Thursday, April 8, 2021

A Psychiatrist Takes An Overly Detailed Look At Endoscopy

 


I started typing this shortly after completing an esophagoduodenoscopy (EGD) and a screening colonoscopy. Starting at age 25 I have probably had a total of 4 EGD’s and 4 screening colonoscopies. About three weeks ago I started to experience dysphagia. During those episodes food fails to pass through the esophagus and causes pain.  In the extreme food does not pass at all and that leads to all the symptoms associated with esophageal obstruction. It is an extremely uncomfortable sensation that can lead to esophageal perforation and the need for emergency surgery. The last time that happened to me was about 25 years ago. Over the years I have had a couple of close calls but two recent episodes of near obstruction led me to going to see my primary care physician who set up the test.

My immediate association and worry was that I may have esophageal cancer. Three second-degree relatives and one first-degree relative had pancreatic cancer. It is rumored that my maternal great great grandfather died of stomach cancer. 2 second-degree relatives died of stomach cancer. All of the second-degree relatives had risk factors primarily cigarette smoking, but you can certainly develop cancer in the absence of risk factors and aging alone is a risk factor for cancer.  Since my first esophageal obstruction, I have not eaten beef (the source of the acute obstruction) and have also tried to avoid foods that have been implicated in G.I. cancers such as smoked and preserved foods as well as excessively hot beverages. I have never used tobacco products and do not drink alcohol. I have also tried increase foods that may be protective such as vegetables and tree nuts. The nuts were easy but vegetables require much more of an effort. I am one of those people that has an aversion to the taste of most vegetables, but for the past ten years I have been eating 2-3 vegetables per day.

Over the years of the screening colonoscopies, I always asked the gastroenterologist whether or not I should also have an EGD to see if there any after effects from the initial obstruction and dilatation. They all said that there was no reason to repeat it unless I had additional symptoms but that was never very satisfying response. Cancers of the esophagus and gastroesophageal junction are difficult to diagnose. Symptoms often do not appear until the cancer is advanced and not treatable.  One of the gastroenterologists seemed more concerned about the dilatation procedure. He advised me that the anatomy of the esophagus is multiple layers of transverse fibers and that dilatation procedures can disrupt that anatomy. He gave me a tip sheet on how to avoid dysphagia and esophageal obstruction by changing eating habits in some cases making sure that a mouthful of food is chewed at least 40 times.

The screening colonoscopies have generally been uneventful yielding one or two small noncancerous polyps per screening. That result led to the recommendation for screening every five years instead of every 10 years. Since the last screening I decided to greatly increase my fiber intake to 40 to 50 g per day and take additional wheat dextrin – 18-24 g/day.

As a psychiatrist who is as neurotic as the next person, I always reflect on how the neurosis affects my medical encounters. As a kid I had a high degree of death anxiety. I was always concerned that I had a fatal illness and that I would die within a year or two. In retrospect it is easy to think about how the family environment was the origin of those thoughts. I was exposed to relatives who are also very neurotic and preoccupied with health concerns. I had an aunt who died of pancreatic cancer in those days the entire family was involved in treatment largely because there was no coordinated blood banking and she needed transfusions from her siblings. At some point in my mid-to-late teens I realized my worries about dying were excessive because of the obvious fact that I was still alive. But old habits die hard. I am still very safety conscious about every possible hazard to the point that my wife says I am “paranoid.”  On an ongoing basis, I pay attention to every reference in the medical literature that might apply to my somatic concerns. The most recent examples are a commentary and an article in the New England Journal of Medicine (1,2) on the immunotherapy of esophageal cancer that was described as a major advance.  Over the years I have also tracked the complications in this area that were not related to cancer but more to scarring or fistula formation. None of this keeps me awake at night, it is what I do as normal activity.

