Introduction
Flexible sigmoidoscopy is a commonly
performed technique for examination of the rectum and distal colon.
Sigmoidoscopy has been advocated every 3 to 5 years for individuals
older than 50 years of age as a screening strategy to detect adenomas
and colon cancer. The technique is safe, easily performed in an office
setting, and produces a 30% to 40% reduction in colon
cancer mortality. Training in endoscopic maneuvering and in anatomy and
pathology recognition is required for the performance of sigmoidoscopy.
Experienced practitioners often perform the procedure in less than 10
minutes. Most physicians report comfort with performing the procedure
unsupervised after completing 10 to 25 preceptor-guided sessions.
About 60% of all colorectal
cancers are within reach of the sigmoidoscope. Rectal bleeding in
individuals older than 50 years should be evaluated by full colonoscopy
because of the risk for isolated proximal neoplasms beyond the view of
the sigmoidoscope. Multiple options exist when evaluating a younger
individual with rectal bleeding. For persons between the ages of 30 and
39 years, the incidence of colon cancer is only three cases per 1,000
people, but differentiating the few with serious pathology from those
with anal disease can be difficult. Because proximal lesions also peak
in individuals before the age of 40 years, full colonoscopy and flexible
sigmoidoscopy with barium enema are appropriate strategies for
individuals between the ages of 30 and 49 years. Most bleeding in
individuals younger than 30 years is caused by benign anal disease.
Flexible sigmoidoscopy is a reasonable option in that age group if
anoscopic findings are normal.
View OriginalView Original
About 7% to 10% of
flexible sigmoidoscopies reveal the presence of adenomas. Historically,
the presence of an adenoma necessitated referral for colonoscopy to look
for proximal neoplasia. Some physicians have recommended colonoscopy
only for larger (>1 cm) adenomas, because larger lesions were
more likely to have higher-risk villous features. However, the major
benefit of universal biopsy of polyps discovered at sigmoidoscopy may be
to distinguish tubular adenomas from villous adenomas. Persons with
tubular adenomas of any size appear to have the same rate of proximal
neoplasia as individuals with no adenomas at sigmoidoscopy (about
5.5%). A distal tubulovillous or villous adenoma has a higher
rate of proximal neoplasia (about 12%), and this finding should
incur referral for colonoscopy.
Diminutive (<5 mm) polyps found
at sigmoidoscopy often are hyperplastic. Although hyperplastic polyps
generally are not thought to be associated with proximal adenomas, this
opinion is not universally accepted in the literature. Many practices
offer barium enema, and others recommend no further screening when
hyperplastic polyps are found on sigmoidoscopic biopsy.
Many physicians recommend full
colonoscopy for colon cancer screening every 10 years for all
individuals older than 50 years. Individuals at higher risk (i.e., those
with a family history of colon cancer) may benefit from this strategy.
Significant feasibility issues continue to prevent this approach from
being recommended for population screening. A more feasible strategy is
to perform screening sigmoidoscopy at age 50 for average-risk
individuals. Only a small proportion of screened individuals with an
occult proximal neoplasm will have the lesion progress to symptomatic
colon cancer, and those that do progress take many years. Periodic
sigmoidoscopy followed by a single screening colonoscopy at age 65 may
be a more appropriate, cost-effective population strategy.
The average procedure time for
sigmoidoscopy without biopsy is about 17 minutes. Performance of a
biopsy adds about 10 minutes to the procedure. Although it is desirable
to insert the entire scope length (60 to 70 cm), the average depth of
insertion is about 52 cm. Both procedure time and the depth of insertion
appear to be operator dependent. Women have a more acute angle at the
rectosigmoid junction, making endoscope passage more difficult. Studies
in women also demonstrate that a history of prior pelvic or abdominal
surgery increases the discomfort and decreases the depth of endoscope
insertion. Sigmoidoscopy in women averages insertion depths of only 40
cm.
In a large series in England, about
80% of individuals rated the discomfort of sig- moidoscopy as
"no or mild pain. " The remainder rated their discomfort as
moderate to severe, with women reporting significantly more discomfort.
