Colon cancer is the second commonest cause of death due to cancer. Most colon cancers develop within benign but potentially cancerous “Adenomatous Polyps” aka “Adenomas” (cancer may develop many years later). Finding and removing adenomatous polyps is the primary goal of “Screening Colonoscopies” (and an important second goal of diagnostic colonoscopies – which are done to evaluate bleeding, pain, change in bowel habits, anemia or other symptoms).

Screening colonoscopies are recommended for everybody over 50 (the American Cancer Society recently suggested starting at age 45). Since we cannot predict which adenoma will become a cancer - detecting as many as might exist and removing them will reduce the risk of colon cancer.

Colonoscopy Quality is best assessed by looking at the percentage of patients undergoing screening colonoscopies (aged 50 to 75 with no symptoms) who are found to have one or more adenomatous polyps. This is called the Adenoma Detection Rate (ADR). A large review of colonoscopies – published in the New England Journal of Medicine in 2014 and another in the journal Gastroenterology in 2017– found that patients of a colonoscopist with a higher ADR were less likely to get colon cancer and less likely to die in the future.

The United States Multi Society Task Force on Colon Cancer called Adenoma Detection Rate the Primary Colonoscopy Quality Measure and recommends that at least 30% of men and 20% of women undergoing screening Colonoscopies should be found to have adenomatous polyps - ie., an ADR of 30% in men and 20% in women (A lower ADR makes it the more likely that adenomatous polyps were missed).

Mayo Clinic (Jacksonville) reviewed their experience in 2013 and found an ADR (Adenoma Detection Rate) of 41% of men and 25% of women. But it is likely that even these numbers are under-estimations – indicating that some adenomatous polyps were missed. A report from the MD Anderson Cancer in Hospital in Texas in 2013 reported an ADR of 60% (though many of the patients in this study were cancer survivors and may therefore have a higher than average risk of having adenomas and colon cancer). It has been suggested that the ADR target of 30% and 20% in men and women may be too low and should be increased. The ADR depends on how well the colon has been cleaned in addition to the technique employed by the colonoscopist, the quality of the equipment used and the time spent examining the colon.

Dr. Ravi’s Adenoma Detection Rate was over 68% (July 2013 to February 2017) and these results were reported May 7, 2017 at the annual meeting of the American Gastroenterological Association - Digestive Diseases Week in Chicago, IL. A high Adenoma Detection Rate is achieved by rigorous cleansing and as careful an examination as possible. While we cannot guarantee that every adenoma or currently existing cancer will be picked up – and every future cancer prevented, we must try to be as meticulous as possible, so please follow the preparation instructions exactly!

You have been scheduled for a Colonoscopy at Glenwood Surgery Center. Please go to Suite 200 and ask for directions.

Colonoscopy involves passing a floppy tube with a “lens and light” system through the rectum, usually to the end of the colon. The purpose is to examine the insides of the colon and look for abnormalities, including fleshy growths called “polyps”. We may have to cut them out or burn them off and send tissue for analysis. Remember that this test is not perfect and there is a small possibility that significant lesions can be missed. As noted above, polyps are of concern because they may become cancerous or may have cancer in them and removing these polyps before cancer develops, appears to significantly reduce the risk of a future cancer. Sometimes, even if cancer has developed, the lesion can be removed using the colonoscope, thereby hopefully obviating the need for surgery. At other times surgery may be needed to handle the problem identified.

We can do this procedure with an easy-to-take laxative and finish it off quickly, but this will not be the best possible quality exam, unlike a rigorous cleansing which will enable a meticulous examination.

Usually we do the procedure with “moderate sedation” in which you are awake but in “la-la land” - jelly may be applied to the rectum for lubrication and sedative medicines (usually Morphine, Demerol or Fentanyl, Atropine or Phenergan and Versed) are given before (often by Intramuscular injection - if you prefer not to have the Intramuscular Injection and wish to get all the medicine by vein, please let us know) and during the procedure. The test can take anywhere from 20 minutes to an hour and a half. While our aim is not to “knock you out”, the medications usually induce a degree of amnesia and many patients have no recollection of the test and often say they were completely out. The other way to sedate you is called "deep sedation" (also called “MAC” – Modified Anesthesia Care) with Propofol which requires an Anesthesia specialist. This will ensure that you are “completely out” but may involve a greater expense. The moderate sedation method is probably a bit safer and may help us do a better exam in most patients. However, for some patients Dr. Ravi might suggest “deep sedation”.

