Colonoscopy Principles and Practice Thanks to our wivesaMeg Waye, Leslie Rex and Christina Williamsafor their support in yet another time-consuming enterprise Thanks also to those to whom we have taught colonoscopy and the many on whom we have performed colonoscopy We have learned so much from you all, as we have from our friends the contributors to this book Colonoscopy Principles and Practice EDITED BY Jerome D Waye MD Director of Endoscopic Education Mt Sinai Hospital Chief of Gastrointestinal Endoscopy Lenox Hill Hospital Clinical Professor of Medicine Mount Sinai Medical Center New York USA Douglas K Rex MD Professor of Medicine Indiana University School of Medicine Director of Endoscopy Indiana University Hospital Indianapolis Indiana USA Christopher B Williams BM FRCP FRCS Consultant Physician St Mark’s Hospital London UK © 2003 by Blackwell Publishing Ltd Blackwell Publishing, Inc., 350 Main Street, Malden, Massachusetts 02148-5020, USA Blackwell Publishing Ltd, 9600 Garsington Road, Oxford OX4 2DQ, UK Blackwell Publishing Asia Pty Ltd, 550 Swanston Street, Carlton, Victoria 3053, Australia The right of the Authors to be identified as the Authors of this Work has been asserted in accordance with the Copyright, Designs and Patents Act 1988 All rights reserved No part of this publication may be reproduced, stored in a retrieval system, or transmitted, in any form or by any means, electronic, mechanical, photocopying, recording or otherwise, except as permitted by the UK Copyright, Designs and Patents Act 1988, without the prior permission of the publisher First published 2003 Reprinted 2004, 2005 Library of Congress Cataloging-in-Publication Data Colonoscopy: principles and practice/edited by Jerome D Waye, Douglas K Rex, Christopher B Williams – 1st ed p.; cm Includes bibliographical references and index ISBN-10 1-4051-1449-5 Colonoscopy [DNLM: Colonoscopy–methods WI 520 C7179 2003] I Waye, Jerome D., 1932– II Rex, Douglas K III Williams, Christopher B (Christopher Beverley) RC804.C64C63 2003 616.3′407545a dc21 ISBN-10 1-4051-1449-5 ISBN-13 978-1-4051-1449-3 A catalogue record for this title is available from the British Library Set in 9.5/12pt Palatino by Graphicraft Limited, Hong Kong Printed and bound in India by Gopsons Papers Limited, New Delhi Commissioning Editor: Alison Brown Managing Editor: Rupal Malde Production Editor: Jonathan Rowley Production Controller: Kate Charman For further information on Blackwell Publishing, visit our website: http:/ /www.blackwellpublishing.com 2003010434 Contents Preface, vii List of Contributors, viii Section 1: General Aspects of Colonoscopy History of Endoscopy in the Rectum and Colon, H Niwa, Y Sakai & C.B Williams The Colonoscopy Suite, 21 M.E Rich The Colonoscopy Assistant, 44 L.E Taylor & J.A DiSario Informed Consent for Colonoscopy, 55 A.D Feld Section 2: Teaching and Quality Aspects Training in Colonoscopy, 63 M.L Freeman Teaching Aids in Colonoscopy, 70 M Schapiro 13 Cost-effectiveness of Colonoscopy Screening, 139 A Sonnenberg 14 Hereditary Colorectal Cancer, 151 R.F Wong, S Kuwada, R.W Burt 15 Complications, 170 J Church Section 4: Reports and Imaging 16 Standardization of the Endoscopic Report, 183 M.M Delvaux 17 Reporting and Image Management, 199 L Aabakken Section 5: Preparation for Colonoscopy 18 Preparation for Colonoscopy, 210 J.A DiPalma 19 Antibiotic Prophylaxis for Colonoscopy, 220 D.J Bjorkman Teaching Colonoscopy, 76 R.H Teague & R.J Leicester 20 Management of Anticoagulation and Antiplatelet Agents, 224 G.M Eisen Role of Simulators in Endoscopy, 84 S Bar-Meir 21 Sedation for Colonoscopy, 229 G Zuccaro Jr Continuous Quality Improvement in Colonoscopy, 89 J.B Marshall Section 6: Hardware 22 The Video Colonoscope, 238 D.E Barlow Section 3: Indications, Contraindications, Screening, and Complications 23 The Colonoscope Insertion Tube, 259 D.A Howell 10 Indications and Contraindications, 102 A Habr-Gama, P.R Arruda Alves & D.K Rex 24 Magnetic Imaging of Colonoscopy, 265 B.P Saunders & S.G Shah 11 Diagnostic Yield of Colonoscopy by Indication, 111 F Froehlich & J.-J Gonvers 25 Accessories, 276 G.G Ginsberg 12 Screening Colonoscopy: Rationale and Performance, 131 D Lieberman 26 Clips, Loops, and Bands: Applications in the Colon, 287 M.J Bourke & S.J Williams v vi Contents 27 Colonoscopic Biopsy, 295 W.M Weinstein Section 11: Neoplastic Detection and Staging: New Techniques 28 Cleaning and Disinfection, 309 D.A Greenwald 41 Magnifying Colonoscopy, Early Colorectal Cancer, and Flat Adenomas, 478 H Kashida & Shin-ei Kudo Section 7: Basic Procedure 42 Flat and Depressed Colorectal Neoplasia in the Western Hemisphere, 487 G.S Raju & P.J Pasricha 29 Insertion Technique, 318 C.B Williams 30 Missed Neoplasms and Optimal Colonoscopic Withdrawal Technique, 339 D.K Rex Section 8: Colon Polyps: Incidence, Growth and Pathology 31 Polyp Biology, 351 C.R Boland 32 Colon Polyps: Prevalence Rates, Incidence Rates, and Growth Rates, 358 B Hofstad 33 Pathology of Colorectal Polyps, 377 N Harpaz Section 9: Polypectomy 34 Principles of Electrosurgery, Laser, and Argon Plasma Coagulation with Particular Regard to Colonoscopy, 393 G Farin & K.E Grund 43 Chromoendoscopy, 501 D.E Fleischer 44 Optical Techniques for the Endoscopic Detection of Early Dysplastic Colonic Lesions, 509 R.S DaCosta, B.C Wilson & N.E Marcon 45 Endoscopic Ultrasonography of the Colon, 536 J.W Stubbe & P Fockens 46 Virtual Colonoscopy in the Evaluation of Colonic Diseases, 547 M Macari Section 12: Clinical Use of Colonoscopy 47 Colonoscopy and Severe Hematochezia, 561 D.A Jensen & G.A Machicado 48 Endoscopy in Inflammatory Bowel Diseases, 573 G D’Haens & P Rutgeerts 49 Infections and Other Noninflammatory-BowelDisease Colitides, 582 R.M Lim & J.B Raskin 35 PolypectomyaBasic Principles, 410 J.D Waye 50 Acute Colonic Pseudo-obstruction, 596 H Nietsch & M.B Kimmey 36 Difficult Polypectomy, 420 U Seitz, S Bohnacker, S Seewald, F Thonke, N Soehendra & J.D Waye 51 Radiation Proctopathy, 603 C.J Gostout 37 Retrieval of Colonic Polyps, 443 B.E Roth Section 10: Malignant Polyp, Surveillance Post-Polypectomy, Post-Cancer Surveillance 38 Management of Malignant Polyps, 448 S.J Winawer & M O’Brien 39 Postpolypectomy Surveillance, 459 J.H Bond 40 Colonoscopy after Colon Cancer Resection, 468 F.P Rossini & J.D Waye 52 Benign and Malignant Colorectal Strictures, 611 T.H Baron 53 Pediatric Colonoscopy, 624 M.E Ament & G Gershman Section 13: Future Colonoscopy 54 The Future of Colonoscopy, 630 P Swain Index, 639 Preface Flexible endoscopy of the colon was introduced in 1963, six years after Basil Hirschowitz developed the fiberoptic gastroscope Since the first attempts at intubating the entire colon, this procedure has now become a primary diagnostic and therapeutic tool for evaluation and treatment of colonic diseases Using the ability to inspect, obtain tissue samples and remove colon polyps, colonoscopy has expanded our knowledge of the natural history of colonic neoplasia Multiple large studies have shown that removal of benign adenomas will prevent colorectal cancer Because of the increasing awareness of colorectal cancer being a common cause of death from cancer throughout the world, and the possibility to interrupt the adenoma to carcinoma sequence by polypectomy, the volume of colonoscopies around the world continues to be driven upward by widespread acknowledgement of the effectiveness of the procedure Colonoscopy is not merely a tool in the hands of a practitioner, but it is a discipline with an infrastructure built upon many areas of medicine, including internal medicine, the general practice of medicine, and gastroenterology in particular, as well as surgery, pathology, radiology, pediatrics, and molecular biology The expanding horizon of colonoscopy was the stimulus for us to organize a new comprehensive textbook on this field The chapters in this volume address every aspect of colonoscopy, and its interface with all of the other sections of medicine The editors of this book learned and indeed developed many techniques of colonoscopy when imaging was limited to the barium enema and there was no capability to visualize the intraluminal topography in the intact patient This book represents the “state of the art” in colonoscopy However, colonoscopy is a procedure in evolution and investigators around the world are actively pursuing improvements Colonoscopy is a relatively new discipline, and although tremendous strides have been made since its introduction, there are many unanswered questions such as how can we improve training in colonoscopy? Can bowel cleansing be made less toxic and less miserable? Can colonoscopy be made painless? Can we improve the detection of neoplasia? Can we make colonoscopy faster? Can we eliminate complications from both diagnostic and therapeutic procedures? The answers to these questions will determine the future of colonoscopy and its ultimate impact on colorectal disease We look forward to the continuing pursuit of answers to all questions concerning colonoscopy, and urge future generations of colonoscopists to continue the quest for knowledge and add more information to each of the chapters in this book For many colonoscopists and certainly for ourselves, colonoscopy is not considered as part of a job, but rather as a passion Every colonoscopy presents an opportunity to improve a patient outcome, to learn, often to reassure, to identify new questions and problems both clinical and scientific, and to enjoy the application of skills both manual and cognitive in nature Thus, to edit a volume on colonoscopy has been for us a particular pleasure We extend our most sincere thanks to the authors who contributed to this volume The list of authors includes the world’s most foremost practitioners from every aspect of medicine Their expertise, diligence, and friendship are deeply appreciated On behalf of all the authors, we thank the many, many thousands of patients who have trusted us and been our teachers Jerome D Waye Douglas K Rex Christopher B Williams vii List of Contributors L Aabakken, MD, PhD M.J Bourke, MB, BS, FRACP A.D Feld, MD, JD Chief of Endoscopy, Department of Medical Gastroenterology, Rikshospitalet University Hospital, Oslo, Norway Consultant Gastroenterologist, Westmead Hospital, Westmead, NSW, Australia Chief, Central Division of Gastroenterology, Group Health Cooperative, Seattle, WA, USA R.W Burt, MD D.E Fleischer, MD, MACP M.E Ament, MD Professor of Pediatrics and Chief, Division of Pediatric Gastroenterology, Hepatology and Nutrition, David Geffen School of Medicine at UCLA, Los Angeles, USA P.R Arruda Alves, MD, PhD Associate Professor of Surgery, University of São Paulo Medical School, Brazil D.E Barlow, PhD Director of Technology Assessment, Olympus America, Inc, Melville, NY, USA T.H Baron, MD, FACP Professor of Medicine, Division of Gastroenterology & Hepatology, Mayo Clinic Rochester, MN, USA Professor of Medicine, University of Utah School of Medicine, Salt Lake City, Utah, USA J Church, MD Victor W Fazio Professor of Colorectal Surgery, Department of Colorectal Surgery, Cleveland Clinic, Cleveland, Ohio, USA R.S DaCosta, PhD Department of Medical Biophysics, University of Toronto, Toronto, Ontario, Canada Chair, Division of Gastroenterology and Hepatology, Mayo Clinic Scottsdale, Professor of Medicine, Mayo School of Medicine, Scottsdale, AZ, USA P Fockens, MD, PhD Associate Professor of Medicine, Director of Endoscopy, Academic Medical Center , University of Amsterdam, Amsterdam, The Netherlands M.L Freeman, MD Associate Professor of Medicine, University of Minnesota, Division of Gastroenterology, Hennepin County Medical Center, Minneapolis, USA M.M Delvaux, MD, PhD Gastroenterology Unit, CHU Rangueil, Toulouse, France S Bar-Meir, MD F Froehlich, MD Division of Gastroenterology PMU/CHUV, University of Lausanne, Switzerland Professor of Medicine and Director, Department of Gastroenterology, Chaim Sheba Medical Center, Tel Hashomer and Sackler School of Medicine, Tel Aviv, Israel G D’Haens, MD, PhD Department of Medicine, Division of Gastroenterology, University Hospital Gasthuisberg, Leuven, Belgium J.