On this episode, Jules and Erica talk all about colonoscopies with Jules's gastroenterologist, Dr. Eric Goldberg of the University of Maryland School of Medicine. Dr. Goldberg answers:
1) Why should everyone get a colonoscopy by at least age 45, if not sooner? Who might have to get a colonoscopy sooner, including those with family history or alarm symptoms?
2) Why is the colonoscopy prep necessary? Do we really have to drink all that gross liquid? Are there other options for colonoscopy prep?
3) What actually goes on during a colonoscopy and what is a gastroenterologist looking for during the procedure?
4) What are the risks of a colonoscopy?
5) What happens during the recovery from a colonoscopy?
6) How often does someone need to get a colonoscopy?
We also cover follow-up care for celiac disease, including how often serology should be done, and how often celiac patients should undergo follow-up endoscopy.
Thank you to our guest Dr. Eric Goldberg.
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Hey. I'm Erica.
And I'm Jules. Most people have at least 1 thing that they can't or won't eat.
Now we're definitely like that.
When we started this podcast to talk about the gluten free food industry,
Like new products and some of the stories behind your favorite brands.
And living life with especially diet and also some important health care topics.
Since we're basically both broken inside,
You Had Me At Eat. Welcome everybody to another episode of You Had Me At Eat. We are honored today to be joined by doctor Eric Goldberg, who is associate of medicine and clinical director of gastroenterology and associate chief of gastroenterology at the University of Maryland. He's also my personal physician, so I'm happy to see you here today on the podcast. Thanks for joining us, doctor Goldberg.
Dr. Eric Goldberg [00:01:06]:
Thank you for having me.
So Jules is is fully clothed, which is probably very different than
what you see. Recognize me, doctor Goldberg?
Dr. Eric Goldberg [00:01:17]:
I do have a running joke. Sometimes they say turn around, but for this one, I won't.
Dr. Eric Goldberg [00:01:22]:
Thanks a lot. Yeah.
So good. GI jokes GI jokes are honestly the best jokes. So we we we fully appreciate those here on the podcast. So thank you so much for that.
Yeah. And doctor Goldberg, you don't know Erica, but, she has a a big history of, GI jokes. So you probably are gonna hear a lot of them today. She her poop emoji is, like, her favorite thing, and she I think you have a poop, little, puff thing in the background.
I have I have so many. I've been to so many DDWs and collected all the poop swag. So Yeah. She's
Dr. Eric Goldberg [00:01:56]:
Well, I definitely need to arm myself with some more GI jokes. The more the merrier.
Yeah. Alright. Well,
Erica will give you some today. So, okay. Well, we wanted to, have you on today to talk, all things colons. So, are you ready, doctor?
Dr. Eric Goldberg [00:02:11]:
I am ready.
Dr. Eric Goldberg [00:02:13]:
Armed and ready.
Armed and ready. Yeah. Well, first, do we wanna talk about how You had multiple colonoscopies, but what were your issues that prompted you to even see a GI And that prompted doctor Goldberg to actually have you undergo a colonoscopy.
Okay. So We're talking about me personally. I believe that doctor Goldberg answered the, SOS call from doctor Fasano many, many years ago, which is how I first met you, doctor Goldberg. I don't even remember when that was, but, doctor Fasano Is another wonderful friend of mine, and I have had many GI problems after my diagnosis with celiac disease. Because as As we know, just because you have celiac disease and your celiac is under control, that does not mean that you cannot have a cascade of other problems, especially If your celiac disease was not diagnosed early and your body is, riddled with other other problems. So Doctor Fasano called his good friend, doctor Goldberg, and said, please get my friend Jules in to see her, to see the insides of her body. Like, please tell us what's going on. That was many years ago, and he's performed I don't even remember how many colonoscopies you've performed on me since then, but, most recently, just a few weeks ago because I've had continuing issues with colitis.
And that has been just something that I've had for many, many years since after my diagnosis with celiac disease, just ups and downs of colitis. Is that something that you see a lot with people who have celiac disease, do you see a lot of, commingling of problems with celiac and colitis or celiac and other IBD issues?
