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flexible sigmoidoscopy

A procedure for viewing the rectum & sigmoid colon. 35 & 60 cm sigmoidoscopes are used. Indications: 1) follow-up for rectal cancer 2) screening for colon cancer* - screening interval= every 5 years - once, age 55-65 years, reduces colorectal carcinoma incidence & mortality [4] - yield of screening depends on sigmoidoscopist [3] - colorectal adenomas detected in 9-16% of screenings - neglible benefit in older women [7] 3) evaluation of change in bowel habits 4) rectal bleeding 5) abdominal pain 6) decompression of sigmoid volvulus 7) removal of foreign body Contraindications: 1) patient refusal 2) patient is dying or at the point of death (moribund) 3) unstable cardiac condition 4) respiratory insufficiency 6) peritonitis 7) known or suspected perforation 8) toxic megacolon 9) sigmoid stricture 10) fulminant colitis 11) severe acute diverticulitis Benefit/risk: - number needed to treat (NNT) - 1000 over 9.4 years to prevent 1 death due to colorectal cancer [6]* - numbers needed to harm = 1000 sigmoidoscopies to result in 1 serious complications [6]# * it is difficult to reconcile that 1/2 of colon cancers appear to be right-sided with the often reported benefits of flexible sigmoidoscopy as comparable to colonoscopy * this is especially so in the context of financial incentives for preforming procedures in a fee for service setting # since the recommended time interval for sigmoidoscopy is every 5 years, 2 patients would be harmed for each patient benefitted Procedure: Patient preparation: 1) informed consent 2) avoid eating red or orange gelatin the day prior to the procedure 3) fleet enema* every 30 min beginning 2 hours before procedure until the return is clear 4) left lateral position with right knee flexed more than left * see bowel preparation for colonoscopy or flexible sigmoidoscopy Complications: 1) intestinal perforation 2) bleeding 3) vasovagal reaction 4) transient bacteremia (< 1&) Notes: Caution: 1) 10% of patients have combustible levels of hydrogen & methane in the bowel 2) do NOT use electrocautery during sigmoidoscopy because of risk of explosion 3) making the patient and appointment & offering a single screening test results in best compliance [5]

Related

bowel preparation (whole bowel irrigation, bowel evacuation) colonoscopy

Specific

flexible sigmoidoscopy with ablation of neoplasm/polyp flexible sigmoidoscopy with cautery flexible sigmoidoscopy with decompression of volvulus flexible sigmoidoscopy with removal of foreign body

General

gastrointestinal endoscopy

References

  1. Saunders Manual of Medical Practice, Rakel (ed), WB Saunders, Philadelphia, 1996, pg 334-36
  2. Medical Knowledge Self Assessment Program (MKSAP) 11, American College of Physicians, Philadelphia 1998
  3. Journal Watch 24(12):97, 2004 Atkin W, Rogers P, Cardwell C, Cook C, Cuzick J, Wardle J, Edwards R. Wide variation in adenoma detection rates at screening flexible sigmoidoscopy. Gastroenterology. 2004 May;126(5):1247-56. PMID: 15131784
  4. Segnan N et al. Once-only sigmoidoscopy in colorectal cancer screening: Follow-up findings of the Italian Randomized Controlled Trial - SCORE. J Natl Cancer Inst 2011 Sep 7; 103:1310 PMID: 21852264
  5. Bevan R et al. Implementing a national flexible sigmoidoscopy screening program: Results of the English early pilot. Endoscopy 2015 Mar; 47:225 PMID: 25268309
  6. Tang VA, Boscardin WJ, Stijacic-Cenzer I, Lee SJ Time to benefit for colorectal cancer screening: survival meta-analysis of flexible sigmoidoscopy trials. BMJ 2015;350:h1662 PMID: 25881903 http://www.bmj.com/content/350/bmj.h1662 - Brenner H Colorectal cancer screening for older adults. BMJ 2015;350:h2029 PMID: 25882058 http://www.bmj.com/content/350/bmj.h2029
  7. Holme O et al. Effectiveness of flexible sigmoidoscopy screening in men and women and different age groups: Pooled analysis of randomised trials. BMJ 2017;356:i6673 PMID: 28087510 Free PMC Article http://www.bmj.com/content/356/bmj.i6673 - Haug U. Flexible sigmoidoscopy screening for colorectal cancer. Different outcomes in men and women are a challenge for decision makers. BMJ 2017;356:j75 PMID: 28087640 http://www.bmj.com/content/356/bmj.j75 - Holme O, Loberg M, Kalager M et al Long-Term Effectiveness of Sigmoidoscopy Screening on Colorectal Cancer Incidence and Mortality in Women and Men: A Randomized Trial. Ann Intern Med. 2018. April 24. PMID: 29710125 http://annals.org/aim/article-abstract/2679355/long-term-effectiveness-sigmoidoscopy-screening-colorectal-cancer-incidence-mortality-women
  8. Flexible Sigmoidoscopy https://www.niddk.nih.gov/health-information/diagnostic-tests/flexible-sigmoidoscopy
  9. MedlinePlus Sigmoidoscopy http://www.nlm.nih.gov/medlineplus/ency/article/003885.htm