-J Gonvers, MD D.J Bjorkman, MD, MSPH (HSA), J.A DiPalma, MD G.G Ginsberg, MD SM (Epi) Division of Gastroenterology, University of South Alabama College of Medicine, Mobile, Alabama, USA Professor of Medicine, Senior Associate Dean, University of Utah School of Medicine, Salt Lake City Utah, USA S Bohnacker, MD Department of Interdisciplinary Endoscopy, University Hospital Eppendorf, Hamburg, Germany J.H Bond, MD J.A DiSario, MD Associate Professor of Medicine, Director of Therapeutic Endoscopy, University of Utah, Health Sciences Center, Salt Lake City, USA Division of Gastroenterology PMU/CHUV, University of Lausanne, Switzerland Associate Professor of Medicine, Director of Endoscopic Services, Gastroenterology Division, Hospital of the University of Pennsylvania, Philadelphia, PA, USA G Gershman, MD Associte Professor of Pediatrics and Chief, Division of Pediatrics, Gastroenterology and Nutrition, Harbor–UCLA Medical Center, Los Angeles, USA G.M Eisen, MD, MPH C.J Gostout, MD Associate Professor of Medicine, Oregon Health Science University, Portland, Oregon, USA Professor of Medicine, Mayo Graduate School of Medicine, Mayo Foundation, Rochester, Minnesota, USA C.R Boland, MD G Farin D.A Greenwald, MD Chief, Division of Gastroenterology, Baylor University Medical Center, Dallas, Texas, USA Director of Research, Erbe Elektromedizin GmbH, Tuebingen, Germany Division of Gastroenterology, Montefiore Medical Center, New York, USA Chief, Gastroenterology Section, Minneapolis Veterans Affairs Medical Center, Professor of Medicine, University of Minnesota, Minneapolis, USA viii List of Contributors ix K.E Grund, MD R.M Lim, MD F.P Rossini, MD Professor of Surgery, Department of Surgical Endoscopy, Center for Medical Research, Eberhard-Karls University, University Hospital Tuebingen, Germany Assistant Professor of Clinical Medicine, Division of Gastroenterology, University of Miami School of Medicine, Miami, FL, USA Head Emeritus Gastroenterology, A.S.O San Giovanni Battista di Torino Hospital, Professor of Gastroenterology, Post Graduate School of Gastroenterology, University of Turin, Italy A Habr-Gama, MD, PhD Professor of Surgery, University of São Paulo Medical School, Brazil M Macari, MD Associate Professor of Radiology, NYU Medical Center, Tisch Hospital, New York, USA G.A Machicado, MD N Harpaz, MD, PhD Director, Division of Gastrointestinal Pathology, Department of Pathology, The Mount Sinai Medical Center, NY, USA B Hofstad, MD Senior Gastroenterologist, Division of Gastroenterology, Ullevaal University Hospital, Oslo, Norway D.A Howell, MD Director, Pancreaticobiliary Center, Maine Medical Center, Portland, Maine, USA Clinical Professor of Medicine, UCLA School of Medicine, Van Nuys, CA, USA N.E Marcon, MD St Michael’s Hospital, Center for Therapeutic Endoscopy & Endoscopic Oncology, Toronto, Ontario, Canada J.B Marshall, MD Professor of Medicine, Division of Gastroenterology, University of Missouri Health Sciences Center, Columbia, Missouri, USA Professor of Medicine, UCLA School of Medicine, Director of Human Studies Core, CURE: Digestive Disease Research Center, WLA VA Medical Center/CURE, Los Angeles, CA, USA P.J Pasricha, MD Professor of Medicine, Division of Gastroenterology, University of Washington, Seattle, USA Center of Endoscopic Research Training and Innovation, Division of Gastroenterology and Hepatology, University of Texas Medical Branch, Galveston, Texas, USA Consultant Surgeon, St George’s Hospital, London Tutor in Endoscopy to the Royal College of Surgeons, UK G.S Raju, MD Center of Endoscopic Research Training and Innovation, Division of Gastroenterology and Hepatology, University of Texas Medical Branch, Galveston, Texas, USA J.B Raskin, MD, FACP, FACG Professor of Medicine and Interim Chief, Division of Gastroenterology, Cye Mandel Chair in Gastroenterology University of Miami School of Medicine, Miami, FL, USA U Seitz, MD Department of Interdisciplinary Endoscopy, University Hospital Eppendorf, Hamburg, Germany S Seewald, MD Department of Interdisciplinary Endoscopy, University Hospital Eppendorf, Hamburg, Germany S.G Shah Research Fellow, Wolfson Unit for Endoscopy, St Mark’s Hospital, London, UK N Soehendra, MD Professor of Surgery and Director, Department of Interdisciplinary Endoscopy, University Hospital Eppendorf, Hamburg, Germany D.K Rex, MD A Sonnenberg, MD, MSc Professor of Medicine, Indiana University School of Medicine and Director of Endoscopy, Indiana University Hospital, Indiana, USA J.W Stubbe, MD D Lieberman, MD Professor of Medicine, Division of Gastroenterology, Oregon Health Sciences University, Oregon, USA B.P Saunders Clinical Professor of Medicine and Gastroenterology, David Geffen School of Medicine at UCLA, Los Angeles, California, USA M.B Kimmey, MD R.J Leicester, OBE, FRCS Professor of Medicine, Department of Medicine, Toho University, Ohashi Hospital, Tokyo, Japan M Schapiro, MD Professor of Pathology and Laboratory Medicine, Boston University School of Medicine, Boston, Mass., USA Assistant Professor of Medicine, Program Director, Division of Gastroenterology, University of Utah School of Medicine, Salt Lake City, Utah, USA Y Sakai, MD Professor of Medicine, St Marianna University School of Medicine, Kawasaki, Japan M O’Brien, MD, MPH S Kuwada, MD Department of Medicine, Division of Gastroenterology, University Hospital Gasthuisberg, Leuven, Belgium H Niwa, MD, DMSc Associate Professor, Digestive Disease Center, Showa University Northern Yokohama Hospital, Yokohama, Japan Professor, Chairman, Digestive Disease Center, Showa University Northern Yokohama Hospital, Yokohama, Japan P Rutgeerts, MD, PhD Senior Lecturer in Endoscopy, Wolfson Unit for Endoscopy, St Mark’s Hospital, London, UK H Kashida, MD, PhD Shin-ei Kudo, MD, PhD Professor of Medicine and Chief, Clinical Affairs, Division of Digestive Disease, David Geffen School of Medicine at UCLA, Los Angeles, California, USA Assistant Professor, Martin Luther University, Halle-Wittenberg, Germany H Nietsch, MD D.M Jensen, MD B.E Roth, MD M.E Rich, AIA Architect P.C., 2112 Broadway, New York, NY, USA Department of Veterans Affairs Medical Center, Portland, USA Department of Gastroenterology & Hepatology, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands Index bleeding disorders, hemoclip use, 289 –90 blood, light absorption, 516, 518 blood-borne pathogens, 49 –50, 637 “bow-and-arrow” sign, 336 bowel habit, altered, diagnostic yield, 121–2 bowel preparation commercial kits, 550 complications, 171 hematochezia, 562 pediatric colonoscopy, 625 – standard, 341 virtual colonoscopy, 548 –50 bowel relaxants, 551 bowel resection, 456 Bozzini, Phillipp, 1–3 breast cancer, Cowden’s syndrome, 164 British Society of Gastroenterology, competence procedures, 64 broadband, 40–1, 73 brush cytology, 48, 611 calcium, polyp growth effects, 370 camera single-tube, 14 see also photographic images; photography Campylobacter, 583 cancer family syndrome see hereditary non-polyposis colorectal cancer (HNPCC) cap, transparent, 284 –5, 346, 428 cap-fitted colonoscopy, 346, 348, 428 capnography, 46 carbon dioxide colonic insufflation, 550 –1 insufflation, 344 carbon particles, 452 see also India ink carbonization, thermal, 395, 399, 404 carcinoembryonic antigen (CEA), 469, 472 monoclonal antibody, 527, 529 –30 carcinogenesis depressed lesions, 494 –5, 496 flat adenomas, 494 –5, 496 genes in, 351–2 multistep, 354–6 process, 461 carcinoid tumors, 390 –1, 542 carcinoma in situ see dysplasia, high-grade cardiac events, 176 cardiopulmonary complications, 175 – care, standards of, 44 caseload, average daily, 23 – β-catenin gene, 355, 356 cathartics, 210–11, 211 cathepsin B, 528 cathepsin D, 528 catheters, toposcopic self-everting, 632 CCD see charge-coupled device CD markers of lymphoma, 390 CD-ROMs teaching courses, 74 training, 71, 72 CEA see carcinoembryonic antigen cecal intubation Scope-Guide imager, 271 success rate, 65, 66, 67 audit, 265 family physicians, 67 screening, 97 targets, 97 without parenteral sedation/analgesia, 234–5 cecostomy, percutaneous, 601 cecum, 336 perforation risk, 597 ulceration, 583 celecoxib, 158 adenoma regression, 354 certification of procedural confidence, 63 Charcot–Leyden granules, 586, 627 charge-coupled device (CCD) color-chip, 250–2 color mosaic, 252 development, 247 digital imaging, 202 endoscopic image production, 195 fluorescence detection, 520 frame-transfer, 246 image sensor, 244–56 image signal, 255 interline transfer, 246–7 light sensitivity, 252 line-transfer, 245–6 reading image, 245–6 RGB sequential imaging, 249–50 size, 254 technology, 14 infrared light detection, 17 types, 245–7, 255–6 unit, 241 video colonoscope, 239 wavelength sensitivity, 248 children colitis, 624 gut lavage, 213 suction biopsy, 296 see also pediatric colonoscopy Chlamydia trachomatis, 588–9 chromic agents, 280 chromoendoscopy, 280, 347–8, 501–7 cresyl violet see crystal violet crystal violet, 17, 18, 478, 483, 484, 502 depressed tumors, 490 detection, 496 flat adenomas, 490, 496 gross appearance of adenoma/ carcinoma, 478–84, 485, 486 indigocarmine, 490 indocyanine green, 17, 438 localized lesion detection, 479 methylene blue, 17, 47–8, 502 neoplasm detection, 503–4 polyps detection, 504 diminutive, 504–6 ulcerative colitis, 506–7 chromophores, 510, 511 chromosome instability, 353 chronic obstructive pulmonary disease, 176 CHRPE see congenital hypertrophy of retinal pigment epithelium cisapride, 213 clearing colonoscopy, 118 repeat, 463 641 Clinical Outcomes Research Initiative (CORI), 90 clinical practice guidelines, 90, 91 clip-fixing devices, 281 clipping technique, 288 