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Diminutive polyps found on flexible sigmoidoscopy are predominantly hyperplastic, but it is impossible to rely on endoscopic appearance to make an accurate diagnosis. Colonoscopy, polypectomy, and full pathologic evaluation are recommended for all such polyps. Follow-up care varies depending on the nature of the lesion.
BACKGROUND: Flexible sigmoidoscopy (FS) has been recommended as a screening method to reduce mortality from colorectal cancer (CRC). The present study evaluates the effect of adding FS to the fecal occult blood test Hemoccult-II (H-II) on diagnostic yield of colorectal neoplasia. METHODS: A total of 10,978 normal persons aged 50-75 years were invited to participate, 5495 persons being allocated at random to H-II and FS and 5483 to H-II alone. RESULTS: In spite of a lower compliance (40% versus 56%) for the combined procedure, the diagnostic yield of colorectal neoplasia was higher than for H-II alone (12 CRC versus 4 CRC, and 72 large adenomas versus 14). Within 24-62 months after screening there were fewer CRCs detected after H-II + FS than after H-II alone. The stage distribution was less favorable than in screen-detected cases. CONCLUSION: One FS may not be an optimal way of screening, but FS deserves to be evaluated in randomized population studies including repeated H-II tests in the control arm.
Sixty-nine per cent of a group of children with chronic mucoid diarrhoea who would not normally be seen in a tertiary health care facility had endoscopically demonstrable abnormality in the distal bowel, especially in the distal rectum. Sigmoidoscopy and punch biopsy of the rectum are safe procedures which can be undertaken in primary health care facilities. The inclusion of such investigations will facilitate the elucidation of the aetiology of chronic mucoid diarrhoea.
This study compared selected types of information given before sigmoidoscopy to determine if one intervention was superior to the other in decreasing anxiety. The design was two-group, pre- and posttest quasi-experimental. Anxiety was measured by the State-Trait Anxiety Inventory (STAI) and heart rate monitoring. Preparatory information consisted of 3 to 5 min audiotaped messages. Subjects in a convenience sample of 22 men were randomly assigned to one of two information conditions, procedure (control) or procedure plus sensation (experimental). t tests and analysis of variance were used to analyze the data. Data analysis revealed no significant difference (p = .05) in anxiety between groups postintervention. There were no significant changes in heart rate between groups by time or within groups over time. Subjective comments on postsigmoidoscopy questions were strongly positive regarding the benefits of both types of preparatory information.
Screening flexible sigmoidoscopy (FS) is an effective tool for the detection of colon cancer. Nonetheless, persons are reluctant to undergo FS for a variety of reasons such as anxiety, discomfort, and the possibility of abnormal findings. Nurses caring for FS patients can implement interventions to allay anxiety and promote comfort in an effort to enhance satisfaction and future compliance. Music therapy is one nonpharmacologic intervention that has been shown to be effective in allaying anxiety, reducing discomfort, and promoting satisfaction in other patient populations. A two-group pretest, posttest experimental design with repeated measures study recruited 64 subjects undergoing FS from one Midwestern tertiary care center. Subjects were randomly assigned to a control condition of usual procedural care or to an experimental condition of music therapy during the examination. State and trait anxieties were measured at pretest. State anxiety, discomfort, satisfaction, and perceived compliance with future screening were measured after the procedure. Subjects in the music group reported less anxiety and discomfort than subjects in the control group. There were no differences on satisfaction ratings or perceived compliance with screening guidelines. Nurses caring for patients undergoing screening FS can offer music therapy as one nonpharmacologic intervention to ameliorate anxiety and reduce discomfort.
The expectation of pain is a statistically significant factor negatively affecting patient compliance with current screening flexible sigmoidoscopy recommendations. Numerous pain reduction modalities have been studied with limited success. Transcutaneous electrical nerve stimulation (TENS) has been used to treat pain of various origins. The purpose of this pilot study was to determine the efficacy of TENS in reducing discomfort experienced during screening flexible sigmoidoscopy.A double-blind study was conducted in which 90 subjects were randomized to receive TENS, sham TENS, or control (standard care). The same pulse frequency and intensity were used for all subjects in the TENS group. Subjects completed preprocedural and postprocedural questionnaires, and the endoscopist completed a postprocedural questionnaire. A slight, but statistically insignificant (p =.526) reduction in the mean pain score reported by the TENS group was noted when compared with the sham TENS and control groups (2.00, 2.27, and 2.23 respectively). In light of the fact that only one pulse frequency and intensity of the TENS intervention were used in this study, further study with this safe and cost-effective modality is warranted.
