Colonoscopic DiagnosisQuestions and Answers

The following is an abridged transcript from a paneldiscussion conducted during the A/S/G/E postgraduatecourse on colonoscopy held at Los Angeles in January,1975.

Dr. Berk: Dr. John Morrissey gave us a long list ofindications for colonoscopy. John, will you tell us what thesituation is now with respect to the conventional 25 emsigmoidoscope? Is it an archaic instrument?

Dr. Morrissey: I would say it still has a very importantrole. In our own institution we do 10 to 12 standardsigmoidoscopies for every colonoscopy. It is the way wefollow most ofour inflammatory bowel disease patients. It isthe first study we do in anyone with symptoms suggestingthe presence of colorectal disease. It is certainly mucheasier to perform as a standard diagnostic procedure, and itis less expensive in terms of technician time and cost to thepatient. We are not doing fewer sigmoidoscopies than wedid 10 years ago, and colonoscopy has not replaced thestandard sigmoidoscopic examination.

Dr. Berk: Let's consider the patient who has a polypoiddefect that is discovered by the ordinary sigmoidoscope.Should a total colonoscopic examination then be per­formed?

Dr. Morrissey: If a patient has I polyp, then the chancesof that patient's having another polyp are, in my view, highenough to merit an examination of his entire colon. Even ifthe original polyp was within the range of the standardsigmoidoscope, we would then proceed to examine theentire colon, take out all the polyps we find, and on the wayout remove the one that is down low. I prefer to take polypsout with the fiberscope rather than with the standard 'scope,unless the polyp lies very low.

Dr. Berk: In patients who have had 1 or more adenoma­tous polyps removed, how often do you advocate thatpatient be re-examined by means of total colonoscopy?

Dr. Morrissey: We usually advise annual re-examinationif there were multiple polyps of any size, or if any polyp islarger than I em, but especially if they have had multiplelarge polyps. However, if they have just a solitary 5 mmpolyp, I do not think that person has to be screened on aregular basis.

Dr. Berk: What about the patient who has had a cancerremoved? How often would you advocate total colonos­copy?

Dr. Morrissey: I have been doing it at 6 months, a year,and then yearly.

Dr. Berk: Among the indications for colonoscopy, youincluded lower bowel bleeding. Can you prepare that bowelso as to see anything if there is profuse, fresh bleeding?

Dr. Morrissey: First we do a standard sigmoidoscopic

Endoskipie und Biopsie in der Gastroenterologie(Endoscopy and Biopsy in Gastroenterology)

By P. Fruehmorgen and M. Classen. Springer-Verlag, Berlin­Heidelberg-New York, 220 pages, 1974. Price $8.10.

This is a well-rounded, small reference book with editors,who need no introduction. The content covers all proce­dures from total enteroscopy, through therapuetic endos­copy, to laparoscopy and biopsy of the pancreas. Athorough section on basic issues such as care of instrumentsand documentation should be recommended reading foreveryone starting out in gastrointestinal endoscopy. Thedetailed discussion on obtaining intestinal biopsies by Elsterand the excellent description of cytology techniques byWidenhiller are commendable.

The remaining portion of the book is well organized intosections devoted to each procedure with subdivisions fordescription of instruments, preparation of the patient, post­procedural care, technique, indications, contraindications,and complications. Almost equal space allotted to eachprocedure may give a wrong impression about their indi­vidual frequency and importance. For example, an excel­lent section on colonoscopy is most detailed in descriptionof instrument introduction and advance (by Fruehmorgen),while the article on emergency endoscopy by Koch appearssomewhat sparse. The up-to-dateness of this little book isemphasized by an article by Fruehmorgen and Classen ontherapeutic endoscopy, in particular on foreign body re­moval and polypectomy of the upper and lower gastrointes­tinal tract. The sections on the technique of percutaneousliver biopsy by Menghini and on laparoscopy and its adjunc­tive procedures (visualisation and biopsy of the pancreas,cholecystography, and splenoportography) by Lindner etal. are well written and contain valuable practical hints.

