Tips to make colonoscopy prep more bearable

At least once a month, a patient asks if I’ve read Dave Barry’s column about getting a colonoscopy. The humor writer discusses how fear kept him from getting the procedure until he was 60 – a decade after the recommended age to begin screening. After learning his brother had colon cancer, he finally scheduled an appointment and began his amusing journey into preparing for a colonoscopy.

Not everyone finds such humor in colonoscopy prep. Who wants to choke down a large amount of sometimes disgusting-tasting bowel-clearing liquid and then cope with the resulting diarrhea? Many find it more uncomfortable than the actual procedure, during which they’re usually sedated and don’t remember it.  

Colonoscopies may eventually be replaced by less-invasive, less-preparation-intensive screening methods, but for now, they are the best way to protect yourself from colorectal cancer. So let’s look at how the colonoscopy prep process works and how you can make it a little less uncomfortable.  

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How does colonoscopy prep work?

Colonoscopies detect colon and rectal cancers while they are still small and treatable, but they also are used to find and remove polyps, which are small growths that can develop into cancer. To see these growths, the doctor needs a clear view during the procedure. This requires emptying the colon of its contents.  

If the colon isn’t completely clean, the danger is we may miss tumors or polyps. It also could lead to a longer colonoscopy because we need to spend more time washing away waste to see more clearly.  

The preparation process may differ slightly between medical centers and doctors, or from patient to patient. You doctor will explain exactly what you should do. In general, the process involves a liquid diet and laxatives.  

The form of laxatives can vary. We generally prescribe four liters of a generic lavage solution, which is cheap and easy to get. Four liters is a lot to drink. It’s the equivalent of nearly seven 20-ounce bottles of soda. Some patients can get away with drinking half of that if they take Dulcolax tablets first.  

Many patients ask us about alternatives to this part of the prep: “I heard from a friend you can just take a pill.” This is sort of true, but it’s not one pill, it’s 32. And it has a “black box” warning – the strongest warning the Food and Drug Administration issues – for its risk to the kidneys. It’s also not recommended for people older than 65.  

We sometimes use an off-label prep that’s basically MiraLAX dissolved in 64 ounces of Gatorade. It’s still a lot to drink, but it tastes better.  

We ask that you do a split prep, which means you drink half the night before and the other half six hours before the procedure. I know this can be annoying if your procedure is at 8 a.m. and you need to get up at 1 or to finish the drink, but you’ll get a more thorough cleansing.

How to make your colonoscopy prep easier  

I know this process isn’t fun. But it’s important, and there a few things you can do to make it a little easier:

  • Listen to your doctor’s instructions: Take notes and ask questions if you don’t understand something.
  • Arrange your schedule: You’ll want to be home – and in your own bathroom – during colonoscopy prep. If you have children, find someone to help care for them while you’re indisposed.
  • Cut back on fiber a couple days beforehand: Fiber is the indigestible part of plant foods and leaves a high amount of residue in the colon. Stick to a low-fiber diet, and avoid foods such as:
    • Beans
    • Nuts
    • Raw fruits and vegetables
    • Whole grains
  • Maintain a liquid diet: Water gets boring pretty quickly. Have a few other options on hand.
    • Clear broth
    • Coffee or tea
    • Italian ice
    • Jell-O
    • Popsicles
  • Drink your prep: Some of these solutions don’t taste great, but as mentioned, it’s the most important part of the prep process.
    • Add flavoring such as Crystal Light or Kool-Aid powder if the prep isn’t flavored.
    • Drink it cold.
    • Use a straw.
    • Suck on a lemon or hard candy afterward.
  • Prepare the bathroom: Once the prep solution starts working, you’ll want to stay close to a bathroom.
    • Wear loose clothing.
    • Stock up on soft toilet paper.
    • Use skin-soothing products such as baby rash ointment.
    • Keep entertainment handy; you may be there a while. This could include books, a laptop or a tablet.

