Gastroenterologist Says Colonoscopy Needed Again Within the Year

Endoscopic examination of the bowel

Colonoscopy
Colonoscopy existence performed
ICD-9-CM	45.23
MeSH	D003113
OPS-301 code	i-650
MedlinePlus	003886
[edit on Wikidata]

Colonoscopy () or coloscopy ()^[1] is the endoscopic examination of the big bowel and the distal part of the minor bowel with a CCD camera or a fiber optic photographic camera on a flexible tube passed through the anus. Information technology can provide a visual diagnosis (e.g., ulceration, polyps) and grants the opportunity for biopsy or removal of suspected colorectal cancer lesions.

Colonoscopy can remove polyps smaller than i millimeter. Once polyps are removed, they can be studied with the assistance of a microscope to determine if they are precancerous or not. It tin can take up to 15 years for a polyp to plow cancerous.^{[ citation needed ]}

Colonoscopy is like to sigmoidoscopy—the difference existence related to which parts of the colon each tin can examine. A colonoscopy allows an examination of the entire colon (1200–1500mm in length). A sigmoidoscopy allows an exam of the distal portion (about 600mm) of the colon, which may be sufficient considering benefits to cancer survival of colonoscopy have been express to the detection of lesions in the distal portion of the colon.^{[2] [3] [4]}

A sigmoidoscopy is often used as a screening procedure for a full colonoscopy, often done in conjunction with a fecal occult claret test (FOBT). About 5% of these screened patients are referred to colonoscopy.^[v]

Virtual colonoscopy, which uses 2D and 3D imagery reconstructed from computed tomography (CT) scans or from nuclear magnetic resonance (MR) scans, is likewise possible, as a totally non-invasive medical test. Virtual colonoscopy does not allow therapeutic maneuvers such as polyp and neoplasm removal or biopsy, nor visualization of lesions smaller than 5 millimeters; if a growth or polyp is detected using CT colonography, it would crave removal during a standard colonoscopy. Surgeons accept used the term pouchoscopy to refer to a colonoscopy of the ileo-anal pouch.

Medical uses [edit]

Conditions that telephone call for colonoscopies include gastrointestinal hemorrhage, unexplained changes in bowel habit and suspicion of malignancy. Colonoscopies are ofttimes used to diagnose colon cancer, but are also frequently used to diagnose inflammatory bowel disease. In older patients (sometimes even younger ones) an unexplained drop in hematocrit (one sign of anemia) is an indication that calls for a colonoscopy, commonly along with an esophagogastroduodenoscopy (EGD), fifty-fifty if no obvious blood has been seen in the stool (carrion).^{[ commendation needed ]}

Fecal occult blood is a quick test which can be washed to test for microscopic traces of claret in the stool. A positive test is almost ever an indication to do a colonoscopy. In most cases the positive result is only due to hemorrhoids; all the same, it tin can also be due to diverticulosis, inflammatory bowel illness (Crohn'south affliction, ulcerative colitis), colon cancer, or polyps. Colonic polypectomy has become a routine part of colonoscopy, allowing quick and simple removal of polyps during the process, without invasive surgery.^[6]

Colon cancer screening [edit]

Colonoscopy is one of the colorectal cancer screening tests bachelor to people in the U.s.a. who are 45 years of historic period and older. The other screening tests include flexible sigmoidoscopy, double-contrast barium enema, computed tomographic (CT) colongraphy (virtual colonoscopy), guaiac-based fecal occult claret test (gFOBT), fecal immunochemical test (FIT), and multitarget stool DNA screening test (Cologuard).^[7]

Subsequent rescreenings are and so scheduled based on the initial results institute, with a five- or ten-yr retrieve being common for colonoscopies that produce normal results.^{[viii] [9]} People with a family history of colon cancer are often first screened during their teenage years. Among people who take had an initial colonoscopy that found no polyps, the risk of developing colorectal cancer within five years is extremely low. Therefore, there is no need for those people to have another colonoscopy sooner than five years after the first screening.^{[x] [11]}

Some medical societies in the US recommend a screening colonoscopy every 10 years kickoff at historic period l for adults without increased risk for colorectal cancer.^[12] Inquiry shows that the risk of cancer is low for 10 years if a high-quality colonoscopy does not find cancer, so tests for this purpose are indicated every ten years.^{[12] [13]}

Colonoscopy screening prevents approximately two-thirds of deaths due to colorectal cancers on the left side of the colon, and is not associated with a significant reduction in deaths from correct-sided illness.^[2]

