Sigmoidoscopy is a diagnostic and screening procedure in which a rigid or flexible tube with a camera on the end (a sigmoidoscope) is inserted into the anus to examine the rectum and lower colon (bowel) for bowel disease, cancer, precancerous conditions, or causes of bleeding or pain.
Sigmoidoscopy is used most often in screening for colorectal cancer or to determine the cause of rectal bleeding. It is also used in diagnosis of inflammatory bowel disease, microscopic and ulcerative colitis, and Crohn's disease.
Cancer of the rectum and colon is the second most common cancer in the United States. About 155,000 cases are diagnosed annually. Between 55,000 and 60,000 Americans die each year of cancer in the colon or rectum.
After reviewing a number of studies, experts recommend that people over 50 be screened for colorectal cancer using sigmoidoscopy every three to five years. Individuals with such inflammatory bowel conditions as Crohn's disease or ulcerative colitis, and thus are at increased risk for colorectal cancer, may begin their screenings at a younger age, depending on when their disease was diagnosed. Many physicians screen such persons more often than every three to five years. Screening should also be performed in people who have a family history of colon or rectal cancer, or small growths in the colon (polyps).
Some physicians do this screening with a colonoscope, which allows them to see the entire colon. However, most physicians prefer sigmoidoscopy, which is less time-consuming, less uncomfortable, and less costly.
Studies have shown that one-quarter to one-third of all precancerous or small cancerous growths can be seen with a sigmoidoscope. About one-half are found with a 1 ft (30 cm) scope, and two-thirds to three-quarters can be seen using a 2 ft (60 cm) scope.
In some cases, the sigmoidoscope can be used therapeutically in conjunction with such other equipment as electrosurgical devices to remove polyps and other lesions found during the sigmoidoscopy.
Experts estimate that in excess of 500,000 sigmoidoscopy procedures are performed each year. This number includes most of the persons who are diagnosed with colon cancer each year, a greater number who are screened and receive negative results, persons who have been treated for colon conditions and receive a sigmoidoscopy as a follow-up procedure, and individuals who are diagnosed with other diseases of the large colon.
Sigmoidoscopy may be performed using either a rigid or flexible sigmoidoscope. A sigmoidoscope is a thin tube with fiberoptics, electronics, a light source, and camera. A physician inserts the sigmoidoscope into the anus to examine the rectum (the first 1 ft [30 cm] of the colon) and its interior walls. If a 2 ft (60 cm) scope is used, the next portion of the colon can also be examined for any irregularities. The camera of the sigmoidoscope is connected to a viewing monitor, allowing the interior of the rectum and colon to be enlarged and viewed on the monitor. Images can then be recorded as still pictures or the entire procedure can be videotaped. The still pictures are useful for comparison purposes with the results of future sigmoidoscopic examinations.
If polyps, lesions, or other suspicious areas are found, the physician biopsies them for analysis. During the sigmoidoscopy, the physician may also use forceps, graspers, snares, or electrosurgical devices to remove polyps, lesions, or tumors.
The sigmoidoscopy procedure requires five to 20 minutes to perform. Preparation begins one day before the procedure. There is some discomfort when the scope is inserted and throughout the procedure, similar to that experienced when a physician performs a rectal exam using a finger to test for occult blood in the stool (another important screening test for colorectal cancer). Individuals may also feel some minor cramping pain. There is rarely severe pain, except for persons with active inflammatory bowel disease.
Private insurance plans almost always cover the cost of sigmoidoscopy examinations for screening in healthy individuals over 50, or for diagnostic purposes. Medicare covers the cost for diagnostic exams, and may cover the costs for screening exams. Medicaid benefits vary by state, but sigmoidoscopy is not a covered procedure in many states. Some community health clinics offer the procedure at reduced cost, but this can only be done if a local gastroenterologist (a physician who specializes in treating stomach and intestinal disorders) is willing to donate personal time to perform the procedure.
The purpose of preparation for sigmoidoscopy is to cleanse the lower bowel of fecal material or stool so the physician can see the lining. Preparation begins 24 hours before the procedure, when an individual must begin a clear liquid diet. Preparation kits are available in drug stores. In normal preparation, about 20 hours before the exam, a person begins taking a series of laxatives , which may be oral tablets or liquid. The individual must stop drinking any liquid four hours before the exam. An hour or two prior to the examination, the person uses an enema or laxative suppository to finish cleansing the lower bowel.
