Gahrzerkire
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Posts posted by Gahrzerkire
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You sound like its so easy to balance weapons.
Except it is not. Looking just at DPS and TTK does not account at all at how easy the weapon is to use.
Yes its not "easy" per say but its not hard, mostly it takes lots of time, lots of effort, and lots of determination. All of which a dedicated team has.
Bro...
Article 2) balance all weapons DPS based off the TTK, The DPS of the weapon within the target TTK is determined by the following: recoil, firerate,cone of fire, accuracy, recoil, travel time, mag size, ammo pool.
Yes no 3rd grader could balance the weapons, its takes skills like multiplication, geometry, logic, and basic physics, but ITS NOT THAT HARD. If you gave me say 48 hours to do nothing but balance all the weapons in Warframe for PvP, I could. Its not that hard, you find your target TTK, allow a 20-30% increase or decrease around said TTK, you break your weapons into groups determined by weapon type and firerate, you break those groups into burst DPS, and sustained DPS, you break the DPS groups into close range, long range and medium range, All close range weapons have higher DPS 10% to 20% higher then the target avarege TTK, all medium range weapons get more or less 0% to 10% above the avarege TTK some maybe -10% depending on their accuracy DPS and other such values, All long range weapons get modified to 10% to 20% lower then the avarege TTK. AOE weapons are treated as long range weapons however they get the 0% increase or decrease and damage/TTK is calculated a little differently.
Now your probably thinking of several things right now: What about status? what about crit? what about recoil? what about accuracy? well accuracy determines weapon type when put into conjunction with the weapon firerate, low accuracy + high firerate = SMG moderate accuracy with moderate firerate = Assult to LMG, low firerate high accuracy = battlerifle to sniperrifle. Status is simply a potential buff, and as far as I can tell not even relevant in PvP though IT SHOULD BE. Crit should come back, it adds variety and for our gamblers would be a fun addition to the game. Crit is essentially factored into the DPS calculations and handle accordingly, it is extremely simple to deal with crit, and the idea of having crit weapons, factor crit into DPS and bing bang boom done, crit weapons return. "BUT WHAT ABOUT HEADSHOT CRITS?" what about them? yeah double damage big whoop, maybe critical hit weapons with obscene firerates like the soma should maybe I dunno... HAVE MORE RECOIL? HAVE A BIGGER CONE OF FIRE? its a fuggin LMG that's as accurate as a sniper and no one sees the real problem with the damn gun, they just yell DPS and scream NERF!
If you all want, I can literally explain how to balance all the weapons in the game, but it will take about a page and a half, and I am completely willing to write it and explain how you would make it work for each individual weapon class.
Final question/complaint that is common, which I will respond to, is this: "WONT THAT MAKE LOTS OF WEAPONS SIMILAR???" yes, yes it will, and this is a good thing, because it stops one weapon from being "required" it makes more sidegrades, which means more customization, more user choice, more personal preference, and more fashion frame. How many times have you wanted to use a weapon in PvP because of the way it looks and been like "but I cant... because then I will get wrecked, cuase the DPS sucks" well what if it was just a sidegrade to a very balanced category of weapons? what if it was completely viable and only required some playstyle changes? welp, that my friend is called a balanced weapon class. When you can use literally ANY weapon, and as long as you play to the weapons strengths and fight intelligently you win. not "this is meta cuase DPS lets use it"
TLDR: Me spoon feeding the process of balancing weapons.
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why havent a played warframe in a while? oh yeah becuase PvP sucks. why does it suck? becuase it is constantly changing.
disclaimer
basically read everything or at least read 50% of it, so you know where the conversation has gone and what we are talking about, I don't want to have to say the same thing 40x
The PvP team needs to do four things:
1) figure out what you want your TTK to be.
2) balance weapons DPS around that TTK, taking into consideration the recoil, spin up, cone of fire, mag size, ammo pool, and all that other stuff.
3) Ensure that they are balanced BASED OFF THE NUMBERS, create pie charts, graphs, even algorithms for perfectly balancing weapons (as was done for games like planetside 2).
