Different Types of Colonoscopies, with Dr. Keith Siau

Episode Transcript

Ariel: All righty. So, let me just make sure I also have all of my notes in place. Okay. Great. All right. I will just do the brief intro. Let me grab my water. Okie dokie. Okay. All right. Are you ready to get started?

Dr. Keith: Yeah.

Ariel: Okay. Awesome. Here we go. Hello. Good morning. Good afternoon. Good evening. Whatever time it is that you happen to be listening to this podcast. This is your cohost Ariel Bridges back again for another episode of the “Colon Health Podcast.” I am very excited for this week’s guest, Dr. Keith, I’m going to throw it over to him now to introduce you himself, Dr. Keith. Hi, how are you? Can you share a little bit about who you are and what you do with our audience?

Dr. Keith: Hello, Ariel. Thank you so much for inviting me to come onto your show. My name is Keith Siau. I’m a gastroenterologist based in Cornwall Royal Hospitals NHS Trust in the UK. My interest lies with colonoscopy training and improving quality as well as research-based in endoscopy. I used to be the research fellow for the Joint Advisory Group in the UK, which ensures quality of endoscopy for trainees and services. And I have a passion in making sure that trainees receive excellent training and perform really, really good colonoscopy. Well, all types of endoscopy. So, thank you so much for inviting me here today to talk about something that I’m really passionate about.

Ariel: Thank you so much for being here. We are so excited to have you here. We’ve had a few other doctors on the show in the past, but no one that does exactly what you do, which is exciting for me. Because I would like to talk more about the different types of colonoscopy. You mentioned other endoscopies as well. I think when most patients hear colonoscopy, they just kind of think of the same standard procedure. Can you share the different types of colonoscopies and share a little bit about if there’s one that’s better than the other, and how can patients know to ask their doctor about what kind of colonoscopy they’ll be receiving?

Dr. Keith: Thank you for kicking off with this great question. A colonoscopy is basically an endoscopic examination of the colon. An endoscopy involves putting a camera that has a light at the end and a video attachment into the bowel to diagnose problems and to treat problems. And that’s entered usually to the bottom end of the rectum, and that’s passed all the way up to the other end of the colon called the cecum. And sometimes we can actually enter the small bowel also called the ileum or the terminal ileum. There is one main endoscopic way of assessing the colon and that’s called a colonoscopy. Sometimes we can do a partial camera test called a flexible sigmoidoscopy, which only looks at the left side of the colon. And that involves basically the same procedure, except that it’s a shorter test and patients might not necessarily have to have a bowel preparation to clear out their colon. So, these are the two main endoscopic types of assessing the colon.

Now, there are other ways that don’t involve endoscopy, in the way that you would think about a person putting a camera up the bottom end. These include scans in the form of CT scans or, with new advances, there was something called a colon capsule, where a patient would swallow a camera that’s in a capsule, certainly bigger than a 2P coin in diameter. I’m not sure what the equivalent in the U.S. coinage would be, about an inch wide, perhaps, swallow it down. And that would take photos and a live stream of your small bowel and then the colon, and record it onto a computer screen, which can then be looked at. So, this is a newer technology that doesn’t require a camera put up the bottom end. So, it’s far less intrusive. But the disadvantage of that is that if we do find something, then we wouldn’t be able to treat it, and that would require possibly a colonoscopy later on. So, it could delay therapy, so there are costs that there are pros and cons to these slightly different types of approaches.

Ariel: Awesome. And do you have any advice for patients that are maybe wanting to explore the different options? How do they know what’s best for them, or is that something that they should leave up to their physician to tell them?

Dr. Keith: I think, the gastroenterologist or a specialist would advise on the best type of modality, best type of investigation for the patient, depending on the reason why it’s needed. So, if, for instance, if there’s a strong family history of bowel cancer, or if on the screening test like a stool test that deemed a slightly higher risk of bowel cancer or colon cancer in the U.S., then the gold standard by far is a colonoscopy. But a colonoscopy is not perfect. It is operator-dependent. It relies on good quality bowel preparation and good views, and there is a misfit to pathology. So, there was a misfit of adenoma in the order of around 20%. But most of these are not really significant.