It is regrettable that this small and inexpensive book is notavailable in the English language. It represents a perfectintroduction for the novice, a reference guide for the experi­enced, and should have its place in every gastro­enterologist's library.

Klaus Anselm, MDSouthern Colorado Clinic

Pueblo, ColoradoKolondivertikulitis(Acute Problems of Diagnosis and Therapy)

Edited by M. Reifferscheid. Georg Thieme Verlag Stuttgart, 114pages, 1974.

This booklet contains reproduction of papers given at asymposium (workshop) in Aachen in 1973. It has excellentcontributions by noted internists, pathologists, radiologistsand surgeons. Ottenjann's article on the development andpathophysiology of diverticular disease is of particular in­terest, as is the thorough paper by de Graff on progressiveand regressive diverticulosis as well as pseudo­diverticulosis.

As happens with other editions of conventions and work­shops, duplications are apparent and unavoidable. A recentissue of Clinics in Gastroenterology provides equal if notbetter information, and purchase of this booklet appearsunnecessary unless one is primarily interested in colorectaldisease.

Klaus Anselm, MDSouthern Colorado Clinic

Pueblo, Colorado.

Moderator:Panel:

J. E. Berk, MDRichard Corlin, MDWilliam G. Friend, MDWalter D. Gaisford, MDJohn F. Morrissey, MD

54 GASTROINTESTINAL ENDOSCOPY

examination to be sure the bleeding is coming from abovethe sigmoidoscopic level. Establishing that it is above thatlevel, we give the patient a magnesium citrate purge andallow 6 hours to elapse so that there is a gross evacuation ofcolonic contents. We then examine the colon, preferring touse the 2-channel ACMI 'scope so that we have a largesuction channel to evacuate blood clots. However, we havealso used the Olympus single-channel 'scope as well.Whether I am using an ACMI or an Olympus 'scope in thissituation, I do not use the standard suction system, but Iattach an extra suction tube directly on to the externalsuction (biopsy) channel. I use a tracheal aspirating tip witha hole in it to give me an on/off suction control. With thissystem you can dislodge a plugged clot by taking the tube offand injecting a syringe of fluid through the biopsy channel.Your technician can always do that for you. In this way youare not going to have your 'scope suddenly inoperative. Ifthe problem is just a little blood on the lens, I use thestandard suction and water to clean the lens. When you tryto evacuate either stool or blood, you first want to dilute it.So I have my assistant, with a large syringe, inject waterdirectly into the small channel and aspirate through the largechannel. It is possible in this fashion to get through thebowel in the face ofgross bleeding; it takes a little time, but itis worthwhile in terms of what we have found. We havefound polyps as the cause of major bleeding, we have foundlocalized granulomatous colitis involving only the trans­verse colon causing bleeding, we have localized the sites ofvascular anomalies that have caused bleeding, and we havebeen able to determine that blood was coming from the smallbowel and not the colon.

Dr. Berk: I would like to make a,pitch for the adjunctiveuse of ultraviolet endoscopy in such situations. We've usedthis in the upper gastrointestinal tract, and now we havebegun to apply it to colonoscopy as well. We had an experi­ence with a vascular defect that we could not see bleeding,but when we injected fluorescein and examined it under theultraviolet light, the whole cecum lit up. It was obviouslyoozing some blood at the time that we didn't see with whitelight.

Dr. Gaisford, is it your view that colonoscopy is appro­priate as an office procedure?

Dr. Gaisford: In a large majority of cases, yes. I don't usefluoroscopy except in unusually difficult cases involvingfixed sigmoid segments. In general, routine colonoscopy,not operative colonoscopy but diagnostic examinations, canbe done on an outpatient in an office very well.

Dr. Berk: You are saying then that fluoroscopy is notmandatory but desirable if available?

Dr. Gaisford: Right, and I think only in a very few cases isit really necessary.

