Flexible Sigmoidoscopy

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Flexible Sigmoidoscopy

• Scott M. Strayer, MD, MPH
• Assistant Professor
• University of Virginia Health System
• Department of Family Medicine

2
A Case

• 45 yo male presents with rectal bleeding X1.
• Physical exam reveals small non-thrombosed
  hemorroid.
• What other history would you like to have?
• Are any further tests warranted?

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One more case

• 50 year old presents for physical exam.
• What questions would you ask to determine
  preferred method of colon cancer screening.

4
Colon Cancer

• 150,000 cases per year.
• 50,000 deaths annually.
• 2 cause of cancer mortality in non-smoking males
  and females.

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Screening Recommendations

• The USPSTF strongly recommends that clinicians
  screen men and women 50 years of age or older for
  colorectal cancer. (A recommendation)
• Good evidence that periodic fecal occult blood
  testing (FOBT) reduces mortality from colorectal
  cancer and fair evidence that sigmoidoscopy alone
  or in combination with FOBT reduces mortality.
  Insufficient evidence that newer screening
  technologies (e.g., computed tomographic
  colography) are effective in improving health
  outcomes.

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Screening Recommendations

•  
• AAFP-No published standards or guidelines for
  low-risk patients
• ACOG-After age 50, annual FOBT (DRE should
  accompany pelvic examination) sigmoidoscopy
  every 3 to 5 years
• ACS-After age 50, yearly FOBT plus flexible
  sigmoidoscopy and DRE every 5 years or
  colonoscopy and DRE every 10 years or
  double-contrast barium enema and DRE every 5 to
  10 years

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Screening Recommendations

• AMA-Annual FOBT beginning at age 50, and flexible
  sigmoidoscopy every 3 to 5 years beginning at age
  50
• AGA-FOBT beginning at age 50 (frequency not
  specified) sigmoidoscopy every 5 years,
  double-contrast barium enema every 5 to 10 years
  or colonoscopy every 10 years.

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Screening Recommendations

• CTFPHC-Insufficient evidence to recommend using
  FOBT screening in the periodic health examination
  of individuals older than age 40 insufficient
  evidence to recommend sigmoidoscopy in the
  periodic health examination insufficient
  evidence to recommend screening with colonoscopy
  in the general population
• USPSTF-After age 50, yearly FOBT and/or
  sigmoidoscopy (unspecified frequency for
  sigmoidoscopy)

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The Evidence

• Screening for colorectal cancer reduces
  cancer-related mortality at costs comparable to
  other cancer screening programs. Given an
  expected screening compliance rate of 60 and
  current costs of the various procedures, annual
  rehydrated fecal occult blood testing plus
  sigmoidoscopy every 5 years is most
  cost-effective. If the cost of colonoscopy is
  reduced by 25 or more, screening every 10 years
  with colonoscopy is preferred by this model (LOE
  2b).
• Frazier AL, Colditz GA, Fuchs CS, Kuntz KM.
  Cost-effectiveness of screening for colorectal
  cancer in the general population. JAMA
  20002841954-61.

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More Evidence

• 16 of colorectal cancers prevented with FOBT.
• 34 of colorectal cancers prevented with flex
  sig.
• 75 prevented with colonoscopy.
• Colonoscopy q 10 years was more cost-effective
  than flex sigs q 5-10 (LOE?).
• Sonnenberg A, et al. Cost-effectiveness of
  colonoscopy in screening for colorectal cancer.
  Ann Intern Med October 17, 2000133573-84.

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Even More Evidence

• Screening with sigmoidoscopy There is evidence
  from case control studies, to recommend that
  flexible sigmoidoscopy be included in the
  periodic health examination of patients over age
  50 B, II-2, III. There is insufficient evidence
  to make recommendations about whether only 1 or
  both of fecal occult blood testing and
  sigmoidoscopy should be performed C, I.
• CMAJ 2001 Jul 24165(2)206-8 20
  references

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Is there enough time for prevention?

• Patient panel of 2500
• Age and sex distribution similar to US pop.
• To fully satisfy the USPSTF recs, it would take
  1067 hours per year or 4.4 hours per working day
  of a physicians time
• If you include children and pregnant women 1621
  hours per year / 6.8 hours per day

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Priorities among recommended clinical preventive
services
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Priorities among recommended clinical preventive
services
Coffield AB, Maciosek MV, etal. Am J Prev Med
200121(1)1-9.
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Is it cost effective?

