Procedures

• What We Tell Parents Before a Colonoscopy
• Preparing for and Having an Endoscopy
• How I Explain Endoscopy to a Child
• Parent Reactions to a Child’s Procedure
• IBD and IBS
• Colonoscopy
  

What We Tell Parents Before a Colonoscopy

When a child is going to have a colonoscopy, we spend a lot of time on the phone with the parents beforehand, and we even talk to the kids, if they want to talk to us. Many don’t, but some do. We often ask to talk to kids because if they’re coming in for a colonoscopy, we want to make sure that we answer their questions.

We talk to families about the importance, first of all, of the preparation being done correctly, because it’s essential that the colon be clean so that we can see what we need to see and so that they can make sure that they have the right tests and they only need their tests once. So we give them some hints for getting everything together, making sure that they get the instructions, that they know to call us if they have questions. We tell them what to use for preparation, and we also give them hints about how to make it more palatable, because the worst thing about the prep is the taste. There are a few different preparations we use, and each one has it’s own advantages and disadvantages. We tell them what types of juices and other liquids they can mix them with, and give them suggestions about keeping the liquid cold by putting it over ice, using straws, and getting up and walking around between glasses in case they feel bloated. Using popsicles between sips can be helpful too, to lessen the taste on the tongue; the straw also pushes fluid back a little further so you don’t taste it as much. We tell them to start the preparations early in the day, and to make sure that they have a little time to complete them so they’re not up all night going to the bathroom. We suggest that they drink the preparations at 2pm and at 6pm. If they are able, we may encourage them to start them at noon (to get a head start), Sometimes that’s difficult because their parents need to be available while they are drinking the preps and often they have to work the day before, since they’re taking a day off for the procedure. We make sure the patient leaves to have a procedure well informed and understanding what’s happening, so that there are no surprises. And we tell them that there are no surprises; everything that is going to happen will be explained to them, so the only surprises will be good ones.

Lisa Heard, Clinical Coordinator, Endoscopy Program

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Preparing for and Having an Endoscopy

We see a lot of patients with IBD who are diagnosed with IBD here at Children’s Hospital because of symptomatic changes in their lifestyle, such as bloody stools, pain, and extraintestinal symptoms, such as arthritic symptoms. They come to us after having completed the most difficult part of their procedure, which is the preparation for colonoscopy. About fifty percent of the Endoscopy procedures done at Children’s are done in the Endoscopy Unit under sedation. Colonoscopies may be done with sedation or general anesthesia. We do a lot of counseling prior to procedures on the preparation, giving them tips and ideas about how to prepare for the procedure and how to actually do the bowel preparation that you have to do to clean the colon so that we’re able to see the entire colon. It’s a very challenging preparation. We spend a lot of time talking about what the procedure’s going to be like, bringing music to listen to, IV insertion and topical anesthetics to make that a little better for them, and sedation. We also use pre-procedure anti-anxiety medicine to help take the edge off of our anxious patients. They’re not given as a rule, but anybody who is anxious may receive this medicine. The IV is generally inserted after the anti-anxiety medicine is given. A nurse stays with the child throughout their whole procedure, and the physicians are stay as well. We encourage patient parental presence up until the actual procedure; we don’t let parents stay for the procedure because it can be difficult for a parent to watch. It also allows the caregivers to pay complete attention to their child. But we really do encourage parents to stay with their child until we can separate them in the patient room, and there’s very little separation anxiety then because the medication has taken effect and the child will be to the point of sleep when we separate them. We like them to be a little bit responsive so they know that their parents are leaving, and it’s good for the parent to see that they’re not affected by it. We stay with the child during the procedure, monitoring them- there’s a nurse there for every patient and their sole responsibility is to monitor the patient; with no other tasks in the room. We care for them until their procedure is done and they go to the recovery room. All of the patients are recovered in the main OR recovery room, where they usually wait about 30 to 45 minutes until they have something to drink and they’re stable, and then they get to go home. Their lifestyle will be normal the next day, but they’re encouraged to relax and rest the day of the procedure. Most children can resume their normal diet once they are at home. We encourage the child to drink extra fluids on the day of their procedure to make sure they are well hydrated.