clips, 280–2, 287–91 applicators, 288 hemostatic, 283 iatrogenic perforations, 290, 291 location marking, 437 mucosal, 282 three-layered system, 288 clonality, 351 clopidogrel, 227 closed loop phenomenon, 611 Clostridium difficile, 311 diarrhea, 585 pediatric colonoscopy, 627, 628 pseudomembranous lesions, 578 coagulation coaptive, 410 thermal, 394–5, 396 depth, 400–1, 404, 406 heater probes, 397 hemostasis, 401 high-frequency, 399–402 coagulation probes, 397, 563 coagulopathy hematochezia, 561 hemoclip use, 289–90 postpolypectomy bleeding, 177 cobblestone appearance of mucosa, 574 colectomy dysplasia-associated lesion or mass lesion, 306 FAP, 157 juvenile polyposis, 163 laparoscopic-assisted partial, 439 – 40 malignant polyps, 384 partial for colonic angioma, 570 subtotal for HNPCC, 161 colitis acute, 519 acute self-limited (ASLC), 582 adenomas, 306 allergic, 627, 628 amebic, 585–6 bypass, 476 children, 624 chronic, 131 collagenous, 298, 543, 589 diversion, 591–2 drug-induced, 592 Escherichia coli, 584 fulminant, 108 glutaraldehyde, 314 indeterminate, 576 infectious, 301 ischemic, 567–8, 590 Escherichia coli differential diagnosis, 584 lymphocytic, 299, 301, 589 microscopic, 105, 121, 123, 299, 301, 628 pseudomembranous, 585, 628 radiation, 592 sexually transmitted diseases, 588 –9 see also diarrhea collagen contraction, 395 collagenosis, 495 642 Index colo-anal anastomosis, occlusive web, 474 colo-colon anastomosis with stricture, 475 colon acute pseudo-obstruction, 108, 596 – 601 adenocarcinoma, 154 adhesions, 329 anastomosis, 474 appearance, 475 – anatomy, 265, 266 angioma, 569–70, 571 anterior resection, 474 ascending, 336 – biopsy, 302–7 bleeding sites, 563, 564 cleansing, 210 –15 administration, 214 elderly people, 213 electrolyte lavage solutions, 211, 212, 213 hematochezia, 562 instructions for use, 214 pediatric use, 213 reduced-volume lavage, 213 safety, 214 sodium phosphate lavage, 171, 214–15, 593 colonoscopic decompression, 598, 599–601 decompression, 598 preoperative for malignant strictures, 616 deflation, 330, 332, 333 descending, 331 sigmoid colon junction, 329–31 distension, 550 –2 recurrent, 599 erosion, 191–2 evaluation proximal to obstructing lesion, 554, 556 excess air suctioning, 321 filling defects, 551, 552 fixed pelvic loop, 265 flexures/folds, withdrawal technique, 343 haustral folds flattening, 346 withdrawal technique, 343 hepatic flexure, 334, 335 – ileocecal region, 336 –8 insufflation, 321, 344, 550 –1 laparoscopic-assisted resection, 436 lesions detection of localized, 479 inaccurate localization, 180 location, 435–40 looping, 265 reversed splenic flexure, 332–3 luminal distension, 344 marker injections in wall, 437–40, 439–40 mobile, 265, 336 mobility, 331 pneumatic blowout, 172 preparation, 45, 210–16 progressive dilation, 598 proximal colonofiberscope insertion, 12, 13 tube insertion, 13 retroflexion, 344 –5, 346 splenic flexure, 331–3 mobile, 334 stenosis, 474–5, 574 stents, 616 surface structures, 479 surgery, 455–7 transmural ischemia, 598 transverse, 333–5 gamma looping, 334 hand pressure, 335 long, 266 ulcerations aphthous, 191–2, 573–4, 583 immunosuppression, 587, 588 see also crypts; mucosa; perforation, traumatic; pits, colonic; pseudoobstruction, acute colonic; sigmoid colon; strictures, colorectal colon cancer familial, 151–2, 153 FAP progression, 154 inherited syndromes, 153 juvenile polyposis, 163 linitis plastica, rectal, 542–3 colonocamera, colonofiberscopes development, 10–12, 12 forward-/side-viewing, 11 magnifying, 16–17, 18 rotating prism, 10, 11 tip angulation, 11, 12 colonoscopes aids for advancing, 630–1 automated reprocessors, 314 choice of instrument, 262–3 design, 314–15 disinfectant choice, 312–13 disinfection, 313–14 double balloon, 633 double-channel, 260 drying, 314 friction reduction, 631–2 handling, 320, 321 imager, 16 incarceration, 177 Innoflex®, 260–1 insertion distance, 436–7, 452 insertion tube, 259–63 lens, 366 color correction, 318 magnifying, 478–83, 485, 486, 501–7 pit patterns, 480 mechanical cleaning, 312 mother-and-baby system, 631 overtubes, 15, 260, 630–1 double-balloon method, 633 lubrication, 632 pediatric, 262, 626 pediatric-diameter long-length, 259 polypectomy, 411 large polyps, 424 propulsion systems, 632–6 ant, 635 balloon devices, 633–4 belts, 636 earthworms, 632–4 inchworm, 633 legs, 634–5 limpet, 634 lizard, 635 millipede, 634–5 octopus, 636 serpentine robot, 634 snakes, 634 starfish, 634 suction crawler, 634 water jet, 636 wheels, 636 reprocessing, 309, 312–14 compliance, 314 current standards, 314 retroflexion, 344–5, 346, 443 rinsing, 314 robots, 633–4, 635, 636 rotation, 418, 428 short bending segment, 260 spines, 631 standard, 262 stiffeners, 13, 15, 260, 262, 631 storage, 314 straightener, 259 therapeutic, 424 tip angulation, 9, 10 variable-stiffness, 260–1, 263 magnetic imaging, 273 technique, 261–2 wireless capsule, 636–7 zoom, 478 see also insertion technique; looping of scope; video colonoscope colonoscopy assistant, 44–54 nurses, 44 patients monitoring, 45–6 preparation, 44–5 sedation, 46 personal protective equipment, 46 postprocedure care, 49 preparation, 52–4 during procedure, 46–7 protective equipment, 49–50 recovery care, 49 reusable equipment processing, 50 –1 setting up room, 45 snare operation, 47–8 stock checklist, 51, 52 supplies ordering, 51 colonoscopy suite planning, 21–7, 28, 29–35, 36, 37–43 administration area, 41–2 air conditioning, 39 ambulatory facilities, 22–3 arrangement, 27, 29–31 assessment, 23 block diagrams, 31 business office, 41–2 cabling, 35, 37, 40 capacity, 24 changing areas, 26, 29 communications systems, 39 – 40 connectivity, 40–1 design, 23 development, 31–5, 36, 37– 42 emergency system, 41 environmental factors, 42 flow patterns, 29–30 heating, 39 intercom system, 40 lighting, 39 offices, 22 operational efficiency, 24 panic buttons, 41 Index patient movements, 30 plumbing, 39 preliminary plan, 31 preparation areas, 29 –30 privacy regulations, 25, 42 procedure rooms, 23 – 4, 25, 29, 30, 31 cabling, 35, 37 components, 32 conduits, 37 design, 31–3 doors, 37, 38 emergency facilities, 38 –9 equipment arrangement, 33 –5, 36, 37 layout configurations, 32–3, 34, 35 materials, 38 privacy, 37–8 setting up, 45 size, 31–2, 33 soundproofing, 37– TV monitor positioning, 35 walls, 37, 38 program, 23, 26–7, 28 project planning, 21–3 recovery space, 24 – 6, 29 –30, 31 regulatory requirements, 42–3 room size standards, 26 –7 scope cleaning/storage, 26, 29, 30 security system, 41 staff movement patterns, 30 needs, 27 step-down room, 25– storage requirements, 26 telephone service, 40 ventilation systems, 39 waiting areas, 29 –30, 42 wireless system, 40 coloproctectomy, restorative, 578 color-chip video imaging, 250 –2 color sources, juxtaposition, 252 color video, 249–52 colorectal cancer (CRC) abdominal pain, 122 adenocarcinoma children, 628 staging, 538–42 anastomotic, 468, 469, 472, 474, 475 bleeding indications, 103, 104 carcinoembryonic antigen, 469, 472 monoclonal antibody, 527, 529 –30 care costs, 136 chromosome loci, 152 colonoscopy follow-up, 468–76 protection, 339 Crohn’s disease, 106 depressed tumor relationship, 493 detection, 96 diagnosis, 111, 297 diarrhea, 120–1 distribution, 108 familial risk determinants, 151–2 family history, 131 adenoma prevalence risk, 363 flat adenoma relationship, 493 genes/genetic testing, 152 gross appearance, 478– 84, 485, 486 hereditary, 151– 64 genetic testing, 156 –7 high-frequency ultrasonography, 541–2 incidence and polypectomy effect, 339, 460, 463–4 inflammatory bowel disease, 124 invasive, 364, 461, 479 adenomas, 482–3 depressed lesions, 483, 484 iron-deficiency anemia, 115, 116, 117 melena, 123 metachronous, 473 metastases, 385, 473, 541 metastatic potential, 385 microsatellite instability, 339–40 missed, 179, 339–43 mortality polypectomy effect, 463–4 reduction with NSAIDs/aspirin, 354 mucosal tumors, 542–3 multistep genetic events, 365 N-stage assessment, 540–1 pits classification, 482 pattern, 480 polypectomy effect on incidence/mortality, 339, 460, 463–4 polypoid carcinoma, 456 poorly differentiated carcinoma, 452, 454 positive fecal occult blood test, 119–20 precursors, 379 preoperative staging, 538–42 prevention, 96, 111, 339 programs, 144 rate, 136 progression from adenoma, 354, 358, 362 recurrence, 472, 473 anastomotic, 474, 475 detection, 541 early diagnosis, 473 intraluminal, 468–9, 473 local, 473 rate, 107–8, 464 resection colonoscopy after, 468–76 follow-up after, 118–19 surveillance after, 107–8, 469, 470 risk following polypectomy, 460 stratification, 464 screening diagnostic yield, 122–3 familial cancer, 152 mortality impact, 341 risk reduction, 134 sensitivity, 341 sigmoidoscopy, 132 sporadic, 137, 340 staging, 539–41, 542 submucosal tumors, 542–3 surveillance, 118–19, 304–5, 469, 470 after resection, 107–8, 469, 470 survival rate, 470–2 T-stage assessment, 538–40, 542 tandem studies, 341–2, 462 TNM classification, 538–41, 542 tumor tracking, 427–8 ulcerative colitis, 575–6 unexplained weight loss, 123 virtual colonoscopy, 547–8 sensitivity, 557 643 see also depressed tumors; hereditary non-polyposis colorectal cancer (HNPCC) colorectal tumorigenesis model, 495, 496 colorectal wall anatomy, 537–8 colostomy cleansing, 215 end, 475 evaluation, 475 communication, informed consent, 57 competence acquisition, 65–6, 67 assessment, 63–4, 67–8 conscious, 79 definition, 63 procedures for achieving, 64–5 unconscious, 79 complications of colonoscopy, 170 – 80 anxiety, 176 bleeding extraluminal, 174–5 intraluminal, 174 bowel preparation, 171 cardiopulmonary, 175–6 inaccurate localization of lesions, 180 infectious, 176–7 intubation, 171–7 missed lesions, 179–80 mortality, 171 perforation, traumatic, 171–7, 598 postpolypectomy syndrome, 179 rates, 57 snare impaction in polyp, 179 therapeutic procedures, 177–9 thermal injury, 179 computed tomography (CT) multidetector row spiral scanners, 552, 553, 558 stent artifacts, 616 computed tomography (CT) colonography, 104, 460 cost-effectiveness, 144 CRC recurrence, 541 incomplete colonoscopy, 556 screening, 133 sensitivity, 558 see also virtual colonoscopy computer-assisted colonography, 144 –5 computer-based simulators, 85–7 condylomata, 589, 590 confidentiality, 61 conflicts of interest, 57 congenital hypertrophy of retinal pigment epithelium (CHRPE), 155 Congo red, 503 Conjoint Committee for Recognition of Training in Gastrointestinal Endoscopy of Australia, competence procedures, 64 constipation, 105, 266 contaminated areas, cleaning, 51 continuous quality improvement, 89 –100 cycles, 92 endoscopic unit record, 93–4 endoscopy gastrointestinal, 92–5 review process, 94 physician-specific quality indicators, 95 procedure reports, 93 644 Index continuous quality improvement (cont.) process, 91–2 quality indicators, 95 –9 contraindications to colonoscopy, 108 –9 contrast agents, 280 intravenous, 552 contrast