Colon capsule is an alternative technology, but that is a good alternative, but that’s not available everywhere. And also that requires specialists who are able to interpret it and read through it and sit through potentially an hour or two of film of a camera going through the colon. So, it is quite labor-intensive. And I’m not sure how it works in the U.S. in terms of billing and things like that. NHS is a lot simpler, where everything is free for patients. There’s no, you know, patients don’t need to think about costs when they come for these procedures. And these are often advised by their physicians, or surgeons based on availability and the indication and why they need it. But if patients are, you know, really, really, really not keen to go for the colonoscopy for whatever reason, then we often discuss other ways of doing it, which are less invasive. And this may include things like a CT colonoscopy or capsule colon in centers that have it available.

Ariel: Speaking to someone who might be hesitant to get a colonoscopy for whatever reason. Do you have any advice for someone who may be, you know, maybe hesitant to move in that sort of direction? What’s important for them to consider? Or why do you think that they maybe should strongly consider getting a colonoscopy?

Dr. Keith: I think, anyone in their right mind would be slightly hesitant to undergo a colonoscopy.

Ariel: Yeah.

Dr. Keith: [inaudible 00:09:14] medical is absolutely understandable. I would be in the same light because it is quite an invasive and intrusive procedure at the end of the day. But what really outweighs it is the need to have it done for a diagnosis, or reassurance, or for therapy, and to put your mind at ease, because colonoscopy is one of the few things that can prevent and treat cancer of the colon before they form. And unfortunately, colon cancer is in the top three most common cancers in the world. And I think the commonest other two are lung and breast. And these other two cancers can be detected before the cancers are formed. So, breast cancer screening involves screening for cancer at an early stage, as well as, colon cancers can be detected when they are in something called a precursor state.

So, usually, most cancers are caused by something called polyps, which are little growth that turn into cancers in a number of years, and this is called an adenoma to carcinoma sequence. And, these cancers can be prevented or treated and stamped out early in the adenoma phase so that they can be cut out and treated before they even grow into a cancer. And very few treatments or screening tools offer this ability. And therefore this can give patients, you know, excellent, excellent prognosis and reductions in mortality. And it’s so good to have a tool that can stamp out cancer before it even turns into one. So, really, you know, this is a test that in the high-risk patients who are deemed to need it, or even in the sense of screening people who do have symptoms it’s worthwhile in people with risk factors, including people of certain ages, people with certain family history, and even more so in people with relevant symptoms, like change in bowel habit, bleeding from the bottom end, etc., etc. And so if a medical professional feels that it’s sensible to have it excluded, you know, I think it’s really important to go for the investigation, get a diagnosis, get reassurance if the diagnosis is clear, and then get peace of mind.

Ariel: Yeah. I feel like the fact that colon cancer is one of the cancers that are uniquely preventable with this sort of testing and examination is definitely enough reason for me. So, let’s say you convinced me, I wanna get a colonoscopy. You specialize in training for these types of tests, as a patient who’s looking to have a provider that is capable and that has undergone, you know, the appropriate testing, how do I know how to find that provider? Which sort of questions should I be asking them?

Dr. Keith: I think it’s different in the UK, where there is a certification pathway. Where people have to undergo quite vigorous training in order to get that stamp of approval, I’m less clear about how it works in the U.S. But in all independent providers, we have monitoring of our colonoscopy activity. And this is usually done in national databases based on the endoscopy reports that we do. So, whenever we fill in an endoscopy report, we log where we get to whether it’s completed, whether we find pathology, whether we treat it properly, whether we retrieve the specimens, etc. And these all act as a surrogate marker of quality colonoscopy. And these can be compiled on an individual basis called a key performance indicator. Now, the visibility and the transparency of these performance indicators will vary by health setting.