Lisa Heard, Clinical Coordinator, Endoscopy Program

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How I Explain Endoscopy to a Child

Endoscopy is a procedure that allows us to look right into the stomach and the large intestine. We use a small, very thin instrument that’s really soft and has a light at the end that can take pictures. We can look inside and actually see inside the large intestine. This allows us to see how everything looks. Upper endoscopy is a procedure that doesn’t take very long, and it’s not uncomfortable. It can pretty much be done without medication, but we give people medication so that they’re comfortable and relaxed during the whole procedure. An upper endoscopy can take about 10 to 15 minutes; it’s pretty quick, and you can get pretty good information about how to take care of the gut.

The lower endoscopy is a little different; it sometimes takes a longer time, but it also gives us very useful information. We can look at their whole intestine, up until the small intestine, and if we can get into the small intestine that gives us a lot of information about what might be happening with them. We give them medication for lower endoscopy because sometimes it’s uncomfortable when we look around, because it’s very twisty, and sometimes it feels like you might have to go to the bathroom and you might have some cramps. So we give people some medicines that make it more comfortable, and then they’re not so aware of what happens. I always tell the kids that they’ll be sleepy enough that they’ll know what’s going on and hear our voices, but they won’t care. Basically, it’s like being in bed in the morning and listening to your mom trying to wake you up for school. You hear her, but you’re really not really paying attention. We always know before the kids do when they need more medication, and we give them more if needed, so that they stay a comfortable level.

Now everything that’s done in the operating room under anesthesia is really different; the experience is different, because people have no knowledge of what’s going on during the procedure and are completely asleep. In that case, what they’ll remember is the preop area, coming in for their procedure and going into the operating room. Sometimes the operating room is scary for kids, because it’s sterile-looking, but some children and some families prefer to go there for their procedure because they just want to be knocked out.

Lisa Heard, Clinical Coordinator, Endoscopy Program

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Parent Reactions to a Child’s Procedure

It’s very difficult for us to have to tell parents to leave the procedure room while their child has a colonoscopy. There are many parents that we’ve walked down the hall in tears, and many parents I’ve hugged at the end of the hall and told, “Okay, we’re going to take good care of you, and we’re going to take the best care of your son or your daughter.” I also tell them that it’s more traumatic for them than it is for their children. As a parent you have a long-lasting memory of every minute, but the kids are sedated and they don’t remember. We try to give parents as much support as we can. Sometimes it’s easier being a patient than it is being a parent. There are so many parents who say, “I wish this were me and not him; that I could go through this and not him.” Every parent wants to take away every little bit of pain from their child. As parents or as nurses or caregivers, we all feel that way.

Kate Donovan, Special Projects Coordinator, Endoscopy

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IBD and IBS

The distinction between IBS and IBD is not a difficult one. The problem is that IBS is very prevalent in children who also have IBD, and the distinction of what symptoms are related to IBD and what symptoms are related to IBS is difficult. And if you don’t think about that, people will go through invasive procedures, not realizing that a lot of their symptoms are due to IBS. I think how much IBS is contributing depends a lot on the person. It’s not easy to tell from the symptoms. And IBS is not a diagnosis of exclusion- it has to be a positive diagnosis. I don’t know that any studies have shown that the prevalence of IBS is higher in the IBD population, but IBS is so common that many kids with IBD have it.

IBS is related to many things. One of them is how the nerves are reacting and how your arousal state is. So if you have Crohn’s and you have some nerve damage, and then you’re anxious, then you have the right predisposition for IBS on top of your IBD, but I don’t know if it’s more prevalent.

Samuel Nurko, MD, Physician, Gastroenterology Program

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Colonoscopy

I think that the procedure that kids fear the most is the colonoscopy. It involves their bowel being cleaned out, which often means they have to drink a bad tasting medicine to make them go to the bathroom. The medicine is really salty, and they have to drink a lot of it. If they’re not able to drink it, they have to be admitted to have a tube put in their nose, and that’s not very pleasant to go through.

Often, in the initial diagnosis, we’ll have a kid get general anesthesia to have a colonoscopy done, but generally people are pretty comfortable during the actual procedure, although I think that people worry a lot about what we’re going to find. I’m not sure that there is a better way to do it, because the bowel does have to be clean, but it isn’t the most comfortable procedure.

Lori Hartigan, RN, Clinical Coordinator, IBD Program

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