Virtual Colonoscopy Anyone?

[Guest]

Sierra,
The change in the INR is probably minimal. You continue the warfarin and vitamin K is a fat soluble (long acting) vitamin. This is why the INR is always changing (varying consumption amounts) but seldom would a change like this cause it to get far out of range or stay out for very long. The amount of vitamin K in the spinich probably varies in different seasons, soils, amount of sunlight etc so it is never going to be exactly the same even if you weighed the spinach.

 

[Marty]

Status of virtual colonoscopy April 14, 2004?

Status of virtual colonoscopy April 14, 2004?

The lead article in my 4/14/04 JAMA addresses this question. The lead investigator is Peter B. Cotton M.D. University of South Carolina.They checked 600 patients by "virtual" and immediately followed with conventional colon oscopy. They found "virtual" detected 39% of 6mm polyps and 55% of 10 mm lesions.This is a little bit different than the 95% sensitivity reported at MGH. We don't have an explanation but in my view this means that "virtual" is not yet ready for prime time. Your best bet is colonoscopy with Lovenox bridge . If this is not available ,I recommend air contrast barium enema by an older radiologist who was trained how to do it correctly. This exam picks up a lot of polyps and almost all "killer" cancers.By the way, conventional colonoscopy is not perfect and is very dependent on the skill and experience of the colonoscopist.Al's point about the time lag has some validity but does not change the significance of the report. Continuing evidence based study is indicated lest we foist another expensive inaccurate test upon the unsuspecting public.It may be another ten years before we discover the truth.

 

[Guest]

Marty's opinion carries the most weight since this is his specilaty.

 

[Guest]

I am working on the web page about protecting yourself when you need a colonoscopy.

 

[bvdr]

Thanks, Al.

I think it is a much needed reference. As a group, I think we are quite informed and pro-active concerning our particular health issues including anti-coagulation. As you know, bridge therapy/no bridge therapy has presented confusion for us and I'm sure even more so to the affected population as a whole.

 

[Marty]

Rx for bridging!

Rx for bridging!

Al, This is much needed. I for one, will print it out and distribute it to as many of our clinicians as I can.

 

[warrenr]

another great link (Bristol-Myers Squibb Company)

another great link (Bristol-Myers Squibb Company)

Coumadin "Full Prescribing Information" from the manufacturer. Go to page 4 of the link, right hand side just beneath table 3. This info is from June 2002. They seem to understand the importance of staying anticoagulated.
http://www.bms.com/cgi-bin/anybin.p...RODUCT_PPI where PPI_SEQ = 91&key=PPI

 

[tommy]

I'm due for a colonoscopy within the next few months, I keep putting it off.

My wife found an article in "Pulse" magazine. "Pulse" serves the North Texas area with medical stories. The April edition is focused on cancer. A 2-page article espouses the benefits of the virtual colonscopy. It cites a "New England Journal of Medicine" study of 1233 patients. The date of the study is not given. The study indicates that the traditional colonoscopy detected 87.5% of 6mm polys vs 88.7% using the virtual method.

Many thanks for everyone that has contributed to this thread. As a results of posts here, I read the "Pulse" article with some skepticism. The NEJOM is highly regarded, but the rest of the story is "feel good" and appears to be propaganda. One interesting thing is a comment that the virtual test requires a fair amount of training and learning.

To me there are two issues.

1. Initial test without lovenox? This would require a second procedure (with lovenox bridge) should polyps be found. I've decided against this. I might as well do the lovenox bridge the first time around to avoid a second procedure. If no polyps are found, and no cutting is done, that would be terrific. But if the doc needs to take care of business while he's in there, that would be better than prepping twice.

2. Virtual vs. traditional. I feel much more comfortable with the traditional test. If the doc wants to do a virtual, he will have to convince me that he is well trained and experienced. Even so, I'll feel more secure with the traditional test. Besides, the traditional test can be done in one shot, where the virtual test requires two procedures (see #1).

I have two more unresolved concerns:
1. What about the 10+% of polyps not discovered?
2. What about those 5.9mm polyps?
Can't have 100% - no gaurantees, I know.

Thanks again for all of your input.

 

[Guest]

The curious thing about the NEJM article vs the JAMA article is that the JAMA article is the most recently published but when you read when the studies were actually done, the NEJM study is three years more recent than the JAMA study. I don't think JAMA did the world a service by publishing this old study making it look like the newest evidence was that virtual colonoscopies were inferior.