I don’t think that in the UK, or even in the U.S., these are publicly available for patients who want to select providers. But these are usually available to unit leads who oversee colonoscopy practice or training in their services. But these patients can ask their provider, you know, what is your units? Or what is your things like completion rates? What is your polyp detection rate or adenoma detection rate? Etc, etc. And in some institutes, they may even have data about patient satisfaction. So, in the UK, we have, JAG accreditation standards, and units are accredited based on their quality on how they need these performance measures so that they can be vetted in A, B, or C depending on the level of quality they offer. But this is based on a more unit-level rather than a specific provider level.

Ariel: Okay. This is really helpful. I think I want to say a majority of our audience is in the United States, but for our listeners that are overseas, I think this is very helpful to know. And even the questions that you shared, like, what is your polyp detection rate? What’s your adenoma detection rate? These are all very helpful things to know going in. I think too, that this just shows that you should make sure that before you go and choose a provider, that you do your research, you know, take some time to look them up, look for their reviews and things like that. Don’t be afraid to ask questions. You don’t have to go with the very first provider that you speak with.

Dr. Keith: Absolutely. Absolutely. In the UK coloscopy is done slightly differently. In the UK, we barely use things like general anesthesia for colonoscopy in the U.S. people would shriek, whenever we mentioned this on Twitter, they’d say, “Come on, what? You do what now? You don’t put patients out when you do a colonoscopy. That’s barbaric.” And, you know, to be honest, we, you know, we’re used to this where we deliver this throughout training, you know, I rarely do procedures under general anesthetic. And in fact, patients, you know, are highly satisfied on the whole, with using sedation or even unsedated endoscopy. But some people may wish to just go with general aesthetic, and, you know, and go with that and have fixed feelings about going for it. And sometimes we can’t change their minds. And in which case, you know, they should speak to a provider who can offer those kinds of services and speak to the provider who is best geared for their condition, because bowel cancer screening is not all that we look for. It’s not all that we do. We look for pathology in the GI tract for which there are hundreds, there’s inflammatory bowel disease.

And there are specialists colonoscopists that look at inflammatory bowel disease day in day out. So, if patients have, inflammatory bowel disease, they may wish to have a colonoscopist who specializes in that. You know, if they’re undergoing things like not just diagnostic, but what we call surveillance colonoscopies. So, in patients, who’ve had inflammation in the bowel for more than eight years or so, their risk of cancer goes up. And, I think these are higher-risk patients, who should really be done by a specialist. And usually, that is done with things like dye spray, putting blue dye in the colon to cover the bowel walls and make lesions easier to see. And sometimes it can be tricky to sort out inflammation from slightly nastier growth, and this is why you need a good trained eye for that. So, having a condition-specific colonoscopist may also be helpful and something to think about as well as whether the providers are happy to provide, to offer, things like general anesthesia, in patients who really have done that research and want it.

Ariel: That is absolutely fascinating to me. I’ve had two colonoscopies. I’ve shared my history on some other episodes of this podcast, but for any of you that this may be your first time listening to me chat. I am a lot younger than the normal kind of standard age for getting colonoscopies, but I have a family history. I also have IBS and a lot of other GI conditions that, kind of necessitated my getting tested early. So, whenever I go for colonoscopy, for me, it’s often a combo colonoscopy, upper endoscopy sort of situation. So, I’m usually always under general anesthesia, but for those that are just getting colonoscopies, I have to agree with you. I think that here in The States, people would just gawk at the idea of not being put to sleep first. So, that’s so fascinating, but I have imagine too, that any procedure that you can do without anesthesia, because just with anesthesia just comes additional risk. I imagine that has to go away a little bit, is that correct? I’m not sure if you know the statistics of anything along those lines.

