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Tuesday, March 11, 2014
Colonoscopy in Heart Patient
Hello, Your help will be greatly appreciated. My brother is a long time heart patient with CHF and CAD (70 yo, CABG 15 years ago). He has been somewhat anemic since last year and also complained of a general discomfort in the abdomen area (parallel to the navel). He also has GERD (takes a PPI). A GI specialist refused to perform a colonoscopy due to his heart condition. A few months later, my brother`s hemoglobin fell to 75 suddenly and FOBT was positive. The GI doctor still did not want to do a colonoscopy. An endoscopy and bone marrow biopsy were done instead, both normal (although the bone marrow was termed as "sluggish") and anemia of chronic disease was established. However, my brother continues to be anemic (Hb between 90-110 with EPO and occasional blood transfusions), and continues to have a non-defined stinging pain across his abdomen (no cramping).
Recently after having a bout of pneumonia, he became constipated and now often feels he is not emptying his bowels completely. He is often tired (but this could be due to other conditions in someone with a chronic illness). There is no history of colon cancer in the family.
His doctor thinks he should have a colonoscopy. His cardiologist also thinks so but is worried about the effect of sedation on his heart (a non-sedated procedure is not being recommended).
Are there recommendations for such a patient profile? Do symptoms such as anemia, plus the abdominal issues, not raise enough concern to warrant a colonoscopy? Given these types of general symptoms, how does one assess the risk to reward of sedation versus colonoscopy? Are there any other options? Virtual colonoscopies are not possible due to the contrast dye and his kidney function.
NetWellness does not provide diagnostic services, only information. Your very pertinent questions should therefore be addressed primarily to your brother's doctors. Anemia is one of the most important clues to a diagnosis of colon cancer, which is one of the commonest cancers. The diagnosis is most often made by colonoscopy, which is still the gold standard, allowing visualization of the entire large bowel and also biopsy of suspicious lesions. There are however some newer, less invasive imaging technologies such as CT scanning, and wireless camera endoscopy. The latter method does not require the use of contrast, an advantage for those patients with poor kidney function.
In the United States sedation is customary but it is possible to perform colonoscopy without sedation, or with fairly light sedation. There is some evidence that colonoscopy done with moderate or deep sedation detects more lesions, which stands to reason, as the endoscopist need not be concerned about completing the procedure as quickly as possible in order to avoid a lengthy period of discomfort for the patient.
While the risk would be greater, even a patient with severe heart failure or other major disease can be sedated for a colonoscopy, with the expectation of a rather low rate of sedation-related complications. The over-riding determinant of safety in these circumstances is the expertise of the anesthesia provider. Interventional cardiologists have some experience with the administration of sedation but this is truly the domain of the anesthesiologist.
The best way to make an assessment of the risks and benefits of the procedure in this context would be for the anesthesiologist to communicate directly with the cardiologist to understand the exact nature and severity of underlying heart disease. The risks and benefits of the sedation and of the colonoscopy itself can then be communicated to the patient, along with a plan of action to allow the procedure to take place as safely as possible.
Gareth S Kantor, MD
Assistant Professor of Anesthesiology
School of Medicine
Case Western Reserve University