Tag: flexible sigmoidoscopy

Posted on

Flexible Sigmoidoscopy Should Be Encouraged

“Flexible Sigmoidoscopy Should Be Encouraged”

I would like to comment on the two reports from Baltimore on the subject of colonoscopy as a screening tool (“Symptoms not enough to predict women’s colorectal CA,” and “Colonoscopy screening: specialists walk the talk,” the Medical Post, Nov. 4, 2003).

One was a large retrospective study done by Dr. Radhika Srinivasan of the University of Pennsylvania Medical Centre in Philadelphia.

Dr. Srinivasan said most symptoms of colorectal cancer are poor predictors for the presence of the disease. Since colon cancer can occur without any symptoms, Dr. Srinivasan recommends screening colonoscopy for men and women over the age of 50.

The second study was by Dr. Prem Chattoo of St. Vincent’s Hospital in Manhattan, New York. His study showed 70% of gastroenterologists older than 50 years have had a routine screening colonoscopy, compared to about 15% of patients age 50-plus in the general population.

This finding is not surprising. We know screening for colorectal cancer saves lives. But the ideal method of screening remains controversial. Dr. Chattoo’s finding suggests the general public and the referring physicians are still not convinced an asymptomatic person over 50, with no risk factors, needs to undergo screening colonoscopy.

In Canada, my impression is the percentage of asymptomatic patients, at average risk for colorectal cancer undergoing screening colonoscopy, is probably less than 15%. Although colonoscopy remains the gold standard for screening, it is not without disadvantages.

There is a fair amount of waiting before a patient can get in for a consultation. Then there is more waiting before the patient gets a procedure. In the meantime, the patient wonders whether he has cancer or not.

Colonoscopy is as good as the skill and patience of the operator. There is a small risk of bleeding and perforation. Some patients react adversely to sedatives used during the procedure.

Endoscopy time in a hospital setting is at a premium and takes up a significant amount of hospital resources. There is a fair amount of inconvenience to patients and their families before and after the procedure (bowel prep, taking time off work, getting a ride to and from hospital, etc.). There is a great amount of anxiety about the procedure and waiting for the results.

It is estimated colonoscopy costs our health-care system about $1,000 per procedure. Eighty-five per cent of colonoscopies are usually normal and 95% of colonoscopies do not show any cancer.

Gastroenterologists and other GI endoscopists (I used to be one) are keen on promoting colonoscopy as a screening procedure. But somehow, either there is a credibility gap or there is failure in communication. Or there is no convincing argument that screening colonoscopy is as good as screening mammography or Pap smear.

What about symptomatic patients? Do all patients with lower GI symptoms need colonoscopy? Are there other tools that can be used safely and appropriately?

Flexible sigmoidoscopy is a good instrument for symptomatic patients under the age of 40 or even 50 if their symptoms are hemorrhoidal in nature. Patients younger than 40 have an incidence of colorectal cancer anywhere from 1% to 6%. Overall, for an average risk patient the lifetime risk for developing colorectal cancer is 5%.

Flexible sigmoidoscopy has many advantages. It is being underused and undervalued by many endoscopists and physicians. It is safer than colonoscopy. It is easy to perform in an office setting and does not require hospital resources. It is highly sensitive within the distance.

It is a good test for younger patients especially those who have symptoms related to the ano-rectal area. It is a good test for older patients at low risk for colorectal cancer. It is a useful test for reducing the waiting list for colonoscopies. It will make room for symptomatic patients who really need colonoscopy on an urgent basis for whom sometimes it is impossible to find a spot.

Most endoscopists find it easier to book patients for colonoscopy in a hospital than to do a flexible sigmoidoscopy in an office. This is quite a natural process as most endoscopists spend more time in hospital looking after sick patients.

Besides, to buy and maintain a flexible sigmoidoscope in an office requires a fair amount of investment for equipment and staffing. Naturally, the overhead goes up. Hence there is no incentive for physicians to set up a system in the office.