4) release the weapon balanced, and NEVER, change it again, ignore the community whining, make your weapons balanced to the point, that the community CANT complain, there are many games with weapon balance systems that are infinitely better, again planetside 2 is an amazing example of excellent weapon balancing and the community cant whine, because it was well thought out and logical. If you do the above steps properly youll never have to go back and balance it again because it will stand for itself, because it will be logical, because it will make perfect sense as to why it performs that way.
love Warframe, and literally my favorite thing about it is the PvP, ALL THE PVP NEEDS to get me and many others back is consistency, plan your S#&$, before you release it, so you don't have to "balance" it later. PvP is good, when players are comfortable with weapons and playstyles, and this will never happen if you never let anyone settle, constantly forcing players from weapon to weapon because NOTHING is balanced properly, gets nothing done. If the PvP wanted to, they could balance all the weapons in the game within a week, using equations and statistics to even out DPS and TTK based off of weapon stats.
So far any update with PvP changes that further escalate the balance issues feel like this:
^^has swears, and the insult is directed toward pretty much any weapon that has been "balanced" 400x
EDIT: to add an edit line that explains my last edit was the added disclaimer for the youtube video. but this game is rated M.... so... yeah.... ;)
WEAPON BALANCE NEEDS TO BE DONE WITH STATISTICS AND FACTS NOT "player experience" as is stated it shall be balanced by on the DEV post. That's is wrong, it needs to be done with math, you can never argue with the math or reasoning behind a weapon. But "i got killed with it 20 times means nothing. maybe someone was simply a better player?" -
Where the hell is our DAY OF THE DEAD NEKROS SKIN???
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Well...at least this is a change-up in the PvP feedback section...kinda...
So glad no one has mentioned nerfing Loki's invis after a round or two of Overpowered or something. I think it's coming, though.
Dude... try playing loki.... seriously... you have any idea how hard it is to survive with a literal sub one second ttk..... with every sniper one shotting you... you have any idea how little that invis helps... really man, go use it. tell me how you fair. its not as easy as you think I have a hard time and I play loki only, once players know what to look for the invis becomes useless. Just like invis in Planetside 2.
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true but they are the same weapon class, and the ignis is about 3 times its size, you would think logically that when it was buffed it would have been buffed better then other secondary flame throwers as it is the only flame thrower in the game.
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Examples please.
The Atomos alone, having both higher DPS, and equal AOE if more then an example. The ATOMOS a secondary out DPS's the ignis.
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enemies under 50% should die instantly.
#viral proc + SOTD = insta gib, so no.
What they couyld do is make it do more damage the lower the enemies health as was stated earlier in this thread. but I'm too lazy to reference. Then give it the viral proc, and then it would be purrrfect.
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I'm confused why DE didn't actually buff the Ignis in the one area where it needed help: raw damage. No crit chance buff, no crit damage buff. Everything else is icing on the cake, with no cake. Are they afraid if it becoming remotely strong?
You shouldn't have to crutch a weapon on a frame to make it usable.
^^ EVERYTHING I HAVE BEEN TRYING TO SAY, Thank you noble cactus for you are much more concise then I.
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Am i the only one here who understands that the elements and the elemental combos affect the appearance of the fire?
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I have a 4 forma ignis, and i have tried 7 different builds, 2 emphasized on damage, and 4 on status and damage, so far they have all buckled when fighting level 30+ corrupted. I have used 2 builds that were hellfire ember accerlant builds with a max damage ember, and it was still doing less DPS then the atomos.
all felt very underwhelming -
Everything about the buff was great. But it still has a very hard time killing lvl 30 enemies. And that is depressing, not becuase its not OP, but becuase to be truely mid teir you need to be able to kill mid level enemies, and that is level 30.
There is only one thing that needs to happen for it to get there: give it a 20% crit chance, that way it has a 50% chance to crit. And deal double damage. This is just the right amount to make this gun go from mediocre, to great! please DE, consider this last push for the ignis, to make it mid to high tier.
Another reason for it to be buffed is its a primary and the atomos is a secondary, and guess what, that atomos FAR outshines the ignis, even with the buff. -
I BELIEVE,
That we are getting the Mios!
That we are getting that Rhino skin!
That we are getting the Archer frame!
That we are getting balance changes to CC!
THAT WARFRAME WILL IMPROVE!
WHOSE WITH ME!!!!!!??? -
Well not really nerfed, more like fixed. Soul Punch used to ragdoll enemies and upon that ragdoll, (and soul punches in particular) if you had punch through on your weapon (braton prime + punch through), you would deal finisher damage to every individual body part, resulting in one shotting of level 200. I will miss this unintended feature, and forever morn at the now lackluster soul punch T.T
Seriously, you punch them in the friggin soul and it does 200 impact?? like hold up, you PUNCH THEM IN THE SOUL, you FORCIBLY exercise a mu1hafucka and it deals ONLY 200 impact? come on, maybe make it deal 200 impact, 200 slash, and 200 puncture + lowers armor by 50%.... along with lowering anyone else's armor (who gets hit by the soul projectile) by 30%, now that is an ability. Or leave the 200 impact, but make it so the soul has to fly all the way back to the body before they can get back up, make it so they stay quivering on the ground in pain until their soul returns, Devoid of all hope love and life. -
It can still proc only once per second, so adjust mods accordingly.
