Use of stents beyond heart disease

The use of stents for treatment of atherosclerotic disease of the heart has become popular in the past decade.  A recent recipient was the Prince Phillip of England  (Dec. 2011).   A stent is a small, hollow, plastic device inserted into the arteries of the heart in order to prevent the blood vessel from closing due to excess plaque.  Stents can be life saving devices as they maintain circulation (including oxygen and nutrient delivery) to the heart muscle.

Similarly larger stents can be used in the digestive tract to preserve patency (opening) of the esophageal or bowel lumen.  Esophageal stent placement involves the use of both endoscopy and fluoroscopy (x-ray).  Once the location of the esophageal narrowing is established, the physician is able to insert a long delivery apparatus through the mouth in order to deliver the stent at the point of narrowing or blockage in the esophagus.  Once the stent is deployed it expands within the esophageal lumen. This keeps the esophagus open in order to help the patient swallow or drink more easily. Esophageal stents are made of polyester (plastic), nitinol (metal) or hybrid material. These stents are typically used to treat patients suffering from advanced malignant (cancerous) disease.

Similarly, colonic stents are used for management of colorectal cancers.  Although these cancers are typically treated with surgery, in patients with advanced morbidity (with likelihood of surgical complication) or in patients needing preoperative chemo-radiation, colonic stents serve as a management option.  The insertion of colonic stents involves the use of an endoscopy (with fluoroscopic assistance). Once the stent is inserted through the endoscope and deployed, it expands to a diameter of 20mm.  This support structure remains in place permanently, relieving symptoms of blockage  which includes bloating, nausea, constipation and pain. These stents do not rust nor interfere with daily activity. Complications of colonoscopy are very rare but can include bleeding, perforation, infiltration of tumor (and recurrent blockage) and migration (stent movement).

What are the causes of rectal bleeding in adults?

Rectal bleeding is a common complaint among patients seeking care in a GI clinic.  Patient presentation can be quite variable.  There is also the concern that the underlying disease may be serious.  The vast majority of patients with isolated rectal bleeding (> 95%) have a benign disease process.   In younger patients (< age 40) with minimal bright red blood noted in the toilet or stool, we worry about the following problems:

1.  HEMORRHOIDS – Symptomatic (internal) hemorrhoids are perhaps the most common cause of bleeding in clinical practice.  These swollen blood vessels in the rectum can also be associated with anal discomfort, itching and protrusion.  The bleeding is typically bright red and typically coats the stool or drips in the toilet.  Some patients notice blood on the toilet paper.  Risk factors include underlying constipation, straining, pregnancy, long distance driving or cycling and hereditary factors.

2.  ANAL FISSURES – Bleeding from anal fissures is typically associated with sharp pain during defecation.  Fissures are tears in the lining of the anus and thus produce a sharp stabbing or tearing pain (and bleeding) during bowel movements.  They can be treated with topical anal cream but have a tendency to recure.

3.  PROCTITIS and INFLAMMITORY BOWEL DISEASE (IBD) that can cause rectal bleeding at any age.  Additional symptoms of this condition include loose frequent BMs and urgency to defecate.  Some patients can also have rectal/abdominal soreness and discomfort.

In older patients or those with significantly brisk bleeding we worry about the following issue:

4.   DIVERTICULOSIS – Diverticula are small out pocketing of the large intestine that are very common beyond age 50.   These herniated sacks usually do not cause symptoms.  However in older patients blood vessels that erode into these sacs can be a cause of profuse bleeding requiring hospitalization

5.   VASCULAR DISEASE – Abnormal vascular structures or diseases can be a source of bleeding in older patients.   These conditions include angiodysplasia, radiation colitis and ischemic colitis.  Although they do not typically produce profuse bleeding they can be associated with pain (in the case of colitis) or anemia (low blood count).

6.  COLON POLYPS AND CANCER  - Serious growths and tumors in the large intestine (colon) can occur at any age.  However the prevalence of these conditions tend to increase with age.   Clinical presentation of these patients is quite variable.  Some individuals are not even aware that they are losing small quantities of blood in their stool and are anemic upon presentation.  Obviously the diagnosis of such abnormalities should be made early in order to achieve the best clinical outcome.

