Episode Transcript
Dr. Johnathon Aho:
We know that polyps turn into colon cancer. We can take these polyps out when they’re small before they turn into colon cancer. The same people that are saying, “I don’t want to have a colonoscopy,” almost certainly they weed their garden, or they are doing other preventative things in their life. You take out a small weed from your garden before it becomes a big weed. A big weed in this case means colon cancer. Take it out when it’s small. Get it dealt with before it turns into something sinister that’s a threat to your life.
Cassie Alvine (announcer):
This is the “Health and Wellness” podcast brought to you by Sanford Health. The conversation today is about colonoscopy prep. Our guest is Dr. Johnathon Aho. Our host is Alan Helgeson with Sanford Health News.
Alan Helgeson (host):
Today we’re talking about getting ready for your colonoscopy. Our guest today is Dr. John Aho. And Dr. Aho, thank you for joining us.
Dr. Johnathon Aho (guest):
Yeah, thank you for having me, Alan. I’m Dr. John Aho. I practice general surgery in Luverne and endoscopy in particular. Colonoscopy is a large part of our practice preventing colon and rectal cancer within our population out in southwest Minnesota.
Alan Helgeson:
Let’s start right away with the importance of who should get screened for colorectal cancer. This may be done through a screening colonoscopy?
Dr. Johnathon Aho:
Yeah. basically anybody over the age of 45 that is in this category we call average risk. So somebody who hasn’t had a colon and rectal cancer in a relative at a relatively young age, somebody who doesn’t have a family history of, or personal history of what’s called FAP or familial adenomatous polyposis, also called FAP or Lynch syndrome, which used to be called HNPCC.
But it essentially, people who are regular risk are regular in terms of their, their risk profile. Typically, we start colon and rectal cancer screening at about the age of 45. But there may be certain instances – talk to your family medicine doctor, your primary care physician – because that does get tailored pretty quickly if there are certain types of polyps or other risk profiles within your family or personal risks that you have, such as, you know, if you’re a very frequent lifelong tobacco user, some people would start
screening a little bit early. But the guidelines would say age 45 for those at average risk.
Alan Helgeson:
So you’re talking about the age 45 here. Can we dig in a little bit into that, Dr. Aho, and some of the stats about colon cancer?
Dr. Johnathon Aho:
Yeah, sure. So colon and rectal cancer is a leading cause of morbidity and mortality, in particular mortality in the United States. People think it’s a lot of other diseases, but honestly, colon cancer is a leading killer.
And there’s a reason that your insurance company is willing to pay for a colonoscopy. It’s because it’s a good investment. It’s something that you can catch early. The earlier you catch it, the cheaper it is to treat. You can catch it when they’re polyps and when they’re not cancers, because we do know that certain kinds of polyps do turn into cancers, and we know that that happens with a certain frequency, and we know that that starts to happen as you age.
So there’s a reason that that age is being recommended. You start to have polyps around that age, and those polyps eventually turn into cancer in a not-trivial amount of people. I hate to see it where we screen somebody at age 70 and they have a more advanced polyp than they would’ve had at age 50 or 45.
Alan Helgeson:
Dr. Aho, I really appreciate those stats and really starting out with a who and the why for a colorectal cancer screening, but we know what really holds people back is – everybody talks about it, and it’s the big aura around the prep, right?
Dr. Johnathon Aho:
Yeah,
Alan Helgeson:
Now, I’m going to go out of here and talk about maybe a little too much information, but I’ve had a screen, a colonoscopy. I’ve had a couple of those, and you know, the prep isn’t great, I’ll be honest about it. But I would much rather have a colonoscopy. And I’ll tell you, I am thankful for doing it both times and that my Sanford providers have been amazing each time that I’ve done it.
But the purpose of this podcast here today is we want to talk about the prep for a colonoscopy, all the details that go into it, and give people the important information about that prep. So let’s get right into that. Why is it important to follow the prep instructions for a colonoscopy?
Dr. Johnathon Aho:
Well (laugh), without sounding too crass, your colon has stool inside of it. The polyps are on the inner lining or the inside of that pipe. Imagine your colon is a pipe, or just like your water pipes in your house. The polyps are on the inside of that pipe. I cannot see the polyps, or I would miss polyps if there were gunk on the inside of that pipe. All of that gunk has to get cleaned out, and in this case it’s stool so that I can see small polyps, medium polyps, and large polyps, and actually, you know, tell that they’re there. You can’t see them underneath the dirt. The dirt has to come out in order for me to see if there’s a polyp there or not.