Colonoscopy reduces cancer rates by detecting some colon polyps and cancers on the left side of the colon early on plenty that they may be treated, and a smaller number on the right side; many of these left-sided growths would take been detected by a sigmoidoscopy procedure.^[2]

Since polyps ofttimes take 10 to 15 years to transform into cancer in someone at average gamble of colorectal cancer, guidelines recommend 10 years after a normal screening colonoscopy earlier the next colonoscopy. (This interval does not apply to people at high risk of colorectal cancer, or to those who experience symptoms of colorectal cancer.)^{[14] [fifteen]}

Although widely touted in the US as the "gilded standard" of colon cancer screening, colonoscopy has never been studied as a screening tool. Most of the potential benefits of colonoscopy accept been extrapolated from randomized trials of the sigmoidoscopy. The CONFIRM trial, a randomized trial on colonoscopy vs. FIT is currently ongoing.^[16]

Recommendations [edit]

The American Cancer Guild recommends, commencement at historic period 45, both men and women follow one of these testing schedules for screening to find colon polyps and/or cancer:^[17]

1. Flexible sigmoidoscopy every 5 years, or
2. Colonoscopy every 10 years, or
3. Double-dissimilarity barium enema every 5 years, or
4. CT colonography (virtual colonoscopy) every v years
5. Yearly guaiac-based fecal occult blood test (gFOBT)
6. Yearly fecal immunochemical test (FIT)
7. Stool Deoxyribonucleic acid test (sDNA) every 3 years

Medicare coverage [edit]

In the Usa, Medicare insurance covers the following colorectal-cancer screening tests:^[eighteen]

1. Colonoscopy: average risk — every 10 years beginning at age fifty, high hazard — every ii years with no historic period restriction^[xix]
2. Flexible sigmoidoscopy — every four years beginning at historic period 50^[twenty]
3. Double-contrast barium enema: average risk — every iv years start at age 50, high chance — every 2 years^[21]
4. (CT) colongraphy: not covered past Medicare
5. gFOBT: boilerplate risk — every yr beginning at age 50^[22]
6. FIT: average risk — every twelvemonth beginning at age 50
7. Cologuard: average risk — every 3 years kickoff at historic period 50^[23]

Risks [edit]

Nearly 1 in 200 people who undergo a colonoscopy feel a serious complication.^[24] Perforation of the colon occurs in about i in 2000 procedures, bleeding in 2.6 per 1000, and death in 3 per 100,000,^[25] with an overall risk of serious complications of 0.35%.^{[26] [27]}

In some depression-risk populations screening past colonoscopy in the absence of symptoms does non outweigh the risks of the procedure. For example, the odds of developing colorectal cancer between the ages of 20 and xl in the absence of specific adventure factors are about 1 in 1,250 (0.08%).^[28]

The rate of complications varies with the practitioner and establishment performing the procedure, and other variables.^{[ commendation needed ]}

Perforation [edit]

The nigh serious complication generally is gastrointestinal perforation, which is life-threatening and in nigh cases requires firsthand major surgery for repair.^[29] Fewer than xx% of cases may be successfully managed with a conservative (not-surgical) approach.^[29]

A 2003 analysis of the relative risks of sigmoidoscopy and colonoscopy brought into attention that the take chances of perforation after colonoscopy is approximately double that after sigmoidoscopy (consequent with the fact that colonoscopy examines a longer department of the colon), a difference that appeared to be decreasing.^[30]

Bleeding [edit]

Haemorrhage complications may exist treated immediately during the procedure past cauterization using the instrument. Delayed bleeding may also occur at the site of polyp removal upwards to a calendar week later the procedure, and a repeat procedure tin and then exist performed to treat the bleeding site. Even more rarely, splenic rupture tin occur subsequently colonoscopy because of adhesions between the colon and the spleen.^{[ citation needed ]}

Anaesthesia [edit]

As with whatsoever procedure involving anaesthesia, other complications would include cardiopulmonary complications such as a temporary driblet in claret pressure level and oxygen saturation usually the result of overmedication, and are hands reversed. Anesthesia can too increase the risk of developing blood clots and lead to pulmonary embolism or deep venous thrombosis. (DVT)^[31] In rare cases, more than serious cardiopulmonary events such equally a center attack, stroke, or even death may occur; these are extremely rare except in critically ill patients with multiple risk factors. In rare cases, coma associated with anesthesia may occur.^{[ citation needed ]}

