February 18th, 2009
Sedation-Free Colonoscopy: Why Isn’t It the Standard?
This Saturday’s Wall Street Journal featured an intriguing article on sedation-free colonoscopy, which is standard in Europe and Asia but rarely done in the U.S. One could argue that Americans are just “weenies,” but I think the blame rests solely with us doctors.
Sedation-free colonoscopy is successful in most who try it (I did!), but it does require a more careful exam to ensure that patients are comfortable. Over-distension, looping, and other problems that can cause pain must be avoided, and that means the doctor must spend more time and perform more maneuvers during each procedure. And therein lies the rub. Even though sedation-free colonoscopy is safer and cheaper for patients, most gastroenterologists already feel rushed when they see patients and don’t want to take the time to even broach the subject of sedation-free colonoscopy, let alone actually perform it.
What’s my recommendation? Discuss the availability and benefits of sedation-free colonoscopy with all your patients, and let’s let Americans know to ask for it. It’s a better way to get the exam — and you can even drive yourself home that day!
45 Responses to “Sedation-Free Colonoscopy: Why Isn’t It the Standard?”
M. Brian Fennerty, MD
Editor-in-Chief
NEJM Journal Watch Gastroenterology
Biography | Disclosures | Summaries
Learn more about Gut Check on Gastroenterology.
NEJM Resident 360 Curbside Consults Podcast- How the Pediatric Boards Are Made with Dr. Andrew Dwyer
- Global Health, GLocal Health, and the Indian Health Service with Dr. Adriann Begay
- Immune Checkpoint Inhibitors with Dr. Kerry Reynolds
- Management of Acute Coronary Syndrome in Older Adults with Dr. Abdulla Damluji
- Culinary Medicine with Dr. Jaclyn Albin and Milette Siler, RD
I regularly have minor dental work done without local anesthesia, after minor surgery I only take plain Tylenol, and there is no way in the world that I would have a colonoscopy without sedation. It is hard enough to persuade people to be screened for colon cancer when they expect to have little or no memory of the procedure–how fast do you think they will run if the option of sedation is taken away? The Europeans should be emulating us, not the other way around.
How absurd! As a health care professional, and a patient, I have undergone sedation-free, and sedated colonoscopies. The difference…inhumane, barbaric, excrutiating, and unnecessary pain.
Leave sadism and barbarism behind. Welcome to the 21st century!
Everyone has different thresholds for discomfort, and I am for letting the patient decide by making sure they are aware of all options.
Letting the patient decide after explanation of the options is the way we do it (private practice, Wuppertal). Most of our patients ask for sedation and of course they get it. Having undergone a sedation-free colonoscopy myself I just give this hint. And meanwhile there is a still small, but increasing number doing it ‘without’.
@pasqualina: every patient starting colonoscopy without sedation / analgesia has the possibility to ask for during the procedure whenever it starts to feel pain – so choosing this option is no irrevocable decision till the end of the examniation. No one will suffer !
I agree that I should be an option as long as the MD is at a comfort level with this idea also. “Lets put everyone at ease, especially the one performing the procedure!” AS for my personnal vote: I would be terrified to have the colonoscopy peformed without pain relief and sedation.
I think the patients should be given the choice to make a decision about sedation. In UK few centres practice sedation free colonoscopy. I can definitely say that sedation free colonoscopy is advantageous for some patients who dont want to be dependant on others at all. Especially for those who come for surveillance and know exactly what they are going to face they are the one to whom we offer sedation free colonoscopy. Also it depends on the experience of the endoscopist and the time one has to perform. In UK its NHS system which is free so finances does not come into play. The place where I am training atleast 10% are done without sedation.
I would feel that having a procedure like a colonoscopy would require sedation. I had a client who did not want sedation and she being a trooper did in fact have suffering and the worry about passing gas and bloating had her so nervous she could hardly compose herself. She became very self conscious about everything happening to her body during this procedure. She started to sweat profusely and her blood pressure dropped suddenly . She did finish and she was not ready to drive home. She did not complain and she could tolerate pain at a high level. This procedure has been done on her since with sedation and she has commented numerous times that she would never go again without sedation. So with that said I am definitely encouraging my patients to have sedation, although the final word is up to them.
Having a strong family history and having had five colonoscopies beginning in my 40’s, I could never tolerate these procedures without sedation. Let us not return to “biting down on a stick.”
