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Flexible Sigmoidoscopy

  • Author: Gaurav Arora, MD, MS; Chief Editor: Vikram Kate, MBBS, PhD, MS, FRCS, FRCS(Edin), FRCS(Glasg), FACS, FACG, FIMSA, MAMS, MASCRS  more...
 
Updated: Feb 01, 2016
 

Background

Flexible sigmoidoscopy is a procedure wherein a sigmoidoscope is inserted through the anus, the distal colonic mucosa (up to 60 cm from the anal verge) is examined, and any diagnostic or therapeutic maneuvers performed, as needed.

Intracolonic visualization with an endoscope dates back to 1958, when Matsunaga used a gastroscope for this purpose in Japan.[1] The next step was the incorporation of the fiberoptic bundles into the gastroscopes, which in turn led to the development of the first fiberoptic flexible sigmoidoscope by Overholt and its successful use in 1963.[1] Continuing development through the years has led to the modern sigmoidoscope, which uses a charge–coupled device connected to a video processor.

Alternatives to flexible sigmoidoscopy include the following:

  • Colonoscopy, which examines the whole colon
  • Fecal occult blood testing for colorectal cancer screening[2]
  • Barium enema for visualization of large polyps or cancerous lesions (no longer recommended as a screening test for colorectal cancer screening)
  • Computed tomography (CT) colonography, which examines the whole colon but is less invasive than colonoscopy[3]
  • Rigid sigmoidoscopy (not commonly performed)
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Indications

The following are the usual indications for flexible sigmoidoscopy[4] :

  • Screening for colorectal cancer[5, 6, 7]  - Although flexible sigmoidoscopy and fecal occult blood testing are comparable when applied as screening tools to reduce mortality due to colorectal cancer, there is little evidence to indicate that screening with either approach reduces colorectal cancer deaths more than the other[8]
  • Preoperative evaluation before anorectal surgery
  • Surveillance of a previously diagnosed (treated or untreated) malignancy (or polyp with high-grade dysplasia) in the rectum or the sigmoid colon
  • Local treatment of ailments such as radiation proctitis
  • Removal of rectal foreign bodies
  • Biopsy of the gastrointestinal (GI) pathology in the rectum and the sigmoid colon
  • Performance of therapeutic procedures such as endoluminal stent placement for strictures, balloon dilation, and decompression with placement of a decompression tube, however a conventional colonoscopy is often commonly used
  • Hematochezia necessitating hemostasis
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Contraindications

Absolute contraindications for flexible sigmoidoscopy include the following:

Relative contraindications for flexible sigmoidoscopy include the following:

  • Lack of informed consent - This is a contraindication except in emergencies, during which two physicians must document the life-threatening nature of the condition before treatment can continue
  • Lack of patient cooperation
  • Lack of good bowel preparation
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Technical Considerations

Anatomy

The rectum lies in the sacrococcygeal hollow and changes to the anal canal at the puborectal sling formed by the innermost fibers of the levator ani. The rectum has a dilated middle part called the ampulla. The rectum is related anteriorly to the urinary bladder, prostate, seminal vesicles, and urethra in males and to the uterus, cervix, and vagina in females. Anterior to the rectum is the rectovesical pouch in males and the rectouterine pouch in females. The anal canal is related to the perineal body in front and the anococcygeal body behind; both of these are fibromuscular structures.

For more information about the relevant anatomy, see Large Intestine Anatomy, Colon Anatomy, and Anal Canal Anatomy.

Best practices

The following measures are recommended for improving the performance of flexible sigmoidoscopy:

  • Never push against resistance
  • Always keep the lumen in view
  • When in doubt, pull back, insufflate, and advance once the lumen is in view
  • Learn how to use torque effectively to control the instrument tip
  • Use air (as much as needed but as little as possible); too much distention can lead to patient discomfort and kinking of the colon
  • When encountering many large diverticula, take the necessary time to determine the direction of the true lumen
  • Know when to abandon the procedure
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Contributor Information and Disclosures
Author

Gaurav Arora, MD, MS Assistant Professor of Internal Medicine, Division of Digestive and Liver Diseases, Department of Internal Medicine, University of Texas Southwestern Medical Center at Dallas, Southwestern Medical School

Gaurav Arora, MD, MS is a member of the following medical societies: American College of Gastroenterology, American Gastroenterological Association, American Society for Gastrointestinal Endoscopy, American Association of Physicians of Indian Origin

Disclosure: Nothing to disclose.

Coauthor(s)

Frank J Lukens, MD Assistant Professor of Medicine, Program Director of GI Fellowship Program, Director of Endoscopy and Endoscopic Training, Division of Gastroenterology, Hepatology and Nutrition, Department of Internal Medicine, The University of Texas Health Science Center at Houston Medical School

Frank J Lukens, MD is a member of the following medical societies: American Society for Gastrointestinal Endoscopy, Texas Medical Association

Disclosure: Nothing to disclose.

Specialty Editor Board

Mary L Windle, PharmD Adjunct Associate Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Nothing to disclose.

Chief Editor

Vikram Kate, MBBS, PhD, MS, FRCS, FRCS(Edin), FRCS(Glasg), FACS, FACG, FIMSA, MAMS, MASCRS Professor of General and Gastrointestinal Surgery and Senior Consultant Surgeon, Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), India

Vikram Kate, MBBS, PhD, MS, FRCS, FRCS(Edin), FRCS(Glasg), FACS, FACG, FIMSA, MAMS, MASCRS is a member of the following medical societies: American College of Gastroenterology, American College of Surgeons, American Society of Colon and Rectal Surgeons, Royal College of Surgeons of England, Royal College of Physicians and Surgeons of Glasgow, Royal College of Surgeons of Edinburgh

Disclosure: Nothing to disclose.