How are you all okay with continuous weapons procing once a second?? HOW? They should SHAME the projectile and energy weapons in terms of procs per second, like absolutely obliterate them!
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LPO-50 Flamethrower,РОКС-1, РОКС-2, & РОКС-3, M1A1 Flamethrower
from a distance without optics, they look exactly a rifle
the point of the rifle design is to keep him alive before he fires
well, kind of pointless when scorches have different armor with normal lancer
STILL THOUGH! I like the look of the old flamethrower. it had its own appeal. and I never felt it looked too much like the grakata, and hey maybe someday ak-ignis, then the name is what everyone yells when you weild it. "AK! he has an ignis!"
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It's basically the same weapon as Boltor P, except with Truth, better clip size, 15% less spike DPS and lower accuracy. Truth sucks. Clip size is usually not that important. Boltor P is easy to get. Power is relative.
Let's put it this way: If one has to choose between Boltor P, Dread, Tonkor, Sancti Tigris, Secura Penta, Some P, (Vaykor) Hek and Synoid Simulor, the choice isn't immediately obvious. If one has to choose between Boltor P and Telos Boltor, the choice is very obvious.
Truth sucks... until you factor in the fact that the more enemies you have around you the more damage it deals... I have oneshot packs of 20-30 level 60 curropted with truth.... I don't know what your whining about...
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Listed status=(1-status)^firerate.
It's not that simple.
Also, continuous weapons need a rework, they were kinda broken back in the day, but they are just as broken now.
Sure it may not be that simple, but good programing is that simple. Its literally a for loop with an if statement that is controlled by a Boolean, and the math is basic programming. It doesn't need to be nearly as complicated as you think it is. or should be. It can be super simple, and it should be super simple. All I am really saying is that every time the ignis, or any other continuous weapon loses 1 ammo, it should have its status chance rolled.
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I guess all I feel is that the new model doesn't look anything like a flamethrower. And that pisses me off. I wish it had a large lower chamber that would hold the "liquid" or "Gas" it ignited. (In the gases case that then ignited the liquid.) the look the old ignis had, and it was cool as hell.
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We simply need conical accuracy to take more of a part in this game. Recoil is fine as it is, but connical accuracy is ridiculous. The braton primes conical accuracy is nigh perfect when it has a short &#! barrel, meanwhile the gorgons conical accuracy sucks balls, even.. though.. it.. has.. a long barrel. If they applied conical accuracy to all weapons they would be range balanced and therefore a sniper at range would have an advantage due to its night perfect accuracy, and a braton would suck cuase it would be extremely innaccurate. Recoil is not the issue. Its the cone of fire.
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Can we have the old ignis as a skin? Because I will miss that. I feel like the old ignis looked a lot more like a flamethrower then the new model.
Does anyone else want to be able to have the old ignis as a skin? -
The answer is really simple, instead of X chance per second, it should be X Chance / (Second / firerate), that way we can actually have status continous weapons that work, and arent extremely annoying and painful to use.
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Use paint.net, its much easier to use than gimp
PREACH
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What if you got close knocked em down with the sonicor and then beat them to deaht using the kogake or another fist based weapon?
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While rankings, which can be fun, are not bad in and of themselves, they tend to bring out some of the worst crowds.
Expect to see a flood of players farming kills off of new players or alts while utilizing the most cheese-filled tactics all to have their name high on the boards.
That's a bit pessimistic (well, I'd say realistic), I know, but we've already seen stuff like this in the PvE rankings.
You could build a ranking and KD system that took into account your experience and the other players experience, and then calculate a score, so that farming noobs basically doesn't reward you at all except on a match to match basis, (as it does now). And then the score for your can is tabulated. This would essentially make it so that if you kill players of your skill level and higher your score increases substantially faster. Basically I would remove the KD rating system and change that completely because we all know KD and skill are often two separate entities.