Bowel preparation [edit]

Dehydration caused by the laxatives that are usually administered during the bowel preparation for colonoscopy also may occur. Therefore, patients must potable large amounts of fluids during the day of colonoscopy preparation to prevent aridity. Loss of electrolytes or aridity is a potential risk that can fifty-fifty bear witness deadly.^[31] In rare cases, astringent aridity can lead to kidney damage or renal dysfunction under the class of phosphate nephropathy.^[32]

Other [edit]

Virtual colonoscopies acquit risks that are associated with radiation exposure.^{[ citation needed ]}

Colonoscopy preparation and colonoscopy procedure can cause inflammation of the bowels and diarrhea or bowel obstacle.^{[ citation needed ]}

During colonoscopies where a polyp is removed (a polypectomy), the gamble of complications has been higher, although nevertheless low at nigh 2.three percentage.^[26] 1 of the most serious complications that may arise after colonoscopy is the postpolypectomy syndrome. This syndrome occurs due to potential burns to the bowel wall when the polyp is removed, and may crusade fever and abdominal hurting. Information technology is a rare complication, treated with intravenous fluids and antibiotics.

Bowel infections are a potential colonoscopy risk, although rare. The colon is not a sterile environment; many bacteria that normally live in the colon ensure the well-functioning of the bowel, and the run a risk of infections is minimal. Infections can occur during biopsies when too much tissue is removed and bacteria protrude in areas they do non vest to, or in cases when the lining of the colon is perforated and the bacteria get into the abdominal crenel.^[33] Infection may as well be transmitted betwixt patients if the colonoscope is not cleaned and sterilized properly between tests.

Minor colonoscopy risks may include nausea, vomiting or allergies to the sedatives that are used. If medication is given intravenously, the vein may become irritated. Nigh localized irritations to the vein leave a tender lump lasting a number of days but going away eventually.^[34] The incidence of these complications is less than 1%.

On rare occasions, intracolonic explosion may occur.^[35] A meticulous bowel preparation is the key to prevent this complication.^[35]

Signs of complications include severe abdominal pain, fevers and chills, or rectal bleeding (more than one-half a loving cup or 100ml).^[36]

Procedure [edit]

Grooming [edit]

The colon must exist free of solid thing for the test to exist performed properly.^[37] For one to three days, the patient is required to follow a low fiber or clear-liquid-simply diet. Examples of clear fluids are apple tree juice, craven and/or beef goop or bouillon, lemon-lime soda, lemonade, sports potable, and h2o. Information technology is of import that the patient remains hydrated. Sports drinks contain electrolytes which are depleted during the purging of the bowel. Drinks containing fiber such as prune and orange juice should not be consumed, nor should liquids dyed cherry-red, majestic, orange, or sometimes brown; nonetheless, cola is allowed. In well-nigh cases, tea or java taken without milk are allowed.^[38]

The mean solar day before the colonoscopy, the patient is either given a laxative training (such as bisacodyl, phospho soda, sodium picosulfate, or sodium phosphate and/or magnesium citrate) and large quantities of fluid, or whole bowel irrigation is performed using a solution of polyethylene glycol and electrolytes. The procedure may involve both a pill-form laxative and a bowel irrigation preparation with the polyethylene glycol powder dissolved into any clear liquid, such every bit a sports drink that contains electrolytes.

A typical procedure regimen and then would exist as follows: in the morn of the day before the procedure, a 238one thousand bottle of polyethylene glycol powder should be poured into i.nine litres (64 oz.) of the chosen clear liquid, which then should exist mixed and refrigerated. Two bisacodyl vmg tablets are taken iii pm; at 5 pm, the patient starts drinking the mixture (approx. 8 oz. (0.5 litres) each 15-30 min. until finished); at viii pm, take ii bisacodyl 5mg tablets; continue drinking/hydrating into the evening until bedtime with articulate permitted fluids. The process may be scheduled early in the day so the patient demand not go without food and only limited fluids until later on.^{[ commendation needed ]}

The goal of the preparation is to clear the colon of solid matter, and the patient may be advised to spend the 24-hour interval at home with fix access to toilet facilities. The patient may also want to have at hand moist towelettes or a bidet for cleaning the anus. A soothing save such as petroleum jelly applied after cleaning the anus will reduce discomfort.