enema, acute colonic pseudoobstruction, 597 CORI see Clinical Outcomes Research Initiative corticosteroids inflammatory bowel disease efficacy, 577 radiation proctopathy, 603 cost-effectiveness analysis, 139 – 40 competing screening strategies, 143 – limitations, 147–8 threshold analysis, 145 coumadin see warfarin Cowden’s syndrome, 163 – cancer screening, 157, 158 CpG island methylator phenotype (CIMP), 353, 354, 356 cresyl violet see crystal violet critical devices, 310 Crohn’s disease activity index, 577 aphthous ulcer, 573 – biopsy, 301–2, 303 – cancer surveillance, 304 – chronic colitis, 131 colon perforation risk, 172 complications, 579 diarrhea, 121 differentiation from ulcerative/ indeterminate colitis, 576 dysplasia surveillance, 98, 305, 306 endoscopic index of severity, 576 –7 endoscopy, 573 –5 perioperative, 577– esophageal involvement, 575 established, 106 fissure ulcerations, 574 ileocecal valve entry, 338 infectious diarrhea differential diagnosis, 583, 584 light-induced fluorescent endoscopy, 515–16 lumps and bumps, 305 – pseudopolyps, 306, 574 stenosis, 574 stents, 615 strictures, 574, 579, 611–12, 614 balloon dilation, 614 surgery and disease recurrence, 578 upper gastrointestinal involvement, 574–5 cross-contamination prevention, 26 Cryptosporidium (cryptosporidiosis), 312, 588, 589 crypts, 479 crosscut, 298– shape, 17, 18 crystal violet, 17, 18, 478, 483, 484, 502 cutaneous lesions, FAP manifestation, 155 cyclo-oxygenase (COX-2) inhibitors, 158 cytomegalovirus (CMV), 587 biopsy, 302, 303 strictures, 612 cytosine–guanine (CpG) sequences, 353 DALM see dysplasia-associated lesion or mass data organization, 184–5 transmission, 61 types, 183–4 decompression, colonoscopic, 598, 599–601 malignant strictures, 616 radiation proctopathy treatment, 606, 607 decompression tubes, 600–1 deep vein thrombosis, anticoagulation, 225, 226 definition type document (DTD), 198 depressed tumors, 481–4, 485, 486 association with advanced pathology, 493 biologic significance, 492–5, 496 carcinoma relationship, 493 clinical significance, 492–5, 496 diagnosis, 483–4, 485, 486 endoscopic criteria, 488 epidemiology, 489–92 genetic pathway, 495, 496 incidence, 509–10 invasive carcinoma, 483 pathologic criteria, 488–9 significance, 493 desiccation, thermal, 395, 398 desmoid tumors FAP manifestation, 155 management, 159 Désormeaux, 3–4 devitalization, thermal, 394, 395 outside coagulation zone, 400–1 diagnosis, consequences, 299 diagnostic yield by indication, 111–26 clinical indications, 112–24 ileoscopy, 124–5 reliability of colonoscopy, 125–6 diarrhea biopsy, 298, 302–3 chronic, 105, 628 diagnostic yield, 120–1, 122, 123 evaluation, 298 FAP, 153 idiopathic, 589–93 infectious, 582–7 see also colitis diathermy burn, endoscopic, 452–3 diazepam, 230 DICOM protocol, 196–8, 204 gastrointestinal endoscopy, 204 diet restrictions, colon cleansing, 210–11 Dieulafoy lesions, 289 band ligation, 292–3 difficulties at colonoscopy, 263, 266, 439–40 see also complications of colonoscopy digital imaging, 202–7 file compression, 202–3 size, 202 pixel density, 202 video, 205–6 digital imaging and communication in medicine see DICOM protocol digital rectal examination, documentation, 341 digital subscriber line (DSL), 73 dilators, over-the wire plastic balloon, 613 disinfectants, 51 choice, 312–13 disinfection, 309–10, 312–15 equipment, 50, 51, 177 high-level, 309, 313–14, 315 distributed processing, 196–7 diverticular disease, 266, 328–9, 591 endoscopy, 591 strictures, 612 stents, 615 diverticular hemorrhage, 564, 565, 566 diverticulitis, acute, 108–9 colon perforation risk, 172 diverticulosis hematochezia, 564 with muscular hypertrophy, 172 polypectomy, 430 diverticulum duodenal, 289 mini-snares, 431–2 polypectomy in narrow segment, 430–5, 436 DNA damage, 352 repair mechanisms, 352 sequencing, 156 DNA methyltransferase, 353 DNA microsatellites, 159 DNA mismatch repair genes, 159, 160, 161 germline mutations, 156, 354 HNPCC, 352, 354 inactivation, 340, 353, 354 documentation informed consent, 59–60 medical–legal risk avoidance, 340 –1 Doppler optical coherence tomography, 524 Doppler ultrasonography, 540 Dormia basket, 428, 445 drugs, fluorescent, 519–20 clinical evaluation, 520–1 duodenal adenoma management, 158– duodenal cancer, 155, 156 duodenal diverticula, 289 DVDs teaching courses, 74 training, 71–2, 73 dye-spraying, 347–8, 490 diminutive adenomas, 515 flat adenomas, 451 indigocarmine dye, 503, 504, 506 dyes, 16, 17 chromocolonoscopy, 478 classification, 501–3 colon wall injection, 438–9, 440, 452 fluorescent, 527, 528 rectal mucosa, 6, see also tattoo, endoscopic; named dyes and stains Index dysplasia, 361, 362, 364, 368, 385 differentiation from hyperplasia, 518 fluorescence endoscopy, 513 light-induced, 515 grade, 362, 381 hamartomatous polyps, 388 high-grade, 381–2, 421, 448 depressed lesions, 492, 493 flat adenomas, 492, 493 frequency, 450 light-induced fluorescent endoscopy, 515, 517 malignancy risk, 450, 460, 461 malignancy rate, 362 nonpolypoid, 487–9 optical techniques for endoscopic detection, 509 –32 pathology, 380–2, 381–2 precursor cells, 495 surveillance, 98, 305, 306 ulcerative colitis detection, 520 –1 surveillance, 98, 305, 306 uterus, 161 dysplasia-associated lesion or mass (DALM) lesion, 305, 306, 385 light-induced fluorescent endoscopy, 515–16, 517 e-learning, 72–3 echoendoscopes, 536 elderly people, gut lavage, 213 electric arcs, 398–9 electric current, target tissue, 398 electro-hydro-thermo probes, 399 electrocautery, 283 multipolar device, 280 needle-knife device, 614 electroincision of strictures, 614 electrolyte lavage solutions, 211 adjuncts, 213 sulfate-free, 212, 213 electronic images capturing systems, 201 color manipulation, 207 enhancement, 206 –7 information sharing, 201 narrow-band, 207 pictures needed, 206, 207 spectroscopy, 207 standardized terminology, 207–9 electronic media, training, 70 –3 embolic event risk, 226 emergencies, informed consent, 59 endocarditis see bacterial endocarditis endoloop see snares, loop, detachable endoscopes automated reprocessors, 314 cleaning, 26, 309, 312–15 color chip, 247 design, 314–15 double-channel, 425 early, 1–4 electronic, 13–14 early, 14 hematochezia, 562, 563 imaging configuration, 15–16 lubrication, 632 optical techniques for dysplasia detection, 509–32 rigid, 1–6 shaft looping, 15 stiffening, 14–15 storage, 26 ultra-thin, 14, 14 stiffening, 14–15 vibrating, 632 video camera connection, 14 endoscopic coagulation, radiation proctopathy, 605–8 endoscopic database, 184–5 statistical analysis, 194 endoscopic dilation of strictures, 612–14 endoscopic images color, 247–54 compression, 204–5 algorithms, 206 DICOM protocol, 196–8 digital video, 205–6 exchange, 196–8 management in computer systems, 196 Minimal Standard Terminology (MST), 183, 185–7, 188–90, 190–5, 208–9 production of digital, 195–6 reading, 245–6 reporting, 201 shape, 247, 248 standardization, 195–6 standardized terminology, 207–9 use in clinical practice, 198 see also Minimal Standard Terminology (MST) endoscopic mucosal resection (EMR), 424–30 biopsy specimens, 296–7 cap-assisted, 284–5 dysplasia-associated lesion or mass lesion, 306 submucosal fluid cushion, 425–7 endoscopic report, 199–209 diagnosis, 187 elements, 199–201 extent of examination, 186 findings, 186–7 Minimal Standard Terminology, 183, 185–7, 188–90, 190–5 reasons for examination, 186 software for generation, 68 standardization, 183–98 text, 199–201 therapeutic procedures, 187 endoscopic retrograde cholangiopancreatography (ERCP) catheters, 280 simulators, 84, 85, 86 endoscopic therapy for strictures, 612–18 endoscopic ultrasonography (EUS) see ultrasonography, endoscopic endoscopists expert and magnetic imaging systems, 272–3 specialty background, 65 endoscopy argon plasma coagulation, 406 Crohn’s disease, 573–5 depressed lesion detection, 496–7 645 diathermy burn, 452–3 diverticular disease, 591 everting toposcopic, 632 flat adenoma detection, 496–7 high colonic, 6–7 historical prediction, 1, history, 1–20 image enhancement, 17, 18 inflammatory bowel disease, 573 –9 ischemic colitis, 590 landmarks, 437 learning curves, 65–6 magnifying, 16–17, 478 Nd:YAG laser, 405–6, 606–7 open-access, 96–9 outcome variations, 65 radiation proctopathy therapy, 604 –8 retroflexion, 260 thread-guided pull, 631 ulcerative colitis, 575–6 white-light, 509, 510, 513, 514, 518, 519 wireless capsule, 636–7 see also fluorescence endoscopy; ultrasonography, endoscopic (EUS) endoscopy information system (EIS), 183, 184 enemas, 210–11 Entamoeba histolytica, 585–6, 587 enteric fever, 582 Enterobacter transmission, 311 enterocolitis, 582–3 enteroscope double-balloon, 633 push, 259 rope-way, 631 epinephrine, 48 hematochezia, 565, 568, 569 hemostasis, 283 pedunculated polyps, 422 polypectomy, 425 retroflexion, 338 sessile polyp, 423 eptifibatide, 227 equipment accessories, 276–85 arrangement in colonoscopy suite, 33–5, 36, 37 availability for sedation/analgesia, 233 cleaning, 50–1, 177, 309–15, 637 contaminated, 176–7 decontamination, 50 disposable, 51 hematochezia, 562, 563 pediatric colonoscopy, 626 reprocessing, 50–1, 309 reusable, 279 processing, 50–1 sterilization, 50, 177, 309–10 see also disinfection; named items Erlangen simulator models, 85 erythromycin, intravenous, 599 Escherichia coli, 584 esophagogastroduodenoscopy simulators, 84, 85 esophagus, Crohn’s disease, 575 ethylene oxide sterilization, 309 European Diploma of Gastroenterology, 64 646 Index European Society for Gastrointestinal Endoscopy (ESGE), 204 evidence-based approach, 91 eye protection, 50 facial trichilemmomas, multiple, 164 familial adenomatous polyposis (FAP), 153–9, 354 adenoma regression, 354 cancer development, 358 familial polyposis, 131 gene mutations, 133 family physicians, cecal intubation rate, 67 fatty acids, short-chain, 603 fecal impaction, 568 fecal matter, residual, 210 fecal occult blood tests, 105, 108 combined flexible sigmoidoscopy, 132–3 compliance with repeat screening, 132, 134 cost-effectiveness, 143, 144 frequency, 547 positive, 111, 112 colonoscopy following, 144 diagnostic yield, 119 –20, 121 follow-up testing, 133 – screening, 131, 132, 134 fecal tagging, 550 fecoliths, 591 Federation of Digestive Disease Societies, competence procedures, 64 fentanyl, 626 fibergastroscope development, fiberoptic confocal imaging, 526 fiberoptic viewing bundles, 7, 11–12 composition, 243 fiberscopes, 8–9 fine-needle aspiration biopsy, 537 lymph node staging, 541 fissure ulcerations, 574 fistulae Crohn’s disease, 574 palliation of malignant, 618 flexible sigmoidoscopy see sigmoidoscopy, flexible fluid suction, 321–2 withdrawal technique, 344 flumazenil, 98–9, 231 fluorescein isothiocyanate, 529 fluorescence detection geometry, 516, 518 drugs, 519–20 clinical evaluation, 520 –1 exogenous photosensitizer-induced, 519–20 nondysplastic, 519 tumor-associated mucins, 528 fluorescence