Flexible Sigmoidoscopy

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Flexible Sigmoidoscopy

Introduction

Equipment

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

sigmoidoscopy with barium enema are appropriate strategies for

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.

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

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

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

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.

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

appear to be operator dependent. Women have a more acute angle at the

rectosigmoid junction, making endoscope passage more difficult. Studies

surgery increases the discomfort and decreases the depth of endoscope

insertion. Sigmoidoscopy in women averages insertion depths of only 40

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)

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

continue the procedure in practice. One study documented that the main

deterrents to continuing to offer the service included the time required

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

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,

5% " lidocaine ointment may decrease discomfort from

Step 1 View Original Step 1 View Original

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.

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

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.

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

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.

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.

The hooking and straightening

technique may be used for passage through a tortuous sigmoid. As the

maximally deflected, and the sigmoid is "hooked " (B)

as the scope is withdrawn (C). The scope tip can paradoxically

withdrawn. The sigmoid is straightened, and the endoscope passes

maximally inserted. Viewing takes place as the endoscope is

withdrawn. Use the markings on the endoscope to document depth of

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

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

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

are of a smaller diameter than adult scopes. Alternatively, a

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

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

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

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

1American Academy of Family

Training Program: A Syllabus for the Physician Starting

1985. 2Atkin WS, Hart A, Edwards R,

et al. Uptake, yield of neoplasia, and adverse

1998;42:560 " 565. [View Abstract] 3Cohen LB.

A new illustrated "how to "

1989;9:13 " 20. 4Davis PW, Stanfield CB.

pearls for passage. Postgrad

1999;105:51 " 62. [View Abstract] 5Esber EJ, Yang P.

1995;51:1709 " 1711. [View Abstract] 6Herman M, Shaw M, Loewen B.

Comparison of three forms of bowel

2001;24:178 " 181. [View Abstract] 7Holman JR, Marshall RC, Jordan B,

et al. Technical competence in flexible

sigmoidoscopy. J Am Board

2001;14:424 " 429. [View Abstract] 8Levin TR, Palitz A, Grossman S,

et al. Predicting advanced proximal colonic

1999;281:1611 " 1617. [View Abstract] 9Lewis JD, Asch DA.

Barriers to office-based screening

1999;130:525 " 530. [View Abstract] 10Lewis JD, Asch DA, Ginsberg GG,

J Gen Intern Med.

1999;14:297 " 302. [View Abstract] 11Lund JN, Buckley D, Bennett D,

et al. A randomized trial of hospital versus home

1998;317:1201. [View Abstract] 12Mayberry MK, Mayberry JF.

Towards better informed consent in endoscopy:

a study of information and consent processes in gastroscopy

2001;13:1467 " 1476. [View Abstract] 13McCallion K, Mitchell RM, Wilson RH,

distribution of colorectal cancer: implications for

2001;48:522 " 525. [View Abstract] 14Ransohoff DF, Lang CA.

1993;269:1278 " 1281. [View Abstract] 15Rees MK.

1992. 17Verne JE, Aubrey R, Love SB,

compared with screening by faecal occult blood

1998;317:182 " 185. [View Abstract] 18Wallace MB, Kemp JA, Trnka YM,

1998;129:273 " 278. [View Abstract] 19Williams JJ.

1993;13:37 " 46. 21Zuber TJ.

2001;63:1375 " 1380,

1383 " 1388. 22Zuber TJ.

The Academy Collection Quick Reference

1999:35 " 42. 232008 MAG Mutual Healthcare

• 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

• 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).

• 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.

• 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.

• 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.

• 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.

• 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.

Complications

• Perforation
• Bleeding following polypectomy

Pediatric Considerations

Postprocedure Instructions

Coding Information and Supply Sources

• 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.

• Olympus Corporation, Center Valley, PA (http://www.olympusamerica.com)
• Pentax Precision Instrument Corporation, Montvale, NJ (http://www.pentaxmedical.com)

Bibliography