The groupings of above diseases are based generalities and there are many exceptions (such as 32 year old patient with rectal cancer, or 76 year old patient with hemorrhoidal  bleeding)

All patients presenting with rectal bleeding to the clinic, irrespective of their age, need a physician evaluation including a digitial (finger) exam and a bedside scope test to evaluate the anus and rectum.  Some patients may need further evaluation of the colon including colonoscopy and laboratory testing.

Simple and inexpensive treatment of common digestive complaints.

Most common problems in the realm of gastrointestinal diseases are “functional” digestive disorders.  These ailments include Irritable Bowel syndrome, Dyspepsia, Functional Bloating and many of the bowel complaints commonly encountered in adults.  These conditions are not structural or pathological abnormalities that can be readily seen or diagnosed by endoscopy, x-rays or laboratory tests.   In contrast these disorders often arise from body’s altered response to external signals, food and stress.  Many of these patients have impairment that may be related to intestinal motility, hypersensitivity of the intestinal nervous system, or alterations in the mind-body signaling.  Much of these disorders are currently under intense medical research.  However effective pharmaceutical treatments are very scarce.   In contrast most of these conditions are readily manageable by common sense recommendations.   Effective implementation of the following lifestyle habits tends to be more useful than any prescription (or nonprescription) medications on the  market.

1. Stress reduction.

Excess stress can increase inflammation, increase indigestion and worsen existing digestive problems.   Stress reduction can be achieved through regular exercise, cultivating a support network, and developing a spiritual practice.   It is also important to get plenty of sleep, control anger & anxiety and consider pursuing innovative relation techniques.  For those with psychiatric problems seeing a therapist may also be helpful.

2. Improve diet

• Eat more fiber – Most adults consume only about half the recommended dose of fiber (30 gm) on a daily basis.  Fiber in the form of fresh fruits, cereals, legumes and grains and oats facilitates regular BMs, regulates blood sugar level s and blood cholesterol.
• Adopt a Mediterranean diet with intake of lean proteins, healthy fats (olive oil), anti-inflammatory fiber-rich whole grains.  Also limit carbohydrates and intake of highly processed foods.  If you need formal education consider seeing a dietitian.
• Downsize meals.  Use a small plate to trick your senses into thinking you’re eating a plateful of food.  Eat until you feel almost full.
• Chew food well and eat mindfully.  Rather than rushing through a meal take time to appreciate the food noticing its color, aroma and texture.  Be thankful for natures harvest.  Chew food well to activate the enzymes to breakdown foodstuff and provide time for stomach to digest nutrients
• Try an elimination diet.  Many people have maldigestion as a result of lactose (dairy) intolerance, fructose intolerance or gluten (wheat) sensitivity.  It may be useful to keep a food diary for several days to determine correlation of digestive symptoms with specific foods.   Elimination of suspected food for periods of 2-3 weeks may be informative.

3. Change undesirable habits (for all the obvious reasons)

• Stop smoking and using illicit drugs
• Discontinue or curtail alcohol use
• Minimize or avoid caffeine intake
• EXERCISE regularly at least three times a week
• Maintain ideal body weight

Emergence of Accountable Care Organization (ACOs) in Healthcare

Key part of the 2010 Health Care Reform has been the development of Accountable Care Organizations (ACO) which is planning to go into effect on Jan. 1, 2012.  These entities will eventually oversee the clinical care and financing for health care in the near future.  They will ultimately be accountable to the payers and will assume the risk of cost and quality of care.  The federal statues outline various requirements that are necessary for organizations to become ACOs.  CMS recently issued proposed regulation on March 31, 2011, to guide the development of ACOs that will contract with Medicare.   Large hospitals systems with strong physician networks will be in good position to become ACOs in the near future.  Similarly large PCP practices (or IPAs with numerous primary care physicians in a community), working with specialist and hospitals may develop the infrastructures to form ACOs in metropolitan centers.  Independent physicians or subspecialists will need to form alliances with regional ACOs in order to take advantage of this healthcare delivery system of the future.  Physicians can participate with several ACOs within a community.

Since ACOs are likely to be led by hospital or primary care groups, subspecialists will need to find innovative ways in working and negotiating with these entities.   Perhaps they will be asked to show quality metric measurements and implementation of cost effective practice guidelines in their practices.  For example gastroenterologists may be given “carve outs” for key illnesses, that they will be responsible for in their entirety.   This may include management of patients with Crohn’s disease, cirrhosis, or irritable bowel syndrome.  Hence the gastroenterologist would not only diagnose, treat and manage patient during an acute flare-up, but would also continue to be responsible for patient’s specific GI disease for the duration of his life.  Obviously this takes considerable knowledge about the cost of such care including costs of medications and being proactive in minimizing flare-ups and hospitalizations.  Since this is not a fee-for-service model, the GI practice will be rewarded by keeping patients healthy and avoiding expensive care and intervention.