endoscopy, 512–14 confocal, 525–7, 530 devices, 526 miniaturization, 526 –7 disadvantages, 518 –19 excitation/emission matrices, 512 –13 excitation wavelength, 516 false positives, 519 imaging, 512 light-induced, 514–16 lesion boundary, 519 mucosal thickening, 517–18 neoplasia, 517–18 point spectroscopy, 512–13 steady-state measurements, 513 fluorophores, 510 excitation, 516 fluorescence spectrum, 511 monoclonal antibody labeling, 527 near-infrared, 530 fluoroscopy, 266 colonoscopic decompression, 600 5-fluorouracil, 107 follow-up colonoscopy, 118 forceps, pronged, 444, 445 formalin, topical for radiation proctopathy, 608 frameshift mutations, 352 fulcrum technique, 428, 430, 431 fungal infection transmission, 311, 312 Gardner’s syndrome, 156 gastric cancer screening, 161 gastric lavage, hematochezia, 562 gastrocamera, gastroenteritis, 582–3 gastroenterologists, competence, 67 gastrointestinal tumors hamartomas, 164 stromal, 542 Gastrophotor, 7, gastroscopes, 259–60 pediatric, 260 polypectomy in narrow diverticular segment, 431–2 gender adenoma prevalence, 361 difficulty at colonoscopy, 263, 266 gene expression silencing, 353 gene mutations, 133, 351, 352 see also named genes genetic testing, 133 Bannayan–Ruvalcaba–Riley syndrome, 164 Cowden’s syndrome, 164 CRC, 152 HNPCC, 160–1 juvenile polyposis, 163 Peutz–Jeghers syndrome, 162 genomic instability, 354 gentamicin, prophylactic, 221 germline mutations, 351 glands of Lieberkühn, 502 glioblastoma multiforme, 156 gloves, 49, 50 glucose desiccation, 395 glutaraldehyde, 49, 313, 314 glycoprotein IIb/IIIa receptor antagonist, 227 gonorrhea, 588 graft-versus-host disease (GVHD), 302 granulomas, 301 gray-scale images, 203 gray-scale shading, 16, 269 grounding pad, electrical, 47–8 guanethidine, 598 gut lavage, 211 administration, 214 contraindications, 215–16 elderly people, 213 flavoring of solutions, 211–13 instructions for use, 214 pediatric use, 213 phosphates, 214–15 reduced-volume, 213 safety, 214 hamartomatous polyposis, 354 hand-coil, 16 Hartmann pouch, 475 haustral folds flattening, 346 polyp lodging, 443 withdrawal technique, 343 hazardous substances, 49–50 Health Insurance Portability and Accountability Act (HIPAA, 1996), 61 health-related quality of life (HRQL), 139, 147 heater probes, 283–4, 396–7 radiation proctopathy, 608 Helicobacter pylori inflammatory changes, 479 transmission, 311 hematochezia, 105, 112, 113, 561–71 bowel preparation, 562 coagulation probes, 563 colonic angioma, 569–70, 571 colonic bleeding sites, 563, 564 delayed postpolypectomy bleeding, 568–9 diagnostic evaluation, 562 diagnostic yield, 112–14 diverticular hemorrhage, 564, 565, 566 endoscopes, 562, 563 epinephrine, 565, 568, 569 equipment, 562, 563 evaluation, 111 internal hemorrhoids, 564, 566 –7 ischemic colitis, 567–8 patients admissions, 563–4 evaluation, 561–2 pediatric colonoscopy, 627 resuscitation, 561 solitary rectal ulcer syndrome, 568 thermal coagulation, 569 transfusion, 564, 567 volume depletion, 561 see also bleeding; coagulopathy hematoporphyrin, 607 hemicolectomy, left, 474 hemoclips, 282, 289–91 metallic, 402 hemorrhoidectomy, surgical, 567 hemorrhoids, 113 internal, 564, 566–7 hemosiderin deposits, 591 adenoma, 382 hemostasis alcohol solution, 283 bands, 287 clips, 282, 287, 288–91 coagulative, 283 collagen contraction, 395 epinephrine, 283 Index hemoclips, 402 laser therapy, 406 loops, 287 snares, 410 thermal, 408 thermal coagulation, 401 Henoch–Schönlein vasculitis, 628 heparin low-molecular-weight, 226 postpolypectomy bleeding, 177 substitution for warfarin, 225 – heparin window, 224, 225 – hepatic flexure, 334, 335– hepatitis B virus, 310, 311 hepatitis C virus, 310, 311, 637 hepatoblastoma, FAP manifestation, 155 hereditary non-polyposis colorectal cancer (HNPCC), 131, 133, 156 cancer screening, 161 clinical presentation, 159 – 60 diagnostic criteria, 160 DNA MMR gene mutation, 354 epidemiology, 159 – 61 etiology, 159 extracolonic manifestations, 159 – 60 family history, 457 genetic testing, 160 –1 malignant polyps, 448 mutation, 352 phenotype, 159 polyp distribution, 361 screening, 157, 158, 161, 340 small flat adenomas, 451 treatment, 161 variants, 160 hereditary polyposis syndromes, 628 herpes simplex virus, anorectal, 589, 589 high-frequency (HF) surgery, 397–9 bipolar instruments, 398 cutting for polypectomy, 400 –1 monopolar instruments, 398 polypectomy, 400 –2 safety, 402 high-frequency (HF) surgical coagulation, 399 – 402 bipolar instruments, 399, 400 electro-hydro-thermo probes, 399 monopolar instruments, 399 Hirschsprung’s disease, biopsy, 302 histoplasmosis, 585 HIV infection, 637 transmission, 310 HNPCC see hereditary non-polyposis colorectal cancer hospital information system (HIS), 183 hospital privilege granting, 63 HRAS1-VNTR mutation, 152 hydrogen, 210 hydrogen peroxide, 313 5-hydroxytryptamine (5-HT4) receptor agonists, 599 hypercapnia, 176 hypertelorism, 163 hypochondrium, 335 hypotension, 175 hypoxia, 176 ICER see incremental cost-effectiveness ratio ileal pouch–anal anastomosis, 578 ileocecal region, 336–8 ileocecal valve, 332, 334 cannulation, 80 entry, 336–8 with biopsy forceps, 337–8 in retroversion, 338 flat polyp, 433 retroflexion, 346 withdrawal technique, 343 ileoscopy diagnostic yield, 124–5 mother-and-baby system, 631 ileostomy, recurrent inflammation, 578 ileum insertion technique, 337, 338 terminal, 338 illumination, wide-beam, 516, 518 image enhancement, 17, 18 imager probes, 16 immunity, impaired, 221, 223 immunophotodiagnostics, 527–30, 531 clinical evaluation, 528–30 immunoscopy, 529 immunosuppression, 587, 588 strictures, 612 implied consent, 59 incomplete colonoscopy, 67, 553–4, 556 incremental cost-effectiveness ratio (ICER), 139, 142, 143, 144 ulcerative colitis, 145 India ink, 438–40, 452 hematochezia, 562 multiple injections, 439 sterilization, 438–9 indications for colonoscopy, 102–8, 103–4 alternative techniques, 104–5 classification, 102–4 diagnostic, 102, 103 diagnostic yield, 111–26 risks, 103 specific, 105–8 therapeutic, 102, 103 yields, 103–4 indigocarmine dye, 17, 18, 478, 483, 484, 485, 503 diminutive polyps, 504 pit pattern detection, 496, 497, 498 ulcerative colitis, 506, 507 indocyanine green, 17, 438 antibiotic prophylaxis, 439 see also chromoendoscopy infection complications of colonoscopy, 176–7 contaminated equipment, 176–7 prevention, 177 reusable biopsy forceps, 279 transmission, 310–12, 637 prevention, 26 inflammation India ink, 438 mild chronic, 299, 302 multifocal, 301–2 recurrent in ileostomy, 578 inflammatory bowel disease biopsy, 298, 303–6 cleansing of colon, 215 diagnostic yield, 123–4 647 diversion colitis, 592 dysplastic polyps, 385 endoscopic ultrasound, 543 endoscopy, 573–9 extent, 576–7 indications, 579 severity, 576–7 inflamed mucosa, 519 iron-deficiency anemia, 115, 116 light-induced fluorescent endoscopy, 515–16 pediatric colonoscopy, 628 pseudopolyps, 306 stents, 615 strictures, 611–12, 614 therapeutic efficacy monitoring, 577 information disclosure, 56 electronic transfer, 61 sharing, 201 withholding, 59 information object, 204 information object definitions (IOD), 197, 204 informed consent, 45, 55–62 documentation, 59–60 elements, 58 endoscopic report, 200 exceptions, 59 failure to obtain, 57 history, 55 legal history, 55–6 missed lesions, 341 person giving, 58–9 postpolypectomy bleeding treatment, 178 process, 58 scope, 59 voluntary, 61 waiving of rights, 59 withdrawal, 60 informed refusal, 59 infrared light, 18 injection needles, 279–80 Innoflex®, 260–1 insertion technique, 318–38 air suction, 321 ascending colon, 336–8 assistants, 320 clockwise twist-and-withdraw maneuver, 330–1 colonoscope handling, 320, 321 completion, 321–3 counterclockwise straightening maneuver, 333 diverticular disease, 328–9 fluid suction, 321–2 hepatic flexure, 334, 335–6 ileocecal region, 336–8 ileum, 337 insufflation, 321 patient position, 318, 330, 332, 337 sigmoid colon–descending colon junction, 329–31 single-handed, 319 splenic flexure, 331–3 steering, 321–3 transverse colon, 333–5 two-person, 320 648 Index insertion technique (cont.) visual clues, 322 withdrawing, 322, 330 –1 insufflation, 321 colon, 550–1 withdrawal technique, 344 insulin-like growth factor receptor (IGF2R) gene, 356 Internet broadband connection, 40 –1 training, 72–3 Internet 2, 73 intervals for colonoscopy, 96 intestinal pull-up methods, 13 intramucosal carcinoma, 448 intraoperative colonoscopy, 172, 437 intubation complications, 171–7 intussusception, 628 iron-deficiency anemia, 105, 111 colonic angioma, 569 diagnostic yield, 114 –17 irritable bowel syndrome, 105 JC virus, 353 joint prostheses, 221 JPEG file compression, 203 juvenile polyposis, 163 cancer screening, 157, 158 K-ras proto-oncogene, 351–2 mutations, 355, 356, 494 –5 Keckring’s folds, notches, 575 ketamine, 233 Kussmaul, Adolph, LAN (local area network), 40 landscaper genes, 354 language, structured, 194, 208 –9 laser fibers, 283, 284, 405, 407, 408 laser phototherapy in radiation proctopathy, 604 laser protection, 50 laser therapy, 404 – 6, 407 flat polyps, 434 malignant strictures, 615 –16 palliation, 617 preoperative therapy, 616 radiation proctopathy, 604, 606 –7 thermal vaporization, 395 video colonoscope, 254 – laxatives, 210–11, 211 learning curves, endoscopic, 65 – learning cycle, 79 learning pyramid, 80 Leiter’s rectoscope, Lhermitte–Duclos disease, 164 licensed practical nurse (LPN), 44 licensed vocational nurse (LVN), 44 light absorption by blood, 516, 518 conductor (lichtleiter), 1– depth of penetration, 510, 511 see also photons light-scattering spectroscopy, 523 linitis plastica, rectal, 542– linkage analysis, 156 lipomas, 542 liquid chemical sterilant (LCS), 309, 312–13 liquids, clear, 210 –11 loop delivery device, 291 looping of scope, 15, 46–7 control, 262 counterpressure, 259, 261, 263, 272 external to patient, 328, 329 frequency of difficulties, 265 identification of site, 266 magnetic imaging systems, 267, 271, 272, 274 patient positioning, 259, 261 training to avoid, 80–1 loops see snares, loop, detachable loss of heterozygosity, 353, 355, 356 lymph nodes dissection, 455 metastatic, 455, 541, 542 size, 541 lymphangioma, 542 lymphatic invasion, 391, 455 lymphogranuloma venereum, 588 lymphoma, 542 B-cell, 389 mantle cell, 389, 390 polypoid, 389–90 Lynch syndrome see hereditary nonpolyposis colorectal cancer (HNPCC) M cells, 495 macrocephaly, 163 magnesium citrate, 213 magnetic endoscope imaging (MEI) device, 80, 262, 263, 265 impact on colonoscopy practice, 270–4 magnetic imaging systems, 265, 266–75 3D, 16 colonoscopy performance, 271–3 colonoscopy training, 273–4 generator coil assemblies, 266–7, 268 hand-pressure sensor, 270, 271 imager display, 267 impact on colonoscopy practice, 270–4 looping of scope, 267, 271, 272, 274 magnetic field generation, 268, 269 patient plate, 270 patient positioning, 268, 270, 271 polyp localization, 437 position