To the Editor,

Colonoscopy is recommended for colorectal cancer screening above the age of 50. It is unclear as to what proportion of gastroenterologists have themselves had the colonoscopy. The patients frequently complain about the preparation and many times innocently ask if the doctor has ever taken the same preparation. The issue of discomfort related to the procedure is also very high on the patients' concerns. The frequency and degree of sedation for this procedure varies widely around the world, ranging from common use of general anesthesia in France to no sedation in a significant subset in Germany. In the United States, sedation is offered (and accepted) to the vast majority of the patients, usually provided by the endoscopist.

To walk in the patient's shoes, so to say, the gastroenterologist needs to take the preparation and have the colonoscopy performed. Most will rule out the option of performance of the procedure by themselves. In such a setting, any discomfort related to the procedure has to be accepted as an unavoidable component because sedation is out of question. There are clear benefits to self-colonoscopy, however. The risk of perforation is likely very low because the discomfort is protective. There is no need for reliance on someone else, and one can be as careful and as thorough as one wants to be. Results are available in real time; there is no prolonged recovery period or need for coordinating schedules with another physician. On the lighter side, informed consent and assumption of risk are nonissues and there would never be a lawsuit against the performing doctor. Self-colonoscopy has been reported by Horiuchi and Nakayama (2006). A literature search in February 2009 revealed no similar published follow-up experiences by anyone else.

This letter reports a self-colonoscopy performed in Pennsylvania. The gastroenterologist (P.K.), age 52 years, with more than 20 years of endoscopic experience and whose average cecal intubation time is 4-5 minutes, elected to perform a screening colonoscopy on himself. The preparation started on the day prior to the procedure, after a light breakfast, in the form of two doses of 30 ml of milk of magnesia (Phillips, Bayer HealthCare, Morristown, NJ), taken in the morning at 9 a.m. and 11 a.m. Clear liquids were taken throughout the day. Three hundred milliliters of generic (over-the-counter) magnesium citrate was mixed with clear liquid (white cranberry peach juice) in a 1:3 dilution and sipped over 1 hour, starting at 3 p.m. This was followed by another 200 ml at 7 p.m. in a similar way. Ice was used to chill the drinks. The taste of this admixture was quite acceptable. Carbonated beverages were not used.

Local hemorrhoid lotion (Balneol, Solvay Pharmaceuticals, Marietta, GA) was used from the outset after every bowel movement. It proved to be effective in preventing local irritation from the preparation. Bowel movements became loose by noon and started to become dark watery liquid by 6 p.m. By 10 p.m., the stools were clear yellow. No nausea/vomiting or abdominal cramping was experienced. It was possible to have a good night's sleep without interruption due to diarrhea. Thirst or hunger did not become significant. A total of seven bowel movements achieved clear stools.

On the day of the procedure, clear liquids (tea and water) were taken till 9 a.m. The gastroenterologist saw patients and did endoscopic procedures till 9:30 a.m. At 10 a.m., 0.125 mg of quick-acting, generic hyocyamine oral tablet was taken. Had it been available, a sublingual dosage form would have been preferred. The procedure was scheduled at 10:15 a.m. in the ambulatory center gastrointestinal (GI) laboratory. The gastroenterologist patient sat on the middle chair of three metal folding chairs without arm rests, covered with a thick sheet to allow reclining. The procedure was started in the sitting position as previously described (Horiuchi & Nakayama, 2006). We agree with these authors' prior suggestion that a specially designed chair with a concave front end would be very helpful. Sitting on the chair upright with feet propped on a stepping device 20-cm high allowed better positioning and maneuverability of the scope. A thin-caliber (pediatric colonoscope) PCF 140 videoscope (Olympus Corp., Center Valley, PA) was used. A variable stiffness option was not present.

In addition to water-soluble lubricant (Surgilube, E. Fougera & Co.) on the exterior of the scope shaft, several 60-ml syringes of water and water mixed with Surgilube were injected through the biopsy channel during the procedure because there are data to indicate that the use of water or other lubricants significantly reduces the discomfort to the passage of the scope and also may reduce the procedure time (Brocchi et al., 2008).

The preparation was excellent with no residue. It was relatively easy to traverse the sigmoid colon and the descending colon. Short periods of cramping were experienced during the passage through these areas. These were significantly relieved by anal passage of insufflated air. Cramps related to the scope shaft pressure were less common but were noted when looping of the scope occurred. Reclining on the adjacent chair and getting into a semi-left-lateral position helped but was difficult to maintain. It was helpful for someone else to hold the scope in position for short periods when complex turning of the control wheels was needed. Hepatic flexure was the hardest to negotiate because significant looping of the scope occurred, as indicated by lack of advancement on insertion. The cecum was visualized in 6 minutes (that felt like eternity). Thankfully, no significant lesions were noted. Total procedure time was 12 minutes. After the removal of the scope, there was no bloating or cramping. The patient then took a shower and resumed the day's work within 20 minutes.

This team has previously reported independent adverse-free use of propofol for GI endoscopic sedation in a freestanding ambulatory center in more than 5,000 cases. This was accomplished by careful titration of propofol coupled with judicious and infrequent use of supplemental oxygen to better monitor ventilation by pulse oximetry (Kumar, 2008). In addition to having performed many unsedated EGDs and colonoscopies for our patients (for patient safety or at the patient's request), this report marks the other end of the spectrum with unsedated self-colonoscopy. We have found many of the abovementioned tips and suggestions to be helpful for all our patients during the preparation and performance of the colonoscopy.

Acknowledgments

The author thanks Shalini Kumar as well as Barbara Acita, LPN, and Betsy Kruel, RN, gastrointestinal nurse team, for their expertise and support.

Pradeep Kumar, MD

[email protected]

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