Further reading:   http://www.gastro.org/journals-publications/gi-quality-and-practice-management-news/2010/may/is-there-an-aco-in-your-future

Summary of CMS Proposal:  http://www.acg.gi.org/physicians/pdfs/ACOCMSProposedRuleBackground.pdf

Medical food for treatment of hemorrhoids

Symptomatic hemorrhoids are among the most complaints in adult patients.  Nearly 50% of the population tends to have hemorrhoid trouble during their life time.  Most common symptoms include bleeding, itching, pain and prolapse.  Conservative (non-invasive) measures in management of hemorrhoids include high fiber diet, adequate fluid intake, sitz baths and topical anal creams (typically consisting of steroids).    Although there are numerous oral medications, and herbals that are marketed for management of hemorrhoidal disease, most of these agents have no proven track record.  An exception to this may be a medication called Diasmon.   This is a flavonoid fraction, a plant secondary metabolite.  Due to lack of any significant side effects, Diosmin is listed by the FDA in the Generealy Regarded As Safe (GRAS) category.   The active ingredient is non-toxic and safe without any know cross reactivity with other compounds.  Rather than a prescription medication, Diosmin is categorized as a medical food and is intended to be used under medical supervision for a specific medical disorder.

Diosmin has been studied in numerous clinical trials over the past twenty years.  It’s mechanism of action is in minimizing chronic venous insufficiency by improving venous tone and suppressing local inflammatory response in veins.  Micronized diosmin, marketed as Daflon has been used extensively in Europe.  In addition to hemorrhoids this compound has also been utilized in the treatment of varicose veins.

As a single agent for the treatment of hemorrhoids, Godeberge (1) showed that diosmin significantly decreased (50%) acute and chronic symptoms of internal hemorrhoids including anal bleeding, pruritus, and edema over a two month treatment period.   In a separate study by Ho (2), there was no significant difference in the treatment of Grade 1 small internal hemorrhoids using diosmin versus rubber band ligation.  However in larger hemorrhoids Yuksel (3) showed that schlerotheapy was more effective than diosmin alone.  Use of diosmin as an adjunct to conservative post-op care from hemorrhoidectomy was studied by La Torre (4).  This study showed that a disomin significantly decreased pain, tenesmus, and bleeding in the post-operative phase of recovery in the first two months after surgery.   Hence, diosmin may be used both in conjunction with conservative therapy for hemorrhoids or as an adjunct to more invasive intervention.  Currently, this medical food can be purchased as a micronized tablet supplement or as brand name Vasculera, which is component of Analpram Advanced Kit containing 2.5% hydrocortisone anal cream.

References:

1) Goldberg, P. Daflon 500 mg in the Treatment of Hemorrhoidal Disease:  A deomastrated Efficacy in Comparison with Placebo.  Angiology 1994; 45-574

2) Ho YH et. al.  Micronized Purified Flavonidic Fraction compared Favorably with Rubber Band Ligation and Fiber Alone in the Management of bleeding hemorrhoids. Dis Colon Rectum 2000; 43-66

3) Yuksel BC, et al Conservative Management of Hemorrhods:  A cComparison of Venotonic Flavonidic fraction to reduce bleeding after haemorrhoidectomy. Br J Surgery 1995; 82:1034.

4) La Torre, et. al.  Clinical Use of Micronized Purified Flavonoid Fraction for Treatment of Symptoms after Hemorrhoidectomy.  Results of a Randomized Controlled Clinical Trial.  Dis Colon Rectum  2004: 47-704

New era in Hepatitis C treatment

This month the FDA approved two new medications for the treatment of chronic HCV disease.  Boceprevir and Telaprevir are both protease inhibitors that block the replication of the HCV virus in the liver.  They are not approved as monotherapy but rather as adjunct treatment to the standard (established) regimen of PEG-interferon and ribovarin.

