After you finish sitting on the pot, having filled it with what seems like gallons of horrid bowel contents, you’ll notice that what’s in the toilet is as clear as a mountain stream. No cloudiness, no poop, no…nothing. Your bowel is now perfectly clean and delightful inside…you could eat off it.

Anyone who has seen a colonoscopy knows that the inside of the colon is pink and clean and perfect when properly prepped. There are no “accretions”, no gum, no leathery chunks, and no parasites unlike the claims of the “high colonic” brigade (but that’s a story for another entry.). So the prep is a pain, but it only lasts a few hours. My advice is to get a good book to read while you’re evacuating your appalling intestines and make the best of it.

I think this is an appropriate place to tell you my personal colonoscopy story, as it also gives you another alternative…the anesthesia-free procedure. Doing a colonoscopy without conscious sedation is not for the faint-at heart, but it’s tolerable, and offers one or two tangible benefits: you can go back to work immediately (if you’re a nut, like I am), and it gives you a great story to tell at parties.

It begins with my friend Joe, who has a condition called “familial polyposis”. This puts him at higher risk for developing colon cancer and he has to have a colonoscopy every year or so. Joe found that the anesthesia made him goofy for at least 48 hours, so he was losing two days of work every time he had the procedure done. We were talking one day and he told me he quit having anesthesia with his ‘scopes a few years ago. I’d honestly never heard of anyone willingly foregoing anesthesia, and at first I thought he was nuts. His response was very pragmatic, though, he just couldn’t afford to waste the time.

The more I thought about it, the more it made sense to me. There was of course the added element of macho idiocy…a ”if he can do it, by god, so can I” sort of thing going on in my head. I decided for my next colonoscopy, I was going bareback, too.

I’d had two colonoscopies and a few upper endoscopies before; my experience had always been just as I described it earlier—I’d lay down, they’d give me the “stupid cocktail” in my vein, I’d blink and it’d be over. The first time it happened, I actually hugged the anesthetist, yelling “WILLIE! You’re a GENIUS!” (still being slightly under-the-influence, apparently.) So why would I even consider going without anesthesia? Well, for one thing, I wasn’t planning to have a colonoscopy any time soon, so it was easy to sound tough. Secondly, in my new job I’m compensated purely on production; if I don’t work, I don’t get paid. Taking even a day off makes me crazy so from a practical point of view, an anesthesia-free procedure makes sense.

As luck would have it, approximately two weeks later I started having pain in my lower abdomen which my GI doctor figured was a little diverticulosis (more on this lovely condition later), and since my insurance was paid up, he thought a colonoscopy would be in order. He gave me my prep and an appointment in the endoscopy suite; as I left, the cold sweat of dread began to dot my brow as I knew I was going to try this one without letting them put me under.

The next week I arrived in the procedure room with a freshly cleansed large intestine and a confident attitude. I put on the gown (open invitingly in the back (ecch)), plopped down on the gurney and announced I was waiving my right to sleeping through the test. “Are you sure?” the nurse asked, somewhat skeptically. “We’ll just start an IV anyway just in case you change your mind half-way through.” I thought this was a wise suggestion, because I was already starting to change my mind. I’d purposely not arranged a ride home, though, so I’d have to go through with the original plan. Then in burst my gastroenterologist and I knew I would soon be a man.

To do the procedure, I had to lie on my left side, legs curled up in a semi-fetal position. There was a large television screen above my head so everyone in the room, including me, could see what the endoscope saw. As the scope approached my rectum, all I could see was a giant hairy butt on the screen. My attention was completely focused on how grotesque that part of my body was (having never really seen it with my own eyes before) and how the nurses were looking at the same screen I was and how disgusted they must be and how every time they saw me in the hall after this I’m sure the only thing they’ll be able to think about will by my hairy ass…then YIKES! my reverie was interrupted by the scope being gently shoved into my colon.

