Monday, February 26, 2018

Colonoscopies, Revisited

[“Let Inga Tell You,” La Jolla Light, published Feb. 28, 2018] ©2018
I was genuinely surprised when one of the biggest responses I’ve ever received to a column was to the one about colonoscopies.  (The recent column about high-pressure dentists had a surprising response too but I’ll follow up on that one another time.)  I will merely say that neither gastroenterologists nor dentists fared well.
The Light only allows me 800 words rather than the 20,000 that I could now easily write about colonoscopies but let me say that horror stories abounded.  One reader shared:  I woke up in the middle of it because they decided to discontinue anesthesia when my blood pressure plummeted to 80/40. The nurse told me to stop screaming because I was upsetting the other patients.
Most readers (although certainly not the one above) agreed that the 14-hour intestinal power wash prior to the procedure was the worst of it.  The most commonly used “bowel prep” agent is still an utterly foul concoction called GoLytely but the newer (and only slightly less toxic) Prepopik is gaining ground, more slowly because Medicare doesn’t cover it.  $44-$100 is lot of money to spend for something that gives you explosive diarrhea.
Fortunately a non-invasive DNA test called Cologuard – a stool test that one conducts in the privacy of one’s own home – is on the market but not considered the “gold standard,” which I think means less gold ends up in the pockets of gastroenterologists.  But any fantasies one might have about discreetly pooping into an ergonomically-designed receptacle, sprinkling in a few drops of a testing agent and putting it out for the unsuspecting postal lady to pick up should be disregarded.  A reader noted:  We are in the process of doing the “Cologuard” test and it has taken us the whole morning to just read the instructions in the booklet which is over 35 pages long!!! Each step has to be followed exactly as outlined, specimen bottles have to be correctly gathered, labeled, and preservatives added so they can be mailed successfully.  If one does not follow the intricate steps, the test could become invalid.  
After experiencing both GoLytely and Prepopik up and close and personally, my ever-perverse mind became obsessed: if these were the products that ended up on the market, what about the ones that FAILED? Inquiring minds HAD to know.
Thus, it was a dream come true when I was contacted by a local retired physician who personally knows “Dr. X,” the developer of GoLytely and who provided me with some of the most fascinating and illuminating correspondence I have been privileged to have in my column career. Totally lovely guy.
I emailed him:  I confess that my imagination has run away with itself about the development of GoLytely. Certainly one could imagine beta versions that didn't get the job done, but surely there were versions that did it way too well?  How much did they pay these people?????  By the way, just so your colleague, Dr. X, understands, his burial site will have to be unmarked.  I cannot even imagine the GoLytely-related atrocities that might occur upon it otherwise. I assume he already resides in the witness protection program. Sincerely, Inga
My new local friend sent me an article from Gastroenterology that covers this exact topic. It was not too surprising to learn that the earliest versions of bowel preps, in 1947 and 1953, were tested on rats and sheep.  But this only raised more questions: How did they get the rats to drink it? Was some poor lab technician in charge of measuring rodent effluvia? I’m trying to even imagine rat colonoscopies with a teeny weeny colonoscope. 

But between 1953 and the unleashing of GoLytely on the innocent masses, there were some definite bumps in the developmental road including some chilling descriptions of the “hazards of volume overload.”  I was also intrigued by the experiment that added 80 mmol of mannitol to the test solution only to discover that “fermentation of mannitol by colonic bacteria yields potentially explosive gases.”  Um, are we not talking human intestines here?  This was apparently mostly a risk if “electrocauterizing procedures” were being used.  With the understated charm so endearing to scientific publications, it was noted: “in only one study was an explosion observed.”
My local correspondent referred me, should I desire more information on “the flammability of colonic gas that is expelled” to papers by Mike Levitt who is the world’s authority on intestinal gas. I’ll bet he is a huge hit at school career day. You can see the utter rapture on the face of every male student. “That’s a real job?”
Personally, I’m rooting for the Cologuard DNA test but preferably in a version whose instruction manual is one paragraph. But even more, I'm really hoping that colonoscopies will become a footnote in med student's texts about barbaric procedures once inflicted among the American public. They’ll shake their heads and marvel, “And millions of people actually agreed to this?”

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