Colonoscopy Or Coloscopy[1] Is The Endoscopic Examination Of The Large Bowel And The Distal Part Of The Small Bowel With A Ccd Camera Or A Fiber Optic
in Off Topic
Posted · Edited by Olivionic_Gearhart
thats lame, there is a mazimum length for titles. also thats from the wikipedia article on colonoscopies.
for those of you who wanted the whole article:
~
Colonoscopy or coloscopy[1] is the endoscopic examination of the large bowel and the distal part of the small bowel with a CCD camera or a fiber optic camera on a flexible tube passed through the anus. It can provide a visual diagnosis (e.g. ulceration, polyps) and grants the opportunity for biopsy or removal of suspected colorectal cancer lesions. Colonoscopy can remove polyps as small as one millimetre or less. Once polyps are removed, they can be studied with the aid of a microscope to determine if they are precancerous or not. It takes 15 years or fewer for a polyp to turn cancerous.
Colonoscopy is similar to sigmoidoscopy—the difference being related to which parts of the colon each can examine. A colonoscopy allows an examination of the entire colon (1200–1500 mm in length). A sigmoidoscopy allows an examination of the distal portion (about 600 mm) of the colon, which may be sufficient because benefits to cancer survival of colonoscopy have been limited to the detection of lesions in the distal portion of the colon.[2][3][4]
A sigmoidoscopy is often used as a screening procedure for a full colonoscopy, often done in conjunction with a fecal occult blood test (FOBT). About 5% of these screened patients are referred to colonoscopy.[5]
Virtual colonoscopy, which uses 2D and 3D imagery reconstructed from computed tomography (CT) scans or from nuclear magnetic resonance (MR) scans, is also possible, as a totally non-invasive medical test, although it is not standard and still under investigation regarding its diagnostic abilities. Furthermore, virtual colonoscopy does not allow for therapeutic maneuvers such as polyp/tumour removal or biopsy nor visualization of lesions smaller than 5 millimeters. If a growth or polyp is detected using CT colonography, a standard colonoscopy would still need to be performed. Additionally, surgeons have lately been using the term pouchoscopy to refer to a colonoscopy of the ileo-anal pouch.
Medical uses[edit]Conditions that call for colonoscopies include gastrointestinal hemorrhage, unexplained changes in bowel habit and suspicion of malignancy. Colonoscopies are often used to diagnose colon cancer, but are also frequently used to diagnose inflammatory bowel disease. In older patients (sometimes even younger ones) an unexplained drop in hematocrit (one sign of anemia) is an indication that calls for a colonoscopy, usually along with an esophagogastroduodenoscopy (EGD), even if no obvious blood has been seen in the stool (feces).
Fecal occult blood is a quick test which can be done to test for microscopic traces of blood in the stool. A positive test is almost always an indication to do a colonoscopy. In most cases the positive result is just due to hemorrhoids; however, it can also be due to diverticulosis, inflammatory bowel disease (Crohn's disease, ulcerative colitis), colon cancer, or polyps. However polypectomy has become a routine part of colonoscopy, allowing for quick and simple removal of polyps without invasive surgery.[6]
Colon cancer screening[edit]Colonoscopy has become a primary routine screening test for people in the US who are over 50 years of age, but flexible sigmoidoscopy every 5 years, or colonoscopy every 10 years, or double-contrast barium enema every 5 years, or CT colonography (virtual colonoscopy) every 5 years are all equally recommended.[7] Subsequent rescreenings are then scheduled based on the initial results found, with a five- or ten-year recall being common for colonoscopies that produce normal results.[8] People with a family history of colon cancer are often first screened during their teenage years. Among people who have had an initial colonoscopy that found no polyps, the risk of developing colorectal cancer within five years is extremely low. Therefore, there is no need for those people to have another colonoscopy sooner than five years after the first screening.[9][10]
Medical societies recommend a screening colonoscopy every 10 years beginning at age 50 for adults without increased risk for colorectal cancer.[11] Research shows that the risk of cancer is low for 10 years if a high-quality colonoscopy does not detect cancer, so tests for this purpose are indicated every ten years.[11][12]
Colonoscopy screening prevents approximately two thirds of the deaths due to colorectal cancers on the left side of the colon, and is not associated with a significant reduction in deaths from right-sided disease.[2]
Colonoscopy reduces cancer rates by detecting some colon polyps and cancers on the left side of the colon early enough that they may be treated, and a smaller number on the right side; many of these left-sided growths would likewise have been detected by a safer sigmoidoscopy procedure.[2]
