I was recently asked to review the tragic case of a large woman who was so fearful of the " hassle" of medical intervention that -- exacerbated by the insensitive treatment by some in the medical system -- she deteriorated and died unnecessarily. If there is one thing that is true of many or most, fat people it is fear of seeing the doctor. As a physician I am ashamed to acknowledge that the vast majority of my colleagues attribute most medical problems in large people to weight. The more people seek help, the more they are frustrated by the suggestion that nothing will resolve unless and until they lose weight. In fairness, obesity can aggravate or lead to some medical problems, but it most certainly is not the source of all (medical) evil.

Another dilemma that leads many large people to avoid seeking medical help is the embarrassment and discomfort of undergoing diagnostic testing. This is especially true of invasive procedures such as endoscopy or biopsy procedures. "Will I fit into the gown, break the machine or be humiliated in front of the staff?." These are all common concerns.

I encourage you never to ignore abnormal symptoms or avoid important diagnostic testing. You can be accommodated if you are aware of what is involved. In this issue I will focus on the new technologies of gastrointestinal diagnostics so that you know what to expect.

COLONOSCOPY
Some people have a history of large (lower) bowel problems. If stool is abnormal in consistency, shape, or timing of evacuation, or if one has varying amounts of bleeding or dark colored feces, there might be trouble brewing. In order to assess for abnormal growths (polyps), inflammation (e.g. colitis) or tumors amongst other aberrations, doctors may want to slip a long flexible hose in the rectum. A direct view is possible by means of fiber optic technology.

PREP SCHOOL
For the week leading up to the procedure patients are advised not to take any iron containing vitamins or aspirin products. These may cause oozing, that might confuse the outcome of the test or actually promote bleeding during or after the procedure.

Approximately 24 hours prior to the test resign yourself to clear fluids, lots of clear fluids! Clear soups, juices, carbonated beverages, gelatin, tea, coffee, and even hard sugar candies are acceptable. The key in preparation is to clean out your bowel and that means you will have to take a powerful laxative. Sweetened Senna is a natural plant bowel stimulant and is commonly consumed in a dark liquid form. Also very popular is Phospho-Soda which tastes like concentrated sea water. A small bottle is usually taken in the morning and then again at supper time with a glass or two of Ginger Ale (which hides the taste temporarily).

Be prepared for some nasty diarrhea to keep you running to the bathroom every half hour or so and watch the toilet bowl to make sure that a very liquidy, often yellowish, fluid is all that remains in your bowel. Too much fecal material left in the bowel will muck up the procedure, rendering it ineffective. Once midnight comes you should have nothing at all to eat or drink (with the exception of a tiny gulp of water with any regular medication you are supposed to take on a daily basis). Hide your tooth brush and coffee cup to make sure you don't unconsciously drink in the morning.

THE RUBBER HOSE TREATMENT
Make sure that your doctor and the institution where your test(s) will be done are aware of your special requirements. This might include a chair without arms to sit in and a hospital bed on wheels (as opposed to a thin hard stretcher), which will serve as the berth for both the procedure and your recovery,

Although many examining gowns are available for purchase by a variety of outlets that supply people of size, most major institutions now carry large sizes in stock. Regardless of whether you encounter nurses and ancillary staff that are sensitive to your predicament, tell yourself that from this moment on nothing else matters but your health and comfort.

Once in the procedure room you will likely receive a short-acting sedative and pain killer combination by intravenous injection. Even if you have a sleep disorder like sleep apnea or a heart condition there is little reason for worry. Midazolam and Fentanyl are drugs whose effects are short-acting or can be rapidly reversed, if necessary, by an antidote. Be prepared to lie on your side --usually the left-- and ask to actually watch the procedure on a TV screen. It is a very interesting diversion, and makes for engaging conversation (how often can one say they have seen their insides "live" and "in action"?).

As the scope moves into the colon, air is used to inflate the area for a better view. The air, as well as the movement of the scope at kinks in the bowel, may cause cramps and the doctor will press on your abdomen or ask you to move on your back to allow easier passage. The procedure is surprisingly brief, lasting about fifteen minutes. Your speech may be slurred for a half hour or so and you can expect some bloating and cramps. Be prepared to blow gas for an hour or two as you get rid of the air trapped during the procedure. Roll around on your bed with your bottom elevated and don't be shy about letting loose with some "rippers'; you will feel relief shortly.

