This guide explains all you need to know about getting a colonoscopy in Singapore, as well as the cost factors of a colonoscopy in Singapore.
The negative stigma surrounding colonoscopies in Singapore is unwarranted. In this comprehensive guide, I hope to clear your doubts on the purpose of a colonoscopy, and explain the possible benefits it can provide you in your journey towards maintaining good health.
Why is a colonoscopy so important?
The recent change in screening guidelines by the American Cancer Society to recommend the commencement of colorectal cancer screening at age 45 for people at average risk of colorectal cancer (as compared to age 50 previously) has raised concerns about the rising incidence of colorectal cancer around the world.
This rising trend has been observed in Singapore too, with worrying statistics that up to 1 in 5 Singaporeans diagnosed with colorectal cancer are under 55 years old.
Colorectal cancer is the number one cancer in Singapore. 60% of patients also present in advanced stages of the disease. So one can appreciate the importance of early detection of pre-cancerous polyps or cancers – this would allow for less invasive treatment options and better outcomes.
In the article below, I will attempt to explain everything you need to know about getting a colonoscopy in Singapore, and address some of the most common concerns that my patients have about colonoscopies.
What are the signs that you should have a colonoscopy?
If you have symptoms such as bowel habit changes, bleeding in the stool, unexplained weight loss, abdominal bloating, or gas, your doctor may refer you to a colonoscopy.
Cancers often bleed inconsistently and insidiously. In some cases, cancer patients may have life-threatening anemia before they even notice blood in their stools. (This is why the stool occult blood test is commonly carried out as a screening tool in Singapore. It enables doctors to test for blood that is invisible to the naked eye.)
Commonly, we investigate a patient for bleeding from piles (hemorrhoids), only to discover a cancer in the colon (which had no symptoms).
This explains why your doctor might advise you for a colonoscopy even if it seems like the source of the bleeding is likely to be from your anus, especially in the presence of risk factors or being in the screening age group.
Should I be worried about blood in my stool?
Seeing blood in your stools often sets off alarm bells as it can be quite shocking, especially if the bleeding appears profuse with blood staining the entire toilet bowl.
While it should rightly set you on an early course of self-discovery to investigate the source of bleeding, such bleeding is often not due to cancer, but other causes such as:
• Anal fissures or
• Diverticular disease
Do note that these can also have serious health implications if left untreated, so it is important for you to see your doctor if you notice any bleeding!
If your doctor tells you that you need a colonoscopy, does it mean you have colon cancer?
No, it does not mean you have colon cancer.
A colonoscopy is just a way to look inside your colon. It enables us to:
1. Investigate the cause of your bowel symptoms
2. Screen for colorectal cancer
The colonoscopy procedure involves the use of a flexible camera that is inserted into your colon via your anus.
While colonoscopies sound scary and unpleasant, it is often performed under sedation, which reduces any discomfort you might experience. Often, our patients do not recall the entire procedure.
When should you get your first colonoscopy?
The latest American Cancer Society Guidelines suggest commencement of colonoscopy screenings at the age of 45 years old for average risk individuals.
In Singapore, we commence screening:
• When you are 50 years old
• Before you are 50 years old if you have an increased risk (e.g. a family history of colorectal cancer or related cancers).
Do note that these guidelines only apply if you do not have symptoms.
If you have symptoms such as a change in your bowel habits or blood in your stools, you need to be investigated earlier as the cause of your symptoms, whether it is cancer or not, needs to be identified and treated.
Remember, a colonoscopy is just a way to look inside your colon, and in some instances, treats the problem. It should not be associated with looking for cancers only.
What happens during a colonoscopy?
In a screening colonoscopy we will be looking out for:
• Other incidental findings such as diverticulosis
This can be done for patients with no symptoms. Polyps will be removed (with a polypectomy) for histological confirmation and prevention of possible progression to cancer, while large tumours will be biopsied for histological confirmation of their nature.
In a diagnostic or therapeutic colonoscopy, for patients with symptoms, on top of looking for the findings above (and more), we will also be looking for the source of the patient’s symptoms and treating it if possible.
For example, in patients who have profuse bleeding from diverticular disease of the colon, a colonoscopy can be attempted to stop the bleeding through a variety of ways. Any suspicious-looking polyps can also be biopsied.
Finally, colonoscopies are also a good modality to investigate patients with suspected inflammatory bowel disease and infective colitis which have not been responding to medical therapy.
How much does a colonoscopy cost in Singapore?
The cost of a colonoscopy varies widely and there are many cost factors.
Prices are easily obtainable when you call or send in an enquiry to the centres where you are interested in having your colonoscopy.