Since polyps often take 10 to 15 years to transform into cancer, in someone at average risk of colorectal cancer, guidelines recommend 10 years after a normal screening colonoscopy before the next colonoscopy. (This interval does not apply to people at high risk of colorectal cancer, or to those who experience symptoms of colorectal cancer.)[13][14]
Recommendations[edit]The American Cancer Society recommends, beginning at age 50, both men and women follow one of these testing schedules for screening to find colon polyps and/or cancer:[15]
- Flexible sigmoidoscopy every 5 years, or
- Colonoscopy every 10 years, or
- Double-contrast barium enema every 5 years, or
- CT colonography (virtual colonoscopy) every 5 years
- Yearly guaiac-based fecal occult blood test (gFOBT)
- Yearly fecal immunochemical test (FIT)
- Stool DNA test (sDNA) every 3 years
Risks[edit]5 in 1000 people who have a colonoscopy have a serious complication.[16] Perforation of the colon occurs at a rate of about 1 in 1000 procedures, and death at a rate of 1 in 3300 to 1 in 333000; therefore, in some low-risk populations, screening in the absence of symptoms would not outweigh the risks of the procedure. For example, the odds of developing colorectal cancer between the ages of 20 and 40 are only 1 in 1250.[17] This procedure has a low (0.35%) risk of serious complications.[18][19] In a 2006 study of colonoscopies done from 1994 to 2002, Levin et al., found serious complications occurred in 5.0 of 1000 colonoscopies,[16] comprising 0.8 in 1000 colonoscopies without biopsy or polypectomy, and a rate of 7.0 per 1000 for colonoscopies with biopsy or polypectomy; although McDonell and Loura criticize this rate as being unacceptably high.[20]
The rate of complications varies with the practitioner and institution performing the procedure, as well as a function of other variables.
The most serious complication generally is the gastrointestinal perforation, which is life-threatening and requires immediate major surgery for repair. A 2003 summary study of 25,000 patients showed a perforation rate of 0.2%,[19] and a death rate of 0.006% on a total of 84,000 patients. The 2006 study by Levin et al. showed a perforation rate of 0.09%;[16] while a 2009 study quoted a similar perforation rate of 0.082%.[21] Appendicitis has been associated with either perforation or colonoscopy, in case reports in Korean, Italian and English journals.
According to a study published in the Annals of Internal Medicine, for which researchers reviewed colon cancer screening data from 1966 to 2001, the most severe complications from colonoscopy are perforation (that occurred in 0.029% to 0.72% of cases), heavy bleeding (occurring in 0.2% to 2.67% of colonoscopies) and death (occurring in 0.003% to 0.03% of colonoscopy patients).[22][23]
A 2003 analysis of the relative risks of sigmoidoscopy and colonoscopy, brought into attention that the risk of perforation after colonoscopy is approximately double that after sigmoidoscopy (consistent with the fact that colonoscopy examines a longer section of the colon), even though this difference appeared to be decreasing.[24]
Bleeding complications may be treated immediately during the procedure by cauterization via the instrument. Delayed bleeding may also occur at the site of polyp removal up to a week after the procedure and a repeat procedure can then be performed to treat the bleeding site. Even more rarely, splenic rupture can occur after colonoscopy because of adhesions between the colon and the spleen.
As with any procedure involving anaesthesia, other complications would include cardiopulmonary complications such as a temporary drop in blood pressure, and oxygen saturation usually the result of overmedication, and are easily reversed. Anesthesia can also increase the risk of developing blood clots and lead to pulmonary embolism or deep venous thrombosis. (DVT)[25] In rare cases, more serious cardiopulmonary events such as a heart attack, stroke, or even death may occur; these are extremely rare except in critically ill patients with multiple risk factors. In very rare cases, coma associated with anesthesia may occur.
Virtual colonoscopies carry risks that are associated with radiation exposure.
Severe dehydration caused by the laxatives that are usually administered during the bowel preparation for colonoscopy also may occur. Therefore, patients must drink large amounts of fluids during the days of colonoscopy preparation to prevent dehydration. Loss of electrolytes or dehydration is a potential risk that can even prove deadly.[25] In rare cases, severe dehydration can lead to kidney damage or renal dysfunction under the form of phosphate nephropathy.[26]
Colonoscopy preparation and colonoscopy procedure can cause inflammation of the bowels and diarrhea or even bowel obstruction.
During colonoscopies where a polyp is removed (a polypectomy), the risk of complications has been higher, although still very uncommon, at about 2.3 percent.[18] One of the most serious complications that may arise after colonoscopy is the postpolypectomy syndrome. This syndrome occurs due to potential burns to the bowel wall when the polyp is removed. It is however a very rare complication and as a result patients may experience fever and abdominal pain. The condition is treated with intravenous fluids and antibiotics while the patient is recommended to rest.
