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Don’t Make a Mistake in Colonoscopy!

Aug 22, 2024

Lessons from the United European Gastroenterology Education Forum

Over the last few years, gastroenterologists across Europe have come together to learn from each other and improve their skills. Here are some important things we have learned from each other.

A calm patient prepared and ready to undergo colonoscopy.

Colonoscopy is an important test and safe colonoscopy is key. The procedure can detect bowel cancer, inflammatory bowel diseases such as ulcerative colitis and Crohn’s disease. It can also find polyps (pre-cancerous growths) which can be easily removed. This reduces the risk of a patient developing cancer later on.

The most important decision the doctor must make is whether this patient needs this test now. The issues that the doctor should consider include

Whether there are other tests that are easier for the patient (for example a non-invasive stool sample can tell the doctor quite a lot about what is and what is not wrong with the patient).
Whether the patient has other health issues (for example, a colonoscopy should not be done soon after a heart attack, and if the patient is taking blood thinning medicines, these may need to be stopped or indeed, it may not be safe to stop them for the test).
Which medicines should be used for bowel preparation. Some people have bad constipation and an enhanced bowel preparation regime might be needed.

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Engaging with Patient Safety

Planning and preparation are critical non-technical skills. An excellent and safe endoscopist is not just a competent practitioner. The endoscopist also needs to have interpersonal and social skills. This is important to put the patient at ease and also to ensure that the endoscopy team works smoothly. A well functioning team puts good communication between the doctor, nurses and paramedical staff at front and centre. The team will start by ensuring that a pre-procedure safety checklist is completed with the patient. This highlights potential risks, such as whether the patient is allergic to certain medicines, or is taking blood thinning medicines as well as ensuring that they have an escort to take them home if they are going to receive sedation. For more complex therapeutic procedures it gives the team an opportunity to check that all the specialist equipment they might need is available and on hand. This has a further benefit, by reassuring the patient that the team is fully prepared for the procedure they are about to undergo so that the patient has a safe colonoscopy experience.

Doing the Procedure Carefully and Correctly

It is a truism that no two people are the same. Even their colons are different. Some people have a loopy, or narrow bowel. In others it is straighter and wide. For some it is floppy, and in others the walls are surrounded by firm muscles. Furthermore, some people will have cleared all the stool from the bowel whereas others, who still follow the bowel preparation routine correctly, can have significant residual stool. This can make a very big difference to the ease of the procedure.

Over the years, we have learned that inflating the bowel with carbon dioxide rather than air makes the procedure less painful and leaves the patient feeling better immediately afterwards with less cramps, bloating and discharging of wind. More recently, we are realising that flushing the bowel with large amounts of water make the procedure faster, more comfortable and cleaner with a higher chance of detecting subtle abnormalities. All of these issues should be considered by a careful colonoscopist.

One of the key issues is to ensure that the colonoscopist has reached the far end of the large bowel (the caecum). But this comes with its own risks. If the doctor is too focused on achieving this key performance indicator, once they have done so, they may switch off and not focus properly on the more important part of the exam which is a slow, careful withdrawal making sure that enough time is spent assessing the entire colon for subtle (and not-so-subtle) abnormalities. We have been working on artificial intelligence systems as a ‘second pair of eyes’ to help endoscopists spot abnormalities. We have shown that this dramatically improves the likelihood of spotting polyps as well as working towards ever safer colonoscopy.

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Write a Clear Report

Communication remains key after the procedure is finished. It is not standard practice to video the entire colonoscopy but it is crucial to ensure that a well-structured and fully informative report is produced. This will communicate to the patient and their doctor what the next steps should be.

If medicine is recommended, who will prescribe it and how long should it be taken for?
If samples are being sent to the laboratory, a follow up consultation is usually advised so that the findings can be discussed fully with the patient. It is amazing how many patients have an essentially normal colon, but a biopsy sample is taken and the findings from the pathology laboratory are not clearly communicated to the patient. This leads to completely unnecessary anxiety.

The report is not just a technical document. It is there to clarify the final diagnosis, and define how to move forward. A well performed colonoscopy will mean that the procedure itself is done well (that should really go without saying). But it will also mean that the patient and their loved ones are clear about what has been found, and what they should be doing as a result of that.

Safety and quality remain key to a successful patient journey. These concepts must always remain front and centre, whatever the pressures brought to bear by the ever increasing demands of a twenty first century healthcare system.

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