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Archive May 2015 XVI, No. 5

Ready for Difficult Colonoscopies?

The right tools and techniques can get you through unexpected problems.

Jim Burger

Jim Burger, Senior Editor


Difficult Colonoscopies NO SURE THING The patient you'd expect to be as routine as they come may turn out to be just the opposite.

Can you tell just by looking at a patient that the colonoscopy you're about to start isn't going to be run-of-the-mill? True, you know that patients who are particularly thin, particularly heavy and particularly old are likely to be more challenging, but does that mean every patient who's none of the above is going to be a cinch?

"Anybody can be turn out to be difficult," says Samir Parikh, MD, FACS, FASCRS, of the Riddle Surgical Center in Media, Pa. "Sometimes you see the most average-looking person, someone who should have the easiest colonoscopy in the world, and it turns out they have a redundant colon."

Dr. Parikh, who estimates that he's performed close to 15,000 colonoscopies, breaks the population down this way: 50% to 60% are easy, 30% are in the middle, and the remaining 10% or more are tough — for what might be any number of reasons. That redundant colon, for example, is going to have a lot of twists and turns, and require a lot of maneuvering to get through.

Steven Gorcey, MD, AGAF, chief of gastroenterology at Monmouth Medical Center in Long Branch, N.J., and an assistant clinical professor at Drexel University Medical Center in Philadelphia, is wary of 2 scenarios. "One is where you're in the middle of a colonoscopy and all of the sudden you go, Wow, this is getting hard, or I can't go anymore. The other is where someone else failed, or you remember from the previous time that this was a brutal colonoscopy," says Dr. Gorcey.

Given the choice, he'd rather know in advance about a difficult case. That way, he can modify his approach beforehand. For example, says Dr. Parikh, if you're dealing with an elderly patient who's had multiple bouts of diverticulitis, that patient may require a smaller or thinner scope. "Choosing the right scope to start with is the first thing," he says. "For the proverbial shorter, thinner elderly woman with diverticulitis, we may want to use a pediatric colonoscope or even a gastroscope."

If you need something thinner than a colonoscope, Dr. Gorcey prefers the gastroscope, because it's less likely than a pediatric scope to loop, he says. "You're only talking about a couple of millimeters' difference in width, but there's a significant performance difference in terms of stiffness."

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