As the scope is advanced, gas is pumped into the intestine to billow it out so the endoscopist can get a good view of every inch. It’s amazing to watch, actually, as the inside of the intestine rushes by like the wormhole scene in “Contact”. I had a good prep, and the first few minutes went by pretty smoothly. It simply felt as if someone was shoving a rubber tube into me, with a little abdominal pressure. In other words, it felt just like it should have, nothing more, nothing less. I was impressed that there was so little discomfort.

The first part of the colon you see is the sigmoid and “descending” colon (see figure x). The sigmoid is so-named because it is vaguely shaped like the letter “S”. When you get to the top of the descending colon, you have to take a left-hand turn at the spleen. Turning endoscopes can be a source of pain, but for me, this first 90 degree turn was a piece of cake. If you do this yourself, you’ll notice that the next part of the colon is vaguely triangular in cross section…this is the transverse colon and it means you’re at least half-way done. Pumping up my transverse colon with gas didn’t cause much discomfort, and I started to wonder why anyone even bothers with anesthesia. That’s when the scope got stuck.

At the end of the transverse colon, the scope has to take another 90 or so degree left turn downward to enter the ascending colon (which ends in a pouch called the cecum). Now you have a 4 foot scope that’s already done one right-angle turn and you’re asking it to do another one and move forward another foot or two to finish the job. As it turns out, this is a lot to ask, sometimes. In my case, the scope wouldn’t move. I could see the cecum about a foot away, mocking me as my gastroenterologist tried this trick and that trick to advance the scope. No matter what he did, it simply wouldn’t budge. They pushed on my abdomen, moved me from side to side, had me change positions, and nothing worked. Finally the doctor said “this is going to feel like you’re being kicked in the stomach” and he started shoving foot after foot of endoscope into me. I wish it had felt like being kicked in the stomach…instead I felt like John Hurt in “ALIEN”. As I felt the scope coil and recoil in my gut, the pain was simply astounding. For a second I contemplated jumping off the gurney and running out of the room, dragging the scope and anyone stupid enough to be holding on to it with me.

In medicine, we use a “Visual Analog Scale” to rate pain. The scale starts at zero (denoting no pain at all), and ends at 10, which symbolizes the worst pain possible. Sometimes people will describe a 10 as being akin to sawing off your leg with a rusty blade. To misquote “Spinal Tap”, my pain went to 11.

Then suddenly, apparently in response to an absolute refusal by my gastroenterologist to stop shoving tubing into my recalcitrant bowel, the scope leapt forward into the cecum. I’d never been so happy to see a cecum before. My pain went from an 11 to an 8, which produced an involuntary “Ahhhhhhh” of pleasure from my mouth. It was still pretty bad, but it wasn’t as bad as before and that felt pretty good. Total time of discomfort: 5 seconds—it only seemed like an eternity.

After that, the whole procedure was anticlimactic. Uncoiling the scope and withdrawing it felt so good I wanted to tell everyone in the room just how much I loved them, and that we’d be friends forever. Then I saw my awful hairy ass on the screen again and the procedure was over.

That is, until I realized I had a colon full of gas that wasn’t going to just disappear. I ran to the bathroom and expelled some of the noisiest outgassings I’ve ever heard. It was so loud that I could hear conversations on the other side of the wall stop cold in amazement. I knew the nurses were just outside the door cleaning up from the procedure and I wanted to stick my head out and say in my best fake-suave voice, “So! What are you doing tonight, good lookin’?” Instead I just pulled up my pants, retrieved my clipboard from the locker, and meekly slunk off to go to work.

Later in the day, I was in the emergency room talking to one of the docs when my gastroenterologist walked by…he gave me a high five and said “How’s it going, JOHN WAYNE!? Can you believe this guy just had a colonoscopy without anesthesia?” The look of awe in the face of the ER doc made the whole thing worth it. I was, indeed, for that short post-procedure period of time, “the man.”

When I have my next colonoscopy, I’ll do it without anesthesia. It wasn’t the most enjoyable experience, but it really wasn’t half-bad. The fact that I could go straight to work and drive myself home without the post-anesthesia grogginess I was used to was a real plus. I’m not recommending this idea to you with any force, gentle reader, but it’s certainly an option.

Weird Medicine Addendum with Doctor Steve

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