Quality service in gastroenterology makes painless, accurate pancolonoscopy a top priority. Gastroenterologists now spend 50-70% of their time performing endoscopy, the bulk of this being colonoscopy. In the preface to their new textbook devoted exclusively to the principles and practice of colonoscopy, the editors Doctors Waye, Rex and Williams ask the question :”Can colonoscopy be made painless” (1).
 
While nurse administered propofol sedation (NAPS) is a reality in certain select centers, it remains to be seen whether this will become widely disseminated. The added expense of trained personnel and resistance of anesthesia societies to allowing gastroenterologists to administer propofol remain barriers to its widespread use.
 
Quality assurance in endoscopy may require measurable parameters such as patient subject pain assessment to be monitored and documented. Other important parameters may include insertion time, withdrawal time and rate of polyp detection and removal.
 
Until recently at the Sutter Santa Cruz, colonoscopy tolerance was measured by subjective nurse observation during the procedure and categorized as well, fairly or poorly tolerated. Post procedure calls are made to all patients. A retrospective nurse driven analysis of 587 patients revealed that 4% of patients experienced discomfort once the sedative/analgesia wore off over the 8 to 10 hours post discharge from the facility. Analysis of these cases revealed the common features of gas/bloating and difficulty evacuating air. It is quite easy to inflate as much as 8L of air into the colon and small intestine during colonoscopy as there is little way of monitoring the volume of air flow. A colleague who recently joined our group demonstrated water assisted colonoscopy using a water pump. Her initial result were disappointing in that large volumes of water (>1000 cc) could cause discomfort and explosive evacuation of the water in the recovery area. With the pump there was a tendency to overuse the water. However, using a small hand held syringe, careful instillation of small volumes of water has been reported in the literature by Baumann and Church (2,3)