Some time later you may notice a bit of blood in the stool if the doctor had to "snip" a polyp or other sample of your bowel during the procedure. Don't worry unless you are losing a lot of blood or abdominal pain persists. In this case contact your doctor or return to the hospital.

"THE TUBE": SIGMOIDOSCOPY
The sigmoid is the bottom 10 to 15 inches of the bowel. Since the majority of serious tumors are found in this area, a physician may choose to do this very brief procedure with little preparation, right in his or her office. Expect to be on your hands and knees and experience a bit of cramping for five minutes. If this position is uncomfortable or impossible, ask your doctor to allow you to lie on your left side. Most physicians use a more comfortable flexible scope (which you should insist upon), but some still utilize an old fashioned rigid tube. Make sure that the physician uses lots of lubrication.

BARIUM ENEMA
Barium enema sounds like a way to dispose of a slain foe on the battle field. In fact, it is an excellent x-ray test which outlines the nooks and crannies of the large bowel that might be missed by the physician's scope. Preparation is very similar to that for colonoscopy. A radiologist sticks a tube into the rectum and inflates the bowel with a liquid contrast medium and air. Some cramping is to be expected, and one can anticipate being turned in a variety of positions on the x-ray table during the procedure. Because the urge to defecate may occur, a balloon is occasionally inflated to keep the contrast material in the bowel. After the first set of films are taken you will be allowed to void. About a half an hour later another set of x-rays is done to see if any barium remains stuck in abnormal pockets of the bowel.

Some cramping and pain at the rectum may necessitate the use of an anesthetic ointment or mild enema after the procedure.

BARIUM SWALLOW
The easiest and most comfortable of all the procedures involves swallowing a barium milk shake to reveal many abnormalities of throat, food tube, stomach, and upper small bowel. People with heartburn, excessive vomiting, bloody regurgitation or unexplained anemia or weight loss are often candidates for this procedure along with gastroscopy. The major difficulty with this test involves the fact that you will be positioned on a mechanical table that tilts your body in a variety of positions. Unfortunately, many companies still produce tables that cannot support very large people, therefore it is important to discuss this potential problem with the radiologist or technician who will be performing the procedure well in advance of the appointment.

GASTROSCOPY/ENDOSCOPY/"ERCP"
The gold standard for upper gastrointestinal examination is direct visualization with a flexible scope. After the patient is given some mild sedation, the doctor sprays a local anesthetic in the back of the throat. It tastes lousy and there is often a brief scary sensation of not being able to feel yourself swallow. But fear not, the procedure is very safe.

Once you are lying on your left side, the doctor puts a "bite block" mouth piece between your lips to prevent you from accidentally clamping down on the hose. There will be a few moments of gagging as the tube passes down the food pipe but most people adapt quickly to this strange sensation. Even though you will not be able to speak while the tube is in, there is no need to panic: air flows freely in the nose and mouth.

The technology has become so sophisticated that some skilled physicians can actually introduce a tiny accessory scope into the diminutive passages that connect your gall bladder and pancreas to the small bowel, enabling discovery of any cryptic blockage or other abnormalities.

The technical term for this added procedure would take a full page to write and explain so I will simply refer to it by its common abbreviated name "ERCP."

LIVER BIOPSY
Sometimes the body's waste treatment and blood production plant (also known as the liver) produces problems that elude exact diagnosis by non-invasive tests. The best way to make a definitive diagnosis involves obtaining a small chunk of liver tissue directly.

Often, sedation isn't necessary because the procedure is very brief. However, you should have an injection of local anesthetic in the skin overlying the liver in the right upper quadrant of your abdomen. A small incision is made in the anaesthetized skin while a patient lies on his or her left side. Expect to hold your breath for a few seconds after exhaling to bring the liver close to the surface. A very thick needle is then quickly jabbed into the liver, and a core specimen is "pickled" for examination in the laboratory.

People with bleeding tendencies have to be cautious in undergoing the test, but for the most part there is little pain and no untoward problems. On rare occasion, a little air gets trapped under the diaphragm causing shoulder tip pain.

RESULTS
Make sure that your physician gives you a thorough report of test results within a reasonable time period (sometimes up to a week is required for special microscopic or other laboratory procedures). Above all, never let the fear of humiliation or embarrassment about your size or appearance deter you from taking care of your health. Even the most ignorant and insensitive health care professionals will forget all about you when they look at their own human frailties in the mirror.

As always, I welcome your letters. Be well and enjoy life. ß

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Heretic Physician