Dr. Berk: You stated earlier that general anesthesia wascontraindicated.

Dr. Gaisford: Yes, and for 2 reasons: (f) You do not havethe patient as a monitor to tell you when you are doingsomething wrong. Causing discomfort to the patient isdangerous. You can tear the mesentery, you can injure thebowel or overdistend it, and the patient won't be able to tellyou. (2) In many cases, general anesthesia may paralyze thebowel and make it more difficult to pass the colonoscope.

Dr. Berk: Would you say that applies as well to the

VOLUME 22, NO, 1, 1975

examination of children?Dr, Gai4ord: Yes, I have examined a number of children

in my office. I have used intravenous sedation, and theyhave tolerated it very well.

Dr. Berk: I don't believe you mentioned the various drugsthat you used. Do you use glucagon at all?

Dr. Gaisford: No. There has been a recent evaluation ofits use in a double blind study, and the authors did not findany particular advantage in the success of passage of theinstrument or the examination.

Dr. Berk: Is there anybody on the panel who usesglucagon?

Dr. Morrissey: The only time I use it is if( am trying to doa polypectomy in an area of great motor activity and Icannot, by repositioning the patient, find a position wherethe bowel will hang open. I may use glucagon to try tosuppress contractions in order to make the polypectomy alittle safer.

Dr. Berk: Dr. Gaisford, you mentioned that in the prep­aration for colonoscopy enemas should be given until thereturns are clear. How many enemas should the patient get?

Dr. Gaisford: For the fragile or elderly patient, bothpurgatives and enemas must be given with caution. For theaverage patient, 2 to 6 enemas usually remove the liquidstool.

Dr. Berk: I have been impressed that older patients, afterbarium enema examination were rather exhausted, andsome of them collapsed with hypotension. We'made a studyof blood volume in patients over the age of 60 before andafter barium enemas. It was amazing what an appreciableincrease in total circulating blood volume had occurredbecause of the absorption of fluid that was in that bowel. Iworry whenever I see an order that is written, "Giveenemas until returns are clear". We may get clear returns,but I am not sure the patient will be with us all the time.

Dr. Gaisford: I think that is a good precaution, but moreoften than not my concern has been with dehydration andhypovolemia from the purgative and from insufficient clearliquids by mouth.

Dr. Berk: Dr. Corlin, how often does your preparation forcolonoscopy cause a serious flare-up in patients withinflammatory bowel disease?

Dr. CorLin: I haven't seen that. I use magnesium citraterather than castor oil. It is not an irritative cathartic. It is asaline cathartic, and we have found it to be extremelyeffective. If there is any stool remaining in the colon, it isalmost always thin, liquid stood and no problem to get outthrough the suction channel.

Dr. Berk: Have you any concern that mucosal biopsy inulcerative colitis might induce perforation?

Dr. Corlin: We haven't had that problem occur. Thebiopsy forceps are exceedingly small, and we haven't usedgreat pressure against the wall and have always biopsiedonly under direct vision. Whenever possible, both for pur­poses of safety and ease ofobtaining the biopsy, we will takethe biopsy specimen right from the peak of a fold.

Dr. Berk: You talked about the importance of doingcolonoscopy in patients who showed "pseudopolypoid le­sions in association with ulcerative colitis". What is it thatyou are looking for when you do colonoscopy in suchpatients?

55

Dr. Carlin Distinguishing pseudopolyps from true polypsor carcinoma.

Dr. Berk: Can you do that?Dr. Carlin: Grossly, I don't think so, but the pathologist

can when he reviews the biopsy specimens.Dr. Berk: Did you also suggest that it was your objective

to try to remove as many of these pseudopolyps as possible?Dr. Carlin: That is the case where there is a limited

number of lesions.Dr. Berk: How many is a limited number?Dr. Carlin: I think the most I have ever taken out at one

sitting has been about 5 or 6.Dr. Berk: John, why do you feel that pseudopolyposis is

an indication for colonoscopy? What is it that you arelooking for?