sensing, 266–7, 268 prototype, 266–7, 268 sensor coils, 268 tip location, 271–2 use, 274 variable-stiffness colonoscopes, 273 magnetic positional imager, 80 magnetic resonance imaging (MRI), stent artifacts, 616 magnetic resonance imaging (MRI) colonoscopy cost effectiveness, 144 CRC recurrence, 541 screening, 133 magnifying colonoscopy, 478–83, 485, 486, 501–6, 507 diagnostic colonoscopy, 637 history, 16–17 pit patterns, 480 malignancy carcinoid tumors, 391 invasion depth, 539 strictures, 611–12 ulcerative colitis, 575–6 Mallory–Weiss tears, 289 band ligation, 293 malpractice actions, 57–8 Markov process, 141–2, 143, 145 mass, use of term, 192 medical device categories, 309 –10 medical–legal risk, missed neoplasms, 340–1 melanosis coli, 592 melena, 105, 111 diagnostic yield, 123 meperidine, 230, 231 mesenteric damage, 174–5 mesocolon, transverse, 334 mesorectal excision, total, 474, 541 metastases CRC, 385, 473, 541 lymph nodes, 541, 542 regional, 455 methane, 210 methylene blue, 17, 47–8, 502 with Congo red, 503 spatter distance, 50 see also chromoendoscopy metoclopramide, 213 microelectronic micromachined systems (MEMS), silicon-based, 526 –7 microorganism transmission, 26, 310 –12, 637 microsatellite instability, 159, 353, 356 genetic pathway, 339–40 HNPCC testing, 160–1, 340 microscopy, intraluminal, midazolam, 230, 231 pediatric colonoscopy, 626 with propofol, 235 mini-snares, 415, 416, 430 diverticulum, 431–2 Minimal Standard Terminology (MST), 183, 185–7, 188–90, 190 –5, 208 –9 advantages of use, 193 dissemination among software developers, 195 list of terms, 187, 188–90, 190 –2, 193 maintenance, 194–5 standardization, 194 validation, 193 miniprobes, 536, 537 missense mutations, 352 models, practice, 80 molecular beacons, 348 monoclonal antibodies CEA, 527, 529–30 fluorescence-conjugated, 529 –30 fluorophore labeling, 527 mortality rate, 171 MPEG compression algorithm, 206 MSH mutations, 160, 356 MSH6 syndrome, 160 Minimal Standard Terminology see MST MTHFR mutation, 152 mucins, colonic, 528 mucosa cobblestone appearance, 574 congested, 191 erythematous, 191 melanosis coli, 592 Index misplaced, 382, 383, 385 pressure-induced, 568 prolapse, 388–9 rectal, 6, stercoral ulcers, 593 thickening, 517–18 traumatic herniation, 382 tumors, 542–3 ulcerated, 192, 193 ulcerative colitis, 575 – visualization, 346 –8 see also endoscopic mucosal resection (EMR) mucosa-associated lymphoid tissue (MALT), marginal zone lymphoma, 389, 390 Muir–Torre syndrome, 160 multipolar electrocautery (MPEC) probes, 283, 284 muscularis propria damage avoidance, 393, 397 invasion, 391 mutational signatures, 353 – see also gene mutations mycobacteria transmission, 311, 312 Mycobacterium avium–intracellulare complex, 587 Mycobacterium tuberculosis, 311, 312 diarrhea, 584–5 myocardial infarction, 108 complication of colonoscopy, 176 screening colonoscopy complication, 135 Nakao snare and retrieval net, 446, 447 see also polyp retrieval naloxone, 98–9 narcotics, 230–1 propofol combination, 235 National Television System Committee (NTSC) standard, 257 Nd:YAG laser, 254 –5 electroincision technique, 614 flexible endoscopy, 406 laser phototherapy, 604 malignant strictures, 616 principles, 405–6 radiation proctopathy, 606 –7 safety in flexible endoscopy, 406 thermal vaporization, 395 near-infrared light, 522, 527 fluorophores, 530 needles, injection, 279 – 80 metal coil sheathed, 280 negligence, 57–8 Neisseria gonorrhoeae, 588 neoplasia/neoplasms, colorectal alternative pathways, 355 chromocolonoscopy detection, 503 – CIMP pathway, 356 fluorescence endoscopy, 517–18 genetics, 351 gross appearance, 480 microsatellite instability pathway, 356 missed, 339–43 cap-fitted colonoscopy, 346, 348 dye-spraying, 347–8 evidence for, 341–2 reduction, 346 – tandem studies, 341–2 variation between examiners, 342–3 wide-angle colonoscopy, 346–7, 348 nonpolypoid, 487–9 pit pattern, 480, 481 prior, 111 progression, 461 speed of conversion, 354 neostigmine, 108, 598–9 adverse effects, 599 nets, retrieval, 428, 444, 445, 446–7 nitrous oxide/oxygen mixture, 235 non-steroidal anti-inflammatory drugs (NSAIDs) adenoma regression, 354 biopsy information, 301 collagenous colitis, 589 colopathy, 592 COX inhibition, 226 CRC mortality reduction, 354 FAP management, 158 polyp reduction, 365 postprocedure bleeding, 227 stricture induction, 614 noncritical devices, 310 nongastroenterologists, competence, 67 nutritional therapy, 603 obstruction of colon, 192 occlusion of colon, 192 Occupational Safety and Health Administration (OSHA) regulations (US), 49–50 office endoscopy program, 27, 28 OMED standardized terminology, 208 oncogenes, 351–2 open-access colonoscopy, 60–1 optical biopsy, 531 optical coherence tomography, 496–7, 523–5, 530 clinical evaluation, 524–5 diagnostic colonoscopy, 637 mucosa/submucosa resolution, 542 optical image conversion, 245 osteoma, FAP manifestation, 155 outcomes management, 90–1 overtubes, 15, 260, 630–1 double-balloon method, 633 lubrication, 632 oxygen hyperbaric, 603 supplemental, 46 p53 gene, 353 inactivation, 355, 356 mutations, 494–5, 496 point mutations, 356 pancolitis, 583 pancreatic cancer, FAP manifestation, 156 pancreatitis, strictures, 612 panendoscopy, 562 paradoxical movement, 333 parasite transmission, 311, 312 parasympathetic nervous system, 596–7 pathologists biopsy, 298–302 information provision, 300–1 polyp specimens, 379 questions for, 301–2 649 patient plate, 270 patients acceptance of colonoscopy, 134 admission with hematochezia, 563 – age, 112, 114 cleansing instructions, 216 colonoscopy contraindications, 554, 556–7 diagnostic yield by indications, 112 drug regime, 301 gender, 112 history, 301 taking, 44–5 information for, 44, 56–7, 60 monitoring automated, 232–3 intraprocedure personal, 232 obese, 263 outcomes with missed neoplasms, 339–40 positioning, 259, 261, 268, 270, 271 endoscopic ultrasonography, 536 –7 insertion technique, 318, 330, 332, 337 polyp retrieval, 443 polypectomy, 419 stent endoscopic insertion, 619 postprocedure care, 49 preparation, 45, 232, 637 children, 625–6 colonic distension, 550–2 endoscopic ultrasonography, 536 –7 stent endoscopic insertion, 618 –19 virtual colonoscopy, 548–52 preprocedure assessment, 44 –5, 232 privacy, 37–8, 61 privacy regulations, 25, 42 recovery care, 49, 233–4 satisfaction, 99 screening option refusal, 554, 556 –7 sedated, 60 selection for training, 81 virtual colonoscopy preference, 556 –7 see also bowel preparation; informed consent pediatric colonoscopy, 624–8 bowel preparation, 625–6 complications, 627 contraindications, 624–5 equipment, 626 explanation to patient, 625 indications for, 624–5, 627–8 preparation, 625–6 risks, 627 sedation, 626 technique, 626–7 therapeutic, 628 pediatric scopes, stiffness, 15 peracetic acid, 313 percutaneous cecostomy, 601 perforation, traumatic, 171–7, 598 balloon inflation, 634 earthworm propulsion, 634 extraperitoneal, 173 pediatric colonoscopy, 627 polypectomy, 423 postpolypectomy, 178–9 prevention, 172, 178–9 rate, 171–2, 265 recognition, 172–3 650 Index perforation, traumatic (cont.) risk, 172, 329 surgical repair, 173 treatment, 173 – 4, 179 perforations, 99 free, 108 see also complications of colonoscopy performance indicators, 78 personal digital assistant (PDA) devices, 40 Peutz–Jeghers syndrome, 157, 158, 161–2 hamartomatous polyps, 387 Peyer’s patches, 338 phosphates gut lavage, 214 –15 red ring sign, 593 photodynamic therapy, radiation proctopathy, 607 photoelectric effect, 244 photographic images, 70 cecal landmarks, 97 endoscopic, 271 medical–legal risk avoidance, 340, 341 photography, sigmoidoscope, – photons absorption, 510 Raman spectroscopy, 521–2 scattering, 510 phrenicocolic ligament, 331, 333 o-phthalaldehyde, 313 pigment spots, Peutz–Jeghers syndrome, 162 pigs, simulator models, 85 piroxicam, polyp growth effects, 370 pits, colonic, 479 –81 classification, 479 – 80, 482 histology, 480 –1 patterns, 480–1, 483, 484, 485, 486 diminutive polyps, 504, 505 predictive value, 496, 497, 498 stains, 502 platelet aggregation, 226 –7 platelet cell-surface adenosine diphosphate receptor (P2T receptor) antagonists, 227 platelet inhibiting agents, 177 point mutations, 352 polyethylene glycol, bowel preparation, 550, 554 polyethylene glycol electrolyte lavage solution (PEG–ELS), 211–12, 213 administration, 214 polygon rendering, 270 polymorphonuclear leukocytes, stool smear, 627, 628 polyp trap, 416, 443 see also polyp retrieval polypectomy air aspiration, 417 ambulatory, 422– bleeding management, 282–3 cancer incidence, 463 – mortality, 463 – risk, 460 cap-assisted, 428 coagulation current, 411 colonoscopic, 410 colonoscopic snare, 13, 47– complications, 423 CRC protection against, 339 rate reduction, 134 current type, 411 cutting current, 411 difficult, 420–40 electrosurgical unit, 410–11 endoscopic, 452–3 open-access, 96–9 energy delivery, 411 epinephrine use, 178, 425 following flexible sigmoidoscopy, 144 fulcrum technique, 428, 430, 431 high-frequency surgery, 401–2 high-frequency surgical cutting, 400–1 iatrogenic perforations, 290, 291 injector needles, 414 inpatient, 422–4 malignant polyps, 384, 385 narrow diverticular segment, 429–35, 436 obscured vision, 418–19 perforations, 423 piecemeal, 297, 428, 429, 432–5 repeat clearing colonoscopy, 463 precolonoscopic laboratory testing, 415 principles, 410–19 rate variation, 343 repeat clearing colonoscopy, 463 residual fragments of adenoma, 434–5, 436 retroversion, 338, 433–4, 439 reverse lasso technique, 432 risks, 97 saline use, 178 site healing, 436, 437–8 localization, 452 marking, 306, 436 slide bar retraction stopping, 412 submucosal injection technique, 424–8, 432 flat polyps, 434 see also endoscopic mucosal resection surgical markers, 306, 436, 438–9, 440 surveillance after, 96–9, 106, 107, 117–18 techniques, 98, 415–19 therapeutic colonoscope, 424 thermal vaporization, 396 U-turn maneuver, 433–4, 435 see also postpolypectomy surveillance; snares polyps, 351–6 adenomatous see adenomas autopsy studies, 358–9 barium enema, 125 biopsy, 48 biopsy specimens, 296–7 carcinoma development, 368 chromocolonoscopy detection, 503–4 clamshell, 432–3, 434, 439 classification, 17 clinical–pathological correlation, 379 colonic adenomatous, 154 configurations, 415 criteria for removal, 421 CT, 133 cytology, 48 diagnosis, 111 diagnostic accuracy, 377 diagnostic yield, 117–18 diarrhea, 120–1 diminutive, 504–6 light-induced fluorescence endoscopy, 515 duodenal, 154–5 elevation, 426, 427, 428 embedding, 379 endoscopy studies, 359–61 FAP, 354 fixation, 378, 449 flat, 433, 433–4 ulcerative colitis, 506–7 follow-up, 117–18 fragment removal, 428 gastric, 154 growth, 365–71, 372 observational studies, 368 –70 protective factors, 370 risk factors, 370 hamartomatous, 161, 387–8 hematochezia, 112, 113, 114 histological artifacts, 377–8 hyperplastic, 361, 385–6 differential diagnosis, 510 dysplasia differentiation, 