Individuals need to be careful about medications before having sigmoidoscopy. They should not take aspirin , products containing aspirin, or products containing ibuprofen for one week prior to the exam, because these medications can exacerbate bleeding during the procedure. They should not take any iron or vitamins with iron for one week prior to the exam, since iron can cause color changes in the bowel lining that interfere with the examination. They should take any routine prescription medications, but may need to stop certain medications. Prescribing physicians should be consulted regarding routine prescriptions and their possible effect(s) on sigmoidoscopy.
Individuals with renal insufficiency or congestive heart failure need to be prepared in an alternative way, and must be carefully monitored during the procedure.
There is no specific aftercare necessary following sigmoidoscopy. If a biopsy was taken, a small amount of blood may appear in the next stool. Persons should be encouraged to pass gas following the procedure to relieve any bloating or cramping that may occur after the procedure. In addition, an infection may develop following sigmoidoscopy. Persons should be instructed to call their physician if a fever or pain in the abdomen develops over the few days after the procedure.
There is a slight risk of bleeding from the procedure. This risk is heightened in individuals whose blood does not clot well, either due to disease or medication, and in those with active inflammatory bowel disease. Rarely, trauma to the bowel or other organs can occur, resulting in an injury (perforation) that must be repaired, or peritonitis, which must be treated with medication.
Sigmoidoscopy may be contraindicated in persons with severe active colitis or toxic megacolon (an extremely dilated colon). In general, people experiencing continuous ambulatory peritoneal dialysis are not candidates due to a high risk of developing intraperitoneal bleeding.
The results of a normal examination reveal a smooth colon wall, with sufficient blood vessels for good blood flow.
Morbidity and mortality rates
For a cancer screening sigmoidoscopy, an abnormal result is one or more noncancerous or precancerous polyps, or clearly cancerous polyps. People with polyps have an increased risk of developing colorectal cancer in the future and may be required to undergo additional procedures such as colonoscopy or more frequent sigmoidoscopic examinations.
Small polyps can be completely removed. Larger polyps may require the physician to remove a portion of the growth for laboratory biopsy. Depending on the laboratory results, a person is then scheduled to have the polyp removed surgically, either as an urgent matter if it is cancerous, or as an elective procedure within a few months if it is non-cancerous.
In a diagnostic sigmoidoscopy, an abnormal result shows signs of active inflammatory bowel disease, either a thickening of the intestinal lining consistent with ulcerative colitis, or ulcerations or fissures consistent with Crohn's disease.
Mortality from a sigmoidoscopy examination is rare and is usually due to uncontrolled bleeding or perforation of the colon.
A screening examination for colorectal cancer is a test for fecal occult blood. A dab of fecal material from toilet tissue is smeared onto a card. The card is treated in a laboratory to reveal the presence of bleeding. This test is normally performed prior to a sigmoidoscopic examination.
A less invasive alternative to a sigmoidoscopic examination is an x ray of the colon and rectum. Barium is used to coat the inner walls of the colon. This lower GI (gastrointestinal) x ray may reveal the outlines of suspicious or abnormal structures. It has the disadvantage of not allowing direct visualization of the colon. It is less costly than a sigmoidoscopic examination.
A more invasive procedure is direct visualization of the colon during surgery. This procesdure is rarely performed in the United States.
Bland, K. I., W. G. Cioffi, and M. G. Sarr. Practice of General Surgery. Philadelphia: Saunders, 2001.
Grace, P. A., A. Cuschieri, D. Rowley, N. Borley, and A. Darzi. Clinical Surgery, 2nd Edition. London: Blackwell Publishers, 2003.
Miller, B. E. Atlas of Sigmoidoscopy and Cytoscopy. Boca Raton, FL: CRC Press, 2001.
Schwartz, S. I., J. E. Fischer, F. C. Spencer, G. T. Shires, and J. M. Daly. Principles of Surgery, 7th Edition. New York: McGraw Hill, 1998.