Dr. Morrissey: I think whenever there is pseudopolyposisyou are dealing with a bowel that has tumor-like growths init, and you are concerned about malignancy. We have hadone ulcerative colitis patient in whom we diagnosed a car­cinoma. The thing to remember in a person with ulcerativecolitis is that carcinoma frequently does not begin as apolypoid defect but rather as a plaque-like infiltrating defect,similar to a scirrhous carcinoma of the stomach. It is impor­tant not to look just at the polypoid defects but to lookcarefully at the colon wall. We take "big particle" biopsiesof suspicious lesions. It is important to try to give thepathologist as wide a piece of tissue as possible. We use aprototype name made by ACMI which has a braided wirewith a very small diameter, stiff loop and is quite suited togetting these large particle biopsies.

Dr. Berk: What concerns me, and the reason I am press­ing this point, is that it is my impression, perhaps erroneous,that this lesion (that has such a terribly inappropriate name,"pseudopolyp") is really an island of intact retained mucosain a sea of denuded mucosa. It's not a new growth like anadenomatous polyp. Histologic studies suggest that theorigin of cancerous growths in colons with ulcerative dis­ease is in denuded areas from their epithelial regrowth andnot in the remnant islands that we call pseudopolyps. There­fore, why clean the bowel out of these things? What's thegain and profit from that?

Dr. Carlin: Two things: (1) You can't always be surewhen you look at the lesion at colonoscopy that is what it is,and (2) you can't be always sure by x-ray of what you aredealing with. I am not, at least not yet, an advocate ofroutine, repeated colonoscopy. I think it is still more de­manding of the patient than a properly, gently done bariumenema. Ifbarium enema discloses a lesion, taking a look at itand getting it out will both confirm what it is now and avoidproblems of interpretation on the next barium enema.

Dr. Berk: In your opinion, Dr. Friend, does a patient withroentgen evidence of a lesion that seems clearly to be atumor, a cancer of some type, need have colonoscopybefore surgery?

Dr. Friend: If you are going to operate on a patientregardless of what the colonoscopic findings are, then youmight as well not do the colonoscopy.

Dr. Berk: If you then operated upon that patient on thestrength of that x-ray, without preliminary colonoscopy,would you make any effort at the time of the resection toexamine the rest ofthe bowel to see if there are other lesionspresent?

56

Dr. Friend: I don't do that as a routine, and I wouldprobably find it technically awkward at the time. I either docolonoscopy or surgery, but I don't like doing them both atthe same time. I'm a surgeon; I can't be at both ends at once,you see.

Dr. Gai5ford: Dr. Berk, I would like to offer anotheropinion. I am also a surgeon, and I have had a number ofpatients with it diagnosis of a filling defect, most likelycarcinoma, seen on barium enema x-ray when they havebeen referred to me for evaluation. I have done total con­onoscopy, and I have found at least 2 patients with otherlesions, patients who not only have the carcinoma, but otherpolyps in the colon. I may be in the minority, but I think thata patient who has a known malignant lesion in one part of thecolon deserves total colonoscopy before surgery. The onlyquestion in my mind is whether there is any risk of spreadingthe carcinoma by rubbing the 'scope against the lesion incompleting the total colonoscopy. I doubt very much thatthe risk of that would be as great as the risk of missing otherlesions in the colon. As any surgeon knows, it is verydifficult to feel through the colon at the time of surgery topick up other secondary lesions, so I feel strongly that thepatient should have total colonoscopy before surgery.

Dr. Berk: According to the "no-touch" technique, youare not allowed to touch the lesion at the time you want toresect it. Do you think it is safe to put a 'scope up and downthe colon beforehand?