Dr. Eric Goldberg [00:04:00]:
Most definitely, one of the issues with celiac disease is that celiac disease is an autoimmune disorder. So, what that basically means is That your body's immune system attacks itself. And autoimmune diseases tend to run together. So, in the cases of celiac disease, it's very common to have thyroid disease, for example. So Hashimoto's thyroiditis, graves disease, those are common, Coexisting conditions. You can get, inflammatory bowel disease associated with celiac disease. You can get, microscopic colitis, which is, in Jules' case, one of her issues is that 5% of people with celiac disease will get, an inflammatory condition of the colon where the, It it behaves like Crohn's disease or, sometimes ulcerative colitis, but when you scope the patients, you don't see much. But when you take microscopic biopsies, you see inflammation and sometimes a scarring layer called collagenous colitis, but that is a very common association.
Dr. Eric Goldberg [00:05:11]:
Diabetes is another autoimmune condition that's associated with celiac disease, and and people have autoimmune problems. A lot of these, tend to cluster, and we do see a lot of coexisting problems in patients with celiac disease.
Yeah. So I think a lot of people who have celiac, they think, okay. Well, now I've been diagnosed with celiac. I'm a monoclonal gluten free diet. I'm home free. And that's not necessarily the case, so it's nice to have, a little bit more background on that. Dr. Goldberg, thank you for that.
So what were the red flags that Jules presented that is, like, it's time for a colonoscopy Instead of just being like, oh, it's IBS. You know? Instead of a diagnosis of exclusion or whatever people are calling things now, What are those red flag symptoms that are like, hey. We should probably get you scoped?
Dr. Eric Goldberg [00:06:00]:
Okay. So first of all, a pitch for colonoscopy in general. So, we do lots of colonoscopies in gastroenterology, and that's because, colon cancer is a very common problem. So It's recommended right now that if you have no family history and you're at average risk for colon cancer, everybody starts screening at the age of 45. Things that, if you have a family history of colon cancer, first degree relative, we start, at age 40 or 10 years before that date of the 1st degree relative who had colon cancer. And in some cases, we see very strong clusters of Colon cancer within a family, and we may start even sooner because there are colon cancer syndromes that put you at risk at much younger ages. But in terms of colonoscopy and and when should you do it, for certain GI symptoms? It depends, but a lot of the things that make us worried, are ongoing chronic diarrhea, ongoing abdominal pain, blood in your stool, black stool, which is a sign of old blood in your stool, malabsorption, weight loss. These are the common things that we look for, In patients who have celiac disease, if somebody goes on a gluten free diet and their symptoms persist despite a gluten-free diet.
Dr. Eric Goldberg [00:07:24]:
It's either a celiac, patient who's not responding to a gluten free diet, which is less common, or it's, some type of gluten in the diet that you're not realizing that you're getting, or it's one of those coexisting disorders like microscopic colitis, or Crohn's disease, for example.
And then backing up to your pitch for colonoscopy, which I definitely want to make sure we hit upon on this spot broadcast because, I think so many people are unaware, especially of the fact that it's now 45, not 50 is the recommended age. But, why is it that, You know, to those who are listening, why is it that colonoscopy, something that is, you know, pretty invasive? Why is that's the only way that you can really get a good look and make sure that you're covering all the bases that you've looked and seen That, the patient does not have early signs or does not actually have colon cancer.
Because and my next question was, What about those people who just wanna do something like Cologuard and don't actually want to have a colonoscopy even though it's not invasive compared to all the other things that we've done. It's invasive for most people that don't have any sort of procedures or surgeries. So what about these people who just wanna be like, well, I don't know. Can I just poop in a box and mail it somewhere? Why is the actual colonoscopy the best way to see?
Dr. Eric Goldberg [00:08:50]:
Sure. So colonoscopy is the best option. Okay? But it's not the only option, and I think that's an important distinction to make. For certain people, it's highly recommended that they get colonoscopy versus a less invasive test like a Cologuard. So a Cologuard test looks for mutations, in the stool, and then it looks for blood in the stool as well. So what you have to understand about colon cancer, and is it really an ideal, disease to screen for because number 1, it's a common problem. Number 2, there's a long precancerous phase. So what happens with colon cancer is that you go from normal colon, you get some mutations in the cells of that area of your colon, and that will lead to the development of a small adenomatous polyp.