The patient may be asked not to accept aspirin or like products such as salicylate, ibuprofen, etc. for upwardly to ten days before the process to avert the risk of haemorrhage if a polypectomy is performed during the process. A blood test may be performed before the process.^[39]

Investigation [edit]

Schematic overview of colonoscopy procedure

During the procedure the patient is often given sedation intravenously, employing agents such as fentanyl or midazolam. Although meperidine (Demerol) may be used as an culling to fentanyl, the concern of seizures has relegated this agent to second choice for sedation behind the combination of fentanyl and midazolam. The boilerplate person will receive a combination of these two drugs, normally between 25 and 100µg IV fentanyl and ane–4mg Four midazolam. Sedation practices vary between practitioners and nations; in some clinics in Kingdom of norway, sedation is rarely administered.^{[xl] [41]}

Some endoscopists are experimenting with, or routinely apply, alternative or additional methods such every bit nitrous oxide^{[42] [43]} and propofol,^[44] which have advantages and disadvantages relating to recovery time (peculiarly the duration of amnesia subsequently the process is complete), patient experience, and the degree of supervision needed for safe administration. This sedation is chosen "twilight anesthesia". For some patients information technology is not fully effective, so they are indeed awake for the procedure and can spotter the within of their colon on the color monitor. Substituting propofol for midazolam, which gives the patient quicker recovery, is gaining wider use, only requires closer monitoring of respiration.

A meta-analysis institute that playing music improves tolerability to patients of the procedure.^[45]

The first step is usually a digital rectal examination, to examine the tone of the sphincter and to decide if preparation has been adequate. The endoscope is then passed through the anus upwards the rectum, the colon (sigmoid, descending, transverse and ascending colon, the cecum), and ultimately the final ileum. The endoscope has a movable tip and multiple channels for instrumentation, air, suction and light. The bowel is occasionally insufflated with air to maximize visibility (a procedure which gives the patient the false sensation of needing to take a bowel movement).^[46] Biopsies are oft taken for histology. Additionally in a procedure known as chromoendoscopy, a dissimilarity-dye (such every bit indigo ruby-red) may exist sprayed through the endoscope onto the bowel wall to help visualise any abnormalities in the mucosal morphology. A Cochrane review updated in 2016 found stiff evidence that chromoscopy enhances the detection of cancerous tumours in the colon and rectum.^[47]

In most experienced hands, the endoscope is advanced to the junction of where the colon and small bowel join up (cecum) in under 10 minutes in 95% of cases. Due to tight turns and back-up in areas of the colon that are not "fixed", loops may course in which advancement of the endoscope creates a "bowing" effect that causes the tip to actually retract. These loops oft consequence in discomfort due to stretching of the colon and its associated mesentery. Manoeuvres to "reduce" or remove the loop include pulling the endoscope backwards while twisting it. Alternatively, body position changes and intestinal back up from external manus pressure can oftentimes "straighten" the endoscope to permit the scope to move frontwards. In a minority of patients, looping is often cited as a cause for an incomplete exam. Usage of alternative instruments leading to completion of the test has been investigated, including employ of pediatric colonoscope, push enteroscope and upper GI endoscope variants.^[48]

For screening purposes, a closer visual inspection is then oftentimes performed upon withdrawal of the endoscope over the course of xx to 25 minutes. Lawsuits over missed malignant lesions have recently prompted some institutions to amend document withdrawal time as rapid withdrawal times may be a source of potential medical legal liability.^[49] This is oft a real concern in clinical settings where high caseloads could provide financial incentive to consummate colonoscopies every bit apace equally possible.

Suspicious lesions may be cauterized, treated with laser light or cut with an electric wire for purposes of biopsy or consummate removal polypectomy. Medication tin can be injected, eastward.g. to control bleeding lesions. The process typically takes 20–30 minutes, depending on the indication and findings; with multiple polypectomies or biopsies, procedure times may be longer. As mentioned above, anatomic considerations may also affect process times.

After the procedure, some recovery time is normally allowed to let the allaying wearable off. Outpatient recovery time can take an estimated thirty–60 minutes. Most facilities crave that patients have a person with them to help them domicile subsequently (depending on the sedation method used).

Ane common after-effect from the procedure is a bout of flatulence and small-scale air current pain caused past air insufflation into the colon during the process.