You will be in the center for about 1 to 2 hours or more before and about 1⁄2 to 1 hour after the test. You should not plan to work the day of the test and importantly not drive or operate machinery or make important decisions for 24 hours, because of the effect of the medications. You MUST bring someone close to you – preferably a spouse, child, parent or sibling – to the center to drive you home. Have this person stay with you if possible or be available by phone since Dr. Ravi usually will talk to him/her BEFORE the test. Because the sedation medicine “plays tricks with your mind,” Dr. Ravi will try to talk to this person after the procedure as well if a serious condition is obvious, but if he can't of if he has to wait for the results of biopsies, he will speak with you at the follow-up appointment. Some patients will erroneously think they have been given bad news or even that the procedure was not done, etc. You just cannot go by what you think you were told or what you think happened!

No test or procedure is free of risk. The decision to do any procedure requires careful assessment and Dr. Ravi would have evaluated you before doing the colonoscopy. The risks of a colonoscopy are in part related to the effects of the sedative medication on the heart or lungs and the possibility that the tube will cause a bleed or a tear (which can cause pain, fever and sepsis). There is also the small possibility of an infection caused by bacteria entering the blood stream during the colonoscopy. Bloating, loose stools and minor bleeding (especially if biopsies are taken) are not uncommon. The probability of a life-threatening complication is usually relatively small (under 1%) but not zero, even when everything that can be done to keep that risk as low as possible is done. Since there is always a risk, it is important that a careful deliberation be made to decide if the potential benefits of the test outweigh the risks.

1. To perform the test safely, effectively, and with as little discomfort as possible it is very important that the following directions be observed exactly. Quite simply, since stool - even in minute amounts obstructs visualization, it is ideal that we wash your bowels as clean as possible. The best way to clean your colon out is to drink a liquid called “Golytely” (PEG or Polyethylene Glycol) or equivalent). In Dr. Ravi’s experience, one Gallon of this cleans out the colon well about 80 % of the time. If you can drink 2 gallons, your chances of being cleaned out well are over 95%. So please buy two of these and do your very best to finish both. If the pharmacist says “we usually give only one gallon”, tell him/her of the instructions to drink 2 gallons.

2. Three days before the day of the procedure start a low residue diet (see below). Start a clear liquid diet (see below) the day before the test (for breakfast, lunch and dinner). You may have a light clear liquid dinner the evening prior to the test. Clear liquid is anything that when poured into a glass bowl allows you to read a newspaper through it. Avoid red/pink colored material. Please keep a diary of everything you ingest in these three days and Email it to office@doctorravit.org.

3. Do not eat or drink after midnight except for the cleansing preparation and usual medications – as advised by Dr. Ravi - which you can have with water. However, if the time you are asked to be in the surgery center is after 11 AM, it is OK to have a clear liquid breakfast before 7AM.

4. If you have Diabetes, speak with Dr. Ravi about this, and unless otherwise instructed, do not take any Insulin or Diabetes pills the morning of the test.

5. As soon as you read this sheet (but not more than a week before the test) discontinue (after speaking with Dr. Ravi) Iron pills and Advil and other pain medications other than Tylenol. Talk to Dr. Ravi about Aspirin, Plavix, Effient, Coumadin, Pradaxa or other blood thinners

6. If you are taking medicines for high blood pressure, continue as you normally would, even on the morning of the test.

7. Since frequent bowel movements during preparation can irritate the skin around the anus, apply some diaper rash cream or - even better - vegetable shortening to that area before starting.

8. The prescription for the cleansing solution will be sent electronically to the pharmacy we have on file for you. Add tap-water to the two "Golytely" ("Nulytely", "Colyte" “Gavilyte” and generic PEG3350 are alternatives) bottles, to the line marked and mix well to dissolve the powder (you will need to add about one gallon (four liters) to each bottle). The solution tends to taste better chilled and you can leave it in the fridge or add ice cubes. Using a straw may also help. If you wish, you can add a twist of lime, Crystal light, Soda pop (any color other than red or pink) or vanilla essence for taste. Begin drinking the solution and drink as fast as you can (eg., a tall glass every ten minutes) at about 4PM the evening before the test. You should drink all of the first gallon and half of the second by about 10PM – or at latest midnight. Drink the last half gallon with 4 Gas-X pills before leaving home – take this last half gallon over the last few hours before leaving home, finishing 1⁄2 hour before you leave home. (However, if you are asked to be in the center after 11AM drink 1 gallon the day before and one gallon the morning of the test instead of 1 1⁄2 and 1⁄2 gallons)

9. DO NOT FINISH BOTH GALLONS THE DAY BEFORE THE TEST! DO NOT STOP THE PREPARATION EVEN IF YOU THINK YOU ARE CLEAN.

10. Some insurances may pay for only one gallon and you may have to pay for the other. If you cannot get the second gallon – sometimes the insurance will not even let you even buy the second – then drink half a gallon the evening before the procedure and the other half the morning of the procedure – as later as possible – with the Gas-X pills whether you feel gassy or not. Two gallons split as mentioned above does clean out better than one gallon.

