Monday, November 24, 2014

Colonscopy for Fun and Profit
    — or —
A Show Of Intestinal Fortitude
    — or —
Put it Where the Sun Don't Shine


Colonoscopy. A scary word for some, and embarrassing for most of us. "Yep, I'm going to go have a stranger poke me in the butt. Young women will stand around and watch. And I'll pay for the experience." doesn't quite evoke an image of wholesome family activity. It's not part of polite conversation. Not something to bring up over dinner.

I had mine at Sugiyasu Clinic in Amagasaki. They do colonoscopies and gastroscopies - and only colonoscopies and gastroscopies. That means the clinic owner and his staff is very, very experienced. They've seen it all and they're really good at what they do.

* * *

I'm 45 now, and it's time to worry about serious diseases. As someone once said: "Most of us live through our first fifty years. Very few live through our second fifty." The past ten years we've had several scares and a few losses among friends and family from heart disease, cancers, and infections so I don't take this lightly.

Here's a quick graph of mortality by age group for Japan and Sweden (courtesy of the Ministry of Health, Labour and Welfare, and Statistics Sweden):


Mortality rate in Japan (blue) and Sweden (orange). it tells you the average risk to die during the year for any year of age. The increase is exponential, which means the risk increases by a constant proportion each year. Note that since definitions and methods may differ between the countries the numbers themselves might not be directly comparable. The trend is the same, though.

Notice what happens around age 45-50 or so? Mortality is exponential (think compound interest for disease risk) and really starts to take off in middle age. When you reach the 40's you need to start taking care of yourself in a way you never realized when you were younger.

Here's the same data on a logarithmic scale:


The same data as above, but on a logarithmic scale. The increase is pretty steady, except for people between 15 and 30. Had I plotted the data for 90-95 and 100+ years old as well you would have seen an extra increase there too. 
Overall, the rate of increase is mostly constant through much of our lives. But look at what happens between ages 15-30, for both Japan and Sweden? It's like a hump of recklessness, when we're old enough to strike out into the world on our own, but still not responsible and experienced enough to avoid some very big mistakes.

* * *

A colonoscopy is really very simple. You poke a flexible tube with a fiber-optic camera into the large intestine and look for signs of trouble. If you need to, you can stick in tools through the tube to remove polyps or take samples. A gastroscopy (which I've also had) where you look into the stomach, is much the same but through a different opening as it were.

The problem is that your intestines aren't empty. To actually see anything you need to empty out the bowels, and there's really no comfortable — no delicate — way to do that. That means laxatives and some quality one-on-one time with a toilet.

The preferred way to prepare is apparently different in western countries such as Sweden and the US on one hand, and in Japan on the other. In the west you apparently avoid seeds, tomatoes, fruits, berries and other foods that are colourful or hard to digest for up to a week beforehand. You fast and drink laxatives the entire day before. When you come to the clinic you're already empty (and probably quite hungry) and can go directly on to the examination.

Here in Japan you eat and drink normally until the day before, when you have to avoid fruit, vegetables, milk products or anything with red or purple colouring. I had toast with ham and coffee for breakfast; instant ramen with an egg for lunch; and rice with a fresh egg ("卵かけご飯") for dinner. A chaser of laxative sent me to the bathroom once around bedtime and again the next morning.

When you get to the clinic you sit in a waiting room with half a dozen other patients and drink a bottle-full of laxative over the course of an hour, until the only thing coming through you is water. You dress in a hospital gown, get an enema for that extra-fresh squeaky-clean feeling and are led into the examination room. You're finally ready for your closeup.

* * *

Screening groups of people without symptoms for diseases often only make sense if you're in a high risk group, only once tyou reach a certain age, or (as for prostate cancer) sometimes not at all. Overall, we are probably erring on the side of too much testing, not too little. It's a big issue, and needs a post of its own.

Screening for colorectal cancer starts to make sense once you reach 45-50 years or so. This is one of our most common cancers, and also one of the most treatable. If you find it early the cure rate is nearly 100%. But if you find it late it can often be lethal. And as it often gives you no early symptoms, it's a common cause of death for people in middle age.

The cancer usually appears on polyps that sometimes form in the large intestine. Polyps are quite common, and some people are more likely to get them than others. The best way to prevent cancer is to find and remove the polyps before they cause any trouble. And if one is already turning cancerous you want to find out early, before it spreads outside the polyp itself. In such cases simply removing the polyp during the exam is often all you need; no drugs or hospitalization is necessary.

The easiest test is a stool sample that looks for small traces of blood. You poke a sampling stick into your poo right at home, bring it to the clinic and get the results in a few days. It's not hugely accurate but it's quick, cheap and easy so you can repeat it every year. I've done that for a few years already.

A colonoscopy is much more accurate and will find other things as well, not just polyps, but it's also a lot more invasive. People that tend to get polyps may do it every year, while the stool sample test is sufficient for most other people.

* * *

The examination room is dominated by a steel-frame bed surrounded by piles of hospitalish devices; things with LCD monitors and tubes, things that go beep, that sort of stuff. A couple of nurses in protective garb guide me to the bed where I lie down on my left side, bum conveniently hanging free at the long edge of the bed. I get a saline drip (we've lost a fair amount of liquid with the laxatives after all) and a mild sedative.

The doctor is affable and friendly. I can see the monitor and the sedative has only made me relaxed, not sleepy, so I ask a tentative question about what I see on the screen. Turns out he is just as talkative as I am, and only too happy discussing a job that he clearly loves.

He runs the endoscope through my large intestine up to the ileum, where the appendix and the small intestine starts, then back again, explaining all along. At one point during the return we get into a digression about the appendix, so he runs the endoscope all the way in again to show me. The whole thing was way more informative and much more entertaining than I imagined.


Part of my upper (transverse) colon, I think. Not the most exciting part of this anatomy perhaps, but I really appreciate the composition of triangular forms in this frame.
By the end the tranquilizers were really kicking in (perhaps the nurses were adding more to make us stop talking already) and I was getting quite dizzy. A nurse led me to a reclining chair in the recovery room where I collapsed and promptly fell asleep for half an hour.

Once I woke up I got dressed again, then met the doctor in his office for the results. As I already knew there was not a hint of polyps or of any other problems. My colon is apparently in rude health.

As I had no problems, my plan is to do a stool sample test every year as usual, and redo the endoscopy in five years time. That should be a good balance for me between the risk of missing something bad on one hand, and the risks (it's not completely risk free) and inconveniences of the colonoscopy on the other.

If you are approaching my age or older, and if you don't test yourself for polyps already, then this is a very good time to start. The test can save your life of course, but also be the difference between a quick ten-minute procedure or major surgery and months and years of brutal anti-cancer treatment. The stool sample test is silly easy, and there's really no excuse not to do it.

2 comments:

Richard said...

I now feel like I've seen more of you than I ever wanted to see. Nice triangle!

Interesting graphs though, particularly the 'young adult death hump'. Do you know how this breaks down by gender? One assumes more men die in this age-group, but one's assumptions are often wrong..

Jan Moren said...

Good question - and I like "young adult death hump", though "Surge of Stupid" is perhaps even better. Like you, I assume it's more males than females. Overall demographics, where males die more often (not per person obviously) should ensure that if nothing else; females are just as prone to stupid decisions at that age, but they are perhaps less likely to take a lethal turn.