Both Boceprevir and Telaprevir have been shown to significantly improve cure rates in the most common and difficult to treat group of patients (that have genotype 1 virus).  Typical eradication rates for genotype 1 chronic HVC disease, using 48 weeks of standard therapy are 45%.   The newer agents have been shown to improve this eradication rate to nearly 65-70% with just 24 weeks of treatment.  In patients that have never been treated with antiviral agents, cure rates with triple therapy including Telaprevir may be higher than 80%.   Although response rates in the black population is typically lower with antiviral agents, the use of triple therapy with Boceprevir increased cure rates in one study from 23 to 50%.   Similar improvements were seen, when patient that were previously nonresponders or partial responders to standard therapy, were subject to triple therapy.

Although  the recent data and FDA approval of these protease inhibitors improves the outlook for patients with  chronic HCV disease there are several issues that are of concern.   The triple regimens mentioned above come with significant side effects including flu-like symptoms, headaches, fatigue, depression, anemia and rash.   In the case of Boceprevir over 40% of patients required injectable erythropeitin to manage symptoms of anemia.  In the case of Telaprevir more than 50% of patients developed a skin rash with 7% of patients discontinuing therapy.  Furthermore there is concern that a proportion of previously treated patients (nonresponders) that are exposed to protease inhibitors may develop resistance –associated mutant variants.

As physicians develop programs to improve compliance and effectively manage adverse side effects, the new triple therapy with PEG interferon, ribovarin and a protease inhibitor is likely to become the standard treatment for HCV (genotype 1 ) disease.

References

McHutchinson JG et. al. Telaprevir with Peginterferon and Ribovarin for chronic HCV genotype 1 infection. NEJM 2009 Apr 30; 360-1827

McHutchinson JG et. al. Telaprevir for previously treated chronic HCV infection. NEJM 2010 Apr 8; 362-1292

Poordad F et. al. Boceprevir for untreated chronic HCV genotype 1 infection.  NEJM 2011  Mar 31; 364-1195

Bacon BR et. al. Boceprevir for previoulsy treatd chroinc HCV genotype 1 infection. NEJM 2011  Mar 31; 364-1207

Jensen DM, A new era of hepatitis C therapy begins. NEJM 2011  Mar 31; 364-1272

What is the cost of colonoscopy?

Colonoscopy is considered the gold standard in the anatomical evaluation of the large intestine.  Many patients ask whether a colonoscopy procedure is covered by their health insurance and cost of the procedure (in the case of those patients that have high deductibles and end up paying for this test out-of-pocket).

There are two types of colonoscopies;

1. Screening colonoscopies is performed in patients (typically over the age of 50) that have no symptoms (no complaints).  This procedure is routinely recommended for early diagnosis of polyps and colon cancer.
2. Diagnostic colonoscopy is performed in patients with specific complaints such as rectal bleeding, change in BMs, weight loss of unexplained nature and abdominal pain.

Since the year 2000, most commercial insurance companies and Medicare has covered the expense of screening colonoscopy.   In fact some insurance companies such as Blue Cross and Blue Shield (BCBS) will typically pay the entire cost of the procedure except for small co-pay ($25-50) which the patient is responsible.    The cost of diagnostic colonoscopy is typically covered by insurance companies once the patient’s deductible is met.   For example a patient with a deductible of $2,000 per year may have to pay the entire cost of the procedure out of pocket, if they have not met this deductible earlier in the year.

The cost (reimbursement) of colonoscopy is typically negotiated between the provider (physician’s office) and the health insurance company.   The complete expense of this test consists of the following components;

1. Facility fee (for the use of the Endoscopy Center and instruments)
2. Physician fee for performing the actual examination procedure
3. Anesthesia fee for sedation provided during the procedure

There is also the pathology fee if there is any removal of tissue or polyps

The 2011 Medicare cost of colonoscopy with biopsy (CPT  45380) in Raleigh-Durham area are as follows:

1. Facility fee          $ 362
2. Physician fee      $ 277
3. Anesthesia fee   $ 127

Pathology Fee (per specimen)   $ 112

The cost of colonoscopy services for commercially insured patients can be 40-60% higher than Medicare.   The patients should check with their insurance companies regarding their specifics coverage.

