Indications and Contraindications

Indications. An assessment of the condition of the colonic mucosa is important where there are clinical indications of colitis, i. e., abdominal pain, diarrhea, malabsorption, perianal bleeding as a result of possible intestinal ischemia, inflammation, erosions and ulcers of various geneses, polyps and tumors, diverticula, or vascular malformations. Changes in bowel habits and an increasing tendency toward constipation are cause for performing an endoscopic search for a stricture in the intestinal lumen, e. g., due to neoplasia, diverticular myochosis (thickening of the circular muscle layer), or postinflammation stricture (Tab. 1.1).

Thickening of the intestinal wall can be viewed using imaging techniques such as sonography (Fig. 1.1), computed tomography, and magnetic resonance imaging. A resulting pathological finding is an indication for colonoscopy that often can provide greater accuracy and allows taking a biopsy.

Early detection and cancer prevention. Colonoscopy is becoming increasingly important for early detection and the prevention of colorectal carcinoma in the asymptomatic general population. According to the guidelines established by the German Federal Committee of Doctors and Health Insurers (Bundesausschuss der Ärzte und Krankenkassen) on 5 October 2002 and based on rec

Table 1.1 Indications for colonoscopy

Constipation Diarrhea Abdominal pain

Bleeding per rectum, unexplained anemia, weight loss Postpolypectomy surveillance Prevention/aftercare colorectal carcinoma Pathological thickening of the colon wall detected by other imaging procedures

Primary tumor search with metastasizing malignancy, if resulting therapeutic measures

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Figure 1.1

Thickened intestinal wall in the sigmoid colon. Ultrasound examination of the left lower abdomen.

ommendations from the German Society of Digestive and Metabolic Diseases (Deutsche Gesellschaft für Verdauungs- und Stoffwechselkrankheiten, DGVS), colonoscopy should be performed as a part of cancer prevention every 10 years among those aged 55 and over in the general population (14). Given the polyp-carcinoma relationship according to Vogelstein and the results of large cohort studies in the USA and Europe, there is no doubt about the effectiveness of endoscopic polyp removal in carcinoma prevention (17). With regard to these indications as well, total colonoscopy has proved itself over sigmoidoscopy and Hemoccult testing (11) (Tab. 1.2). Considering the current capacity for colonoscopy it would take 10 years to screen the US population following these guidelines (15).

Contraindications. Only in a limited number of situations do the risks of colonoscopy outweigh the benefits of its diagnostic value. Contraindications include suspected intestinal perforation, imminent risk of perforation accompanying acute diver-ticulitis, deep ulcerous lesions, or vascular necroses (Tab. 1.3).

The overall condition of the patient should always be assessed to determine whether he could tolerate the physical strain of preparing for colonoscopy and endoscopy, including conscious sedation. Colonoscopy in patients with a recent myocardial infarction is associated with a higher rate of minor cardiovascular complications compared with control patients. (3)

Complications and Risks

Table 1.2 Recommendations for cancer prevention

Complications and Risks

Table 1.2 Recommendations for cancer prevention

Population

Periodic colonoscopy for cancer prevention

General population

Once every 10 years starting at age 55

Patients with colorectal polyp

Colonoscopy check-up once every three years, if no pathological findings at first examination, then further check-ups every five years

Patients with hamartomatosis polyposis

No general surveillance recommendations

Immediate family member with colorectal carcinoma or polyp at > 60 years of age

Ten years earlier than the age of the index patient at which carcinoma/polyp occurred, repeat every 10 years

Immediate family member with colorectal carcinoma or polyp at < 60 years of age

First colonoscopy at age 40, repeat every 10 years

Immediate family member with FAP (familial adenomatous polyposis)

Genetic carriers: starting at age 10, annual rectosigmoidoscopy, if polyp detection then colonoscopy; after proctocolectomy annual pouchoscopy Noncarriers: same as general population

Immediate family member with HNPCC

Starting at age 25, annual colonoscopy

Patients with colitis ulcerosa

For pancolitis > 8 years of age or left-sided colitis > 15 years of age: complete colonoscopy with annual biopsy for two years, then once every two years

Patients with Crohn disease

No general recommendations at this time

Table 1.3 Contraindications for colonoscopy

► Perforated intestine

► Acute diverticulitis

► Deep ulcerations

► Severe ischemic necroses

► Fulminant colitis

► Cardiopulmonary decompensation

Attention

► The physical stress of preparation for the examination and the colonoscopy itself limits its use in seriously ill patients.

Constipation Prescription

Constipation Prescription

Did you ever think feeling angry and irritable could be a symptom of constipation? A horrible fullness and pressing sharp pains against the bladders can’t help but affect your mood. Sometimes you just want everyone to leave you alone and sleep to escape the pain. It is virtually impossible to be constipated and keep a sunny disposition. Follow the steps in this guide to alleviate constipation and lead a happier healthy life.

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