About 16% stated that their discomfort was greater than what they
expected. Most procedures can be performed without sedation or
analgesia, but if patients insist, premedication options include oral diazepam (10 mg) or triazolam (0.5 mg) taken 1 hour before the
procedure, intranasal butorphanol (two squirts)
immediately before the procedure, or intramuscular ketorolac (60 mg)
administered 30 minutes before the procedure.
Adequate preparation of the left colon
is essential for flexible sigmoidoscopy. Eating after midnight is highly
associated with stool in the sigmoid, and patients must be instructed to
consume only clear liquids the morning of the procedure. Most practices
recommend the administration of one or two enemas before the procedure.
Home administration of the enemas may reduce patient embarrassment and
time demands on office nursing staffs. However, many patients refuse to
administer home enemas, feeling unable to perform the task or fearing a
mess. Proper education of enema administration and offering an
alternate, orally administered bowel preparation may reduce
noncompliance with home bowel cleansing.
Individuals often choose not to undergo
sigmoidoscopy. Offering fecal occult blood testing simultaneously with
sigmoidoscopy can cause some patients to avoid the invasive procedure.
Increased acceptance of sigmoidoscopy can be achieved by sending a
letter describing the significance of colon cancer and inviting
individuals to participate in colon screening. Other factors that may
favorably increase the uptake of the procedure include enthusiasm of the
primary care physician and staff for the procedure, telephone reminders
before the procedure, higher levels of general education in the target
population, and skill of the practitioner performing endoscopy
(especially for repeated screening).
About one half of primary care
physicians who are trained to perform flexible sigmoidoscopy do not
continue the procedure in practice. One study documented that the main
deterrents to continuing to offer the service included the time required
to perform the procedure, the availability of the procedure from other
physicians in their locale, and the availability of adequately trained
staff. Low reimbursement for the time involved in the procedure,
especially from the Medicare program, is often cited as a reason for
discontinuing sigmoidoscopy screening.
Equipment
- Sigmoidoscope and video
monitoring equipment
Indications
- Colorectal cancer
screening - Evaluation of bright red
rectal bleeding, especially in younger patients - Evaluation of an abnormal
finding on rectal examination (e.g., palpable mass, polyp) - Evaluation of a woman
with prior gynecologic malignancy - Evaluation of an
abnormality identified radiographically - Investigation of
abdominal pain - Suspected foreign
body - Evaluation of symptoms
that could be attributable to the colon (e.g., weight loss,
iron-deficiency anemia, persistent diarrhea, change in bowel
habits, painful defecation) - Surveillance of colon
pathology (e.g., inflammatory bowel disease, prior
polypectomy) - Follow-up after
colectomy
Contraindications (Relative)
- Acute peritonitis
- Uncooperative patient
- Coagulopathy or bleeding
diathesis - Acute diverticulitis (do
not insert the scope past a newly discovered inflamed
diverticulum) - Acute fulminant
colitis - Suspected ischemic bowel
necrosis - Inadequate bowel
preparation - Extensive pelvic
adhesions - Severe cardiac or
pulmonary disease - Pelvic adhesions
(especially women with a prior hysterectomy), which can increase
the procedure 's discomfort - Toxic megacolon
- Anticoagulant or aspirin use at time of
the procedure (discontinue aspirin at least 10 days before and
coumadin at least 2 days before the procedure) - Paralytic ileus
- Large (>5 cm)
abdominal aneurysm - Suspected perforation of
the bowel
The Procedure
Step 1
The patient is positioned in
the Sims or left lateral decubitus position, with the left side of
the body down on the table. The right hip and knee are both flexed,
and the left leg remains fairly straight. A rectal examination is
performed with the lubricated, gloved index finger. The nondominant
hand lifts the right buttock. The anal canal and distal rectum are
examined for pathology and to exclude any obstruction, foreign body,
or stool that may prevent endoscope insertion. Use of
5% " lidocaine ointment may decrease discomfort from
the subsequent endoscopic procedure.
- PITFALL: Overly aggressive performance of
a digital examination will make the patient uncomfortable
and possibly reduce patient tolerance of the ensuing
endoscopy. Perform the examination gently, and talk to the
patient (i.e., verbal anesthesia) from the very
beginning. - Pearl: Because the endoscope does not
visualize the anal canal well, many authorities recommend
performance of anoscopy before sigmoidoscopy (see Anoscopy with or without Biopsy).