518 inverted, 386 light-induced fluorescence endoscopy, 515 hyperplastic–adenomatous, 386 incidence, 363–5 in polyp-free individuals, 364 –5 inflammatory, 388, 628 cloacogenic, 388 inflammatory bowel disease, 124 intramucosal carcinoma areas, 368, 370 juvenile, 163, 164, 628 pathology, 387 large, 420–2, 461 retrieval, 444 location, 177, 436–9 lymphatic invasion, 452 lymphoid, 389–90 malignancy risk, 365–6, 368 malignant, 18, 377–8, 383– 5, 448 –57 colonoscopic removal, 455 endoscopic evaluation, 451–2 endoscopic follow-up, 452– grading, 384–5 incidence, 421 management, 385 resection, 451 risk factors, 449–51 surgery, 452–4 surgical indications, 455 –7 treatment, 451–2 measurement, 366–7 melena, 123 metachronous, 461–2 metaplastic see polyps, hyperplastic miss rate, 341, 462 missed, 364 synchronous, 461–2 variation between examiners, 342 mountain, 436 MRI, 133 mucosal prolapse, 388–9 multiple, 368, 370 neoplastic, 506 Index nonlifting sign, 427 orientation, 378–9 pathology, 377–91 pedunculated, 297, 362, 380, 383 – 4, 414–15 endoscopic removal, 385 management, 455 –7 nutrient artery, 422 polypectomy, 416 pseudoinvasion, 449 Peutz–Jeghers syndrome, 162 pit pattern predictive value, 497, 498 position, 418–19, 428 –30 postpolypectomy incidence, 363 – risk factors, 365 prevalence, 358– 63 cancer incidence, 369 prolapse, 388–9 protective factors, 370 pseudoinvasion, 162 recurrence, 118, 365 redetection, 367 regrasping, 444 regression, 369, 371 reidentification, 368 removal, 47–8, 111 hematochezia, 568 –9 timing, 415 resection along fold, 431 retrieval, 48, 278, 428, 443 –7 devices, 278, 444 –7 reservoir, 443 sampling, 378–9 error, 379 sessile, 362, 380, 384, 415 large, 420–1, 423, 425– management, 455 –7 polypectomy, 416 –18 repeat clearing colonoscopy, 463 submucosal injection technique, 440, 448 surgical resection, 453 – shape, 177 sigmoidoscope photography, size, 177, 410, 420 –2 estimation, 366 –7 small, 415–16 cold snare, 416, 417 retrieval, 443– snare size, 429 –30 virtual colonoscopy detection, 557 snare impaction, 179 spatial clustering, 363 specimen collection trap, 416, 443 stalk zone, 297 suction container, 443 suction removal, 444 surveillance after cancer resection, 119 tandem studies, 462 tenting, 418 transection margins, 378, 384 types, 377, 378, 414 –15 virtual colonoscopy sensitivity, 557 see also adenocarcinoma in polyps; dysplasia pontamine sky blue, postcolonoscopy discussion, 81 postpolypectomy bleeding, 99, 177–8 anticoagulants, 225 band ligation, 293 delayed, 568–9 detachable snares, 292 hemoclips, 289–90 prevention, 178 treatment, 178 postpolypectomy surveillance, 96–9, 106, 107, 117–18, 459–66 cancer risk stratification, 464 colonoscopy, 459–60 costs/cost-effectiveness, 465 frequency, 462, 463 overuse, 341 recommendations, 464–5 recurrence, 516, 517 postpolypectomy syndrome, 179 pouchitis, 578–9 pregnancy, 108 preparation for colonoscopy, 210–16 artifacts, 593 cleansing methods, 210–15 contraindications, 215–16 prion transmission, 312, 637 privacy regulations, 25, 42 probability, 140 procedure rooms see colonoscopy suite, procedure rooms procedure time, 97 average, 24, 25 magnetic imaging systems, 273 polyp identification, 125–6 withdrawal, 97–8, 125 proctitis cystica profunda, 389 proctocolectomy, 147 proctocolitis, chronic idiopathic, proctologic surgery, 456 proctosigmoidoscopes magnified three-dimensional, 6, modern, 4–5 Strauss-type, proctosigmoidoscopy screening, 460 prodrugs, fluorescent, 519–20 prognosis disclosure, 55 promoter methylation, 353, 355 propofol, 233, 235 protective equipment, personal, 46 fluoroscopy, 266 infection prevention, 177 occupational safety, 49–50 protein truncation testing, 156 protoporphyrin IX, 520, 521 protozoal infection transmission, 312 pseudo-obstruction, acute colonic, 596–601 clinical presentation, 597 colonoscopic decompression, 598, 599–601 diagnosis, 597–8 epidemiology, 596 management, 598–601 pathophysiology, 596–7 percutaneous cecostomy, 601 perforation, 598 pharmacotherapy, 598–9 prognosis, 601 surgery, 601 pseudomembranous colitis, 585 pediatric colonoscopy, 628 pseudomembranous lesions, 578 salmonella, 583 Pseudomonas aeruginosa transmission, 311 651 pseudopolyps Crohn’s disease, 574 giant, 306 PTEN gene, 164 germline mutations, 354 pulmonary embolism, 108 quality, 90 see also continuous quality improvement quality adjusted life years (QALYs), 139, 140, 143 quality indicators, 95–9 complications, 98–9 patient satisfaction, 99 precautions, 97 technical measures, 97–8 radiation proctopathy, 603–9 angiectasias, 604, 605–6 argon plasma coagulation, 606, 607– bipolar probe coagulation, 608 endoscopic therapy, 604–8 coagulation, 605–8 formalin therapy, 608 heater probes, 608 laser phototherapy, 604 laser therapy, 606–7 photodynamic therapy, 607 sucralfate enemas, 603–4, 608–9 surgery, 604 treatment, 603–5 radiation protection, 50 radiographic colon imaging, 104 –5 abnormal, 105 screening, 133 radiology images, standard format, 183 radiotherapy colitis, 592 rectal outlet bleeding, 603–9 stricture induction, 615 Raman spectroscopy, 521–3 clinical evaluation, 522–3 sensitivity, 522 ras mutations, 355 rectal bleeding, pediatric colonoscopy, 627–8 rectal cancer preoperative irradiation, 540 recurrence, 474 staging, 539–40 rectal linitis plastica, 542–3 rectal mucosa dyes, 6, intraluminal microscopy, rectal outlet bleeding, 603–9 rectal ulcers, 388–9, 568 rectal valves, withdrawal technique, 343 rectum carpet-like filling defect, 549 endoscope insertion, 318 malignant polyps, 456 retroflexion, 345 red, green and blue, sync (RGBS) cables, 257 red, green and blue (RGB) sequential imaging, 249–50, 251, 252, 253, 254 reflectance, diffuse, 510 Regenbogen’s sigmoidoscope, –7, registered nurse (RN), 44 652 Index remifentanil, 235 resources maximization of utilization, 140 scarcity, 140 screening colonoscopy, 135, 136, 137 retrieval devices, 278, 444 –7 retroflexion maneuver, 344 – 5, 346, 443 retroversion, 338, 433 , 434–5, 439 reversal agents, 98 –9, 231 risks disclosure, 55 – 6, 57 elements, 56 indications for colonoscopy, 103, 104 management, 170 material, 56 pre-existing conditions, 97 serious, 57 rope-way colonoscopy and enteroscopy, 631 Roth retrieval net, 428, 446 –7 saline gut lavage, 211 submucosal fluid in endoscopic mucosal resection, 425 Salmonella, 582–3 transmission, 311 Savary–Gilliard dilators, 613 scanning electron microscopy (SEM), colonic glands, 480 scar, use of term, 192 schistosomiasis, 586 –7 sclerosing cholangitis, primary, 106, 306 Scope-guide, 265, 267–8, 269, 270 hand-pressure sensor, 270, 271 patient positioning, 270, 271 polygon rendering, 270 Scope Guide/UPD (Olympus), 16 screening cost-effectiveness, 142 –3 juvenile polyposis, 163 limitations, 547–8 rationale, 131– sigmoidoscopy, 548 virtual colonoscopy, 557–8 screening colonoscopy, 131, 133 –7 accuracy, 133 average-risk persons, 108 cecal intubation success rate, 97 complications, 134 –5 cost-effectiveness, 139 – 49 costs, 135–6, 140 CRC rate reduction, 134 criteria, 133, 134 decennial, 140 –2, 144 decision analyses, 148 decision tree, 140, 145 demand for services, 135 diagnostic yield, 122–3 efficiency, 135 fecal occult blood test follow-up, 133 – higher-risk categories, 131 intervals, 96, 136 investment, 140 mortality reduction, 136 probability, 140 rationale, 131– replacement, 137 resources, 135, 136, 137 risks, 133 single, 142, 143–4 timing, 136 transition probability, 141–2 sedation, 46, 229–36, 637 anesthesiologists, 234 anesthetic induction agents, 233 chronic obstructive pulmonary disease, 176 conscious, 60 endoscopic report, 200 equipment availability, 233 goals, 230 magnetic imaging systems, 273 novel approaches, 230–1 outcome effects, 234 pediatric colonoscopy, 626 personnel training, 233 procedures without parenteral, 234–5 rapid onset/recovery times, 235 recovery care, 233–4 rectal endoscopic ultrasonography, 537 requirement, 265 safety, 231 standard approach, 230–4 practice guidelines, 231–4 unplanned reversal, 98–9 selenium, polyp growth effects, 370 semicritical devices, 310 service class provider, 197 service elements, 197–8 sexually transmitted diseases, colitis, 588–9 sharp objects, 49 Shigella, 583 sigmoid colon adhesions, 265, 266 alpha maneuver, 326–8 anatomy, 323–4 large polyps, 444 long, 325 loops, 323–4, 325–8 alpha, 326–8, 330 atypical, 328 counterclockwise spiral, 331 N-looping, 325–6, 329, 333 reversed alpha, 328, 331 spiral, 325–6, 329, 330 navigating, 324–5 withdrawal technique, 343–4 sigmoid colon–descending colon junction, 329–31 sigmoidocamera, 7–8, sigmoidoscope, rigid, 296 sigmoidoscopy abnormal, 105–6 positions, positive, 112 repeat, 365 screening, 548 simulator, 86 sigmoidoscopy, flexible, 108 adenoma prevalence, 359, 360 colonic evaluation, 548 combined fecal occult blood test, 132–3 cost-effectiveness, 142–3 development of instruments, 9–13 diarrhea evaluation, 298 ischemic colitis, 567–8 missed neoplasms, 341, 342 –3 polyps, 144 screening, 132 tandem studies, 341 without parenteral sedation/analgesia, 234 silicon semiconductor material, 244 silicone spray, 631 simethicone, 213 simulators, 80, 84–8 types, 84–7 simulcast, 74 single-use devices (SUDs), 51 sliding tubes, 13 SMAD4 mutation, 163 small bowel adenoma, 155 smoking adenoma prevalence risk, 363 polyp recurrence, 365 snares, 401, 402 anchor-tipped, 278 barbed, 278 bipolar, 276, 411 catheter tip placement, 416 catheters, 402 closure sensation, 411–12 cold, 416, 417, 569 electrical activation, 413–14 electrocautery, 282–3 Erlangen, 430, 432 floppy, 430 handles, 402, 411–12 hemostasis, 410 information mark, 413 loop detachable, 49, 282–3, 291–2, 402, 422 opening, 413 placement, 413 secondary ligation, 283 materials, 276 monopolar, 276 multi-angle, 277 needle-tipped, 278 operation, 13, 47–8 complications, 177–8 passing through colonoscope, 413 placement, 428–9 polypectomy, 276–8, 401, 402 narrow diverticular segment, 429 –31 polyps position, 428 regrasping, 444 removal, 443 sessile, 416–17 small, 415–16, 429–30 rotatable, 277, 411 shape, 276, 277 sheath, 413 tip, 413, 414, 418 size, 277 slide bar, 412 closure, 414 retraction, 413, 414 specialty, 277 standard, 431–2 tip, 278, 413, 414, 418 tissue volume estimation, 412–13 types, 277–8, 411 use, 413–14 Index SNOMED, 194 “snow-white” sign, 314 Society for Gastroenterology Nurses and Associates (SGNA), 44 Society of American Gastrointestinal Endoscopic Surgery (SAGES), competence procedures, 64 –5 sodium hyaluronate, submucosal fluid in endoscopic mucosal resection, 425 sodium pentosanpolysulfate, 603 sodium phosphate lavage, 171, 214 –15 red ring sign, 593 safety, 215 solidifiers, 51 solitary rectal ulcer syndrome, 388 –9, 568 somatic mutations, 351, 352 Spaulding classification, 50, 309 –10 specimen collection trap, 443 spectroscopy, 207 specula, history, 1, sphincterotomy simulators, 85 spleen, trauma, 174 splenic flexure, 331– cut-off sign, 