Dr. Eric Goldberg [00:09:45]:
And then you get some more mutations in the cells, And it leads to the formation of a more advanced or larger polyp. And then you get more mutations and it leads to the development of Splasia, which are pre advanced precancerous changes in that polyp. And then you get some even more mutations and it Develops into colon cancer, and then finally get even more mutations of that and that can lead to the spread of the colon cancer. That process doesn't occur overnight. That process takes 5 or 10 years. So the advantage of colonoscopy is that you can detect Pre cancerous phase at an early stage, and then you can actually remove it and prevent the development of colon cancer. So You're not gonna get that type of benefit from Cologuard. That being said, the most important thing when we look for Screening for colon cancer is access to the test.
Dr. Eric Goldberg [00:10:43]:
If you're not willing to undergo a colonoscopy, colonoscopy is not gonna do anything for you. If you're willing to undergo, a test that doesn't have as good as metrics, but it's still better than nothing. A Cologuard test is a very reasonable test, to order. It's It's indicated for patients who are at average risk. So I wouldn't use it in somebody who had blood in their stool. I wouldn't use it in somebody who had, Symptoms consistent with colon cancer or even when using somebody with a family history. But if you had no family history, no symptoms, And you wanted to know if, you know, what's the likelihood, you know, that I have something brewing in my colon. There's a reasonable, sensitivity and specificity, for Cologuard for picking that up.
Dr. Eric Goldberg [00:11:29]:
All other patients I recommend colonoscopy. And, you know, the The testing has changed over the years. 30 years ago, we used to do sigmoidoscopy. So, we used to do that unsedated. Okay. Yeah. We used to do those unsedated.
Dr. Eric Goldberg [00:11:44]:
Patients would come in and we put the scope in, you know, this far and look at the left side of their colon. This far. There you go. And it was very uncomfortable for patients, and it didn't make clinical sense. It would be like An analogy is doing a mammogram on 1 breast. You know, you're gonna miss half the lesions, and a lot of these are are right sided colon lesions. So, It actually probably did more to harm colonoscopy screening today than benefit because A lot of stigma was associated with unsedicated colonoscopies. Today, the hardest part of colonoscopy is getting prepped.
Dr. Eric Goldberg [00:12:21]:
And once you've cleaned your colon out, you come in, you get an IV, you get sedated. Most facilities that sedate you for colonoscopy, are using propofol, although some are using Fentanyl and Versed still, But you don't remember much from your colonoscopy. In fact, you wake up a lot of the times feeling better after the colonoscopy than before, because it's a really nice sleep that the anesthesiologist give you. And in reality, it's a pretty easy test to undergo. I've recently had a test myself, and it's it's a big nothing-burger other than the prep. The prep is the hardest part. But, I try to convince my patients to do the prep, and I say that, you know, there's a lot of Lot of evil humors in your colon.
Dr. Eric Goldberg [00:13:06]:
And, every once in a while, a complete flush of your system Yeah. Is not a bad thing. I
think witchcraft. Gotta get it out.
Dr. Eric Goldberg [00:13:13]:
Yeah. Gotta get it out. And then you get your colonoscopy and you can start anew. And, I do think that, You know, obviously, I'm I'm I'm biased because I'm a gastroenterologist. But all the data indicates that the benefits far Far outweigh the the risk of a colonoscopy.
I do wanna also talk about before we get into the prep, which is everyone's favorite part, I do wanna talk about there are some risks. So what makes a patient not able to have a colonoscopy? Is there certain, Like weight or high blood pressure or what are the things that make someone not able to have a colonoscopy? Or Let's talk about the very minuscule risk because there are some of, like, intestinal perforation. Like, how how big is that risk? Is that something we should be concerned about?
Dr. Eric Goldberg [00:14:04]:
Sure. That's a great question. And anytime you're gonna undergo any medical procedure, it's a risk benefit analysis. So what's the benefit? What's the risk? And then you have to weigh that and determine, you know, is this test right for me? And I would say Any patient who's gonna undergo any surgery or anything, always make sure you understand both sides of that equation. So colonoscopy is generally very well tolerated. Because we use sedation for the, procedure, we have to make sure patients are gonna be able to tolerate that. So the biggest things that concern us are cardiovascular issues. So is there underlying heart disease or potential for heart disease? Are there underlying breathing issues? So respiratory issues? Or, any previous adverse reactions to sedation? Our patients on chronic pain medication where they're gonna require increased doses of sedation in order to get them, asleep.