The prep for screening colonoscopy is an ordeal. It seems to have become more of an ordeal over the years. By that I mean the prep went from an oral stimulant laxative and two sodium phosphate enemas to very large amounts of oral osmotic laxatives like polyethylene glycol 3350 ± additional salts (sodium sulfate, sodium chloride, sodium bicarbonate and potassium chloride).  Any Internet search for colonoscopy preps yields a wide range of recommendations and volumes. The clinic I was going to had the prep for people with chronic constipation that involved consuming the polyethylene glycol over two days (and additional osmotic and stimulant laxatives) and the one that I used started on 5 PM the night prior to a morning procedure.  I prepared 4 liters of a solution of Gatorade + polyethylene glycol 3350 (476 g). The instructions were to drink the first 3 liters at a rate of 237 ml (8 oz) every 10 minutes until gone and then wake up at 4:00 AM and drink the remaining liter – 4 hours before the procedure.

I describe this as an ordeal because just anticipating consuming that much salty fluid can create some anxiety, disgust, and anticipatory nausea. I typically drink fluid volumes every day right around 4 L, but the instructions here were to maintain additional fluid intake on top of the laxative.  I probably consumed an additional 5 L on top of the laxative (per the instructions).  The biology and chemistry of this procedure is interesting. For example, creating solutions rarely produces the original volume. The final solution can be smaller or greater than starting volume, but the difference is generally not factored into the final concentration. In this case, I found that final solution of polyethylene glycol 3350 and Gatorade was about 300 ml greater than 4 L so I discarded it to maintain the recommended volume.  There is also the question of the impact that osmotic laxatives have on fluid and electrolyte balance. Interestingly, the two main products used consist of one product with a combination of polyethylene glycol 3350 and additional electrolytes and one product that is pure polyethylene glycol 3350 mixed with sports drinks containing the additional electrolytes.  The former product contains warnings about use in patients who may have sensitivity to electrolyte imbalances like patients with seizures or arrhythmias.  I received some information about products that are more recent and easier to use including MOVIPREP® and SUPREP®. Both require the ingestion of much lower fluid volumes.

The main thing to remember about preparation for the colonoscopy is that the goal is to induce diarrhea and continue that until it is clear of fecal material. In my case that happened at about 1 AM following the initial 3 L ingestion. I seriously contemplated not drinking the additional leader at 4 AM but did not want to risk having to repeat the whole procedure again if the preparation was inadequate. As a result, I had diarrhea until about 8 PM the next night - about 10 hours after the procedures were completed.

The procedure itself was well coordinated and pandemic precautions remained in place. I had a negative COVID-19 screen two days prior to the procedure.  I was accompanied to the gastroenterology clinic and had to wear a mask throughout the entire procedure with the exception of the EGD. They placed the nasal prong oxygen cannula under my mask. All the nursing staff was masked. The gastroenterologist was wearing a large helmet like face shield in addition to a mask.  That reminded me of my positive affiliation with gastroenterologists. For years, I ate lunch with a group of 3-4 gastroenterologists and the occasional infectious disease specialist.  We typically discussed movies but at times the conversation would wander to hastas (the plant), politics, or medicine. They all had a good sense of humor. Whenever another gastroenterologist was brought up their humorous seal of approval was "He/she really knows their way around the colon!" They were all very likeable and had a great sense of humor.     

The endoscopy suite contained a wall of high-tech equipment. I was advised that the gastroenterologist would talk with me about informed consent. I reflected on that for a minute and realized that the last 10 surgeons and proceduralists that I have had contact with spend less time in aggregate talking about risks and benefits then I typically spend talking about antidepressant risks and benefits with the average patient. I don’t consider that to be a problem because as I have written before, desperate situations in medicine require desperate probability-based decisions and procedures. There are no guarantees.  In addition, I have treated patients who have had most of the known complications of both EGD and screening colonoscopy including perforations and the need for emergency surgery. I have also treated patients who have had spontaneous perforations of the esophagus for unclear reasons. My conversation with the gastroenterologist went something like this:

GE: “The risks of this procedure involve perforation and the need for emergency surgery, but that is rare. There is also some discomfort if we have to perform a dilatation. We will let you know what we find today and what the follow-up needs to be. Do you have any questions?”

Me: “My primary care doctor wanted me to let you know about my family history of G.I. cancer especially pancreatic cancer. He wanted to know if there was any additional screening that needed to be done?”

GE: “We generally do not do screening for pancreatic cancer. With your family history you might want to try to find a geneticist to see if you need any genetic screening. Your primary care doctor might consider a one-time CT scan of the pancreas.”