I’ve had two colonoscopies and will probably have to have another one sometime soon (I’m 24 with Crohn’s disease), and the idea of going without sedation makes me cringe. IBD patients usually are in enough pain already without having to deal with something foreign bashing and banging around down there. The patient is usually up all night anyway with the prep, so the forced nap is a bit of a godsend anyway.
Don’t forget that some of us are allergic to the sedation drugs and that a sedation-free exam is the onlyway that we can get a colonoscopy. I have symptoms and a bad family history as well as severe allergies to midazolam and to propofol. The answer that I have received from the local GI docs is “too bad”.we don’t like to do unsedated exams because it takes a little longer..So I’m put at risk for colon cancer because of a few dollars????
I agree with Gareth. I also have problems with sedation meds and the local GI docs say there is no other choice, and that it is unsafe to do an unsedated colonoscopy. WHY? Everyone is different with different sedation needs. The doc said it is only a 20-minute procedure. Talking about a problem getting people back for a repeat exam, they won’t even get me for the first exam unless I can do it without sedation. How do handle it when there is one consent form for both the procedure and the sedation – they are not separate forms? Why is it such a fight to get docs to realize that some us can’t physically handle and don’t need the sedation?
I had my second colonoscopy just today, no sedation for either one. The first time was 3 years ago, I don’t like drugs and sedatives make me very ill. I discussed with this with my gastroenterologist back then, and he put me at ease because he himself does not have any sedation when he has his own colonoscopies. As a result, he was very gentle with me, and I had very little pain. I left the clinic with a very positive feeling, wondering what the big deal was and why so many people freak out when I tell them about it.
Well, I didn’t really understand then that not all docs are the same or learn the same techniques. Since my last procedure I have moved to a different state, so today’s procedure was performed by a different doctor who has only ever worked on unconscious patients and wouldn’t dream of having this procedure done on herself without drugs. I could certainly tell the difference. She was not even a little gentle and there were several short bursts of pain. I could even feel the scope pushing through on the outside of my abdomen, whereas I did not feel that the first time. I did tell her that I could tolerate a small amount of valium if necessary, but I will not take versed. She informed me that they refuse to use valium and will only use versed, and I had no choice (even though the GI clinic is within the Navy hospital where valium is certainly available in other departments).
As a proactive patient who tries to be educated about what’s happening to my body, it’s frustrating to have docs who seem like they won’t listen or don’t seem to care too much. As a military dependent, I have to take the docs they give me, I’m not able to shop around for a doctor who will understand me based on his own experiences like my first GI doctor did. Since I’m not in the health care profession, I lack the knowledge and credibility to explain that colonoscopies really can be done easily without sedation and the doc should learn how to do it gently for the few patients who don’t like drugs.
Despite today’s more painful experience, I still plan to have my next colonoscopy sedation-free, whenever that will be, five or ten years from now, unless, of course, there are complications. I will be moving again in the next couple of years so I very probably will not see today’s doc again. I can only hope my next doctor will be as understanding as my first doctor was three years ago.
It makes me sad to say, but the GI docs insist on sedation because it makes their job easier and faster, not for the patient’s benefit. Most of the world does these exams unsedated and they are fine. Google versed horror stories and tell me that any thinking person would consent to versed. 6 local GI doc’s told me it was imperative that I get a colonoscopy (FAP), but when they saw that I was allergic to versed and propofol, all said “too bad, we can’t slow things down to do an unsedated exam (and a lot of docs get theirs unsedated; they don’t want the memory loss)…..I’m sick of the USA medical system and wish that my daughter would drop out of medical school, but she’s still under the illusion that docs help people. The last GI doc that told me that she wouldn’t do an unsedated exam was a gem; when I politely walked out of her office (after she told me an unsedated exam was impossible), she followed me into the parking lot and agreed to do the exam unsedated; in fact, she had her own colonoscopy unsedated! She knows my terrible family history and seemed to care that I get this needed exam; she is a sweetheart, but when she grabbed my arm and asked me why I wouldn’t do the exam (unsedated), she didn’t understand the answer: you lied to me repeatedly about the sedation and I wouldn’t want a liar involved in my medical care. I’ll take my risk with colon cancer.