Dr. Keith: And we barely use general anesthesia in the UK, but actually studies which have looked at propofol, which is what you use with the GA tends to be very safe. And it’s cleaner than the data lab, which is at the benzodiazepine that we give as a sedative. And we also give fentanyl as a pain killer, but giving propofol seems to be quite clean, the effects wear off quite quickly and seems to be safe. But that requires a specialist, an anesthetist to be present to monitor the patient, and someone who is skilled in delivering this and is skilled in airway management if the patient needs it. So, it depends on the setup of the service as to what is offered to the patients.

Ariel: That makes a lot of sense.

Dr. Keith: I think, in general, there is data that shows that people who undergo propofol probably have slightly better experiences than someone who undergo traditional sedation. But on the whole, you know, it depends on whether the endoscopist is more familiar with one type of sedation than the other, because if you’re trained to do unsedated colonoscopy, then you do it, the procedure in a slightly more gentle way compared to if you’re trained doing the procedure in someone who is always asleep. Because, you know, we learn to manage, and change what we do depending on the feel, resistance. And, also if the patient reports any sense of discomfort. And sometimes that the sense of discomfort can be helpful in preventing complications because, you know, without that someone’s saying, “Ouch, that’s not…that’s slightly uncomfortable,” then that could be a marker of something not being right. And that may be a good feedback that might feedback to the endoscopist that something’s not quite right.

Ariel: That’s something that I have never thought about. Yes, if someone were awake for a procedure, you could actually get some additional feedback for them. That would be helpful.

Dr. Keith: Good. Yeah. And it’s great that we can chat to the patients as well. And sometimes we go through a consultation with the patients when they’re not having a lot of sedation, they can chit chat, you can joke, you can, you know, show them what they’re seeing, shows them the landmarks. And a lot of patients are really interested in the colon anatomy, and we take them on the journey on the guided tour, which you miss out on if you’re having a general anesthetic.

Ariel: Yes. And I agree that that’s, I feel like that’s something that’s important too, because we talk a lot about on this podcast about this, the stigma surrounding colonoscopies and how a lot of it seems very scary or distant. A lot of people don’t understand what’s really going on. And at the end of our colonoscopies, you know, once we are awake, you know, they send us our…they show us our pictures that they took while they were in there. But that’s not quite the same as being able to see the journey and learn in real-time.

Dr. Keith: That’s right. And I think a lot of people are curious, what they…how their colon appears, what we find, what we do. And, you know, most people are fascinated. There are some who just cover their eyes and refuse to look at the screen. [crosstalk 00:25:14]

Ariel: Wow. Okay. So, I definitely am learning a lot so far. I am curious to hear what are some of the recent advances being made in colonoscopies that you’ve seen come into place? And what are some advances that you think we can expect to see in the near future?

Dr. Keith: We talk about colonoscopy advances, a lot on Twitter, and things about Scoping Sundays with experts across the world, and also at conferences. And here’s some of the things that I think are on the horizon. I think that we are learning to be better at selecting people for colonoscopy using things like non-invasive tools, such as stool tests that may put patients at higher risk of pathology and may indicate the need to do the procedure more. There are also technological advances, like attachment devices on scopes such as cuffs, and other attachment devices that improve the view, improve the detection rates. There is also, things like artificial intelligence, which is the sexy topic that the industry is promoting. And that basically involves an attachment to the lens of the scopes that we’ll look at the views that we see and interpret whether there’s pathology there. So, it would look at the screen and if there’s a polyp there, it would flag up and it would turn, you know, turn bed or something. And the flag up that there’s a problem. It may even tell you what kind of problem it is, whether it’s a low risk or high risk for colon cancer. It may also be there to alter your behavior. So, if you’re withdrawing too fast and not being too cautious with the views, it will tell you to slow down or wash certain areas if the views are inadequate.