Bowel infections are a potential colonoscopy risk, although very rare. The colon is not a sterile environment as many bacteria live in the colon to ensure the well-functioning of the bowel and therefore the risk of infections is very low. Infections can occur during biopsies when too much tissue is removed and bacteria protrude in areas they do not belong to or in cases when the lining of the colon is perforated and the bacteria get into the abdominal cavity.[27] Infection may also be transmitted between patients if the colonoscope is not cleaned and sterilized properly between tests, although the risk of this happening is very low.[18]
Minor colonoscopy risks may include nausea, vomiting or allergies to the sedatives that are used. If medication is given intravenously, the vein may become irritated. Most localized irritations to the vein leave a tender lump lasting a number of days but going away eventually.[28] The incidence of these complications is less than 1%.
On very rare occasions, intracolonic explosion may occur. High frequency ultrasound duodenography and colonography do not carry the risks associated with a traditional colonoscopy.[citation needed]
Although complications after colonoscopy are uncommon, it is important for patients to recognize early signs of any possible complications. They include severe abdominal pain, fevers and chills, or rectal bleeding (more than half a cup).[29]
Procedure[edit] Preparation[edit]The colon must be free of solid matter for the test to be performed properly. For one to three days, the patient is required to follow a low fiber or clear-liquid only diet. Examples of clear fluids are apple juice, chicken and/or beef broth or bouillon, lemon-lime soda, lemonade, sports drink, and water. It is very important that the patient remain hydrated. Sports drinks contain electrolytes which are depleted during the purging of the bowel. Orange juice, prune juice, and milk containing fiber should not be consumed, nor should liquids dyed red, purple, orange, or sometimes brown; however, cola is allowed. In most cases, tea (no milk) or black coffee (no milk) are allowed.[30]
The day before the colonoscopy, the patient is either given a laxative preparation (such as Picosalax, Bisacodyl, phospho soda, sodium picosulfate, or sodium phosphate and/or magnesium citrate) and large quantities of fluid, or whole bowel irrigation is performed using a solution of polyethylene glycol and electrolytes. Often, the procedure involves both a pill-form laxative and a bowel irrigation preparation with the polyethylene glycol powder dissolved into any clear liquid, preferably a sports drink that contains electrolytes.
A typical procedure regimen then would be as follows: in the morning of the day before the procedure, a 238 g bottle of polyethylene glycol powder should be poured into 64 oz. of the chosen clear liquid, which then should be mixed and refrigerated. Two (2) bisacodyl 5 mg tablets are taken 3 pm; at 5 pm, the patient starts drinking the mixture (approx. 8 oz. each 15-30 min. until finished); at 8 pm, take two (2) bisacodyl 5 mg tablets; continue drinking/hydrating into the evening until bedtime with clear permitted fluids. A common brand name of bisacodyl is Dulcolax, and store brands are available. A common brand name of polyethylene glycol powder is MiraLAX. It may be advisable to schedule the procedure early on a given day so the patient need not go without food and only limited fluids the morning of the procedure on top of having to go through the foregoing preparation procedures the preceding day.
Since the goal of the preparation is to clear the colon of solid matter, the patient should plan to spend the day at home in comfortable surroundings with ready access to toilet facilities. The patient may also want to have at hand moist towelettes or a bidet for cleaning the anus. A soothing salve such as petroleum jelly applied after cleaning the anus will improve patient comfort.
The patient may be asked to skip aspirin and aspirin-like products such as salicylate, ibuprofen, and similar medications for up to ten days before the procedure to avoid the risk of bleeding if a polypectomy is performed during the procedure. A blood test may be performed before the procedure.[31][32]
Investigation[edit]During the procedure the patient is often given sedation intravenously, employing agents such as fentanyl or midazolam. Although meperidine (Demerol) may be used as an alternative to fentanyl, the concern of seizures has relegated this agent to second choice for sedation behind the combination of fentanyl and midazolam. The average person will receive a combination of these two drugs, usually between 25 to 100 µg IV fentanyl and 1–4 mg IV midazolam. Sedation practices vary between practitioners and nations; in some clinics in Norway, sedation is rarely administered.[33][34]
Some endoscopists are experimenting with, or routinely use, alternative or additional methods such as nitrous oxide[35][36] and propofol,[37] which have advantages and disadvantages relating to recovery time (particularly the duration of amnesia after the procedure is complete), patient experience, and the degree of supervision needed for safe administration. This sedation is called "twilight anesthesia". For some patients it is not fully effective, so they are indeed awake for the procedure and can watch the inside of their colon on the color monitor. Substituting propofol for midazolam, which gives the patient quicker recovery, is gaining wider use, but requires closer monitoring of respiration.