Finally, remember that this screening could save your life. Excluding skin cancers, colorectal cancer is the third most common cancer diagnosed in the United States, with more than 135,000 cases expected to be diagnosed in 2017. 

When should you be screened for colon cancer?

The U.S. Preventive Services Task Force recommends that people at average risk for colorectal cancer begin screening at age 50.

Your doctor may recommend starting before age 50 if you have factors that put you at increased risk, such as:

  • Family history of colorectal cancer or polyps
  • Personal history of colorectal cancer or polyps
  • Personal history of chronic inflammatory bowel disease
  • African-American descent

Click the button above to schedule your screening or call 202-877-7108 to learn more.

There are alternative screening methods, but colonoscopy is considered the gold standard for colorectal cancer screening. Don’t let the hassle and discomfort of colonoscopy prep keep you from getting this potentially life-saving procedure. Take it from Dave Barry: “If I can do it, you can do it. Don't put it off. Just do it.” 

How do colorectal cancer screenings measure up?

Colorectal cancer is the third most common cancer diagnosed in the United States, according to the American Cancer Society (ACS). Colorectal cancer includes both cancer of the colon and cancer of the rectum. But it doesn’t just appear overnight. It starts as a small growth called a colon polyp and develops into cancer. This process can take 5 to 10 years to happen.  

We tend to start seeing colorectal cancer in people who are 60 and older, so we recommend people start getting screened for colon polyps at age 50. Your doctor may recommend starting earlier if you have certain risk factors, including a family history of colon cancer. Because of their increased risk, we also recommend African-Americans start getting regular colonoscopies at age 45. The idea is to find colon polyps early and remove them before they have a chance to develop into cancer. 

The gold standard for colorectal cancer screening is the colonoscopy. It’s an accurate, effective test that lets us check patients for colon polyps and colorectal cancer. People who have regular colonoscopies may reduce their risk for getting colorectal cancer by 40 percent. But getting ready for a colonoscopy can be a hassle, and some patients would rather have an alternative to this test.  

There are additional tests available for colorectal cancer. One that’s been getting some attention recently is Cologuard, which is a test people can take at home with a doctor’s prescription.  

Though some say these alternative tests are just as effective as colonoscopies, I want to emphasize one important fact: These alternative tests look at different factors than what colonoscopies look at. That’s why it’s important to follow your doctor’s advice and get screened for colorectal cancer according to the current medical guidelines. 

How a colonoscopy works

Before someone has a colonoscopy, we first have to prepare the colon for the procedure. This involves the person having the test limiting their diet to clear liquids the day before the test. The person also has to clear the bowels before the test by taking special laxatives.  

The test itself is fairly simple. We pass a thin, flexible tube called a colonoscope through the rectum so we can see the inside of the colon on a monitor. The patient is usually asleep during the test. For some patients, we use conscious sedation, which relaxes the patient but allows us to give the patient instructions during the test.  

The test itself usually takes about 20 minutes to complete, but preparing for it and recovering afterward could mean the patient has to take a day or two off work. Missing work is one of the complaints I hear about colonoscopies most frequently, along with the bowel preparation. Most people don’t mind the colonoscopy procedure itself. In fact, because of the sedation we use, most people don’t remember the test at all. Most people only need a colonoscopy every 10 years. 

Other tests for colorectal cancer

Most other types of tests for colorectal cancer are what we call stool tests. Rather than looking directly at the colon for evidence of colorectal cancer, stool tests use a stool sample the patient provides. Stool tests have a higher sensitivity for finding colorectal cancer that has already developed. They aren’t as good as colonoscopy for finding colon polyps. There are several types of stool tests, including:

  • Hemoccult test
  • Fecal immunochemical test
  • Cologuard  

Hemoccult test

In a hemoccult test, a doctor gives the patient six cards that the patient uses to collect three stool samples. The patient mails these cards to the doctor, who checks the samples for a molecule in blood called heme. Heme is a component of hemoglobin, which carries oxygen in the blood. Finding heme in a hemoccult test is a possible red flag for colon cancer.  