Step 1 View Original Step 1 View Original
Step 2
The endoscope is held in the
left hand. The umbilical cord to the light source sits over the
thumb web space and travels across the wrist. The endoscope head
sits in the palm of the hand. The left thumb operates the inner (up
and down) and outer (right and left) control knobs. The index finger
and middle finger depress the air or water and suction valves. The
left fourth and fifth fingers grasp and support the endoscope.
- PITFALL: Many individuals with small hands
complain about the difficulty of holding the endoscope. It
may be difficult for the thumb to reach the outer knob if
the operator 's hand is small. Most operators can
learn to manipulate the wheels with the left hand only;
however, in rare cases, individuals with small hands must
learn to operate the wheels using the right hand.
Step 2 View Original Step 2 View Original
Step 3
The right hand is used to
grasp the scope and to twist the scope (A). This helps with the
insertion techniques described later. As the left thumb moves the
scope tip up and down (B), the right hand can torque the curled
scope tip to move it right or left (C). Alternately, some
practitioners prefer to have a nurse assistant perform the scope
insertion and withdrawal and to use the right hand to work the outer
(right or left) knob. Insertion by a second person limits the
ability to feel tension on the colon wall and to perform torquing
maneuvers.
Step 3 View Original Step 3 View Original
Step 4
The scope is lubricated with
water-soluble jelly, and insertion is performed by direct insertion
of the scope tip into the anus or by pushing the scope tip inside
with the index finger behind the scope. Some practitioners press
tangentially on the anal verge to facilitate insertion.
- PITFALL: Do not apply lubricating jelly on
the tip of the scope, as it will smear the lens and distort
the image. - PITFALL: Care must be taken when inserting
the scope in women to avoid an embarrassing and potentially
injurious intravaginal insertion.
Step 4 View Original Step 4 View Original
Step 5
The scope is inserted into
the rectum (7 to 17 cm), and air is insufflated to reveal the lumen.
Some practitioners suction fluid from the rectum. The lumen is used
as a guide for insertion, thereby reducing patient discomfort and
risk of perforation. Air can be continuously or intermittently
inserted to open the inside of the colon for passage and
viewing.
- PITFALL: Avoid suctioning any solid stool
(shown), because this can rapidly dry and clog the suction
channel, necessitating costly repairs to the endoscope. Even
fluid in the rectum may have stool, and suctioning should be
performed only when needed.
Step 5 View Original Step 5 View Original
Step 6
Insert the scope as rapidly
as possible to limit patient discomfort and spasm, which can make
insertion more difficult. Three transverse folds of mucosa are seen
in the rectum, and these are passed to enter the rectosigmoid.
Step 6 View Original Step 6 View Original
Step 7
When maneuvering around folds
or bends, torquing the endoscope with the right hand allows passage
through turns. Dithering is the rapid back-and-forth motion that
sometimes facilitates finding the lumen and passing the scope.
Step 7 View Original Step 7 View Original
Step 8
The hooking and straightening
technique may be used for passage through a tortuous sigmoid. As the
endoscope is inserted in the sigmoid, the sigmoid may bow upward,
producing significant patient discomfort (A). The endoscope tip is
maximally deflected, and the sigmoid is "hooked " (B)
as the scope is withdrawn (C). The scope tip can paradoxically
appear to move forward through the lumen as the endoscope is
withdrawn. The sigmoid is straightened, and the endoscope passes
through the sigmoid (D).
Step 8 View Original Step 8 View Original
Step 9
The endoscope is then
maximally inserted. Viewing takes place as the endoscope is
withdrawn. Use the markings on the endoscope to document depth of
insertion of the scope for all pathology encountered.
- PITFALL: Do not mistake a large
diverticular orifice for the lumen. The posterior walls of
diverticular sacs can be quite thin, and perforation is
easily accomplished by inadvertent entry into a diverticular
sac.
Step 9 View Original Step 9 View Original
Step 10
Biopsy is performed by
threading the metal biopsy instrument through the biopsy channel.
The open biopsy forceps can serve as a guide to the size of lesions,
measuring approximately 5 mm when opened. A syringelike plunger on
the end of the biopsy forceps is used to open and close the
forceps.