Dr. Eric Goldberg [00:15:03]:
Those are the things that we weigh. Most patients even with heart disease and lung disease can be sedated. Although, the venue for where we sedate them changes. So if it's a nice healthy patient with no underlying heart disease or or lung disease, We can do those in generally outpatient facilities. If it's somebody who's really sick, we like to do those patients in the hospital. Obviously, if someone has active chest pain or active breathing issues, most colonoscopies are elective procedures, And we like to address those issues and get those straightened out first. But, even patients with heart disease, can get a colonoscopy. We just have to make sure we've dotted the i's and crossed the t's and and they're gonna they're gonna tolerate the sedation well.
Dr. Eric Goldberg [00:15:49]:
In terms of the actual risks from the procedure, there's 3 things that are worth talking about. Number 1, There's a small risk for perforating or poking a hole in the colon. Now, if we identify most of the time that occurs in the setting of taking off a polyp. But occasionally, it's occurs because the endoscopist was pushing too hard to get around a bend, and we call those elbow perforations and it kinda tears the wall a little bit. I think most experienced gastroenterologists, the likelihood that they get an elbow perforation or from pushing too hard, they generally learn how how hard to push it. Those are uncommon. Taking off a polyp, it really depends on the size of the polyp. A small polyp has a smaller risk of perforation compared to taking off a larger polyp.
Dr. Eric Goldberg [00:16:39]:
And, the likelihood overall, is quoted about 1 in a 1000 cases. So if you wanted to assess your risk, it's A 99.9% chance you're not gonna have a perforation during a colonoscopy. The problem is if you have a perforation, A lot of the times that's gonna require surgery to fix. If your endoscopist, is skilled and recognizes a perforation during the procedure, We can clip those up, or we can, even have suturing devices that some of us are are familiar with. But if you don't recognize it at the time of the perforation, some of the colon contents can spill into the abdominal cavity, cause infection,
and it leads to a
Dr. Eric Goldberg [00:17:24]:
surgical emergency and sometimes that requires a temporary colostomy. Again, there's a 99.9% chance that won't happen, But it does happen. If you do enough colonoscopies, even the best colonoscopies will have, you know, complication like that. The other risk is bleeding, which, again is uncommon if we don't do some type of intervention in the colon. But if I'm doing a big polypectomy, The bleeding risk is about 1%. The good news is that most bleeding stops on its own. Occasionally, we have to put the scopes back in, to make them stop after taking off a big polyp, but, that's not that common. And then, The third thing that's definitely worth mentioning is that colonoscopy is not a perfect test.
Dr. Eric Goldberg [00:18:10]:
So everyone just assumes that they've had a colonoscopy And they're clean, but even they've done studies, where patients get tandem colonoscopies. So one doctor does a colonoscopy and then leaves the room and another doctor comes in and does the same colonoscopy. And what they find is that lesions get missed, even in expert institutions. Some of these were done by, you know, academic physicians. Most of the studies were done in academic centers, and presumably that's where your best colonoscopists are. But even in expert hands, there's a miss rate. So for small polyps less than 5 millimeters, which are probably insignificant polyps anyway, the miss rate is as high as 25%. And then for large polyps or polyps that or even cancers, the miss rate is between 1 5%.
Dr. Eric Goldberg [00:19:01]:
It really makes it important For the endoscopists to take their time, when they're doing their colonoscopies, it's not worth it, in my opinion, to rush through a colon. I mean, if you wanna, like, get to the end of the colon and then start really looking carefully, I think that's fine, but it's not worth it to kind of pull the scope out fast bring the next patient in. You know, as a physician, you have to decide what's important for you, and for me, I don't think I could sleep well at night knowing I didn't do my 100% best job for a patient. So, I'm always taking my time during the colonoscopy And really scrutinizing every area, sometimes putting the scope back into areas that I don't feel like I saw well to make sure I'm not missing anything significant. So, and I think most gastroenterologists feel that way, and do a very good job. But again, that's where, I think Patients need to investigate is, you know, what kind
Dr. Eric Goldberg [00:20:00]:
kind of reputation does your your GI doctor have? Is your GI doctor doing 25 colonoscopies a day? Or are they doing, you know, 6 to 8 a day and and really focusing on doing a good job? So I think that's an important thing.
I will say I saw a picture of a polyp for the first time ever. I guess small polyp, like, something that I've had removed, at An ACG lecture or something, and I'm like, I'm sorry. That's a polyp. It was I don't know how you catch it. I mean, I know that you're trained on this, But it just looked like everything else. I mean, the tiniest things, like, no of course, there's a mystery. It doesn't look any different. I just look at these being, like, even the larger polyps, I'm just like, oh, that's it? Which I guess is why, you know, GIs are are trained so well because to the naked eye, to the layperson, it doesn't look like much.