11. If you are going to have the colonoscopy with “Deep Sedation” or “MAC”, finish the last half gallon of Golytely 2 hours before leaving home.

12. Get six over the counter 80 mg or four 125 mg Gas-X pills (or the equivalent store brand) and chew or swallow one roughly with every other glassful of the last 1⁄2 gallon of Golytely. Take the Gas-X pills even if you do not feel gassy.

13. Some people worry that they may soil their clothes on the way to the center. When you start drinking Golytely the evening before the procedure some people will go right away, but others not for many hours. In the morning however, most people will clean out right away. Use a diaper or an old towel since you will be mostly clean by morning. You can also use the toilet in the center. Delaying the last half gallon helps clean out better enabling a quality exam and that is our primary goal.

14. When we do a colonoscopy we may turn you face down, because this enables a better inspection of parts of the colon.

15. Glenwood Surgery Center will call you on or before the working day before the day of the procedure (e.g. Wednesday for a procedure to be done Thursday) and let you know what time to be in the center for the procedure. They usually give you a time about 1 1⁄2 to 2 hours before the likely time of the procedure. This is necessary for the staff to get the paperwork ready and to start an IV and to give you some of the medications. Because of the many variables that we cannot control, it might take many hours of waiting before the test is done. Please be prepared for an extended wait. If the time you are asked to be at the center is 11AM or later, it is OK to have a clear liquid breakfast before 7AM

16. If you have not heard from the GIenwood Surgery Center by 12 noon of the working day before the procedure (e.g. Wednesday for a procedure to be done Thursday), please call 951-688-7270

17. If there is no way to take the rigorous preparation outlined above, we can suggest less intensive cleansing methods. These unfortunately do not clean as well, though we will do the best exam we possibly can even if the colon prep is less than ideal. It is wise to remember that our first goal is to decrease the risk of your dying of colon cancer and we must strive to leave no stone unturned in that quest.

PLEASE FOLLOW THE INSTRUCTIONS EXACTLY, REGARDLESS OF WHAT OTHER INSTRUCTIONS YOU MAY HAVE READ ABOUT OR ARE ADVISED BY SOMEONE ELSE. IF YOU NEED A CLARIFICATION EMAIL US

LOW RESIDUE DIET

A low residue diet consists of low levels of fiber intake, which will minimize stool output

Allowed:

Two cups of milk a day.

Fruit juices without pulp, canned fruit, ripe bananas and apple sauce. Vegetable juice without pulp, cooked asparagus, beats, green beans, spinach, seedless tomatoes, eggplant, and baked squash without seeds. White breads and rolls, plain bagels, biscuits, white rice, pasta, tortillas, potatoes without skin, cream of wheat, instant oatmeal, cold cereals such as corn flakes, rice krispies, and cheerios. Ground or well-cooked meats including tender beef, lamb, ham, pork, poultry, organ meats and fish. Eggs and cheese. Jellies without seeds, cookies without nuts, plain cake, plain donuts, and sherbet.

Not Allowed:

Prunes and prune juice, fresh fruit such as apples, oranges, grapefruit, figs, pineapple, grapes, pears, peaches, dates, and all berries. All raw vegetables, any vegetables with seeds, dried beans, peas, and corn. Whole grain breads, rolls, and bagels, brown rice, bran cereals, and any baked product with nuts or seeds. Tough, fibrous meats with gristle. Popcorn, jams with seeds, nuts, seeds, coconut, crunchy peanut butter.

CLEAR LIQUID DIET

A clear liquid diet consists of liquids you can see through.

Allowed:

Water, Clear broth (beef or chicken), Gatorade or other clear sport drinks (regular, with sugar) Carbonated drinks, including dark sodas like cola, root beer, Tea or coffee (without milk or cream) Gelatin (without fruit), Popsicles (without fruit or cream), Italian ices, hard candy, Clear fruit juices without pulp (apple, grape, cranberry). You may use salt, pepper, and sugar

Not allowed:

Milk, cream, milkshakes, smoothies, Soup (other than clear broth) Oatmeal, cream of wheat, grits. All ice cream, gelato. Orange, grapefruit, or tomato juice; fruit nectars

The videos below will give you a sense of what a Colonoscopy entails. Please note that some information in the videos may vary slightly from what Dr. Ravi has outlined above. In that case, please follow Dr. Ravi's instructions exactly.