I have been doing flexible sigmoidoscopy in my office for the last 13 years or so. I think flexible sigmoidoscopy should be encouraged and promoted as a good test for many patients. Better fee schedule for the procedure would certainly help. —Dr. Noorali Bharwani, Medicine Hat, Alta.

Start reading the preview of my book A Doctor's Journey for free on Amazon. Available on Kindle for $2.99!

Posted on

Some Answers to Questions About Flexible Sigmoidoscopy

SOME ANSWERS TO QUESTIONS ABOUT FLEXIBLE SIGMOIDOSCOPY

This test has been booked for at to be done in my office.
If you fail to keep this appointment, then we reserve the right to bill you for not showing up.

How to prepare for Flexible Sigmoidoscopy?
1. Stay on clear fluids after lunch the day before the procedure.

2. The evening before the test, take one bottle of Magnesium Citrate at 8:00p.m. One or two hours before coming to my office, use one FLEET ENEMA rectally.

3. No Aspirin or Aspirin containing pills for 7 days and no blood thinners like Coumadin for 3 days before the procedure. Consult your family doctor.

4. Stay on clear fluids the day of the procedure.

5. Take Midazolam 7.5 mg orally with water ½ hour before the procedure. You cannot drive that day.

What is Flexible Sigmoidoscopy?

A Flexible Sigmoidoscope is a short flexible tube that is about the thickness of a finger. It is inserted through the rectum into the large intestine (colon) and allows the physician to carefully examine the lining of the left colon. Abnormalities which are too small to be seen on x-ray may also be identified.

If the doctor sees a suspicious area, he can pass an instrument through the scope and take a small piece of tissue (a biopsy) for examination in the laboratory.

What is Polypectomy?

During the course of the examination, a polyp may be found. Polyps are abnormal growths of tissue which vary in size from a tiny dot to several inches. Polyps are usually removed because they can cause rectal bleeding or contain cancer. Although majority of polyps are benign (noncancerous), a small percentage may contain an area of cancer in them or may develop into cancer. Removal of colon polyps, therefore, is an important means of prevention and cure of colon cancer, which is a leading form of cancer in Canada.

What should you expect during the procedure?

Usually, no medication is required for this procedure. While you are lying in a comfortable position, the scope is inserted into the rectum and gradually advanced through the colon while the lining is examined thoroughly. The scope is then slowly withdrawn while the intestine is again carefully examined.

The procedure is usually well tolerated and rarely causes pain. There may be some discomfort during the test but it is usually mild. A limited examination may be sufficient if the area of suspected abnormality was well visualized. Rarely, the examination may be unsuccessful due to technical reasons.

What happens after flexible sigmoidoscopy?

You may feel bloated for a few minutes right after the procedure because of the air that was introduced while examining the colon. You will be able to resume your diet after the test unless you are instructed otherwise.

Are there any complications from flexible sigmoidoscopy and polypectomy?

Flexible sigmoidoscopy and polypectomy are safe and are associated with very low risk when performed by physicians who have been specially trained and are experienced in these endoscopic procedures. One possible complication is perforation in which a tear through the wall of the bowel may allow leakage of intestinal fluids. This complication usually requires surgery, but may be managed with antibiotics and intravenous fluids in selected cases.

Bleeding may occur from the site of the biopsy or polyp removal. It is usually minor and stops on its own or can be controlled by cauterization (application of electrical current) through the scope. Rarely, transfusions or surgery may be required.

Why is Flexible Sigmoidoscopy necessary?

Flexible sigmoidoscopy is a valuable tool for the diagnosis and treatment of many diseases of the large intestine. Abnormalities suspected by x-ray can be confirmed and studied in detail. Even when x-rays are negative, the cause of symptoms such as rectal bleeding or change in bowel habits may be found. It is useful for the diagnosis and follow-up of patients with inflammatory bowel disease as well.