Cigarette smoking has been associated with adenomatous polyps of the large bowel but not with increased risk of colorectal cancer. Giovannucci et al recently proposed a hypothesis to explain this inconsistency. A key testable aspect of the hypothesis is that smoking in the distant past increases the risk of large polyps. Questions also remain about the association between colorectal polyps and consumption of alcohol. To address these issues, we examined data from 488 cases with adenomatous polyps and 488 controls. Subjects were members of a prepaid health plan in Los Angeles who had a sigmoidoscopy in 1991-1993. As expected, the adjusted odds of polyps in current smokers compared with never-smokers was increased [odds ratio = 2.43; 95% confidence interval (CI) = 1.56-3.79]. For those who had smoked in the distant past (for example, 30 or more pack-years before 20 years ago), the adjusted odds of an adenoma > or = 1 cm, relative to nonsmokers, was 0.88 (95% CI = 0.23-3.42). The adjusted odds of polyps in those consuming > or = 46 gm per day of alcohol compared with nondrinkers was 1.50 (95% CI = 0.72-3.13). Although imprecise, these data do not support the hypothesis that past smoking increases the risk of large polyps, but our results indicate a weak association between alcohol use and risk of adenomatous polyps.
Surveillance has become an established concept to find dysplasia as a premalignant lesion in ulcerative colitis. Since the advent of colonoscopy and the access of the entire colon to biopsy, utilization of the rigid sigmoidoscope and rectal biopsies has been markedly reduced. We have reviewed 940 rectal biopsies obtained from 360 patients with ulcerative colitis of various extent and duration to determine the yield of dysplasia and assess the value of this procedure. The rectal biopsies had been performed for a variety of reasons in the course of clinical management of ulcerative colitis in addition to surveillance. Dysplasia was found in 10.8% of the patients--higher than has been demonstrated by colonoscopy. In four of the 39 patients with dysplasia a carcinoma coexisted (2) or developed subsequently (2). In no instance did dysplasia serve to warrant the colectomy that disclosed the carcinoma, but earlier discovery of the dysplasia or more intense surveillance once it had been found might have led to earlier discovery of the carcinoma. The yield of dysplasia was greater in those with onset of ulcerative colitis in childhood. In more than half, including 71% of patients with onset in childhood, the dysplasia was found before they had the disease for 9 years. Surveillance, therefore, should begin earlier in young patients with ulcerative colitis. Sigmoidoscopic biopsies do not substitute for colonoscopic biopsies in a surveillance program. Nevertheless, the ease of obtaining rectal biopsies, the relatively large yield of dysplasia, and the need for frequent sigmoidoscopy in the clinical management of ulcerative colitis all warrant a high priority role for rectal biopsies to supplement that of colonoscopic biopsies.
Infectious endocarditis is a feared complication of procedures causing bacteremia. Gastrointestinal procedures cause bacteremia, but are seldom followed by infectious endocarditis. Of nine cases found in the English literature, only five have convincing evidence that endocarditis resulted from the gastrointestinal procedure. I present a new case of endocarditis due to Streptococcus sanguis type II after fiberoptic sigmoidoscopy.
In patients about to have hernia repair, preoperative screening studies for early colorectal cancer using the rigid proctosigmoidoscope and barium enema have previously shown minimal cost effectiveness and poor patient acceptance. Flexible sigmoidoscopy may be more acceptable to patients and of greater diagnostic value. Between October 1980 and December 1983, 100 consecutive asymptomatic male surgical patients were examined using the Olympus 60 flexible proctosigmoidoscope. All patients were admitted for elective hernia repair. Age ranged from 21 to 88 years (mean 59.7). All patients with stool positive for occult blood on admission were excluded from this study. In addition, patients with any gastrointestinal symptoms, history of colorectal disease, or family history of colorectal polyps or carcinoma were excluded. Examinations were done under direct supervision of an attending surgeon (W.W. or C.S.C.). Of the 22 patients who had one or more benign polyps, three had villous adenomas. Two additional patients had carcinoma. Results of examination were completely normal in 63, while 13 patients were found to have hemorrhoids or diverticular disease. There were no complications and the procedure was well tolerated by all patients.