Then again, we don't really look at colons
Dr. Eric Goldberg [00:20:58]:
a lot. So So it also helps during during your case, to have the nurses looking while we're doing our procedures And having our text look, having a fellow or resident in the room. The more sets of eyes, the easier it is to kind of pick something up. Believe it or not, AI or artificial intelligence is making its way into screening colonoscopies and they have computers now that hook up to your processor and it will put a circle around a lesion that it thinks is a polyp. And there's a lot of false positives, so it'll put lesions around. Is that really a polyp? I'm not so sure. But it actually, it's beneficial for picking up, polyps, and it definitely helps with the misery.
And so one benefit of our robot overlords taking for us is that maybe we can get more polyps detected on a colonoscopy. How exciting for us and our our robot gods. So before we let you go, I think the biggest question, we've gotta ask about the prep, Jules. Yes. We have to
ask about the prep because a lot of people are so afraid of this prep. But the last couple times that I've gone through it, I've specifically asked for the Miralax prep, which is very much less, I think, traumatic. So Yeah. Could could you, maybe describe the 2? As far as I know, there's 2 basic
prep options. Several prep options.
But there's there's a pill.
Well, then tell us all the prep options.
There's so many. We're so it's so confusing and all we just know that it's going to be an uncomfortable night for us. But I think that giving options at least makes us feel a little better. So, yeah, hearing the options would be great, and what you honestly think about them.
Dr. Eric Goldberg [00:22:55]:
Yeah. So myself, I've had 3 or 4 colonoscopies. I have some underlying GI issues.
Welcome to our club.
Dr. Eric Goldberg [00:23:03]:
Very good. So, yeah, I'm part of the club now. I'm officially part of, the club.
Dr. Eric Goldberg [00:23:09]:
Not the celiac club, but the inflammatory bowel disease club. So, again, autoimmune problems run run rampant through my family and they certainly run rampant through me. But, In terms of the prep, one of the most important things is adherence to a liquid diet The entire day before the prep. So where we see problems, with poor preps, a lot of the times patients will, Well, actually try to eat a solid food or, eat, Something that they shouldn't be eating, but they think that
they can get away with it.
Dr. Eric Goldberg [00:23:46]:
Another thing. Yeah. So, but staying on a liquid diet, anything that you can see is generally fine, coffee is fine. But, doing that the entire day helps to flush your system. Another thing is certain foods are very good for the colon, like like salad, nuts, high fiber foods, But they're not good for your prep. So those are foods that you kind of want to stay away from, in the days before your colonoscopy. So, I think that's important for kind of clearing that out because when we do your colonoscopies, we generally can see what you've been eating if it's not fully flushed out.
Do you guys stand around
in the OR like,
Dr. Eric Goldberg [00:24:26]:
Sometimes you say, what is that? Is that corn or that watermelon seeds. That looks a lot like onion.
Must be the running joke between you. Alright. $5 says that's, like, ew.
Dr. Eric Goldberg [00:24:47]:
We we we we see some interesting stuff. Like, one time, I thought it was a polyp, and I I I reached in and I realized it wasn't attached. But we still send it to the lab, and I removed it. And it comes back as, like, skeletal tissue. And then I'm like, what's the skeletal tissue doing in there? It just turns out it's like some type of animal meat. But, you'd be interested what we we, we see in in colons.
Speaking of witchcraft
Oh, gross. What did this person eat?
Dr. Eric Goldberg [00:25:19]:
Yeah. We get used to it. I'm kind of I'm kind of numb to all of that stuff. People always say, yeah. How do you become a gastroenterologist? You know, with dealing with all this kind of stuff. But when you do medicine, you kinda have to pick your poison. And if you're a cardiologist, you're dealing with blood. And if you're a trauma surgeon, you're dealing with blood.
Dr. Eric Goldberg [00:25:39]:
Or if you're ENT, you're dealing with snot. If you're a, you know, pulmonologist, you're dealing with sputum. So as a GI doctor, we deal with some blood, but we deal with occasional vomitus and and stool contents. But most of the patients do a very good job on their prep. So 95%, they come in and their colon is wiped clean and it looks great. So, that makes a big difference, in terms of the quality of the exam. In terms of the actual prep, volume is important. So If you're gonna do Miralax, which, you know, it turns out to be somewhere between 13 and 15 scoops of the Miralax.