Note that the price quoted can increase if a biopsy or polypectomy is performed. This is because there will be an additional charge for:
1. The procedure itself
2. The instruments used for the procedure
3. The pathology laboratory cost
Can you claim Medisave for getting a colonoscopy in Singapore?
The Medisave claim amount for a colonoscopy is standardized at $950.
The tricky question is whether your insurance covers the procedure. This is a question I get every day and unfortunately, the answer lies with you.
Whether your insurance covers the procedure depends on whether there are any restrictions placed on your purchased medical coverage.
Do check with your insurance agent or insurance company if the procedure is covered by the plan that you purchased, and if there are any restrictions on the specialists that you can see for your colonoscopy.
What is the most common misconception that Singaporeans have about colonoscopies?
My patients often ask me if choosing a different investigation will allow them to avoid drinking the bowel preparation fluid or avoid having the discomfort of air being pumped in through their anus.
However, these measures are still necessary regardless of the chosen investigation in order to:
• Cleanse the bowel of stools
• Inflate a collapsed colon so that we can survey the colon accurately
Remember, any investigation is only as accurate as your bowel preparation. The cleaner the preparation, the more accurate the investigation is.
Are there alternatives to a colonoscopy?
Yes, there are alternatives to a colonoscopy, depending on your symptoms. However, each alternate modality has its own benefits and drawbacks.
It’s useful to understand the pros and cons of each alternative, so that you can appreciate the possible differences in investigative outcomes.
The key benefit of a colonoscopy is:
1. The direct visualization of your colon through the lens of the camera
2. The ability of the colonoscopy to perform procedures such as biopsies and polypectomies, which not only provides histological confirmation of the visualized problem, but also allows us to remove pre-cancerous polyps
However, as with all invasive procedures, there are risks involved. These are mainly that of:
• Bleeding from the colon
• Perforation of the colon (which occurs in 1 in 1000 patients)
Such complications might need surgical intervention to treat.
When is a CT colonography offered instead of a colonoscopy?
A Computed Tomography colonography is offered when:
1. You are concerned about the possible complications of a colonoscopy
2. You are not suitable for a colonoscopy (e.g. kinks in the colon preventing the passage of the colonoscope)
3. You are unable to tolerate the procedure despite sedation
CT colonography involves the use of a CT scan to create a 3D image of the colon after pumping air and fluid in.
So yes, you will still need to drink your bowel preparation/oral contrast, and yes, you will still have an anal tube inserted to pump air in.
What is the disadvantage of a CT colonography?
The downside of a CT colonography is that:
1. It is unable to directly visualize the lesion through a lens (e.g. a piece of stool stuck to the wall of the colon can be mistaken for a polyp)
2. It is unable to biopsy the lesion even if it detects one
Hence, if your CT colonography picks up a problem, you will still need to go for a colonoscopy to:
1. Visually confirm that the lesion is truly present
2. Biopsy the lesion to confirm its nature histologically
Other issues with a CT colonography include the use of radiation to generate the images, and the use of intravenous contrast agents (which can affect kidney function) to provide a sharper image.
Why is CT colonography still used then?
Well, certain groups of patients face a much higher risk than average when undergoing colonoscopy.
1. Patients whose medical conditions necessitate the use of strong blood thinners, which increases the risk of life-threatening bleeding from a colonoscopy, or
2. Patients who are too medically frail to undergo a colonoscopy
In these patients, it would be a viable alternative to undergo a non-invasive procedure first to allow the patient and his medical team to decide if the risk of undergoing a subsequent colonoscopy is worth it.
If the CT colonography shows a serious pathology in the colon, which might affect their prognosis, then the risk of proceeding with a colonoscopy (and the subsequent treatment plan) might be balanced by the potential benefits.
When is a barium enema offered instead of a colonoscopy?
Barium enemas are seldom performed nowadays with the advent of the CT colonography.
In essence, a barium enema performs the same function as the CT colonography, but uses an X-Ray machine instead of a CT scanner.
How should you prepare for your colonoscopy?
Different doctors have unique concoctions with regards to their preferred bowel preparation regime.
These recipes vary according to:
• The type of laxatives used
• The number of laxatives used
• The timings that they are administered
There are many reasons for these variations, ranging from the endoscopist’s experience, to what is available in the centre that you are getting your colonoscopy performed at.
In general, the preparation involves three phases:
1. Pre-preparation phase
Ensure that you have informed your doctor if you are taking any blood thinning medications such as Warfarin, Aspirin, Plavix, Rivaroxaban, etc, as these might cause bleeding during the colonoscopy.
If you are not sure, please run through your medications with your endoscopist prior to the colonoscopy.