Endoscopic removal of premalignant adenomas from the distal bowels of the entire population, 3 to 5-yearly from age 50, is advocated in the US as a feasible method of reducing colorectal cancer mortality rates. In the UK, a single flexible sigmoidoscopy (FS) is regarded as a more cost-effective option. Although more acceptable than colonoscopy, FS and polypectomy are expensive and invasive procedures carrying a small risk of serious harm. We believe that, before implementing mass screening, precise estimates are required of the magnitude of the reduction in mortality and costs (financial, physical and emotional). Several randomized trials, including a large British study, are currently evaluating these aspects.
OBJECTIVE: We established a fast-track flexible sigmoidoscopy service to meet the two-week target for colorectal cancer, and have performed a prospective observational study over three years to assess its impact on the proportion of patients with colorectal cancer presenting as an emergency. METHODS: The fast-track system was established on 1 November 1999 using six screening criteria to select high-risk patients. Data on all high-risk patients referred through the fast-track system and all patients diagnosed with colorectal cancer were recorded prospectively in two time periods: six months before fast-track (1 November 1998 to 30 April 1999, Period 1) and three years following fast-track (1 November 1999 to 31 October 2002, Period 2). RESULTS: In Period 2, 2294 fast-track referrals were received. A total of 635 cases (321 male, 314 female) of colorectal cancer were diagnosed in Period 2 vs. 84 cases (43 male, 41 female) in Period 1. In Period 1, 30 patients with colorectal cancer (35.7% of the total) presented as an emergency vs. 165 patients (25.9%) in Period 2 (P = 0.059, chi(2)test). CONCLUSION: Introduction of a fast-track service to meet the two-week target has resulted in a trend towards fewer emergency presentations with colorectal cancer.
CONTEXT: The recommended interval for colorectal cancer screening with flexible sigmoidoscopy (FS) was recently lengthened from 3 to 5 yr. Direct evidence supporting the longer interval is lacking. The appropriateness of the longer interval has been questioned. OBJECTIVE: To compare the incidence of neoplasia detected on FS in individuals who had undergone an FS either 3 yr or 5 yr after a normal examination. DESIGN, SETTINGS, AND PATIENTS: Subjects were drawn from 5,359 individuals who underwent two FS examinations performed for colorectal cancer screening. Examinations were performed by gastroenterologists at a single academic medical center between 1987 and 2002. A total of 2,146 subjects with a normal baseline examination and a follow-up examination 3 and 5 yr later was included. MAIN OUTCOME MEASURE: To compare the incidence of neoplasia, including advanced neoplasia, detected 3 yr versus 5 yr after a normal FS. RESULTS: 915 subjects underwent FS at 3 yr and 1,231 subjects at 5 yr after a normal examination. Neoplasia was detected in 3.2% of the 3-yr and 4.3% of the 5-yr subjects (p=0.17). No significant differences were detected in the pathology, multiplicity, or size of neoplasms between the 3- and 5-yr groups. Advanced neoplasms occurred in 0.9% (including one adenocarcinoma) of subjects at 3 yr and 1.1% of subjects at 5 yr (p=0.67). CONCLUSIONS: Few individuals will develop rectosigmoid neoplasms 3 or 5 yr after a normal FS. The majority of neoplasms detected are low-risk lesions. A screening interval of 5 yr after a normal FS does not portend an increased risk of advanced neoplasms including cancer. This direct evidence supports the current recommendations of a 5-yr interval for colorectal cancer screening with FS.