Alan Helgeson:
So this might sound a little bit redundant, and these next questions may follow that, but I really want to get to the core of that and really underscore why you’re saying that. So what happens if the prep is not done correctly?
Dr. Johnathon Aho:
I will miss a polyp and/or I won’t be able to get all the way through the colon. The colonoscope that’s going through your colon, you cannot safely see where the lumen or the hole or the center line of that pipe is. So you’re not able to drive that colonoscope all the way to the end of the colon because there’s stool in the way, essentially. And then on the way back out, even if you are able to reach the end, you’re not going to be able to see the small polyps or medium sized polyps. You’ll probably be able to see a large polyp okay.
But it depends on, you know, how severe or how badly the prep was done. But you’re definitely going to miss polyps, and it’s not going to be what I would consider an adequate colonoscopy. And you’re going to need to have it repeated if you want it to count, basically, because I can’t say with any certainty that I saw what I needed to see in order to say that the colonoscope was good. And we didn’t miss any polyps. I couldn’t go to sleep at night and say, yeah, it was a great colonoscope. We didn’t see any polyps. Well, we didn’t see any polyps because there was stool on the inside of the colon.
Alan Helgeson:
So, beyond that, are there any other reasons why people should not try and cheat the prep protocol?
Dr. Johnathon Aho:
The Cliff Notes version is it makes the colonoscopy not only technically challenging in that it’s hard for me to see where the polyps are. I would say it makes it borderline unsafe and it potentially puts you into needing a second procedure, almost always. And then you’re going to have to go through the whole rigamarole again, and then you need to get another prep, or you need to stick around on that same day and drink more prep and clean things out more.
And there are some people who, you know, it’s their first colonoscope, their colon maybe doesn’t move as quickly as others, and they need an additional prep. And we don’t know about that right out of the gate. And so it’s not necessarily everybody who needs to be re-prepped was in that “they’re trying to cheat” basically category. But some people, you need a little bit of additional prep and there’s nothing wrong with that.
But the main thing is you need to see the inside of the colon safely. That’s what I would reiterate. And prep is a component of that. It’s a big major component of that. That’s you guys meeting us halfway.
Alan Helgeson:
I’ve got friends that I know that, you know, getting them to have a colonoscopy in the first place, a challenge. And then if they didn’t follow the prep appropriately and we had to send them home, chances of getting them to come back, probably pretty slim. Even though they know they should.
Dr. Johnathon Aho:
It’s incredibly frustrating to think you did an adequate job and then you go to sleep and you expect to wake up and you, you know, maybe you had a polyp taken out and everything went great and high fives and go home and (laugh) go about your day. Nope, you need to go home, or you need to stick around and prep more and you need to come back for another colonoscopy. That just takes the wind out of your sails completely. And yeah, the likelihood that you would come back after that is not high. And I can see why.
But don’t try to cheat it. Do it. Do it correctly. Do it completely. It needs to be a liquid and liquid without any elements of formed stool in it for that to be adequate. The amount of volume that we give people is a lot of volume. And if you figured out how to get somebody’s colon ready without having them drink that much volume or having them on the toilet all day, you’d be a millionaire. But we just don’t have that technology yet (laugh). And the only way we have to clean people out is we have to clean them out.
Alan Helgeson:
So with that, how Dr. Aho, can we make the prep more bearable or ways to reduce discomfort?
Dr. Johnathon Aho:
Basically follow the instructions is the most straight, is the best way to make sure that you’re doing it correctly. Ask the nurse or whoever’s telling you about the instruction or who is handing you the instructions. You know, in particular, questions: What am I allowed to eat? What should I be doing? Should I be drinking and, and being well hydrated the day before I start the prep? People think about, well, it’s just the day of the prep that I need to be worried about. No, you should go into that well-hydrated, making sure that you’ve had plenty of fluids the day before you have the prep.
There are some surgeons and endoscopists that would recommend that you try simethicone for gas pain on top of the prep. Some people think that that’s extraneous, but figure out what your options are, and share your concerns with the nurse and the care team.