Additional Contributors

Joseph K Lim, MD Associate Professor of Medicine, Director, Yale Viral Hepatitis Program, Section of Digestive Diseases, Yale University School of Medicine

Joseph K Lim, MD is a member of the following medical societies: American Association for the Study of Liver Diseases, American College of Gastroenterology, American College of Physicians, American Gastroenterological Association, American Society for Gastrointestinal Endoscopy

Disclosure: Nothing to disclose.

Acknowledgements

Medscape Reference thanks Dawn Sears, MD, Associate Professor of Internal Medicine, Division of Gastroenterology and Hepatology, Scott and White Memorial Hospital; and Dan C Cohen, MD, Fellow in Gastroenterology, Scott and White Hospital, Texas A&M Health Science Center College of Medicine, for assistance with the video contribution to this article.

References
  1. Cotton PB, Williams CB, Hawes RH, Saunders BP. Practical Gastrointestinal Endoscopy: The Fundamentals. 6th ed. Singapore: Wiley-Blackwell; 2008.

  2. Stern C. Flexible sigmoidoscopy versus fecal occult blood testing for colorectal cancer screening in asymptomatic individuals. Clin J Oncol Nurs. 2014 Aug 1. 18(4):471-2. [Medline].

  3. Regge D, Iussich G, Senore C, Correale L, Hassan C, Bert A, et al. Population screening for colorectal cancer by flexible sigmoidoscopy or CT colonography: study protocol for a multicenter randomized trial. Trials. 2014 Mar 28. 15:97. [Medline]. [Full Text].

  4. Cappell MS, Friedel D. The role of sigmoidoscopy and colonoscopy in the diagnosis and management of lower gastrointestinal disorders: technique, indications, and contraindications. Med Clin North Am. 2002 Nov. 86(6):1217-52. [Medline].

  5. [Guideline] Rex DK, Johnson DA, Anderson JC, Schoenfeld PS, Burke CA, Inadomi JM. American College of Gastroenterology guidelines for colorectal cancer screening 2009 [corrected]. Am J Gastroenterol. 2009 Mar. 104(3):739-50. [Medline].

  6. Institute for Clinical Systems Improvement (ICSI). Preventive services for adults: level I - colorectal cancer screening. Available at https://www.icsi.org/guideline_sub-pages/preventive_services_adults/level_i__colorectal_cancer_screening/. October 2014; Accessed: February 1, 2016.

  7. Armaroli P, Villain P, Suonio E, Almonte M, Anttila A, Atkin WS, et al. European Code against Cancer, 4th Edition: Cancer screening. Cancer Epidemiol. 2015 Dec. 39 Suppl 1:S139-52. [Medline].

  8. Holme Ø, Bretthauer M, Fretheim A, Odgaard-Jensen J, Hoff G. Flexible sigmoidoscopy versus faecal occult blood testing for colorectal cancer screening in asymptomatic individuals. Cochrane Database Syst Rev. 2013 Oct 1. 9:CD009259. [Medline].

  9. Ormarsson OT, Asgrimsdottir GM, Loftsson T, Stefansson E, Kristinsson JO, Lund SH, et al. Clinical trial: free fatty acid suppositories compared with enema as bowel preparation for flexible sigmoidoscopy. Frontline Gastroenterol. 2015 Oct. 6 (4):278-283. [Medline].

  10. Cappell MS, Friedel D. The role of sigmoidoscopy and colonoscopy in the diagnosis and management of lower gastrointestinal disorders: endoscopic findings, therapy, and complications. Med Clin North Am. 2002 Nov. 86(6):1253-88. [Medline].

  11. Levin TR, Farraye FA, Schoen RE, Hoff G, Atkin W, Bond JH. Quality in the technical performance of screening flexible sigmoidoscopy: recommendations of an international multi-society task group. Gut. 2005 Jun. 54(6):807-13. [Medline].

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Splenic flexure as shown by flexible sigmoidoscopy.
Descending colon as shown by flexible sigmoidoscopy.
Sigmoid colon as shown by flexible sigmoidoscopy.
Rectum as shown by flexible sigmoidoscopy.
Rectum (retroflexed view) as shown by flexible sigmoidoscopy.
Flexible sigmoidoscopy: inflammation due to diverticulitis in sigmoid colon. Video courtesy of Dawn Sears, MD, and Dan C Cohen, MD, Division of Gastroenterology, Scott & White Healthcare.
Flexible sigmoidoscopy: inflammation of rectum (proctitis) in patient who had surgery with J pouch created. Video courtesy of Dawn Sears, MD, and Dan C Cohen, MD, Division of Gastroenterology, Scott & White Healthcare.
Flexible sigmoidoscopy: pseudopolyps in colon. This is common in inflammatory bowel disease (eg, Crohn disease or ulcerative colitis). Video courtesy of Dawn Sears, MD, and Dan C Cohen, MD, Division of Gastroenterology, Scott & White Healthcare.
Flexible sigmoidoscopy: segmental colitis associated with diverticulosis (SCAD). Inflammation is apparent in setting of diverticulosis in sigmoid colon. Video courtesy of Dawn Sears, MD, and Dan C Cohen, MD, Division of Gastroenterology, Scott & White Healthcare.
 
 
 
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