Colonoscopy

Defi nition
A colonoscopy is conducted by inserting a colonoscope through
the anus into the colon. It provides information regarding the
lower GI tract and allows a complete examination of the colon.
The colonoscope is similar to the endoscope used in gastroscopy.
Its length ranges from 1.2 to 1.8 metres. It is the most
eff ective method of diagnosing rectal polyps and carcinoma
(MacKay et al. 2010 , Smith and Watson 2005 , Swan 2005 , Taylor
et al. 2009 ).

Anatomy and physiology

The large intestine is about 1.5 metres long. It begins at the ileum
and ends at the anus. The four major structures are the caecum,
colon, rectum and anal canal (Jenkins and Tortora 2013 ). See
Figure 10.15 .

Caecum

The caecum is about 6 cm long and opens from the ileum and
ileocaecal valve (Jenkins and Tortora 2013 ).

Colon

The colon consists of three parts. The ascending colon runs from
the caecum and joins the transverse colon and the hepatic fl exure.
The transverse colon is in front of the duodenum where it
joins the descending colon at the splenic fl exure. The descending
colon travels down toward the middle of the abdomen where it
joins the sigmoid colon which is S-shaped and becomes the rectum
(Jenkins and Tortora 2013 ).

Rectum and anal canal

The rectum is approximately 20 cm long and is a dilated section

of the colon. It joins the anal canal which is approximately 23 cm
long (Jenkins and Tortora 2013 ).

Evidence-based approaches
Rationale

A colonoscopy is performed to investigate specifi c symptoms originating

from the lower GI tract such as bleeding. The endoscopist
uses direct vision to diagnose, sample and document changes in
the lower GI tract (MacKay et al. 2010 , Taylor et al. 2009 ).

Indications

Screening of patients with family history of colon cancer, a serious

but highly curable malignancy.
Determining the presence of suspected polyps.
Monitoring ulcerative colitis.
Monitoring diverticulosis and diverticulitis.
Active or occult lower gastrointestinal bleeding.
Unexplained bleeding or faecal occult blood specifi cally in
patients >50 years.
Abdominal symptoms, such as pain or discomfort, particularly
if associated with weight loss or anaemia.
Chronic diarrhoea, constipation or a change in bowel habits.
Surveillance of infl ammatory bowel disease.
Population screening for colorectal carcinoma.
Palliative supportive treatments such as stent insertion.

Contraindications

Upper gastrointestinal bleeding.

Acute diarrhoea.
Recent colon anastomosis.
Toxic megacolon.
Pregnancy (Chernecky and Berger 2013 ).

Legal and professional issues

Competencies and consent

Competencies and consent will be the same as those discussed

in the section on Gastroscopy, above.

Risk management

The NPSA ( 2009 ) highlighted the risks in relation to bowel preparation

and actions required to minimize these. Harm to patients

has occurred where oral bowel preparations were prescribed to
those with defi nite contraindications; however, the majority of the
incidents were related to the administration of the bowel preparations
(56%) (Connor et al. 2012 ). The NPSA ( 2009 ) report identifi
ed that one death and 218 patient safety incidents resulting in
moderate harm were related to the use of oral bowel preparations
where contraindications were not considered or assessed.

Pre-procedural considerations
Equipment

A colonoscope is a fl exible endoscope which generally uses

fi breoptics to allow direct visualization of the rectum and colon
(Chernecky and Berger 2013 , MacKay et al. 2010 , Smith and
Watson 2005 ).

Pharmacological support

Bowel preparation agents, such as senna tablets and Citramag,

are given to the patient to take 1 day before the colonoscopy to
clear the bowel and minimize faecal contamination (Connor et al.
2012 ). A sedative and possibly an analgesic are usually administered
before the procedure. This involves the administration of a
benzodiazepine such as midazolam and an opioid such as fentanyl
or pethidine which have been prescribed. Doses must be titrated
for elderly patients or those with co-morbidities such as cardiac
or renal failure. An antispasmodic may also be given. Oxygen
therapy should also be administered during sedation. Generally
2 litres per minute is adequate for most circumstances to maintain