I am a registered(endoscopy)nurse who has undergone unsedated colonoscopy. My experience was for the most part painless aside from a cramping sensation around the hepatic and splenic flexures. The gastroenterolgist who performed my exam uses a technique where he basically fluid fills the colon allowing for smoother movement of the scope around to the cecum. I was somewhat sceptical to see if this method actually worked vs. air aided cecal intubation and I have to say he made a believer out of me. I am 35 with a strong family history of colon cancer, so needless to say I’m on the 5 year plan and I will continue to do my colonoscopy procedures without sedative, especially with the fluid filling technique being employed. I think it is a safer option and I enjoy not having to be “out of it” for the remainder of the day. However, I would not necessarily recommend it for those patients who have had hysterectomy or any type of abdominal surgery with adhesions. I do think the medical profession in the U.S. could do a better job of explaining to our patients the option of a non-sedated procedures. If patients had a better understanding of the options their anxiety level would be decreased and they would feel “empowered” to make a better informed decision in regards to sedated vs. non-sedated procedures.
I had my first colonoscopy this year on the recommendation of my physician who suspected I may have an IBD. After several days of research about the procedure and the side effects of the amnesiac drugs used during the procedure, I opted for a non-sedated colonoscopy. I was extremely surprised at how little pain was actually involved in the procedure. I felt some pain when the scope made the final two turns, but other than that it was very mild. It was more of a bloated feeling, not really pain per-say. A trip to the dentist is more painful than an unsedated colonoscopy.
I think it has more to do with the doctors performing the colonoscopy, sedated patients mean they don’t have to actually interact with you or answer questions. From everything I read, the chance of bowel perforation is actually much higher with a sedated colonoscopy. I recommend anyone getting ready to undergo this procedure attempt it without sedation, the risks are far fewer, and the pain was more than manageable; and I have a low tolerance for pain.
I had a sedation free colonoscopy two days ago. I highly recommend it. Perhaps if you have a very low threshold of pain you could not take it. I found the 3-5 seconds of pressure outweighed the medication.
I am a dentist in Pa. I have had two colonoscopies down sans sedation with a couple of small sessile polyps removed each time. On a scale of 1-10 the maximum discomfort was a 2. Some bloating from distending the colon with gas and some mild discomfort around the splenic and hepatic flexures. My gastroenterologist is excellent and considers it an honor to take the few extra minutes to make if more comfortable for me. He was excited to discuss the procedure and I enjoyed seeing my internal anatomy! Most of his patients are horrified at this procedure and are not responsive during it. I would never consider the risk of sedation again and I have to have these tests every 3-4 years. Since the colon has no sensory nerves, there is no pain as he progresses to the cecum. Also, they have to be more careful as the snake their way in which reduces the chances of a perforation! So get off the drugs and be able to drive yourself home right after the procedure. I cut the grass less than an hour after arriving home today. Good luck. Plus it saves 6-800 dollars, either yours or your insurance companies which would reduce premiums if many people started doing it this way.
Our sedation use would be considered very low dose compared to some centers but many of our patients are quite elderly and different ethnic groups can be vastly different in terms of tolerane of the iv sedatives.and many/most watch the procedue on the large screen video set. We do use water infusion. There are many patients who come demanding to be “put out” and I would hate to try to perform colonoscopy on some of our patients with a highly tethered colon after varied abdominal surgeries without at least some sedation. Every patient’s pain threshold is different- there are patient’s who need sedatives to even allow them to take the prep. I agree that it is reasonable in patients who are properly informed and consented to perform exams without sedation but with an iv in so that we can provide pain relief as needed
Good…! Really good. I am a gastroenterologist from Army Hospital in Jakarta, Indonesia. Really, until now we had a sedation-free colonoscopy for our patients and no problem! We can do it saved and cheaper, comfortable in our patients and looking better than in sedation colonoscopy because we knew what the patients convienent or not. Last but not least, I usually getting more water flushing in work of colonoscopy…!
I wouldn’t dream ofnot having short-term sedation. dHT e propophol is amazing. It’s like it’s over in the blink of an eye. I have a difficult colon with at least one difficult loop, so I usually feel something even thru the sedation, but I remember only the groans. I did receive 75 mg. demerol IV last time and this made my gastroparesis worse for several days, so in future I am going to recommend only a versed, valium, propophol combination. I think everyone should have a choice. But I do think not having sedation could hamper the operator, who is trying not to cause any pain or discomfort, rather than trying to find lesions.
Also remember that colonoscopy has replaced the dreaded barium enema. Our aim is timely prevention. By pushing an unsedated exam that can be at least as bad as the worst barium enema is to push early detection back at least 20 years. Non-sedated colonoscopy should remain ONLY an option. I have had 5 sedated colonoscopies and have no complaints except for using the long-acting IV demerol. Who knows, maybe I needed it.