Step 10 View Original Step 10 View Original
Step 11
After the endoscope is
withdrawn to the rectum (i.e., 10 to 15 cm inserted), the scope tip
is retroverted to examine the distal rectal vault. This area is not
well visualized by the forward-directed scope as it passes the area.
Retroversion is achieved by maximally deflecting both the inner and
outer knobs with the left thumb while simultaneously inserting the
scope with the right hand.
Step 11 View Original Step 11 View Original
Step 12
Finally, the scope is
straightened and the lumen viewed. Air is withdrawn from the rectum
before the scope is withdrawn. The scope tip is immediately placed
in soapy water, and the water is suctioned to prevent clogging of
the suction channel. The anus is wiped clean with gauze, and the
patient is offered the opportunity to go to the bathroom. The
patient is permitted to get dressed after the procedure and before
the findings are discussed.
- PITFALL: Vasovagal responses are possible
during or after the procedure. Patients should be allowed to
sit for a minute with the legs dangling off the table before
being allowed to get off the examination table.
Step 12 View Original Step 12 View Original
Complications
- Perforation
- Bleeding following
polypectomy
Pediatric Considerations
Pediatric scopes are available that
are of a smaller diameter than adult scopes. Alternatively, a
gastroscope can be used.
Postprocedure Instructions
After the procedure, patients may
resume their regular diet and activity. They should be warned to contact
their doctor immediately if they experience severe abdominal pain (not
just gas cramps); a firm, distended abdomen; vomiting; fever; or
bleeding greater than a few tablespoons.
Coding Information and Supply Sources
For coding purposes, sigmoidoscopy
involves examination of the entire rectum and sigmoid colon and may
include a portion of the descending colon.
View Large CPT Code Description 2008 AVERAGE 50th Percentile Fee Global Period 45330 Flexible sigmoidoscopy with or without brushings or
washings $300.00 0 45331 Flexible sigmoidoscopy with single or multiple biopsies $413.00 0 45332 Flexible sigmoidoscopy with foreign body removal $537.00 0 45333 Flexible sigmoidoscopy with tumor, polyp, lesion removal
(hot biopsy forceps) $631.00 0 45334 Flexible sigmoidoscopy with control of bleeding (cautery,
coagulator) $610.00 0 CPT is a registered trademark of the American
Medical Association.2008 average 50th Percentile Fees are provided courtesy of 2008
MMH-SI 's copyrighted Physicians ' Fees and
Coding Guide.
Common ICD-9 Codes
View Large Abdominal mass 789.3 Anemia, unexplained 280.9 Iron deficiency anemia secondary to blood loss 280.0 GI bleeding, acute 578.9 GI bleeding, occult 578.1 X-ray abnormality 793.4 Weight loss, severe 783.2 Benign neoplasm colon 211.3 Constipation, slow transit 564.01 Constipation, outlet dysfunction 564.02 Diverticulosis with blood 562.12 Rectal bleeding 569.3 Personal Hx CRCa V10.05 Family Hx CRCa V16.0 Ulcerative colitis 556.9 Rectal pain 569.42 Change in bowel habits 787.99
Instrument and Materials Ordering
- The Ives slotted
anoscope is available from Redfield Corporation, 336 West
Passaic Street, Rochelle Park, NJ (phone: 800-678-4472; http://www.redfieldcorp.com) - Recommendations
for endoscope cleaning appear in Procedural (Conscious) Sedation. - Complete
endoscopy equipment such as endoscopes, light sources, video
endoscopy monitors, cleaning and disinfection aids, and
mouthpieces are available from the following
manufacturers: - Olympus
Corporation, Center Valley, PA (http://www.olympusamerica.com) - Pentax
Precision Instrument Corporation, Montvale, NJ
(http://www.pentaxmedical.com)
- A viscous
2% " lidocaine topical solution is available from Alpharma USPD,
Bridgewater, NJ (http://www.alpharma.com) - Butorphanol tartrate (Stadol) nasal
spray is available from Bristol-Myers Squibb
(http://www.bms.com) - Intravenous
materials (e.g., intracaths, normal saline solution,
intravenous tubing) can be obtained from local hospitals or
surgical supply houses.
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