Additional useful information for Medicare patients (effective Jan 2011)

http://fightcolorectalcancer.org/images/posts/2011/03/Health-Reform-Colonoscopy-Screening-Cost-Sharing.pdf

Improving detection of colon cancers

For the past decade colonoscopy has been considered the gold standard in colorectal cancer screening.  But research published in the past several years has raised concerns about the detection rate of colorectal cancer (CRC) in the general population.  The fact remains that CRCs occur in 6-9% of patients within three years after negative colonoscopy.  These interval cancers may be new, fast-growing lesions in microsatellite stable regions of the large bowel.  However most of these new cancers likely arise from lesions that are missed during recent colonoscopy.  Based on tandem colon examinations performed on the same patient, 10% of polyps greater that 1 cm can be missed during colonoscopy.  Furthermore there are several research articles that show that although screening colonoscopies provide high rate of protection of CRC in the left colon, it does not have much impact in the prevention of CRC in the right colon.  Hence, national statistic that show the incidence of CRC has fallen over the past 30 years primarily in the left colon, but has remained relatively stable in the right colon.  Although the biology of these cancers in the proximal colon may be different than those on the left side, the quality of the endoscopic examination (and the training of the endoscopist) may also explain the discrepancy.   Being an operator dependent diagnostic modality, the detection rate of neoplastic lesions via colonoscopy is dependent on the experience of the physician.  Patients whose colonoscopies were performed by gastroenterologists with high completion rates and high polypectomy rates had 27% to 39%, lower risk for interval cancers.

The current GI society guidelines recommend colonoscopy at 10 year intervals for patients with negative exam, and 3-5 year intervals for those with adenomas or family history of premature colon cancer.  However the variability in quality of colonoscopies in the general community, and the high incidents of interval cancers, create anxiety in the medical community regarding surveillance intervals.   Many asymptomatic patients are referred for colonoscopy prematurely.  A recent study published in the journal Gastroenterology, reveals that use of fecal immunochemical tests (FIT) on a yearly basis, in conjunction with routine surveillance colonoscopy in patents with high risk for colon neoplasia decreased the incidence of CRC by 86%, and advanced neoplasia by 63%.   The diagnosis of colon cancer and advanced neoplasia occurred nearly two years earlier when using FIT on an annual basis, compared with relying on pre-determined colonoscopy intervals alone.  These impressive results were most noticeable in male patients and older age group.  Conversely patients with repeatedly negative results from FIT, compared to patients that were not tested, had almost two fold lower risk of  cancer or advanced adenomas.   In such patients it may be feasible for colonoscopy to be defferd for longer periods of time.  In conclusion, FIT, a simple in-home test when used in conjunction with surveillance colonoscopy can dramatically decrease the incidence of interval colon neoplasms in high risk patient.

Reference:

Interval fecal immunochemical testing in a colonoscopic surveillance program speeds detection of colorectal neoplasia. Lane JM, Chow E, et. al.  Gastroenterology 2010 Dec;139(6):1918-26.

Antibiotic Treatment for Irritable Bowel Syndrome ?

Irritable bowel syndrome (IBS) is perhaps the most common digestive disorder in the U.S.  The syndrome tends to afflict mostly young patients and can manifest with abdominal pain, bloating and altered bowel movements.   The condition is typically managed with a combination of conservative measures including fiber supplements, probiotics and antispasmodics (i.e. Bentyl, Levsin, etc).   In patients with more advanced symptoms, agents that alter visceral sensitivity such as tricyclic antidepressants (Elavil, Disipramine) have been used in low doses with relatively good results.  Currently there are two FDA approved medications for use in IBS.  Lotrenex (alosetrone) is a serotonin reuptake inhibitor that is effective for a subgroup of female IBS patients with severe diarrhea.  Amitiza (lubiprostone) is approved for use in IBS patients with severe constipation, and acts to activate the chloride channels in the small intestinal mucosa with resultant enhanced fluid secretion and fecal transit.

Due to the predominance of intestinal complaints in patients with IBS, intestinal microbes have been speculated as culprits in the underlying pathophysiology of IBS.  Some researchers believe that bacterial overgrowth may be one of the underlying factors in the clinical manifestation of the disorder.  A recent study reported in the New England Journal of Medicine (see abstract on reverse) has shown that rifaximin may be effective in the treatment of IBS patients without constipation.  Rifaximin is a minimally absorbed and relatively safe antibiotic, currently approved (at a lower dose) for the treatment of travellers’ diarrhea.   To evaluate the efficacy of the medication in reducing  symptoms of IBS, investigators conducted two identically designed, industry-sponsored, double blind, randomized, placebo controlled clinical trials involving a total of 1260 patients who had IBS symptoms without constipation.  Patients received high dose rifaximin (550 mg three times a day) or placebo for two weeks, and were followed for additional 10 weeks.  In the combined studies, both study endpoints were reached.   1) Higher proportion of patients (41% vs 32%, P<0.001) in the rifaximin group experienced relief of global IBS symptoms versus placebo.  2) Similarly a higher percentage of patients received relief of bloating on the study medication (40% vs 30%, P<0.001).   Similar type of sustained benefit was also seen in patient’s abdominal pain and loose stools.