A meta-analysis found that playing music improves patient tolerability of the procedure.[38]
The first step is usually a digital rectal examination, to examine the tone of the sphincter and to determine if preparation has been adequate. The endoscope is then passed through the anus up the rectum, the colon (sigmoid, descending, transverse and ascending colon, the cecum), and ultimately the terminal ileum. The endoscope has a movable tip and multiple channels for instrumentation, air, suction and light. The bowel is occasionally insufflated with air to maximize visibility (a procedure which gives one the false sensation of needing to take a bowel movement).[39] Biopsies are frequently taken for histology. Additionally in a procedure known as chromoendoscopy, a contrast-dye (such as Indigo carmine) may be sprayed via the endoscope onto the bowel wall to help visualise any abnormalities in the mucosal morphology.[40]
In most experienced hands, the endoscope is advanced to the junction of where the colon and small bowel join up (cecum) in under 10 minutes in 95% of cases. Due to tight turns and redundancy in areas of the colon that are not "fixed", loops may form in which advancement of the endoscope creates a "bowing" effect that causes the tip to actually retract. These loops often result in discomfort due to stretching of the colon and its associated mesentery. Manoeuvres to "reduce" or remove the loop include pulling the endoscope backwards while torquing the instrument. Alternatively, body position changes and abdominal support from external hand pressure can often "straighten" the endoscope to allow the scope to move forward. In a minority of patients, looping is often cited as a cause for an incomplete examination. Usage of alternative instruments leading to completion of the examination has been investigated, including use of pediatric colonoscope, push enteroscope and upper GI endoscope variants.[41]
For screening purposes, a closer visual inspection is then often performed upon withdrawal of the endoscope over the course of 20 to 25 minutes. Lawsuits over missed cancerous lesions have recently prompted some institutions to better document withdrawal time as rapid withdrawal times may be a source of potential medical legal liability.[42] This is often a real concern in clinical settings where high caseloads could provide financial incentive to complete colonoscopies as quickly as possible.
Suspicious lesions may be cauterized, treated with laser light or cut with an electric wire for purposes of biopsy or complete removal polypectomy. Medication can be injected, e.g. to control bleeding lesions. On average, the procedure takes 20–30 minutes, depending on the indication and findings. With multiple polypectomies or biopsies, procedure times may be longer. As mentioned above, anatomic considerations may also affect procedure times.
After the procedure, some recovery time is usually allowed to let the sedative wear off. Outpatient recovery time can take an estimate of 30–60 minutes. Most facilities require that patients have a person with them to help them home afterwards (again, depending on the sedation method used).
One very common aftereffect from the procedure is a bout of flatulence and minor wind pain caused by air insufflation into the colon during the procedure.
An advantage of colonoscopy over x-ray imaging or other, less invasive tests, is the ability to perform therapeutic interventions during the test. A polyp is a growth of excess of tissue that can develop into cancer. If a polyp is found, for example, it can be removed by one of several techniques. A snare device can be placed around a polyp for removal. Even if the polyp is flat on the surface it can often be removed. For example, the following shows a polyp removed in stages:
Pain management[edit]Polyp is identified.
A sterile solution is injected under the polyp to lift it away from deeper tissues.
A portion of the polyp is now removed.
The polyp is fully removed.
The pain associated with the procedure is not caused by the insertion of the scope but rather by the inflation of the colon in order to do the inspection. The scope itself is essentially a long, flexible tube about a centimetre in diameter, i.e. as big around as the little finger, which is less than the diameter of an average stool.
The colon is wrinkled and corrugated, somewhat like an accordion or a clothes-dryer exhaust tube, which gives it the large surface area needed for water absorption. In order to inspect this surface thoroughly the physician blows it up like a balloon, using an air compressor, in order to get the creases out. The stomach, intestines and colon have a so-called "second brain" wrapped around them, which autonomously runs the chemical factory of digestion.[43] It uses complex hormone signals and nerve signals to communicate with the brain and the rest of the body. Normally a colon's job is to digest food and regulate the intestinal flora. The harmful bacteria in rancid food, for example, creates gas. The colon has distension sensors that can tell when there is unexpected gas pushing the colon walls out—thus the "second brain" tells the person that he or she is having intestinal difficulties by way of the sensation of nausea. Doctors typically recommend either total anaesthesia or a partial twilight sedative to either preclude or to lessen the patient's awareness of pain or discomfort, or just the unusual sensations of the procedure. Once the colon has been inflated, the doctor inspects it with the scope as it is slowly pulled backwards. If any polyps are found they are then cut out for later biopsy.