Another measure proposed (but not absolutely necessary) is to keep to a low fibre diet for three to five days prior to your colonoscopy.
This allows a better laxative effect by reducing the fibrous residue load in the colon prior to bowel preparation.
2. Preparation phase
Follow the preparation regime prescribed by your doctor. The regime varies with:
• The type of laxative used
• The timing of your colonoscopy
It is crucial that you adhere to the prescribed regime and inform your doctor if you do not have clear bowel effluent (your stools after finishing your bowel prep agent) prior to your scope.
If your bowel is still unclean after the bowel prep, it is much better to delay your scope and clear your bowels thoroughly first instead of proceeding with the scope.
Having a scope anyway will be a complete waste of effort and money as your doctor will not be able to visualize your colon well.
3. Pre-scope phase
In general, you should avoid drinking or eating after your bowel preparation, and before your colonoscopy.
This is because it might contribute to new effluent that coats the colon (e.g. coffee) or present as an aspiration risk should you vomit while sedated.
Again, check with your endoscopist on the detailed instructions as they vary depending on the centre that you are getting your scope done.
Who does colonoscopies in Singapore?
In Singapore, only accredited endoscopists who are medical specialists in general surgery or gastroenterology are allowed to perform colonoscopies.
Endoscopy accreditation standards are identical across the board, regardless of specialty.
The specialists who perform colonoscopies most commonly in Singapore are:
• General surgeons
• Colorectal surgeons
What happens during a colonoscopy in Singapore?
On arrival at your endoscopy centre, a pre-procedure safety check will be performed to ensure that you are fit to proceed with the scope, and that the bowel preparation regime was adhered to.
After which, you will be dressed in the endoscopy gown and brought to the endoscopy suite for your procedure.
Your endoscopist will administer the mild sedative after you have settled into the correct position on the bed.
The actual procedure will take approximately 15 minutes, depending on:
1. Whether there are any findings noted on the scope that needs intervention
2. Your cooperation with the procedure
Even though you will likely be sleep through the entire procedure and have no recollection, your body is actually reacting to the endoscopy procedure. Occasionally, patients can resist the procedure to the point that the scope has to be aborted.
After the scope has been completed, you will rest in the recovery area until you are fit enough to be discharged from the centre safely.
The effects after sedation are variable and can last for a few hours, hence you are strongly advised to have someone accompany you home. You also must not drive or operate machinery after your scope.
How painful is the colonoscopy procedure?
A colonoscopy is uncomfortable mainly due to the distension of the colon.
This results from the air pumped into the colon, as well as the sensation of the colonoscope inside the intestines.
However, as most patients undergo the procedure with sedation, you will likely sleep through the whole procedure without much recollection.
Most patients do not experience any discomfort after the procedure once they have passed the air out.
A colonoscopy is not 100% accurate.
In fact, no medical investigation is 100% accurate. So it is important to know how you can help improve the accuracy of the investigations that you are undergoing. This enables you to have peace of mind that the results of the test can be trusted.
The sensitivity of a colonoscopy largely depends on how clean the bowel is after the preparation.
As the suction channel of the colonoscope is very fine, fibrous debris and solid material cannot be sucked out with the colonoscope.
Consequently, it is important that strict adherence to the bowel preparation regime is followed so that we can get the best result possible from the scope.
Even with the best preparation, a colonoscopy is only 95-98% accurate. This is because small lesions can hide behind the folds of the colon (called haustra), as well as behind kinks and corners in the intestine, where they can avoid detection by the lens’ field of vision.
I hope this article has helped to dispel some myths and unwarranted fears about undergoing a colonoscopy.
With an abundance of endoscopy facilities available around the island now, speak to your regular doctor about screening for colorectal cancer. Screening saves lives.
Dr Jason Lim is a qualified specialist in General Surgery and Colorectal Surgery. His subspecialty clinical interests includes the treatment of complex anal conditions e.g. perianal fistula, functional bowel problems including irritable bowel syndrome, intractable constipation and bowel incontinence. He also published the first research paper on the prevalence of faecal incontinence in Singapore.
1. Wadhwa, V., Issa, D., Garg, S. et al, Similar risk of cardiopulmonary adverse events between propofol and traditional anesthesia for gastrointestinal endoscopy: a systematic review and meta-analysis. Clin Gastroenterol Hepatol. 2016; accessed March 2019. https://www.cghjournal.org/article/S1542-3565(16)30434-7/fulltext
2. Colonoscopy. American Society of Colon and Rectal Surgeons. https://www.fascrs.org/patients/disease-condition/colonoscopy Accessed March 2019.