There are several potential issues with the use of rifaximin in IBS patients.  Can a lifelong bowel disorder be cured with a short term of antibiotics?   Although this is improbable in the majority of IBS patients, our experience in treating H. pylori infection in patients with peptic disease suggest that there is certainly precedence.  Given the current overuse of antimicrobial agents in our society, the consequence of using a nonabsorbable antibiotic in large number of patients is unknown and perhaps a bit concerning.   Also the high cost of rifaximin therapy can certainly limit its use in the general population.   A two week course of high dose rifaximin can cost up to $1,300 in patients with limited insurance coverage.   Finally, compliance with treatment may be compromised in young patients having to take a medication three times a day for two weeks.  FDA is currently reviewing the manufacturers New Drug Application (NDA) for the use of rifaximin in IBS patients without constipation.

Reference:   Rifaximin Therapy for Patients with Irritable Bowel Syndrome without Constipation.  Mark Pimentel, M.D., Anthony Lembo, M.D., William D. Chey, M.D., Salam Zakko, M.D., Yehuda Ringel, M.D., Jing Yu, Ph.D., Shadreck M. Mareya, Ph.D., Audrey L. Shaw, Ph.D., Enoch Bortey, Ph.D., and William P. Forbes, Pharm.D. for the TARGET Study Group.  N Engl J Med 2011; 364:22-32 January 6, 2011.

Prevention of Colon Polyps

For many patients who are diagnosed with colon polyps or who require colonoscopy on regular intervals due to their history of colon polyps, a common question arises as to “what can I do to prevent having colon polyps”.   It should be made clear that most polyps of the ‘hyperplastic’ variety are totally innocuous and do not need surveillance.   Adenomatous polyps on the other hand have a complex natural history and are believed to arise through several mutations in the intestinal cell lines.   These polyps are believed to be precursors to most forms of colon cancer (adenocarcinoma) seen in the U.S.   Beyond family history, there are several risk factors that have been identified for formation of colon polyps and colon cancer.   These include history of diabetes, obesity, hypertension, cardiovascular disease, smoking, low fiber diet and history of ulcerative colitis.   For patients with any of these risk factors mentioned above, the reversal of factors is presumed to have potential benefit in decreasing the risk of future polyp formation (although clinical trials have not been undertaken to prove this hypothesis).    Most patients are recommended to eat a diet that is low in fat and high in fiber.  They are also advised to maintain a normal body weight and avoid smoking and excessive use of alcohol

There are several medications that are believed to decrease the risk of recurrent colon polyps; although none of these have been approved by the FDA for use in the general public.   Several studies have shown that regular use of low dose aspirin diminishes the risk of adenomatous polyps in adults.   The mechanism of action of aspirin is not well understood in chemoprovention, but the medication may inhibit tumor cell growth and facilitate apoptosis (engulfment of aberrant cells).  Other inhibitors of inflammation (NSAIDs) may also suppress polyp formation in adults.  However their side effects (including ulcer formation in the stomach lining) have limited their use.  Calcium supplementation (along with vitamin D) has also been shown to have potential benefit in reducing the risk of recurrent colon polyps and perhaps colon cancer.    However the risk of kidney stones and the side effect of constipation have limited its use in the general population.   Another class of medication referred to as statins (such as simvastatin) have also been shown to decrease colon polyps/tumors.   These mediations also have certain side effects which limit their use to selective group of patients primarily with cardiovascular disease or hypercholesterolemia, who deemed to be appropriate candidates for this therapy.

It is believed that the initial (first) colonoscopy is perhaps the most important exam in determining patient’s outlook with regards to colon cancer and polyp detection.  Making sure that the physician performing the colonoscopy is an experienced gastroenterologist that adheres to quality measures of colonoscopy is of outmost importance http://www.raleighgi.com/?p=104.   Furthermore, following the physician’s recommendations in having follow-up colonoscopy at appropriate intervals can minimize adverse outcomes with regards detection of advanced colon polyps and colon cancer.