Dr. Gaisford: Do it very gently.Dr. Friend: The no-touch technique is a concept, it's not a

physical reality. It isn't that we actually must not touch thecarcinoma. For example a carcinoma low in the rectum orlow in the sigmoid colon cannot be removed without touch­ing the colon. The concept of no-touch dictates first the highligation of the veins and then the proper isolation of thetumor. I would probably not deliberately pass the 'scopethrough an annular lesion, not just because offear of spread­ing tumor emboli, but also for fear of causing a perforation.

Dr. Berk: How do the surgeons feel about concomitantcolonoscopy done peroperatively, with the surgeon helpingadvance the instrument introduced through the rectum,guiding it through the abdomen? Does that add anything?

Dr. Gaisford: I agree with Dr. Friend that colonoscopywith the abdomen open, with the surgeon in the abdomen, ismuch more difficult than doing it in the normal way. It maybe of value in a situation where a polyp removed by conven­tional colonoscopy turns out to contain invasive carcinoma.Such a patient deserves to have a colon resection. Occa­sionally, I have found difficulty at the operating table findingthe site where that polyp was removed. A colonoscope,placed in the colon either preoperatively as Dr. Friend hassuggested or intraoperatively, would be very helpful inexactly pinpointing for the surgeon where that malignantpolyp had been removed. Another instance in which it hasbeen helpful is that wherein a known lesion requires opensurgery and there are some associated polyps which thesurgeon wishes to include in his resection. He wants tomake sure that he hasn't missed them, because he can't feelthem well in the colon.

Dr. Friend: Intra-operative colonoscopy has a place, butI would say that in my own personal experience this issomething that I do less than once a year.

GASTROINTESTINAL ENDOSCOPY

Dr. Morrissey: Our experience is similar. We have had anumber of situations where we've found malignant polypsand have gone in the same way to localize them for thesurgeon. We have had I complication doing this whichemphasizes the hazard of this procedure. I think it isdefinitely more dangerous to be passing a 'scope under thesecircumstances. While the surgeon was watching, we wereadvancing a 'scope up within the sigmoid, and there was apelvic adhesion holding the loop of sigmoid down, and as weput a little stress on it, we got a serosal split. It was about 10em long, just a split right through the serosa and the mus­cularis, leaving only the mucosa intact. It was fortunate thatthe surgeon was there, because he just put in a few sutures.Having seen this happen, we wonder how often it happenswhen we don't know about it, and I suspect that this is oneaccident that may happen more frequently than we suspect.There is another situation that we encountered. A patienthad a 4 em x 5 em villous adenoma in the left colon inaddition to a carcinoma of the cecum. The surgeon plannedto remove the carcinoma ofthe cecum as a resection, but wewent in and took out the villous adenoma through thecolonoscope while he watched us to be sure we didn'tperforate when we did it. So we removed the villousadenoma by means of the colonoscope and saved thesurgeon from making an extra incision in the colon.

Dr. Berk: Let's return to inflammatory bowel diseaseagain and see if we can zero in on some things that are notentirely clear to all of us. Is moderately severe or severeulcerative colitis a contraindication to colonoscopy? Thechief reason, I think, for not doing colonoscopy in a patientwho is acutely ill is that you don't have to. It would be anunusual circumstance in which it would provide you withvitally needed information upon which you would make a"go" or "no go" decision with respect to any significanttherapy. In almost all cases, the indications or contraindica­tions that apply to doing a barium enema will apply also tocolonoscopy.

Dr. Morrissey: In 95% of ulcerative colitis patients youwill see an abnormal rectum on standard sigmoidoscopy soyour diagnosis is made by sigmoidoscopy, and you don'tneed colonoscopy. There are only 2 circumstances that Ican think of where you will need colonoscopy. The first is inpatients who have had active disease for 5 years or longerand you are starting to worry about malignancy. Usuallythese people have smoldering disease, often relativelyasymptomatic. The other group are people who have quiteactive proctitis, and you are interested in determining theextent of disease in patients who are not doing very well.You are starting to wonder about whether this should betreated surgically. An example is the patient with an abnor­mal proctoscopyand an apparently normal barium enemawho has continuing symptoms for an inappropriate length oftime. The Milwaukee group has about 20 such patients inwhom they have not just proctitis; the reason they weredoing poorly was that they actually had a pancolitis.