Dr. Eric Goldberg [00:26:17]:
The key is to make sure you're drinking plenty of water and, plenty of fluid while you're prepping. Just to to flush the system, Especially if you have things that slow down your system. For example, narcotics or medicines, that we call anticholinergic medicines. For example, Benadryl that will slow the emptying of the colon. So volume is very important. Because most people don't focus on volume, you have Golytely or Nulitelytely, which are these jugs of fluid that are generally not that palatable. And but they have a a whole, you know, 4 gallons of it so that, you know, 4 liters of it so you can clear yourself out. But yeah.
Dr. Eric Goldberg [00:26:59]:
Exactly. But you can do that on your own if you're drinking enough fluids. So the key is to just keep pounding fluid, with whatever prep you decide to do. There are options besides Golytely, which is polyethylene glycol. In the past, we used one called Fleets Phospha Soda. They still have Fleets enemas, but they don't have Fleets Phospha Soda because The phosphate was damaging people's kidneys
Dr. Eric Goldberg [00:26:16]:
There are some studies showing that, phosphates could could damage kidneys over time. So We got away from some of the electrolyte type preps like Fleet's Phospha soda, but they're still out there for young healthy patients. There's even pills that you could take that have, different types of, laxatives in them. But again, the key is to drink plenty of fluid with the pill preps. The pill preps are generally okay for young people with no hypertension and no kidney disease. But once you get into the fifties and sixties, they generally have some risks that we tend to avoid those pill preps for.
Dr. Eric Goldberg [00:28:03]:
definitely some options.
But regardless of the the prep, you should be what should your toilet contents look like when you are ready to
Dr. Eric Goldberg [00:28:02]:
Basically, you should be able to see through it. So it it it can be yellow. It can be, like a slight tinge of stool in it. But generally, you should be able to see through it. It should be basically resembling what you're drinking.
And here's my question that I always run into. I always feel like I'm going to crap my pants while I'm driving from my home or being driven from my home to the center to Get my colonoscopy? How what is a patient supposed to do during that time?
Dr. Eric Goldberg [00:28:55]:
Yeah. That's a tough one. And, there's no great answer for that, especially if you have a long commute. We have patients. I'm in Baltimore and I have patients who come down for big polyp removals from the Eastern Shore and that's a few hour drive, and it can be hard. I think we don't want to use anything that's going to slow you down. So we don't want anti diarrheal medicines in that circumstance. And so What? Unfortunately, I have to say kind of grin and bear it and and maybe focus on depends or focus on, you know, something to help you, Kind of stay calm to to assist in your
because Mayo Clinic, where I go, is very far away from where I live. So I'm like a 45 minute drive just clenching the car seats, but that's always been my biggest. I mean, the prep also is horrible. Let's not get it wrong, But, like, the drive there, I think, is probably the most uncomfortable for me. There has to be some sort of, like, maybe including a diaper along with the prep. It's like, here, this is for you. Where you go look on us?
Dr. Eric Goldberg [00:30:02]:
Sounds like a business model.
We need to because, honestly, that's one thing that I didn't think about my first Time being like, oh god. Now that I've got rid of everything, how am I supposed to hold it in until the colonoscopy?
Dr. Eric Goldberg [00:30:15]:
It sounds like a great business idea.
And so any tips for someone getting their first one for afterwards? Do you wanna talk about the running joke about the farts In the in the, post op?
Dr. Eric Goldberg [00:30:29]:
Is that me or Dylan?
No. Doctor Goldberg, you you have to Fart before they take you home.
There are so many on TikTok. Like, have you seen them? They're hilarious. Like, the the TikTok, Post colonoscopy, fart videos are very funny.
Dr. Eric Goldberg [00:30:47]:
Yeah. Some some of those are are quite humorous. And I always tell the patients not to worry. You know, we have when we do colonoscopy, different facilities use different types of insufflation devices. So when we do a colon, we have Blow the colon up like a balloon, so that we can see. So most places use air, which is you know 21% oxygen, 79% nitrogen, and it doesn't diffuse out of the colon well. So That air, when you pass it, it has to come out as a fart. And some institutions like, University of Maryland, we use CO2.
