II. Indications

  1. Colorectal Cancer Screening
  2. Surveillance after previous polypectomy
  3. Surveillance of Inflammatory Bowel Disease
  4. Rectal Bleeding or Hemoccult positive stools
  5. Unexplained Anemia, weight loss, or fevers
  6. Change in Bowel habits
    1. New onset or persistent Constipation
    2. Protracted Diarrhea
  7. Abdominal Pain

III. Contraindications

  1. Absolute contraindications
    1. Acute or severe Cardiac or pulmonary disease
    2. Inadequate Bowel Preparation
    3. Active Diverticulitis
    4. Acute surgical Abdomen
    5. Marked bleeding dyscrasia
  2. Relative contraindications
    1. Recent bowel surgery or pelvic surgery
    2. Active infection
    3. Pregnancy

IV. Efficacy

  1. Colonoscopy preferred for Colorectal Cancer Screening
    1. Sigmoidoscopy misses 25% of lesions (proximal)
    2. Occult blood does not increase flex sig sensitivity
  2. References
    1. Lieberman (2000) N Engl J Med 343:207-8 [PubMed]
    2. Lieberman (2001) N Engl J Med 345:555-60 [PubMed]

V. Preparation: Patient

VI. Preparation: Equipment

  1. Flexible fiberoptic sigmoidoscope
    1. Test air insufflation in basin water
    2. Test suction in basin water
    3. Water source connected
    4. Confirm sigmoidoscope plugged into light source
  2. Other equipment
    1. Ive's Slotted Anoscope with light source
    2. Gauze (4x4) approximately 1 inch amount of gauze
    3. One inch of K-Y Jelly or 5% Lidocaine ointment
    4. Basin with water
  3. Sigmoidoscope cleaning
    1. Immediately immerse scope tip in water after procedure
    2. Flush suction channel to prevent clogging with stool
    3. See Endoscope Cleaning

VII. Procedure

  1. Patient Position: Left Lateral Decubitus
  2. Examiner Preparation
    1. Double glove scope insertion hand (right hand)
    2. Single glove other left hand
  3. Initial Examination
    1. Digital Rectal Exam (and Prostate exam in men)
    2. Anoscopy
  4. Sigmoidoscope Control
    1. Insert scope with right hand
    2. Right hand also rotates the tip left and right
    3. Left thumb controls inner knob for up-down control
  5. Sigmoidoscope Insertion
    1. Insert distal scope over top of lubricated finger
      1. Avoid smearing jelly over top of lens
    2. Insert scope 7 to 15 cm
    3. Insufflate air
  6. Sigmoidoscope advancement
    1. Basic Insertion Technique
      1. Attempt to insert scope only when lumen visible
      2. Some continue insertion as long as wall moves
      3. Do not continue to insert against resistance
    2. Advanced Insertion Techniques
      1. Torquing
        1. Twist scope with insertion hand
      2. Dithering
        1. Rapid short back and forth motion
      3. Accordionization (Hook and Pull Back)
        1. Pull back on angled wall segments with scope tip
  7. Sigmoidoscope Withdrawal
    1. Inspect colonic mucosa while slowly withdrawing
    2. Withdraw scope tip to rectal vault (10 to 15 cm)
  8. Sigmoidoscope Retroversion
    1. Confirm scope withdrawn to rectal vault
    2. Maximally turn inner knob with left land
    3. Insert scope with right hand
    4. Visualize black scope in Rectum and anal canal
  9. Study completion
    1. Withdraw air from Rectum
    2. Remove scope from Rectum

VIII. Findings

  1. Polyps
    1. Diminutive polyps (size <5 mm): Biopsy
      1. Hyperplastic polyp on biopsy: No further evaluation
      2. Adenomatous polyp on biopsy: Full Colonoscopy
    2. Large polyps (size >5 mm)
      1. Perform full Colonoscopy with polypectomy
  2. Suspected Cancer
    1. Prompt referral for evaluation and treatment
    2. Biopsy may provoke significant bleeding
  3. Diverticulosis
  4. Internal Hemorrhoids

IX. References

  1. Pfenninger (1994) Procedures, Mosby, p. 907-28
  2. Zuber (2001) Am Fam Physician 63(7):1375-80 [PubMed]

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