Dr. Corlin: These people are not really what we wouldcall acutely ill.

Dr. Morrissey: That's right, they're not. These are peoplethat you have followed for months on medical therapy; theyare not in the early stages of their treatment. The onlypeople in the early stages of inflammatory bowel disease that

VOLUME 22, NO.1, 1975

I colonoscope are those who have normal proctosigmoidos­copic examinations. I want to see if they have diseaseproximally in the colon.

Dr. Berk: Then both of you are emphasizing that the usualprecautions still hold true. We should be most concernedwith the individual who comes in with diarrhea, cramps,passing bloody stools, with all of the clinical signs andsymptoms of acute ulcerative colitis. We had better stay outof their bowel with any type of instrument for the time beingif they are very sick, is that what you are saying?

Dr. Morrisey: Not any type of instrument other than aproctosigmoidoscope.

Dr. Berk: Dr. Gaisford, in reference to technique, what isa "mucosal slide"? Sounds like something in baseball.

Dr. Gaisford: Or skiing. "Mucosal slide" refers to pass­ing the end of the colonoscope freely past the mucosa wherethe lumen of the bowel is not visible. It's almost mandatoryor required in certain parts of the colon. I use it mostcommonly at the junction of the sigmoid colon and thedescending colon. The examiner should know the generaldirection of the lumen. Ifhe doesn't know, maybe he oughtto use fluoroscopy. I don't think you can slide blindly. Youhave to know the direction of the lumen and make sure thatthe tip of the' scope is sliding freely and that it isn't blanch­ing the mucosa and that there isn't undue pressure withpassing and sliding on the mucosa.

Dr. Friend: The mucosal slide is something that I taughtmyself to do back in 1970, necessitated by the limiteddeflection of the orginal Olmypus equipment. Now that thetips of the newer' scopes can be turned a full 180 degrees, Ifind I don't have to use "slide-by" any more, and I likebeing able to see the lumen at all times before I proceed.

Dr. Morrissey: The mucosal slide is not the way to getthrough the sigmoid segment. I would like to emphasize thatif you start doing that you are going to end up with a verylarge, dilated sigmoid that is stretched almost up to thediaphragm, and then you are going to have a lot of troublenegotiating the junction between the sigmoid and descend­ing colon. The only time I like to use mucosal slide is to getfrom the sigmoid into the descending colon. If you startsliding just after you get out of the rectum, it frequentlyhappens that you suddenly see lumen ahead, and you startgoing up the lumen, and it disappears, and you say, "Well, Iknow that lumen was there, I was looking at it just a minuteago." Then there is a temptation to try that slide, and that'swhen you are going to drag that bowel up into the left upperquadrant and be in serious difficulty.

Dr. Gaisford: The technique is to know how much toslide. If you slide all the way into third base, you are going todo exactly what John says. But if you keep the 'scopesquarely in the center of the lumen when you go through thesigmoid colon, and you have to inflate quite a bit of air to dothat, you are going to end up with a great big sigmoid loop. Iam not disagreeing with what John is saying, but I am sayingthat you have to slide a little bit. You see the lumen, and thenyou go past it and avoid making the sigmoid loop, keepingthe sigmoid as straight as possible. If you look at a bariumenema evacuation film, and compare the difference betweenthe sigmoid colon under those circumstances, and againafter the radiologist has it filled with barium, you see that thesigmoid is up to the diaphragm, and that's the difference. I

57

think if you avoid the air and keep that sigmoid in a relativelystraight line when you are going through it, then you willavoid the problem, and that requires a certain amount ofmucosal slide.

Dr. Berk: I can just picture the late Dizzy Dean giving ablow-by-blow radio account of a colonoscopy and saying hejust slid into the sigmoid. I want to ask all the members of thepanel if they will, in turn, comment about their views on theuse of stiffeners, internal and extrernal. Is there value tothem, should they be used, do you use them?