Townsend, C., K. L. Mattox, R. D. Beauchamp, B. M. Evers, and D. C. Sabiston. Sabiston's Review of Surgery, 3rd Edition. Philadelphia: Saunders, 2001.
Wigton, R. S. Flexible Sigmoidoscopy and Other Gastrointestinal Procedures. St. Louis: Mosby-Year Book, 2000.
Mandel, J. S. "Sigmoidoscopy Screening Probably Works, But How Well Is Still Unknown." Journal of the National Cancer Institute 95, no.8 (2003): 571–573.
Nelson, D. E., J. Bolen, S. Marcus, H. E. Wells, and H. Meissner. "Cancer Screening Estimates for U.S. Metropolitan Areas." American Journal of Preventive Medicine 24, no.4 (2003): 301–309.
Newcomb, P. A., B. E. Storer, L. M. Morimoto, A. Templeton, and J. D. Potter. "Long-term Efficacy of Sigmoidoscopy in the Reduction of Colorectal Cancer Incidence." Journal of the National Cancer Institute 95, no.8 (2003): 622–625.
Walsh, J. M., and J. P. Terdiman. "Colorectal Cancer Screening: Clinical Applications." Journal of the American Medical Association 289, no.10 (2003): 1297–1302.
Walsh, J. M., and J. P. Terdiman. "Colorectal Cancer Screening: Scientific Review." Journal of the American Medical Association 289, no.10 (2003): 1288–1296.
American Academy of Family Physicians. 11400 Tomahawk Creek Parkway, Leawood, KS 66211-2672. (913) 906-6000. E-mail: http://firstname.lastname@example.org. http://www.aafp.org .
American College of Surgeons. 633 North St. Clair Street, Chicago, IL 60611-32311. (312) 202-5000, Fax: (312) 202-5001. E-mail: http://email@example.com. http://www.facs.org .
American Society for Gastrointestinal Endoscopy. 1520 Kensington Road, Suite 202, Oak Brook, IL 60523. (630) 573-0600, Fax: (630) 573-0691. E-mail: http://firstname.lastname@example.org. http://www.asge.org .
Society of American Gastrointestinal Endoscopic Surgeons. 2716 Ocean Park Blvd., Suite 3000, Santa Monica, CA 90405. (310) 314-2404, Fax: (310) 314-2585. E-Mail: http://email@example.com. http://www.sages.org .
American Academy of Family Physicians [cited May 5, 2003] http://www.aafp.org/afp/990115ap/313.html .
American Cancer Society. [cited May 5, 2003] <http://www.cancer.org/docroot/SPC/content/SPC_1_Colonoscopy_an _Sigmoidoscopy_FAQ.asp> .
American Society for Gastrointestinal Endoscopy. [cited May 5, 2003] http://www.asge.org/gui/patient/flex.asp .
National Institute of Diabetes and Digestive and Kidney Diseases. [cited May 5, 2003] <http://www.niddk.nih.gov/health/digest/pubs/diagtest/sigmo.htm #x003E; .
National Library of Medicine. [cited May 5, 2003] <http://www.nlm.nih.gov/medlineplus/ency/article/003885.htm 3E; .
Society of American Gastrointestinal and Endoscopic Surgeons. [cited May 5, 2003] http://www.sages.org/pi_flexible_sigmoidoscopy.html .
L. Fleming Fallon, Jr, MD, DrPH
WHO PERFORMS THE PROCEDURE AND WHERE IS IT PERFORMED?
A colonoscopy procedure is usually performed by a gastroenterologist, a physician with specialized training in diseases of the colon. Alternatively, general surgeons or experienced family physicians perform sigmoidoscopic examinations. In the United States, the procedure is usually performed in an outpatient facility of a hospital or in a physician's professional office.
Persons with rectal bleeding may need a full colonoscopy in a hospital setting. Individuals whose blood does not clot well (possibly as a result of blood-thinning medications) may require the procedure to be performed in a hospital setting.
QUESTIONS TO ASK THE DOCTOR
- Is the supervising physician appropriately certified to conduct a sigmoidoscopy?
- How many sigmoidoscopy procedures has the doctor performed?
- What other steps will be taken as a result of my test findings?