Some doctors prefer to work with totally anesthetized patients inasmuch as the lack of any perceived pain or discomfort allows for a leisurely examination. Twilight sedation is, however, inherently safer than general anesthesia; it also allows the patients to follow simple commands and even to watch the procedure on a closed-circuit monitor. For these reasons it is generally best to request twilight sedation and ask the doctor to take his or her time despite any discomfort which the procedure may entail. Tens of millions of adults annually need to have colonoscopies, and yet many don't because of concerns about the procedure.[citation needed]
It is worth noting that in many hospitals (for instance St. Mark's Hospital, London, which specialises in intestinal and colorectal medicine) colonoscopies are carried out without any sedation.[citation needed] This allows the patient to shift his or her body position to help the doctor carry out the procedure and significantly reduces recovery time and side-effects. Although there is some discomfort when the colon is distended with air, this is not usually particularly painful and it passes relatively quickly. Patients can then be released from hospital on their own very swiftly without any feelings of nausea.
Ultrasound[edit]Duodenography and colonography are performed like a standard abdominal examination using B-mode and color flow Doppler ultrasonography using a low frequency transducer — for example a 2.5 MHz — and a high frequency transducer, for example a 7.5 MHz probe. Detailed examination of duodenal walls and folds, colonic walls and haustra was performed using a 7.5 MHz probe. Deeply located abdominal structures were examined using 2.5 MHz probe. All ultrasound examinations are performed after overnight fasting (for at least 16 hours) using standard scanning procedure. Subjects are examined with and without water contrast. Water contrast imaging is performed by having adult subjects take at least one liter of water prior to examination. Patients are examined in the supine, left posterior oblique, and left lateral decubitus positions using the intercostal and subcostal approaches. The liver, gall bladder, spleen, pancreas, duodenum, colon, and kidneys are routinely evaluated in all patients. With patient lying supine, the examination of the duodenum with high frequency ultrasound duodenography is performed with 7.5 MHz probe placed in the right upper abdomen, and central epigastric successively; for high frequency ultrasound colonography, the ascending colon, is examined with starting point usually midway of an imaginary line running from the iliac crest to the umbilicus and proceeding cephalid through the right mid abdomen; for the descending colon, the examination begins from the left upper abdomen proceeding caudally and traversing the left mid abdomen and left lower abdomen, terminating at the sigmoid colon in the lower pelvic region. Color flow Doppler sonography is used to examine the localization of lesions in relation to vessels. All measurements of diameter and wall thickness are performed with built-in software. Measurements are taken between peristaltic waves.[44]
Economics[edit]The abdominal regions scanned in the order.
The duodenal tri-band wall with folds of Kerckring, showing floaters with water contrast.
A high resolution view of colonic haustration.
Researchers have found that older patients with three or more significant health problems, like dementia or heart failure, had high rates of repeat colonoscopies without medical indications. These patients are less likely to live long enough to develop colon cancer. Gordon states, "At about $1,000 per procedure, there’s clearly an economic incentive".[14]
History[edit] Etymology[edit]The terms colonoscopy[45][46][47] or coloscopy[46] are derived from[46] the ancient Greek noun κόλον, same as English colon,[48] and the verb σκοπεῖν, look (in)to, examine.[48] The term colonoscopy is however ill-constructed,[49] as this form supposes that the first part of the compound consists of a possible root κολωv- or κολοv-, with the connecting vowel -o, instead of the root κόλ- of κόλον.[49] A compound such as κολωνοειδής, like a hill,[48] (with the additional -on-) is derived from the ancient Greek word κολώνη or κολωνός, hill.[48] Similarly, colonoscopy (with the additional -on-) can literally be translated as examination of the hill,[49] instead of the examination of the colon.
In English, multiple words exist that are derived from κόλον, such as colectomy,[46][50]colocentesis,[46]colopathy,[46] and colostomy[46] among many others, that actually lack the incorrect additional -on-. It must be noted that a few compounds have doublets with -on- inserted, like colonopathy.[46][47]
See also[edit]- Bow and arrow sign
- Rectal examination
- Sigmoidoscopy
- Polypectomy
- Virtual colonoscopy
- Esophagogastroduodenoscopy
References[edit]