So, AI is a massive step forward in improving quality and try to make colonoscopy a more even playing ground, so that all patients get high-quality examinations. So, AI is definitely on the horizon. But apart from that, you know, colonoscopy is always advancing and the goal of colonoscopy is to try and reduce things like surgery and more invasive procedures to a less invasive means. Even though a lot of members in your audience would disagree that colonoscopy is less invasive, but certainly, is far less invasive than surgery. And to more advanced endoscopic approaches bigger and more advanced tumors can be removed endoscopically in less invasive ways, which is great news for patients. But, on the horizon, there are also efforts to try and improve quality so that even in low-income countries, people can do a simple test better. So, things like water-assisted colonoscopy, i.e using water to insufflate the colon. So, to distend the bowel so that we can see. That is a real game-changer compared to standard colonoscopy, where we use, air or carbon dioxide to open it. I liken that to blowing up a balloon when I talk to my patients. So, if you blew up a balloon with your mouth, with air, then the balloon stretches really, really quickly. And the pain receptors…that activates the pain receptors on the bowel wall, which causes pain. But if you were to use water, that’s a much more gentle distension. It doesn’t inflate it as much, and it’s a lot more tolerable. And that also washes the colon more and, cleans out the bowel wall so that it increases the adenoma detection rate. So, simple things like this are a clear win.

Other things on the horizon, perhaps bowel preparation, as most people would say that bowel prep is the worst part of having a colonoscopy, taking laxatives to completely remove everything within your gastrointestinal tract is not a pleasant experience. And there are always efforts underway to try and improve the patient experience of not just the colonoscopy, but also the bowel preparation and to improve quality of the examination. Above all, we need to be better at selecting the right people so that those who are unlikely to have any problems too need to go for it. And this has to be done through better research and better identification of biomarkers, which are things like blood tests, stool tests, even breath tests, or even [inaudible 00:31:26] tests possibly in future to try and find out who is also low risk and don’t need it at all, and who actually needs it.

Ariel: Oh my goodness. You shared so many exciting things for us to look forward to both in the areas of increasing access to these types of tests, making these tests a little bit more comfortable for patients. Helping providers be able to do even more during these tests to help patients. There’s a lot of exciting stuff on the horizon. That’s incredible. We are actually just about almost out of time. So, I wanted to ask you if there’s anything else that you wanted to share with our listeners, whether it be about training or getting colonoscopies or any sort of, kind of parting guidance you’d like to leave them with.

Dr. Keith: I think people are naturally shy of having endoscopy procedures. And I think it’s really important to speak to a medical professional if there are any doubts questions or reservations, and we are always there. And, you know, these procedures are very, very important and save lives, and I am more than happy to answer any questions. And so is any medical professional, and who are accessible via Twitter they’re excellent…and other sources. There are excellent patient information leaflets available. I have explained procedures in detail. There was also a lot of misinformation out there that patients, you know, that can be difficult to steer away from, which is why using things like, recognized patient information resources, such as those from the ASGE, ACG, and then UK societies can really answer the questions that people are looking for, but usually, you know, people can get access to a specialist, either formally or less formally through social media, if they have a simple question is just want to get off their minds, but it’s important to, you know, to ask these questions and not just, you know, miss an appointment because of a fear of having the procedure done or because they have unanswered questions that shy them away from having a procedure.

Ariel: Oh my goodness. Yes. Please ask questions and please don’t miss your appointments. I will.

Ariel: Yeah. I am going to share links in the show notes, like I usually do to some of these resources that Dr. Keith mentioned. And Dr. Keith, thank you so much again for being here. This was excellent. I learned so so much tonight.

Dr. Keith: Thank you, Ariel. Thank you for having me on your brilliant podcast. And, thank you so much for the work that you do in raising awareness of bowel cancer, but also for raising the profile of colonoscopy which is a really important diagnostic and therapeutic way of sorting out problems in the bowel and the stuff that you do, the speakers that you have are really excellent. So, I’m really humbled to be on the show.

Ariel: Oh, thank you. We couldn’t be more happy to have you, and everyone like Dr. Keith is just saying, “We all have colons, okay. Let’s all take care of them.” Ask those questions. Don’t be scared. Use those resources. Okay? All right. We’ll see you next time. Bye, everyone.

Dr. Keith: Okay. Bye-bye.