The greatest impact is probably in its contribution to the control of colon cancer by polyp removal. Before, major abdominal surgery was the only way to remove colon polyps to determine if they were benign or malignant. Now, most polyps can be removed easily and safely without surgery.

Periodic scoping is a valuable tool for follow-up of patients with previous polyps, colon cancer, or a family history of colon cancer.

Flexible sigmoidoscopy is a safe and extremely worthwhile procedure which is very well tolerated. If you have any questions about your need for this test, do not hesitate to speak to me, and I will be happy to discuss it with you. We share a common goal – your good health – and it can only be achieved through mutual trust, respect and understanding.

Additional Instructions: If due to unavoidable circumstances, you cannot keep your appointment, please let us know well in advance for us to call another patient waiting for this test.

Revised: July 7, 2003

Start reading the preview of my book A Doctor's Journey for free on Amazon. Available on Kindle for $2.99!

Posted on

Screening Can Save Your Life

Dear Dr. B: Are there any recommendations for colorectal cancer screening from the Canadian Task Force on Preventive Health Care? Yours, Mr.C.

Dear Mr. C: Yes. A statement from the Task Force on colorectal screening was published recently in the Canadian Medical Association Journal. These recommendations are for asymptomatic people with no personal history of ulcerative colitis, polyps or colorectal cancer. I will summarise the recommendations here:

Recommendations for people over the age of 50 who are at normal risk:

1. There is good evidence to suggest that these people should have annual or biennial (every two years) test to check for non-visible blood in the stool (fecal occult blood tests).

2. There is fair evidence to include flexible sigmoidoscopy (an office procedure). Some recommend this every five years.

3. There is insufficient evidence to recommend whether only one or both (1 and 2) should be performed.

4. There is insufficient evidence to include or exclude colonoscopy as an initial screening test in this age group. Some recommend colonoscopy every 10 years.

Recommendation for people at above-average risk:

1. There is fair evidence to include either genetic testing or flexible sigmoidoscopy of people in families with familial adenomatous polyposis – a condition in which multiple adenomatous polyps progressively develop throughout the colon. The polyps first appear after puberty. Other benign and malignant lesions may appear on the body.

2. There is fair evidence to include colonoscopy screening in the periodic health examination of people in families with hereditary non-polyposis colon cancer – a condition in which three family members are affected with colorectal cancer, two of whom are in successive generations and at least one is under the age of 45 years. It is unclear at what age the screening should start and how often colonoscopy should be done.

3. There is insufficient evidence to recommend colonoscopy for people who have a family history (people who have two or more first degree relatives) of colorectal polyps or cancer but who do not meet the criteria for hereditary non-polyposis colon cancer. Some experts recommend colonoscopy for this group as it is accepted that people with family history of colon and rectal cancer may be at increased risk but that this risk is not well defined.

What are the advantages of screening? To reduce the number of deaths from colorectal cancer.

What are the disadvantages? The incidence of false positive and false negative tests especially with fecal occult blood testing. There is incidence of perforation from flexible sigmoidoscopy (1.4 per 10,000 procedures) and colonoscopy (10 per 10,000 procedures).

Colorectal cancer is the third most common cancer in Canada. It accounts for more than 12 percent of cases of cancer in both sexes.

It was estimated that there would be 17,000 new cases and 6,500 deaths from colorectal cancer in Canada in 2000. These rates, especially among men, are among the highest in the world.

But how many of us are ready to submit ourselves to screening for colorectal cancer? Not many. The embarrassment and discomfort of a rectal examination, unpleasant bowel cleansing before flexible sigmoidoscopy and colonoscopy, risk of bowel perforation, and anxiety dissuade people from coming forward for screening. Even symptomatic patients take a long time before they see their doctors.

Well, Mr. C, if any of the recommendations apply to you then see your doctor and have yourself checked out. Prevention is better than…….?

Start reading the preview of my book A Doctor's Journey for free on Amazon. Available on Kindle for $2.99!