Dr. Eric Goldberg [00:31:24]:
And CO2 tends to diffuse away, so you don't get as much air left in the colon, as you would with regular air. But I always kinda joke with the patients and their families and I tell them, doctor's orders you have a prescription to fart, you know. You know, get it out because it is a little uncomfortable. And the good news is is that if you're prepped, your farts don't stink. So that's that's the good news. Yeah. But after the colon, You really shouldn't have any discomfort. You should, other than some bloating and the need to pass some gas, there shouldn't be any pain.
Dr. Eric Goldberg [00:31:59]:
The only thing that really hurts in your colon is stretch. So at the end of the colonoscopy, we generally try to suck out as much air as we can to decrease the wall tension and decrease that stretch on the colon, but even biopsies don't hurt inside the colon. There shouldn't be any pain. If there is, it's a red flag sign that, you know, maybe something went wrong during the procedure. So we always have our patients call us if they have pain that persists after a colonoscopy.
I just I wanted to ask a quick question, before we let you go just on some things that patients should be asking their physicians about colonoscopy and endoscopy before they go in because we've been hitting on the colonoscopy the whole time. That's the lower, but the endoscopy is the upper intestinal tract. And that's where a lot of our listeners will be Interested to hear more about that as well because that's where celiac is diagnosed. But, what before you go in for an endoscopy and before you go in for a colonoscopy, What should you be asking your physician in terms of the number of biopsies that need to be taken from each, From the upper endoscopy and from the lower for the colonoscopy in order to be sure that you're getting the best representation of the picture that's been taken. We've already talked about the fact that things can be missed, obviously, because, you know, that's a a very large expanse of territory that you're looking at. But, you know, when you're looking for celiac, for example, you know, there's a certain number of biopsies that need to be taken in order statistically to, get the best representation of a chance, at accurate diagnosis when you're talking about, for colonoscopy, how many are you looking at looking at taking there for biopsies, to get, you know, for something like a microscopic colitis or things like that? How many are you taking from what parts of the colon are you looking to make sure that you've actually touched all the bases?
Dr. Eric Goldberg [00:33:47]:
Sure. So, from the upper procedure for celiac disease, and again, it depends what we're looking for. And there are quality indicators that gastroenterologists are supposed to follow. So when when we're looking for celiac, celiac can be patchy, but in general it tends to affect the most proximal small intestine the worst. And then as it goes down the small intestine, it tends to get a little bit, better in terms of the mucosal damage. So more often than not, the mucosal damage is right there in the duodenum, which is the first portion after your stomach. And the recommendations are that we do 6 to 8 biopsies of that area, to make sure that we're not getting sampling area. Like, we're not biopsying an area that, just doesn't have to the same amount of inflammation as another area.
Dr. Eric Goldberg [00:34:39]:
So I think 6 to 8 biopsies is enough. I generally do 6 biopsies in the 2nd portion of the duodenum, And then I pull back into the duodenal bulb and I do 2 additional biopsies there. A biopsy is not a huge thing. It literally takes to do 2 bites, It takes 10 seconds. Then we take the scope, we take the biopsy forceps out, we put it into a little, biopsy container. They hand it back. And that whole process takes 30 seconds. So to take 8 biopsies, literally, is a 2 to 3 minute, event and there's no reason not to, you know, follow the recommends recommendations of getting 6 to 8 biopsies.
Dr. Eric Goldberg [00:34:38]:
Now if we're looking for h. pylori in the stomach, which is a bacterial infection that affects a lot of people who are going for upper endoscopies. It can cause ulcers. It can cause gastritis. It can even cause stomach cancer. It's recommended that we take at least 2 biopsies from the antrum of the stomach, which is the End of the stomach and 2 biopsies from the body of the stomach. And so, again, it's not long. I can generally do an upper endoscopy and feel like I'm done a really excellent job visualizing everything in 5 to 10 minutes. A colonoscopy, for me to insert it from the rectum to the top of the colon, It takes anywhere between 6 to 12 minutes and then I generally take 10, 15 minutes pulling the scope out.