A 6 mm polyp is about 2/10" across. The colon is not a nice smooth area and it is not perfectly clean even after the prep. It is not like looking for a pimple on a creamy smooth cheek. So 5.9 mm isn't much less likely to be found. With the traditional colonoscopy you have to be able to see it to diagnose it. (They only take pictures of what they see.) Once the tube is pulled out there is no second chance. With a virtual or barium enema, you have pictures of the whole thing that other people can examine too.

In people who have no symptoms, more than 90% of colonoscopies are negative. So there is less than a 10% chance that you would have to prep again.

 

[Marty]

NEJM Virtual Study-2003

NEJM Virtual Study-2003

The NEJM study reported by Pickhardt in 2003 applied recent advances which included 3-dimensional flyby software, elaborate stool tagging with 2 types of contrast, and a group of healthy compliant patients.I'm not sure these assets are available in most parts of the country.Then ,if they find a little polyp by virtual( which could be clipped off by conventional), what do you do? Do you "follow" it with another virtual in a year or go to conventional to have it removed- if they can find it. I quote from the JAMA editorial April 14, 2004-"Yet the differences between what virtual colonoscopy can do and what it will do in ordinary practise circumstances are so great that physicians must be cautious."

 

[Guest]

My "page" is getting long, but I'll add your comments.

 

[Guest]

I finally finished the page about colonoscopies. It is posted at
http://www.warfarinfo.com/colonoscopy.htm

 

[fyrfytr]

Hey Al,
Great job on that page. I will be adding that to my copy of your book. It has Very Good info for all of us. Thanks again for all you have done.
Take Care

 

[Marty]

A very nice paper, Al. Congratulations! You have quoted me correctly throughout the piece. If any of my xray colleagues or cardio friends read these quotes I will probably get some unfriendly mail.I can take the heat .In 1961 there was a paper from MD Anderson in Houston that stated mammography to be 98% sensitive detecting breast cancer. At my hospital we published a paper the following year stating overall accuracy nearer to 80% and in young women with dense breasts accuracy closer to 50%. It caused a firestorm. We were accused of not only being stupid and incompetent but also women haters. By the way, our figures are about right 40 years later.So lets wait and see on "virtual".

 

[warrenr]

Thanks

Thanks

AL,

Thanks so much for sharing my fathers story on the Warfarin website.
Mentally he is doing quite well allthough they do have him on antiphsycotic medication (manzopine?) for halucinations and medication for depression. He has not regained any function on his left side. Medicare has cut off his long term care. They dont feel he has shown significant enough progress.

As it turns out, no one checked his INR from the time he went off coumadin until just before the procedure and so far there is no record of the INR being checked pre or post op. If someone is going to be off Coumadin for 4 or 5 days, how often should INR be checked and whose responsibility is it.

Thanks so much

Warren r Mead

 

[Guest]

If someone is off warfarin for 4 or 5 days there is no need to check the INR because it will be about 1.0 which just proves that they haven't taken any and you knew that to start with.

 

[Karlynn]

Had my appointment w/ my cardio today - everything going smoothly. I go back in 6 months for an echo and we'll see if the aortic valve is behaving itself.

Anyway - I asked her about bridge therapy. I got a bit concerned when she said "What do you mean by bridge therapy?" I said "If I have to have surgery." "OHHHH". She said she uses Lovenox - but that "it's for surgery where they're really going to cut on you." I asked "What about colonoscopies?" And she earned some of my trust when she said "You wouldn't be going off Coumadin for a colonoscopy. There are many many minor surgical procedures and tests where being on Coumadin shouldn't be an issue."

 

[ccrawford]

Al - Thanks to both you and Marty for a valuable addition to the book. I have printed a copy which I will share with my doc (who is already a believer) What would we do without you guys ??? Chris

 

[Guest]

Everything I know was learned from people who take the stuff.

 

[tommy]

Great thread - very helpful.

I just set up an appointment mid May for consultation prior to colonospcopy (50 years young later in the year).

The appointment (nurse) said that requests for virtual colonospopies get referred to another doctor at another facility. They believe that the virtual procedure is not as reliable as the traditional procedure. Further, if they discover something, they have to go back in anyway. And....some insurance companies do not cover the virtual colonoscopy.

Their standard practice is that I go "off" coumadin for the traditional procedure. I will discuss this fully at the consultaion. I have a regular fullow-up apointment with my cardio the next day. Good timing. In know that the cardio will not allow me to be unprotected, and will insist on either a lovenox bridge, or staying on coumadin.

I have full confidence in my cardio, and am sure that the two docs will negociate an acceptable solution. That is the way it has worked three times already. My cardio sticks to his guns. This procedure concerns me a bit more then the previous ones because the bleeding will be so "internal".

I still have some lovenox left over from last fall's hernia surgery. I'll have to check the expitation date.

Thanks again for a great thread and lots of valuable input.