And there are, there are as many ways to prep a colon as there are endoscopists that are doing it. There are home brew over-the-counter type solutions that we use. There are canned or bottled type of solutions that other people use. There’s a lot of different ways to do it, but at the end of the day, the volumes are pretty much equivalent.
It’s going to end up being about 64 ounces of liquid, sometimes a little bit less, sometimes a little bit more, and it’s going to be a lot of things that make you go to the bathroom. But going into that well-hydrated is very important because you do lose a lot of liquid and some very, very infrequently do we have people get dehydrated or lightheaded from their prep. But that can almost always be prevented by, you know, having a bottle of Gatorade or two the day before you start your prep.
Alan Helgeson:
Let’s get to some of that diet. What does the prep diet consist of?
Dr. Johnathon Aho:
So that, that is variable depending on what your endoscopist wants. Cliff Notes version is: Avoid high residue type of things. Corn. Corn will stick around for a million years in your colon. We have no idea. Like some people say they haven’t eaten corn in a month and there’s still a corn kernel in there. And I tend to believe people because I’ve seen that and heard that plenty of times. There are some foods that for whatever reason will just stick around. Corn is notorious.
String beans is another great example. Celery, other types of, you know, long stringy fibers or short round type of things that are fibrous. And so (laugh) adhere to the diet that your endoscopist is recommending.
Eggs are usually hard-boiled eggs or other cooked eggs. For whatever reason, eggs absorb extremely well and they turn into liquid by the time they hit your colon. So if your colonoscopy is later in the afternoon and they said that you could eat breakfast, they’re probably going to recommend hard-boiled eggs.
Alan Helgeson:
How about some prep drink tips, then, doctor?
Dr. Johnathon Aho:
Don’t guzzle it. Don’t do it all at once. If you have – that’s a lot of liquid to try to get down all at once. And I don’t know if you did this out in your part of the country, but did you ever do the one-gallon milk challenge (laugh), where you tried to drink all one gallon of milk? No. Nobody, nobody in their right mind does that. Do the same thing with the prep. Don’t go hog wild on drinking a gallon of prep and try to get it down in an hour and force it down and think it’s all going to go downstream. It almost certainly will not. And peck at it throughout the day. Set a goal for yourself so that you’re finishing the prep right around the NPO time or that you know, nothing by mouth anymore time. So if they’re saying nothing by mouth at midnight, try to have the prep done by 10 p.m.
Figure out when you’re picking up the prep and then break it up into pieces and be thoughtful about it and put little tick marks on the bottles or “I need to be at this point by 9:00 a.m., I need to be at this point by 2:00 p.m.,” and then work your way through it slowly and consistently. But get it all down and don’t try to rush it.
Alan Helgeson:
Well then let’s talk about, you mentioned times. How long does the prep take?
Dr. Johnathon Aho:
I would say it takes the better part of an afternoon. If you are a reasonable drinker in terms of able to get down volume, I would say you’re looking at probably half a day or, you know, perhaps three-quarters of a working day to get that down.
Alan Helgeson:
So we talked about some foods or maybe a prep diet. Are there things that a person should really look at avoiding eating a few days before their prep or maybe some food patterns or anything like that?
Dr. Johnathon Aho:
Yeah, I, I would say that the vast majority of people doing endoscopy are going to say no high residue string beans, no high residue other types of foods like corn or certain kinds of nuts would be another example. Sunflower seeds I hear once in a while, because some people do eat the hulls. Things of that nature I would say are pretty consistently recommended to avoid by almost everybody who’s advising bowel prep for patients.
Alan Helgeson:
Are there any common side effects of the colonoscopy prep?
Dr. Johnathon Aho:
Dehydration definitely. And nausea, vomiting, especially if they’re trying to go too quickly with the bowel prep. That is pretty common, is people are trying to rush things. They get some cramping, some nausea, vomiting. And if they’ve already gone into the prep being borderline dehydrated, they’re going to be dehydrated after the prep.
Alan Helgeson:
I remember doctor, when I was getting ready for my colonoscopy, you know, you go to the store, you get all the supplies, right? So you gather those things. And then I was thinking about, all right, these are the movies that I’m going to download or I’m going to get ready and watch and what does that list of supplies, maybe someone should have to make the prep go easier?