An advantage of colonoscopy over Ten-ray imaging or other less invasive tests is the ability to perform therapeutic interventions during the test. A polyp is a growth of excess of tissue that can develop into cancer. If a polyp is constitute, for case, information technology can be removed by i of several techniques. A snare device can be placed around a polyp for removal. Even if the polyp is flat on the surface it can oft be removed. For case, the following shows a polyp removed in stages:

• 

  Polyp is identified.

• 

  A sterile solution is injected under the polyp to lift it away from deeper tissues.

• 

  A portion of the polyp is at present removed.

• 

  The polyp is fully removed.

Pain management [edit]

The pain associated with the procedure is not acquired by the insertion of the scope but rather by the inflation of the colon in order to practise the inspection. The scope itself is essentially a long, flexible tube about a centimeter in bore — that is, as big effectually as the little finger, which is less than the diameter of an boilerplate stool.

The colon is wrinkled and corrugated, somewhat like an accordion or a apparel-dryer exhaust tube, which gives it the large surface surface area needed for water absorption. In society to inspect this surface thoroughly, the md blows it up similar a balloon, using air from a compressor or carbon dioxide from a gas bottle (CO_ii is absorbed into the bloodstream through the mucosal lining of the colon much faster than air and so exhaled through the lungs which is associated with less mail service procedural pain), in social club to get the creases out. The breadbasket, intestines, and colon have a so-chosen "second brain" wrapped around them, which autonomously runs the chemic factory of digestion.^[50] It uses complex hormone signals and nerve signals to communicate with the brain and the rest of the torso. Normally a colon's job is to digest food and regulate the abdominal flora. The harmful bacteria in rancid food, for example, creates gas.

The colon has distension sensors that can tell when there is unexpected gas pushing the colon walls out—thus the "second encephalon" tells the person that he or she is having abdominal difficulties by fashion of the sensation of nausea. Doctors typically recommend either total anesthesia or a partial twilight sedative to either preclude or to lessen the patient'south awareness of pain or discomfort, or just the unusual sensations of the procedure. One time the colon has been inflated, the physician inspects it with the scope as it is slowly pulled astern. If any polyps are found they are and then cutting out for later biopsy.

Some doctors prefer to work with totally anesthetized patients inasmuch as the lack of whatever perceived pain or discomfort allows for a leisurely test. Twilight sedation is, however, inherently safer than general anesthesia; it as well allows the patients to follow uncomplicated commands and even to spotter the procedure on a closed-circuit monitor. Tens of millions of adults annually need to have colonoscopies, and even so many don't because of concerns about the process.^{[ commendation needed ]}

Colonoscopy tin can be carried out without whatsoever sedation and without problems with pain, which is practised in several institutions in many countries with the patient's agreement. This allows the patient to shift the body position to aid the doctor bear out the procedure and significantly reduces recovery fourth dimension and side-effects.^[51] In that location is some discomfort when the colon is distended with air, just this is non commonly especially painful, and it passes relatively quickly. Unsedated patients can be released from the hospital on their ain without any feelings of nausea, able to continue with normal activities, and without the need for an escort every bit recommended later on sedation.

Ultrasound [edit]

Duodenography and colonography are performed similar a standard abdominal examination using B-mode and color flow Doppler ultrasonography using a low frequency transducer — for example a 2.vMHz — and a high frequency transducer, for instance a 7.5MHz probe. Detailed examination of duodenal walls and folds, colonic walls and haustra was performed using a seven.vMHz probe. Deeply located abdominal structures were examined using 2.5MHz probe. All ultrasound examinations are performed afterward overnight fasting (for at to the lowest degree 16 hours) using standard scanning process. Subjects are examined with and without water dissimilarity. Water contrast imaging is performed by having developed subjects accept at least ane liter of h2o prior to examination. Patients are examined in the supine, left posterior oblique, and left lateral decubitus positions using the intercostal and subcostal approaches. The liver, gall bladder, spleen, pancreas, duodenum, colon, and kidneys are routinely evaluated in all patients.