The role of sigmoidoscopic examination in the diagnosis, evaluation, and treatment of minor lower gastrointestinal bleeding was investigated. A hundred patients with minor rectal bleeding were examined by rigid sigmoidoscopy under general anaesthesia between January 1989 and July 1996. Patients who had bleeding secondary to infections, anal fissure, or haemorrhoids were excluded from study. Patients were reviewed retrospectively according to their diagnosis and endoscopic and histopathological findings. Twenty nine of these patients were girls and 71 boys; their ages ranged between 8 month and 14 years (mean 7.2 years). Endoscopic pathological findings were established in 60 patients; 32 had rectal polyps, 16 non-specific proctitis, four solitary rectal ulcers, three internal haemorrhoids, two ulcerative colitis, two Hirschsprung's enterocolitis, and one haemangioma. It is concluded that sigmoidoscopic examination should be performed for the diagnosis, prognosis, and choice of treatment in patients with minor rectal bleeding and the diagnosis should be confirmed histopathologically.
Perforation of the large bowel can occur as a complication of sigmoidoscopy, rectal or sigmoid biopsy, and even of a simple cleansing enema. If the perforation is extraperitoneal there may be no early symptoms and consequently there may be delay in diagnosis. The risk of perforation during these procedures is small but it should not be ignored. The performance of a barium enema shortly after a rectal or sigmoid biopsy may slightly increase the risk by converting a partial perforation into a complete one. Precautions can be taken to minimize the hazard.
BACKGROUND: Screening for colorectal cancer (CRC) using guaiac based faecal occult blood tests (FOBT) has an estimated programme sensitivity of >60% but <30% for strictly asymptomatic CRC in a single screening round. In search for improved non-invasive tests for screening, we compared a test for faecal calprotectin (PhiCal) with a human haemoglobin immunochemical FOBT (FlexSure OBT). METHODS: In the Norwegian Colorectal Cancer Prevention (NORCCAP) trial, screenees in one screening arm were offered screening with combined flexible sigmoidoscopy (FS) and FlexSure OBT. They were also requested to bring a fresh frozen sample of stool for the PhiCal test which was performed on samples from screenees with CRC (n = 16), high risk adenoma (n = 195), low risk adenoma (n = 592), and no adenoma (n = 1518) (2321 screenees in total). A positive PhiCal test was defined by a calprotectin level > or =50 microg/g. RESULTS: The PhiCal test was positive in 24-27% of screenees whether they had no adenoma, low risk adenoma, or high risk adenoma. Ten (63%) of 16 CRCs gave a positive PhiCal test. The total positivity rate in this population was 25% for the PhiCal test compared with 12% for FlexSure OBT, with a sensitivity for advanced neoplasia of 27% and 35%, respectively. Specificity for "any neoplasia" was 76% for the PhiCal test and 90% for FlexSure OBT. CONCLUSIONS: In colorectal screening, the performance of the PhiCal test on a single spot from one stool sample was poorer than a single screening round with FlexSure OBT and cannot be recommended for population screening purposes. The findings indicate a place for FlexSure OBT in FOBT screening.
BACKGROUND: Flexible sigmoidoscopy (FS) is a complex technical procedure performed in a variety of settings, by examiners with diverse professional backgrounds, training, and experience. Potential variation in technical quality may have a profound impact on the effectiveness of FS on the early detection and prevention of colorectal cancer. AIM: We propose a set of consensus and evidence based recommendations to assist the development of continuous quality improvement programmes around the delivery of FS for colorectal cancer screening. RECOMMENDATIONS: These recommendations address the intervals between FS examinations, documentation of results, training of endoscopists, decision making around referral for colonoscopy, policies for antibiotic prophylaxis and management of anticoagulation, insertion of the FS endoscope, bowel preparation, complications, the use of non-physicians as FS endoscopists, and FS endoscope reprocessing. For each of these areas, continuous quality improvement targets are recommended, and research questions are proposed.
This study determined the incidence and concentration of methane-producing bacteria in tap water enema samples of 130 individuals taken before sigmoidoscopy. The number of subjects classified in five major colonic groups were as follows: normal colon 36, diverticulosis 57, inflammatory bowel disease 11, colon polyps 34, and colon cancer 11. Some patients were placed in more than one category. Ninety four of the subjects or 72% had methanogenic bacteria ranging in concentration from 6 to about 3 X 10(10)/g dry weight of faeces. The predominant methanogen in all groups was Methanobrevibacter smithii. Chi-square analysis showed that the incidence of methanogens in concentrations of 10(7)/g dry weight of faeces or greater in patients with diverticulosis (58%) was significantly greater than in normal patients (25%). High methanogen concentrations are associated with excretion of methane in the breath.