• Flex sig with FOBT Q 5 years-92K per life year
  saved.
• Pap smears Q year-99K per life year saved.
• Annual mammogram (55-64)-132K per life year
  saved.

Frazier AL, Colditz GA, Fuchs CS, Kuntz KM.
Cost-effectiveness Of screening for colorectal
cancer in the general population. JAMA
20001594-1961.
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New Developments
Pignone M, Levin B. Recent Developments in
Colorectal Cancer Screening and Prevention.
American Family Physician 2002297-302.
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Screening Capacity

• National screening program would require approx.
  10m procedures (double current levels) annually
  or 5m colonoscopy procedures (increase of 20).
• Not enough surgeons and GIs to perform the
  additional colonoscopies.

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Indications

• Mostly for screening.
• Should consider colonoscopy if previous polyps,
  family history of colon cancer, rectal bleeding,
  hemoccult positive stools, change in bowel
  habits, protracted diarrhea, surveillance in
  UC/Crohns, anemia, unexplained wt. Loss/fevers,
  abdominal pain.

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Contraindications

• ABSOLUTE
• Acute, severe cardiopulmonary disease.
• Inadequate bowel prep.
• Active diverticulitis
• Acute abdomen.
• History of SBE or prosthetic valves with no
  prophylaxis.
• Marked bleeding dyscrasia.

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Contraindications

• RELATIVE
• Recent abdominal surgery (bowel or pelvic).
• Active infection
• Pregnancy.

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Equipment
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Additional Equipment

• Light source
• Suction apparatus
• Biopsy forceps
• K-Y Jelly
• 4X4 inch gauze pads
• Nonsterile gloves
• Water container (for suction)

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More equipment

• Video unit and monitor
• Anoscope
• Basin of water
• Formalin jars
• Disinfecting cleaner

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Complications

• Bowel perforation (1/10000)
• Bleeding (increased risk with biopsy)
• Abdominal distention and pain
• Infection (SBE, infection from another pt.)
• Vasovagal symptoms
• Missed disease

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Increased Complications

• Watch out for patients with previous bowel or
  pelvic surgery, irradiation, or diverticulosis.
• Caution with blind advancement (only limited
  distances).

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Patient Preparation

• Signed informed consent
• 2 fleets enemas (one 90 minutes prior, and one 30
  minutes) before procedure
• Clear liquids after evening meal
• Take laxative if chronic constipation
• Take normal medications (caution with diabetics)

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Clear Liquid Diet

• Beverages carbonated, coffee, kool-aid (avoid
  red), tea.
• Desserts Jello, clear popsicles
• Fruit Apple juice, cranberry juice, grape juice
• Soups Beef bouillon, clear broth
• Sweets hard candy, sugar.

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Anatomy Review
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The Procedure

• Pt. Placed in left lateral decubitus position
• Rectal examination first
• Lubrication is key, dont smear the lens
• Either directly insert scope, or flex index
  finger behind the scope.
• Hold scope in left hand, use thumb for up and
  down, use right hand for right-left (or can also
  use thumb).

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Rectum

• Insert scope 7-15cm, insufflate and/or withdraw
  to visualize lumen
• Normal rectal mucosa is a nonfriable, vascular
  network.
• Proctitis produces an erythematous, friable
  mucosa, often with bleeding.
• Semilunar valves of Houston appear as sharp edges
  protruding into the lumen (there are 3) with
  shadows noted behind them.

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Rectum

• Ulcerative colitis will produce erythema,
  friability, and mucosal bleeding.

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Rectal Colon CA
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Sigmoid

• Redundant folds, hard to visualize lumen
• May have to insufflate, extensive turning,
  torquing, accordionization, or dithering
• Avoid bowing out.

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Techniques
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Other Techniques
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Descending Colon

• Long, straight tube with concentric haustrae.
• Vascularity is random, reticular.
• Polyps can either be mound-like (sessile) or on a
  long stalk (pedunculated).
• Dont mistake suction polyps or mucous for
  polyps!!

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Pedunculated Polyp
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Diverticulosis
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Crohns Colitis
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C. Difficile Colitis
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The Final Step-Retroflexion

• Accomplished by turning inner knob all the way
  up and outer knob all the way right while
  gently inserting and rotating 180 degrees.
• Make sure you are in rectum, and not to far from
  internal sphincter.

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Retroflexion with Hemorrhoid and Small Polyp
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Be nice to your patient

• Suction air out before terminating procedure!