Hemoccult tests have a few problems. They’re not very sensitive, so they can miss some conditions. And they can result in false positive results, or results that identify a condition that doesn’t actually exist, if there’s any bleeding in the digestive system. 

Fecal immunochemical test

A fecal immunochemical test, or FIT, uses a chemical protein to detect hemoglobin in a stool sample. FIT is a much more sensitive test than the home hemoccult test. One reason for this is that hemoglobin molecules are broken down by the body during digestion. This means that if FIT detects hemoglobin in a stool sample, it’s easier for us to eliminate the stomach or other areas of the digestive system as sources for the blood.

 FIT is typically done on an annual basis. Doctors in some areas without ready access to colonoscopy technology might use FIT as an alternative to patients getting regular colonoscopies.  

Cologuard test

Cologuard is one of the newest tests developed for colorectal cancer. It’s approved by the Food and Drug Administration (FDA) for people who don’t want other forms of colorectal cancer screening.  

Cologuard combines FIT with a test for DNA markers. These markers can get mixed in with stool as it moves through the colon. When a patient sends a stool sample to a lab for a Cologuard test, the lab looks for mutations in the DNA that happen in cases of colorectal cancer. If the test is positive for these mutations, the lab recommends that the patient get further testing for colorectal cancer. Unlike the annual FIT, patients only need to retake the Cologuard test every three years. 

The problem with alternatives to colonoscopy

Because of how these alternative tests work, they may find colon problems that are more advanced than we would find if we had done a colonoscopy earlier in the process. Early detection is key to surviving colorectal cancer.  

As the ACS notes, about 92 percent of people with stage I colon cancer survive at least five years. For stage IV cancer, that rate drops to about 11 percent. And, of course, our ideal goal is to catch colon polyps before they ever turn into colorectal cancer in the first place.  

Another issue with alternative tests is that they may not be effective in helping people avoid colonoscopies—which is a primary goal for many patients. If any of these tests yields a suspicious result, the next step is for the doctor to order a colonoscopy to see if the test’s result was accurate. So avoiding a colonoscopy with one of these tests could just lead to needing a colonoscopy anyway. If that’s the case, why not just have the colonoscopy to begin with? 

Practical realities of colorectal cancer screening

I know not everyone who should have a colonoscopy is going to have one. The American Society for Gastrointestinal Endoscopy notes that more than 60 percent of Americans age 50 or older haven’t been screened at all for colorectal cancer. And that number is probably higher in some areas and parts of the population.  

In D.C. for example, we discovered a high instance of late-stage colon cancer exists among African-Americans in Ward 5. To help combat this, we launched the “Colon Cancer Prevention in the Neighborhood” program. Part of the former Vice President Joe Biden’s Cancer Moonshot, we’re working to increase colon cancer education in Ward 5, perform risk assessments and distribute fecal immunochemical tests that residents can do at home.  

Most people go with their doctors’ recommendations for screening. But some people, for various reasons, just refuse to have a colonoscopy. In that sense, the best screening available for colorectal cancer is one that a person will have. If one of the alternative tests finds something that motivates a patient to get a colonoscopy, and we’re able to detect and treat that person’s condition, then that’s what I care about. 

Personally, I’m going to continue recommending that my patients get regular colonoscopies according to the standards of care. But if the alternative tests lead to more people getting screened and treated for colorectal cancer, that would be a great thing in my opinion.

High Rate of Advanced Colon Cancer Found Among African Americans in Ward 5

Colon Cancer Prevention in the Neighborhood Program Launched, Part of White House Cancer Moonshot

Washington, D.C., October 17, 2016
– Colon cancer is one of the very few preventable cancers, but too many residents from the District of Columbia’s Ward 5 are diagnosed with advanced colon cancer. Today, MedStar Washington Hospital Center is launching its “Colon Cancer Prevention in the Neighborhood” program, to increase early detection and prevention of colon cancer. The program focuses on African-Americans in the Ward 5 neighborhood, where a crisis of late-stage colon cancer exists. “Colon Cancer Prevention in the Neighborhood” is part of Vice President Joe Biden’s Cancer Moonshot efforts to ensure cancer care is equitable throughout the nation.