Dr. Morrissey: Well, the 'scope that I presently use is a2-channel ACMI F9 'scope which is quite stiff, so that formany examinations I probably can get by without using anystiffening device at all. I find that although I don't absolutelyneed the internal stiffener, frequently I can go a little fasterwith the stiffener in getting across the transverse colonbecause it does maintain some rigidity in the sigmoid. It isnot as stiff as an external stiffener for maintaining a straightsigmoid, but it does help. A stiffer 'scope has a tendency toelevate the transverse colon, and elevation is what you wantin a transverse colon.

Dr. Berk: How often do you use it?Dr. Morrissey: I use it pretty routinely. If I'm using a

small diameter 'scope, either ACMI or Olympus, and sinceI almost always want to go the whole way and not knowingwhether I am going to need the stiffener or not, I alwayshave it in place. The external stiffener must always beapplied in anticipation of its use. Once in a great while youwill have a situation where, because of adhesions, thesigmoid is bound down in such a way that you have to leavean alpha curve in there, and you can't derotate it; thestiffener may get in the way, but that is very unusual. Underthose circimstances, if you have the external stiffener on,you have to take the 'scope out, take the stiffener off, and goback in without it. The external stiffener is not that difficultto use, so that I tend to use it routinely with the longinstrument.

Dr. Gaisford: I've had no experience with the internalstiffener, so I can't comment on that. The external stiffenerrequires fluoroscopy, I think, in order to use it safely.Because I don't use fluoroscopy, I don't use the externalstiffener. The stiffener is used almost exclusively with themedium-length 'scope. So I don't use either type of stif­fener.

58

Dr. Carlin: I have no experience with the internal stif­fener, but I really like to use the external stiffener in gettingaround to the cecum. We put it on almost all the time.Sometimes we find that we get around to the cecum beforewe get to the point of having to use it. In effect, it shortensthe amount of 'scope we have available without the use ofthe stiffener. We almost never have to do any sort of alphamaneuver, because we can usually easily get up toward thesplenic flexure, then rotate a little bit clockwise to get anyloop out. Often we will then have some redundancy in thesigmoid, so we will hook the 'scope into the splenic flexureand gently pull back until we see that we've straightened outthe colonoscope. Then under fluoroscopic guidance, gentlyand with rotation, slowly push the stiffener up. We wind upgetting the stiffener up almost to the splenic flexure. Sincewe have pleated the whole sigmoid over it, we can quicklyand easily get around to the cecum with far less patientdiscomfort. I might point out that everybody is always verycareful to lubricate the outside of the stiffener very well, butyou also must remember that you need a lot of lubricationbetween the colonoscope and the stiffener, otherwise thestiffener binds against the colonoscope.

Dr. Friend: I have seldom used the stiffener. One way ofavoiding difficulty when going through that sigmoid colon isto keep a clockwise torque on the 'scope, making shortmovements in and out, with a little bit of deflection on thetip. Most of the time you can get through the sigmoid colonwithout any fancy loops. Once you are up to the splenicflexure area, the clockwise torque will keep that sigmoidcolon relatively straight.

Dr. Berk: Last question, rapidly down the line, yes or no:do you do the alpha maneuver?

Dr. Morrissey: I use it very rarely.Dr. Gaisford: Very rarely.Dr. Carlin: The same.Dr. Friend: I use it deliberately, exactly the way Dr.

Christopher Williams taught me how to use it. The only timeI make a counterclockwise rotation for torquing is with thealpha maneuver. The other method to hold a sigmoidstraight, while advancing to the splenic flexure and hepaticflexure, is to perform a clockwise torquing maneuver. As arule of thumb, if you are not sure which way to go, it's aclockwise torque that holds everything in place, not thealpha loop.

GASTROINTESTINAL ENDOSCOPY