With patient lying supine, the test of the duodenum with high frequency ultrasound duodenography is performed with seven.5MHz probe placed in the correct upper abdomen, and central epigastric successively; for loftier frequency ultrasound colonography, the ascending colon, is examined with starting indicate unremarkably midway of an imaginary line running from the iliac crest to the bellybutton and proceeding cephalid through the correct mid belly; for the descending colon, the examination begins from the left upper abdomen proceeding caudally and traversing the left mid abdomen and left lower abdomen, terminating at the sigmoid colon in the lower pelvic region. Color flow Doppler sonography is used to examine the localization of lesions in relation to vessels. All measurements of diameter and wall thickness are performed with built-in software. Measurements are taken between peristaltic waves.^[52]

Economics [edit]

Researchers have found that older patients with iii or more significant health issues, like dementia or heart failure, had high rates of repeat colonoscopies without medical indications. These patients are less probable to live long enough to develop colon cancer. Gordon states, "At most $1,000 per process, there's clearly an economical incentive".^[xv]

The Hemoccult 2 FOBT (combined with follow-up colonoscopy if indicated past the test) is over v times as cost constructive equally other screening strategies, but is but about 85% as sensitive. Because of this relatively low sensitivity, United states guidelines advocate the over 5 times more than expensive procedures instead, because even the relatively pocket-size increase in lives saved and 5-fold cost increase is seen as worth choosing, given The states living standards.^[53]

History [edit]

In the 1960s, Dr. Niwa and Dr. Yamagata at Tokyo University developed the device. After 1968, Dr. William Wolff and Dr. Hiromi Shinya pioneered the development of the colonoscope.^[54] Their invention, in 1969 in Japan, was an advance over the barium enema and the flexible sigmoidoscope because it allowed for the visualization and removal of polyps from the entire big intestine. Wolff and Shinya advocated for their invention and published much of the early evidence needed to overcome skepticism about the device'south rubber and efficacy.

Colonoscopy with CCD invention and market is led past Fuji movie, Olympus and Hoya in Japan.^[55] In 1982, Dr. Lawrence Kaplan of Aspen Medical Group in St. Paul, MN reported a series of 100 consecutive colonoscopies and upper endoscopies performed in a free-standing clinic miles from the nearest infirmary, demonstrating the safety and cost effectiveness of these outpatient procedures. (Personal communication to the Articulation Commission on Convalescent Care, May 1983)^{[ citation needed ]}

Etymology [edit]

The terms colonoscopy ^{[56] [57] [58]} or coloscopy ^[57] are derived from^[57] the aboriginal Greek noun κόλον, same as English colon,^[59] and the verb σκοπεῖν, look (in)to, examine.^[59] The term colonoscopy is however ill-constructed,^[60] every bit this class supposes that the first part of the compound consists of a possible root κολωv- or κολοv-, with the connecting vowel -o, instead of the root κόλ- of κόλον.^[threescore] A compound such as κολωνοειδής, like a colina,^[59] (with the boosted -on-) is derived from the ancient Greek word κολώνη or κολωνός, colina.^[59] Similarly, colonoscopy (with the additional -on-) can literally be translated as test of the loma,^[lx] instead of the examination of the colon.

In English, multiple words be that are derived from κόλον, such equally colectomy,^{[57] [61]} colocentesis,^[57] colopathy,^[57] and colostomy ^[57] amid many others, that actually lack the incorrect additional -on-. A few compound words such as colonopathy accept doublets with -on- inserted.^{[57] [58]}

See as well [edit]

• Bow and arrow sign
• Esophagogastroduodenoscopy
• Polypectomy
• Rectal examination
• Postpolypectomy Coagulation Syndrome

References [edit]

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Farther reading [edit]

• Gupta Southward, Lieberman D, Anderson JC, Burke CA, Dominitz JA, Kaltenbach T, et al. (March 2020). "Recommendations for Follow-Upwards Subsequently Colonoscopy and Polypectomy: A Consensus Update by the United states Multi-Lodge Chore Strength on Colorectal Cancer". Gastroenterology. 158 (4): 1131–1153.e5. doi:ten.1053/j.gastro.2019.10.026. PMC7672705. PMID 32044092.
• Gupta Southward, Lieberman D, Anderson JC, Burke CA, Dominitz JA, Kaltenbach T, et al. (March 2020). "Recommendations for Follow-Upward Subsequently Colonoscopy and Polypectomy: A Consensus Update by the U.s. Multi-Society Job Force on Colorectal Cancer". Am J Gastroenterol. 115 (3): 415–434. doi:10.14309/ajg.0000000000000544. PMC7393611. PMID 32039982.

External links [edit]

• Colonoscopy. Based on public-domain NIH Publication No. 02-4331, dated February 2002.
• Patient Instruction Brochures. American Social club for Gastrointestinal Endoscopy data
• Colorectal Cancer Incidence and Screening — United States, 2008 and 2010 Centers for Affliction Control and Prevention

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Source: https://en.wikipedia.org/wiki/Colonoscopy

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