Dr. Johnathon Aho:
Think about where your bathrooms are going to be. That seems totally obvious, but that in terms of supplies, make sure that you’re being thoughtful about where you’re going and what you’re doing on that day. In terms of supplies, that’s really the only thing I can think of other than getting the prescriptions, maybe laying them out on the table and saying, this is what the sequence of events for the day is going to look like.
There are different recipes. Your prescriber may recommend different preps than what you had before. So lay out the instructions, lay it out as if you’re doing, you know, some type of project or hobby project or something like that. Plan out what the sequence of events are. Plan out your day. Have a plan going into something.
Alan Helgeson:
What about medications? Can these be taken before the procedure?
Dr. Johnathon Aho:
Talk to your prescriber, but on, in, in general, blood pressure, medications, heart rate medications, those are all fine to take, take those as you normally would. Almost always, they’re going to say avoid blood thinners, aspirin, Plavix, Coumadin, aka Warfarin, Clopidogrel, you know, those types of medications. Avoid those or talk to your prescriber about how long they want you to hold the Eliquis as an example for your AFib. Make sure you mention it while you’re talking to the nurse on the phone because they go through that list of medications and somebody has 30 medications, but it’s not in the same place on our end all the time. So make sure that you volunteer to the person who’s talking to you. Hey, my doctor wanted me on, you know, a baby aspirin once a day.
Some endoscopists will say that’s fine. The majority of endoscopists will say it’s not. And so they would want you to hold it for sometimes three days, sometimes five days. Depends on the endoscopist and who’s doing the procedure and what their comfort and what your comfort with having bleeding risks are. Because these polyps are on the inside of your colon. They’re like moles, like on your skin, but they just happen to be on the inside of your colon. Just like if you take a mole off of your skin, it’s going to leave a raw spot there that you can bleed from and that that’s a place that you’re going to bleed from that you might not notice. It might go into your stool, you might digest that blood a bit and you might not notice that you’re losing blood over time.
If it’s brisk, you’re going to have blood in your stool. But balancing out those bleeding risks, I think are the main concerns for what medications are they going to have you hold. There’s other certain kinds of medications and specialized instances that modify how wound healing happens and things like that. But those are much more rare than a blood thinner type medication. But most medications, talk to your prescriber. Most medications go ahead and take normally, but the blood thinners definitely have a conversation with the person scheduling your colonoscopy. They’re going to know what that endoscopist’s preferences are.
Alan Helgeson:
Why do I need a driver on the day of the procedure?
Dr. Johnathon Aho:
(Laugh) Because the anesthesia we give you is pretty stiff stuff and you’re going to wake up and you’re going to feel like a million bucks. There’s a reason that you wake up and you’re in a decent mood on the average and you feel great. It’s because you have essentially, you know, had a few stiff cocktails, you know, medication type that are going to be lingering in your system for the rest of the day. You do not want be pulled over by a state trooper. It’s going to be unsafe for you to drive. And I would not want somebody on the road that is in that condition.
Alan Helgeson:
Well, Dr. Aho, I think these are some great things to talk about. The prep for a colonoscopy and really an important information because people tell their friends and other people go, “ah, I’m never gonna get one of these things.” Now I’ve had a couple of these things and I tell all my friends, it’s something everybody needs to do if they fit the screening guidelines. Absolutely do this.
As we’re doing the “Health and Wellness” podcast, Dr. John Aho is our guest today.
Dr. Johnathon Aho:
Thank you for your time and you know, for hosting me.
Alan Helgeson:
Our discussion today was about prepping for a colonoscopy, but colonoscopies are not the only screening option for colorectal cancer. Another option is stool-based colorectal cancer screening tests, which can also find possible signs of cancer. To learn what screening option is best for you, talk to your primary care provider or visit sanfordhealth.org for more information.
Cassie Alvine:
This episode is part of the “Health and Wellness” series by Sanford Health. For additional podcast series by Sanford Health, find us on Apple, Spotify, and news.sanfordhealth.org.
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Posted In Cancer Screenings, Digestive Health, Family Medicine, Health Information, Health Plan, Healthy Living, Internal Medicine, Luverne, Menopause Care, Specialty Care