597 mobile, 334 reversed, 332–3 splinting tubes, 13, 15 split-overtubes, 15 spray catheters, 280 stains/staining, 17, 18, 280 absorptive, 501–2 chromocolonoscopy, 478 classification of stains, 501–3 contrast, 502, 503 reactive, 502, 503 see also named dyes and stains Staphylococcus transmission, 311 staples, 475 steam autoclaving, 309 stenosis of colon, 190 –1 stents, migrated, 292 stents, self-expandable metal complications of placement, 618, 621 endoscopic insertion, 618 –21 procedure, 619 –21 fluoroscopic-guided placement, 619–21 imaging artifacts, 616 limitations on use, 621 nonfluoroscopic-guided placement, 619 palliation for malignant strictures, 617–18 patient preparation/positioning, 618–19 preoperative for malignant strictures, 616–17 strictures, 614–15, 616 –17 success rate, 621 through-the-scope placement, 619, 620 types, 618 step-down room, 25 – stercoral ulcers, 592–3 stereomicroscopy, 6, sterilization equipment, 50, 177, 309 –10 heat, 315 India ink, 438–9 stiffening wires, 13, 15, 260 –1 STK11 mutation, 161 stomatoscope, stool smear, polymorphonuclear leukocytes, 627, 628 stop codons, 352, 355 strictures, colorectal, 611–21 balloon dilation, 612 benign anastomotic, 474, 612–15 biopsy, 611 brush cytology sampling, 611 colo-colon anastomosis, 475 Crohn’s disease, 574, 579, 611–12, 614 diagnosis, 611–12 electroincision, 614 endoscopic dilation, 612–14 endoscopic therapy, 612–18 etiology, 611 immunosuppression, 612 inflammatory bowel disease, 611–12, 614 laser therapy, 615–16 malignant, 611–12, 615–18 palliation, 617–18 preoperative decompression, 616 stents, 614 NSAID-induced, 614 pancreatitis, 612 self-expandable metal stents, 614–15, 616 ulcerative colitis, 575–6, 611 string guidance, 13 Strongyloides, 311, 312 submucosa, 542 tumors, 542–3 submucosal injection technique flat polyps, 434 polypectomy, 424–8, 432 sessile polyps, 440 sucralfate enemas, 603–4, 608–9 suction failure, 53–4 polyp retrieval, 48 suction canisters, 51 sulfasalazine, radiation proctopathy, 603 sulfate-free electrolyte lavage solutions, 212 administration, 214 flavoring, 212–13 safety, 214 sulindac, 158, 159 adenoma regression, 354 polyp growth effects, 370 polyp reduction, 365 supplies ordering, 51 surgical markers see dyes surveillance biopsy, 298 childhood cancer, 628 colonoscopy, 118–19 second CRC rate, 496 CRC, 118–19, 304–5, 469, 470 resection, 107–8, 469, 470 dysplasia, 98 intervals, 96 overuse, 341 targeting, 509 ulcerative colitis, 106, 506 cost-effectiveness, 145–7 decision tree, 146–7 threshold analysis, 146 see also postpolypectomy surveillance 653 susceptibility alleles, 152 sutures, 475 sympathetic nervous system, 596 –7 syphilis, 588 tamoxifen, 159 tandem studies, 341–2 tattoo, endoscopic, 48, 271, 439, 452 hematochezia, 562 polypectomy site, 456–7 see also dyes teaching, 76–83 assessment, 81–2 basic information, 77–8 complication rates, 170 feedback, 81–2 methods, 79–81 postcolonoscopy discussion, 81 process, 80 trainers, 78–9 training completion, 81 units, 76 teaching aids, 70–5 teaching courses, 73–5 group sessions, 74 live, 74 live transmission to remote sites, 74 –5 telemedicine centers, 75 video-based, 74 telemedicine centers, 75 television, home for training, 73 tenia coli, 333, 334 therapeutic colonoscopy complications, 177–9 thermal carbonization, 395, 399, 404 thermal coagulation, 394–5, 396 colonic angioma, 570, 571 depth, 400–1, 404, 406 heater probes, 397 hematochezia, 569 hemostasis, 401 high-frequency, 399–402 thermal damage high-frequency surgery, 402 unintentional, 396 thermal desiccation, 395, 398 thermal devices, 283–4 thermal devitalization, 394, 395 outside coagulation zone, 400 –1 thermal effects in biological tissues, 393 –5 thermal hemostasis, 408 thermal interventions ablation, 408 control, 396 electric arcs, 398–9 high-frequency surgery, 397–9 temperature generation in tissue, 395–9 treatments, 393–5 thermal vaporization, 395, 396, 399, 404 threshold analysis, 145 thromboembolism anticoagulants/antiplatelets, 225 risk, 177 thyroid cancer Cowden’s syndrome, 164 FAP manifestation, 156 screening, 156 654 Index ticlopidine, 227 tip angulation colonofiberscopes, 11, 12 colonoscopes, 9, 10 insertion technique, 318, 319, 320 location in magnetic imaging systems, 271–2 retroversion, 318 transparent cap, 284 –5, 346 video colonoscope insertion tube, 241 tirofiban, 227 tissue autofluorescence, 511–21 desiccated, 398, 403 electrical conductivity, 398, 403 laser effects, 408 optics, 510–11 water content, 398 tissue temperature, 395 –9 heat diffusion, 396 toluidine, torque steering, 80, 81, 318, 320 counterclockwise, 334 loop formation, 328 sigmoid colon, 324 withdrawal technique, 343 total internal reflection, 243 toxic megacolon, 108 trainees, 76–7 completion rates, 78 complication rates, 170 cusum graphs, 78 magnetic imaging systems, 272 trainers, 78–9 training, 77, 79 training, 63–8 basic information, 77–8 CD-ROMs, 71, 72 completion, 81 computer-based simulators, 87 debriefing, 81 DVDs, 71–2, 73 electronic media, 70 –3 home television, 73 Internet, 72–3 magnetic imaging, 273 – patient selection, 81 sessions, 79–80 teaching aids, 70 –5 teaching courses, 73 –5 units, 76 transforming growth factor b (TGF-b), 163 transforming growth factor b receptor II (TGF-bRII) gene, 356 transrectal ultrasound, 537 guidance, 474 –5 treatment, legal mandate, 59 Treponema pallidum, 588 trichilemmomas, multiple facial, 164 Trichosporon, 311, 312 tripod grasper, 428 Tübingen simulator, 84 – tumor genetics, 351 use of term, 192 tumor suppressor genes, 352, 353 inactivation, 354 Turcot’s syndrome, 156, 160 TV monitor positioning, 35 typhoid fever, 582 U-turn maneuver, 433–4, 435 ulcerative colitis adenocarcinoma of colon, 628 5-aminolevulinic acid–protoporphyrin IX fluorescence, 520–1 biopsy, 301, 303–6 cancer cost-effectiveness of prevention, 145–7 surveillance, 304–5 chromoendoscopy, 506–7 chronic colitis, 131 differentiation from Crohn’s disease/indeterminate colitis, 576 disease activity, 506 dysplasia detection, 520–1 surveillance, 98, 305, 306 dysplastic polyps, 385 endoscopic indices, 577 endoscopy, 575–6 assessment of extent/severity, 577 established, 106 flat polyps, 506 ileal pouch–anal anastomosis, 578 light-induced fluorescent endoscopy, 515–16 lumps and bumps, 306 malignancy signs, 575–6 mucosa, 575–6 mucosal ulceration, 193 pseudopolyps, 306 strictures, 575–6, 611 surveillance, 106, 506 cost-effectiveness, 145–7 decision tree, 146–7 threshold analysis, 146 ulcerative pancolitis, 98, 106 ultrasonography high-frequency, 536, 537, 541–2 colorectal wall, 537–8 transrectal, 537 ultrasonography, endoscopic (EUS), 18–19, 536–43 colorectal wall, 537–8 CRC, 538–42 staging, 538–41 helical scanning, 19 inflammatory bowel disease, 543 instruments, 536 local recurrence detection, 541 metastatic lymph nodes, 541 rectal cancer, 539–40 “underwater” colonoscopy, 329 United States Preventive Services Task Force, guidelines for CRC, 152 US Multi-Society Task Force on Colorectal Cancer, quality indicators, 96, 97–8, 99 uterus, dysplasia, 161 vancomycin, prophylactic, 221 vaporization, thermal, 395, 396, 399, 404 variceal rubber band ligator, 283 vascular ectasia, iron-deficiency anemia, 115, 116 vascular grafts, 221, 223 vasculitis, 628 vasovagal reaction, 175, 231 vegetable oil spray, 631 ventilation colonoscopy suite, 39 high-flow, 52 occupational safety, 49 Veterans Affairs Cooperative Study, 131–2 video-based imaging systems, 201 video camera, connection to endoscopes, 14 video colonoscope, 238–58 air system, 242, 243 color, 247–54 color-chip imaging, 250–2, 253 –4, 256 laser use, 255 color image display, 252 connections, 257 design, 238–9 development, 247 digital format image, 255 digital-to-analog converter, 255 displayed image shape, 247, 248 endoscope functions, 257 evaluation, 257–8 field capture, 256–7 flicker, 256–7 frame capture, 256–7 illumination characteristics, 257 image quality, 257 insertion tube, 239–44 adjustable stiffness, 240–1 angulation system, 241–2 bending section, 241–2 combined air/water tube, 241 distal tip, 241 flexibility, 239–41 illumination system, 243 – light source, 242, 243–4 safety features, 243 laser therapy, 254–5 luminance/chrominance format, 257 mechanical components, 255 motion reproduction, 252– objective lens, 244–5 preprocess circuitry, 255 processor functions, 255–6 RGB sequential imaging, 249 – 50, 251, 252, 253, 254, 256 solid-state image capture, 244 – 57 special therapeutic procedures, 257 specifications/standards, 257 suction system, 243 synchronization circuitry, 255 system expansion/integration, 258 system features, 257–8 water system, 242–3 see also charge-coupled device (CCD) videocolonoscopes, 479 videoendoscopes, 184 image production, 195 videotapes, 70–1 cecum, 97 teaching courses, 74 Index virtual colonoscopy, 104, 547–59 adenoma detection, 557, 558 bowel preparation, 548 –50 clinical results, 557 colon evaluation proximal to obstructing lesion, 554, 556 colon surface evaluation, 548 CRC, 547–8 data acquisition, 552–3 interpretation, 553, 554, 555 failed colonoscopy, 553 – 4, 556 fecal/fluid tagging, 550 patients indications, 554, 556 –7 preference, 556 –7 preparation, 548 – 52 polyethylene glycol preparation, 550 potential clinical role, 553–4, 555, 556–8 screening, 557–8 sensitivity, 557, 558 three-dimensional viewing technique, 553 two-dimensional view, 553 see also computed tomography (CT) colonography viruses, transmission, 310, 311, 637 vision, trichromatic, 248–9, 252 vitamin A polyp growth effects, 370 polyp recurrence, 365 vitamin C polyp growth effects, 370 polyp recurrence, 365 polyp reduction, 365 vitamin E polyp growth effects, 370 polyp recurrence, 365 vitamin K, 226 vitamins, antioxidant, 365, 370 volcano lesion, 585 “walking-stick handle” effect, 320, 321, 332 warfarin, 226 heparin substitution, 225–6 postpolypectomy bleeding, 177 waste, contaminated, 51 water, filtered/sterile, 311 weight loss, unexplained, 123 wide-angle colonoscopy, 346–7, 348 wide area networks (WANs), 206 withdrawal technique, 339 adenoma detection rate, 125 improvement targets, 346–8 loop removal, 429 optimal, 343–5, 346 polyp appearance, 444 polypectomy, 419, 429 quality, 343 shaft measurements, 437 time, 97–8, 343 WNT signaling pathway, 355 World Organization of Digestive Endoscopy (OMED), 201 Yersinia, 583–4 655 ... ISBN-10 1-4 05 1-1 44 9-5 ISBN-13 97 8-1 -4 05 1-1 44 9-3 A catalogue record for this title is available from the British Library Set in 9.5/12pt Palatino by Graphicraft Limited, Hong Kong Printed and. .. D Waye, Douglas K Rex, Christopher B Williams – 1st ed p.; cm Includes bibliographical references and index ISBN-10 1-4 05 1-1 44 9-5 Colonoscopy [DNLM: Colonoscopy? ??methods WI 520 C7179 2003] I Waye,. . .Colonoscopy Principles and Practice Thanks to our wivesaMeg Waye, Leslie Rex and Christina Williamsafor their support in yet another time-consuming enterprise Thanks