Dr. Eric Goldberg [00:36:07]:
Studies have shown that, you know, gastroenterologists who spend at least 6 minutes pulling the scope out, they pick up more polyps than, gastroenterologist who just pull the scope out with, quicker withdrawal times. And then in terms of biopsying for microscopic colitis, In general, I put it all into 1 jar. And I'll take, 2 biopsies from the cecum, Two biopsies from the ascending colon, 2 biopsies from the transverse colon, 2 biopsies from the descending colon, 2 from the sigmoid and 2 from the rectum. Some people do less than that and they'll just do 2 from the right colon, 2 from the transverse colon and 2 from the left colon. And I think that's reasonable too. I just like take a little bit more. Now if I'm looking for ulcerative colitis, whether or not somebody has dysplasia in their colon that puts them at higher risk for cancer, then I'm doing 4 quadrant biopsies every 10 centimeters in the colon. So It depends on why we're doing the biopsies, you know, what indication.
Dr. Eric Goldberg [00:37:10]:
But there are quality indicators that we follow, that the study show, and We teach it to our residents and fellows that are doing these procedures as well, so that they come out doing it the right way. And, you know, I think as long as you're taking your time and and and trying to follow the guidelines, you're gonna get good things.
Really helpful. Can I just tell you how lucky you are to have such a cool I know? Gastro who's, like, Clearly just in your colon, and it's like, let's check out Jules' colon. That's awesome. I think that's great. It's so interesting to hear Because we don't know what's going on when you have a scope inside of our colon. It's really, really cool to hear what actually happens during a colonoscopy. And hopefully, when readers are listening to this, they're like, oh, I get it. Now I see why it's so important, and it's Not just a, a torture device to try to hate you aging and and hate growing older because you have to have colonoscopies.
Think it's really important, to know how vital and critical these tools are to help you maintain, you know, good health in your digestive tract as you move forward with aging.
Well yeah. And I guess the only last piece that we need to know, you said we have to get we should be getting a colonoscopy at the age of 45. How often is the recommendation after that.
Dr. Eric Goldberg [00:38:34]:
So if everything is clean in your colon, every 10 years is enough. And then in general, we stop screening at age 75. The new guidelines say that if you have small adenomatous polyps, which are those small precancerous polyps I was telling you about, probably every 7 to 10 years is fine. So small being less than 10 millimeters. If you have advanced lesions, so something that's bigger than a centimeter or So we it has what we call valence histology or high grade dysplasia. Then we do that every 3 years.
For celiacs, how often should we be going back for an endoscopy could be just to check and make sure that all signs are are a go. I know we're supposed to get back for the serologies, but how often would you recommend and what is the The current recommendations for actual endoscopy because that is a lot more invasive than just going back to have your blood work done.
Dr. Eric Goldberg [00:39:25]:
Yeah. We definitely see that there can be a discordance between the serology and the histology. So the serology is good to have every year, At least once you've been firmly established and you're under control. If you're having symptoms or you're having issues, that's a different story. But if you're feeling well with celiac and, I think then yearly serology is good. Insurances generally will cover, a upper endoscopy every 5 years or so. And I think it's reasonable to reassess every 5 years or so to make Sure that there's not inadvertent gluten intake in your diet and to make sure that you don't have some type of refractory celiac going on. Celiac can do things that you may not be aware of.
Dr. Eric Goldberg [00:40:15]:
For example, You may be not absorbing certain micronutrients well even though you feel well from a GI standpoint. So if you're not absorbing your vitamin D well, It might put you at risk for osteoporosis down the road. And I think a biopsy could help us understand that your celiac is active or not active. Or, people with celiac have higher risk for certain types of malignancies in their small intestine as well as lymphomas, And it depends on the level of activity of the celiac, whether or not there's mucosal inflammation. So, again, the Serologies are, I think they they make us feel good, but there's definitely some discordance. And I think every 5 years would be reasonable in that circumstance.
Okay. Thank you. I love it. And, obviously, we wanna put the caveat here that you should speak with your own GI and make your own, Medical decisions under the carrier of your GI, but make sure that you have a good GI. Exactly. Honestly, that's the biggest issue that we run into. And, also, feeling comfortable enough to ask these questions that we just asked, doctor Eric.
Well and we thank you very much for We don't wanna take more of it, but do appreciate it very much. Appreciate your bedside manner and appreciate you sharing that with all of us today. And you had me at 8.
Doctor Goldberg, thank you.
Dr. Eric Goldberg [00:41:37]:
I really enjoyed being here. Thank you for having me, and I've anytime you want me to come back, I'm happy to come back.
Thank you so much. Thanks for tuning in to You Have Me The Eat, the number 1 voted gluten free podcast in the country. Remember to like and subscribe, tell all your friends, and we'll talk to you next time.