Me: “Regarding the dilatation, I saw gastroenterologist about 15 years ago who talked to me in detail about the anatomy of the esophagus and how repeat dilatations can disrupt the layered fiber structure of the esophagus. Is that a problem?”

GE: “Well I don’t know about that. If you have to eat-you have to eat. We have some patients who need to get the dilatation procedure every week.”

As we completed our conversation, the nurse advised me that she was going to induce “conscious anesthesia”. I clarified with her that was fentanyl and midazolam that I have taken many times in the past for these procedures. With my interest in consciousness, the idea of conscious anesthesia is something that I pay close attention to.  I missed the key opportunity with this session to ask the nursing staff what I behaved like under conscious anesthesia.  As soon as the anesthesia took effect the only recollection I have over the next 90 minutes was a nurse asking me about bradycardia and my reply was “it’s the beta-blocker”.  I woke up groggy and mildly ataxic. I put my clothes on and walked out to the elevator and left the clinic. The post procedure instructions said not to do anything that required a high level of thought or coordination for the next 12 hours. That is about how long it took the “brain fog” of the anesthesia to wear off. I always compare the current anesthesia to the first round I got at age 25. That combination of medication produced a paradoxical euphorigenic effect and about two hours of continuous laughter. It would be unwise of me to disclose that combination medications.

I can’t recall whether the gastroenterologist discussed the results with me or not but I was provided with two different sets of discharge instructions that read as follows:

Instructions after upper endoscopy (EGD) with biopsy:

Findings:

-Mild Schatzki ring - dilated

-Normal middle and upper third of esophagus. Biopsied to rule out eosinophilic esophagitis

-Normal stomach

-Normal examined duodenum

Instructions after colonoscopy:

-The entire examined: is normal

-The examined portion of the ileum is normal

-Repeat screening is recommended in 10 years

I could not have asked for a better result. No evidence of gastroesophageal reflux or Barrett’s esophagus. No significant esophageal strictures or ulcers. An upper and lower G.I. examination that is fairly unremarkable. That is very reassuring, but I doubt that it will have much impact on my focus on doing everything possible to prevent G.I. cancer and more esophageal problems. The colonoscopy result might indicate that my conscious move to a more high-fiber diet had some impact, but at this point I am questioning the issue of soluble versus insoluble fiber from the standpoint of metabolic and microbiome effects. Like most medical research there are no clear answers and so I am left with myself as an N=1 study and I have the help of an excellent internist.

As I recover, I am thinking about the afferent sensory innervation of the gut and the unusual sensations that it might be producing. I thought I might post a detailed synopsis here but will hold off for now. I think that many neurotic people adapt to some degree by what is currently described as mindfulness.  You get to a point in life where you realize you are probably excessively cautious and that you have to focus on and do many other things in a day. And you are able to do those things.  You adapt to the somatic concerns and there is no significant associated affect. In many ways it might just be another aspect of being goal directed or conscientious.

So I will take a break on that line of thought while I wait for a more detailed genomic analysis of possible risk factors for pancreatic cancer.

 

George Dawson, MD, DFAPA

 

References:

1:  Kelly RJ, Ajani JA, Kuzdzal J, Zander T, Van Cutsem E, Piessen G, Mendez G, Feliciano J, Motoyama S, Lièvre A, Uronis H, Elimova E, Grootscholten C, Geboes K, Zafar S, Snow S, Ko AH, Feeney K, Schenker M, Kocon P, Zhang J, Zhu L, Lei M, Singh P, Kondo K, Cleary JM, Moehler M; CheckMate 577 Investigators. Adjuvant Nivolumab in Resected Esophageal or Gastroesophageal Junction Cancer. N Engl J Med. 2021 Apr 1;384(13):1191-1203. doi: 10.1056/NEJMoa2032125. PMID: 33789008.

2:  Ilson DH. Adjuvant Nivolumab in Esophageal Cancer - A New Standard of Care. N Engl J Med. 2021 Apr 1;384(13):1269-1271. doi: 10.1056/NEJMe2101983. PMID: 33789017.


Graphic Credit:

That is the actual stuff that I drank in addition to another 4 liters of water, tea, and white grape juice.


Additional Credit:

I thank the gastroenterologist and staff involved in my care.  The experience was first rate.

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