Of 1,314 men and women treated for colon cancer from 2006 to 2011 at the Hospital Center, 892 of them, or 68 percent had stages 2 through 4 colon cancer. Of those, nearly 50 percent of stage 3 and 4 colon cancer patients were from Ward 5, echoing a number of studies that consistently show the highest yearly prevalence of colon cancer in the District is among Ward 5 residents. The data also revealed 91 percent of those with stage 3 and 4 colon cancer were African-Americans. Even more alarming, 97 percent of those presenting with advanced colon cancer had health insurance at the time of their diagnosis.

“It is shocking to see that this many residents who have insurance coverage are presenting late, with a disease that could have been detected earlier with screening,” said Elmer Huerta, MD, MPH, director of the Cancer Preventorium at MedStar Washington Hospital Center’s Washington Cancer Institute. “This data validates the need to offer accessible colon cancer screening and education in the community.”

The “Colon Cancer Prevention in the Neighborhood” program will deploy patient navigators to work with Ward 5 residents, building community-based partnerships to deliver colon cancer education, perform risk assessments and distribute easy-to-use fecal immunochemical (FIT) tests that can be done at home. The FIT test measures tiny amounts of blood in the stool that can be a sign of cancer or large polyps. The program will also offer services to connect patients with colonoscopy services, supporting the goal of significantly increasing screening rates among Ward 5 residents. The community-based program is supported by the Herb Gordon Foundation for Gastrointestinal Cancer, the American Cancer Society and private donors.

For the past three years, breast health navigators at MedStar Washington Hospital Center have been actively working in the Ward 5 community to improve breast cancer screening. Hospital Center data found similar results as with colon cancer: 97 percent of the Ward 5 patients with advanced breast cancer were African-American women with health insurance coverage. Thanks to grants from the AVON Breast Cancer Crusade, the breast cancer outreach program is now expanding across the city into Wards 7 and 8.


About the Cancer Moonshot:
During his 2016 State of the Union Address, President Obama called on Vice President Biden to lead a new, national Cancer Moonshot, focused on making a decade's worth of progress in preventing, diagnosing, and treating cancer in five years - ultimately striving to end cancer as we know it. A Presidential Memorandum on January 28, 2016 established the Cancer Moonshot Task Force.

 After meeting with experts across the country and the world, Vice President Biden identified areas of focus for the Cancer Moonshot -- based on barriers to progress and opportunities for improving patient outcomes - and announced a first wave of accomplishments at the Cancer Moonshot Summit on June 29, 2016 at Howard University in Washington, D.C. On Monday, October 17, Vice President Biden is releasing the final report of the Cancer Moonshot Task Force, along with his own Executive Findings after traveling to many of the major nerve centers in the cancer community. He will also unveil a new set of Federal actions, private sector actions, and collaborative partnerships to further advance the goals of the Cancer Moonshot Task Force. More information on the Cancer Moonshot can be found here.


About MedStar Washington Hospital Center:
MedStar Washington Hospital Center is a 926-bed, major teaching and research hospital. It is the largest private, not-for-profit hospital in the nation’s capital, among the 100 largest hospitals in the nation and a major referral center for treating the most complex cases. U.S.News & World Report consistently ranks the hospital’s cardiology and heart surgery program as one of the nation’s best. It also is a respected top facility in the areas of cancer, diabetes & endocrinology, Ear, Nose & Throat, gastroenterology & GI surgery, geriatrics, gynecology, nephrology, pulmonology and urology. It operates MedSTAR, a nationally-verified level I trauma center with a state-of-the-art fleet of helicopters and ambulances, and also operates the region’s only adult Burn Center.

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