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PubMed1986

Screening for colorectal cancer and polyps among pattern makers.

In response to a union request, a cancer screening program was conducted for the Pattern Makers' League of North America. Ten colon cancer cases were detected among the 1,465 white men screened with a flexible sigmoidoscope. The difficulties in obtaining appropriate "expected" numbers were that prevalent detectable preclinical colon cancer is not equivalent to incident disease, and the flexible sigmoidoscope yields results not directly comparable to those of the rigid sigmoidoscope used previously. The "expected" number of cancers was obtained by using an independent estimate of 5 years for the mean duration of the detectable preclinical phase. This implied that the expected number of colon cancer cases should be based on the age-specific incident rates among white men in the next-older 5-year age group and that the annual expected number should be multiplied by five. Therefore, the ten observed cases of colon malignancies represented an approximately threefold increase. For invasive cancer only, there was a slightly less than twofold cancer increase. Fifteen percent of the men had one or more colorectal polyps.

Adult↗
PubMed1993

Removal of bulky tissue at laparoscopic surgery.

A technique for extraction of bulky tissue during laparoscopic surgery is presented. One laparoscopic cannula is replaced with a sigmoidoscope which acts as a wide-bore cannula. At laparoscopic cholecystectomy, 22 of 60 (38%) patients were found to require wound enlargement to remove a grossly diseased gall-bladder. Use of a sigmoidoscope as a cannula was associated with fewer technical complications than surgical wound extension. At laparoscopic appendicectomy, the appendix could not be removed through the standard laparoscopic cannula in 16 of 46 (31%) cases. The incidence of wound infection was significantly lower after laparoscopic appendicectomy than among a group of 98 patients having conventional appendicectomy (P = 0.024). It is concluded that a sigmoidoscope can be used as a replacement cannula allowing uncomplicated removal of bulky tissue and reducing wound contamination.

Appendectomy↗
PubMed1977

Rectal potential difference and histology in Crohn's disease.

The rectal potential difference (PD) was measured in 27 patients with Crohn's disease, and in 16 subjects without gastrointestinal disease to establish a normal range. Sigmoidoscopic assessment and rectal biopsy were performed in all patients with Crohn's disease, and the mean resting rectal PD was significantly reduced in patients with sigmoidoscopically active disease and in those with abnormalities of the superficial epithelium on rectal biopsy. Patients with diarrhoea had a significantly lower mean resting PD than those with normal bowel habit, suggesting that an abnormality of rectal sodium transport may be contributing to the diarrhoea in these patients. The response of rectal PD to mineralocorticoid stimulation with oral fludrocortisone was measured in 13 patients. The PD failed to rise only with patients with sigmoidoscopically active disease, and the test proved to be a less sensitive indication of minor mucosal abnormalities than sigmoidoscopy of biopsy.

Crohn Disease↗
PubMed1988

Treatment of left-sided ulcerative colitis with 4-aminosalicylic acid enemas. A double-blind, placebo-controlled trial.

Twenty-five patients with active left-sided ulcerative colitis were randomly assigned to receive either 2 g of 4-aminosalicylic acid (para-aminosalicylic acid) or placebo in a 60-mL volume as a nightly retention enema. The duration of treatment was 8 weeks. Disease activity was assessed by grading clinical symptoms of blood, mucus, urgency, sigmoidoscopic findings, and degree of histologic inflammation in rectal biopsies. At 8 weeks, 10 of 12 patients (83%; 95% confidence interval [CI], 55% to 97%) who received 4-aminosalicylic acid showed improvement in clinical, sigmoidoscopic, and histologic variables. In contrast, only 2 of 13 patients (15%, 95% CI, 4% to 38%) who had received placebo showed clinical improvement (P less than 0.005). The 11 patients in the placebo group who showed no improvement were treated subsequently with open-label 4-aminosalicylic acid enemas. Of the 11, 9 showed clinical, sigmoidoscopic, and histologic improvement. No adverse effects were seen. 4-Aminosalicylic acid enemas are a safe and effective means of treating left-sided ulcerative colitis.

Adult↗
PubMed1991

The sentinel hyperplastic polyp: a marker for synchronous neoplasia in the proximal colon.

We prospectively screened 129 asymptomatic subjects (mean age 64 yr) with flexible sigmoidoscopy. Colonoscopy was performed at a later date, regardless of the sigmoidoscopic result. Our intent was 1) to establish the prevalence of proximal neoplasms in patients with and without hyperplastic polyps within reach of the 60-cm sigmoidoscope and 2) to determine whether a distal (sentinel) hyperplastic polyp predicts the presence of synchronous neoplastic polyps higher up in the colon. Our results show that 15% of asymptomatic adult subjects without polyps on sigmoidoscopy have adenomas in proximal colonic segments that can be diagnosed only by colonoscopy. By comparison, proximal neoplasms were detected in 32% (p less than 0.05) and 37% (p less than 0.05) of patients when hyperplastic or adenomatous polyps, respectively, were present on the sigmoidoscopic examination. This finding suggests that a distal (sentinel) hyperplastic polyp by itself may be a marker for neoplastic polyps in proximal colonic segments. Also, the "index" adenoma and "sentinel" hyperplastic polyp may be equivalent for predicting the presence of proximal neoplasms. The observed detection rates for these polyps were both significantly higher than expected when compared to patients who did not have polyps in the distal colon or rectum. If these results can be confirmed by a larger prospective trial, then full colonoscopy for detection of proximal neoplasms may be indicated when either an index adenoma or sentinel hyperplastic polyp is detected by sigmoidoscopy.

Aged↗
PubMed1978

A clinicopathologic study on patients suffering from "chronic dysentery".

Fifty adult patients with the self diagnosis of "chronic dysentery" were studied. Their faeces were examined microscopically; they were sigmoidoscoped and their rectal mucosa were examined histologically. Most of them had irritable bowel syndrome. Their sigmoidoscopic appearances were normal and the histology showed only mild increase in the numbers of round cells in the lamina propria. This was regarded as normal for the local population. Ten patients showed cysts of Entamoeba histolytica in the faeces. This was thought to be unrelated to the symptoms. Only four patients had sigmoidoscopic as well as histologic evidence of moderate to severe proctocolitis. One of them was proven to be a case of amoebic colitis. These findings have been discussed.

Adult↗
PubMed1988

Training primary care physicians in flexible sigmoidoscopy--performance evaluation of 17,167 procedures.

The flexible fiber-optic sigmoidoscope is rapidly replacing the rigid sigmoidoscope in routine screening for colorectal cancer. This study was undertaken to evaluate the safety, usage pattern, and efficacy of fiber-optic sigmoidoscopy by evaluating the outcome of training and the results of procedures carried out by a group of primary care physicians. Of 1,153 participants in one-day flexible sigmoidoscopy workshops, 764 (66%) returned questionnaires evaluating their experiences following this training. Of these, 438 physicians had obtained a flexible sigmoidoscope, used it frequently, and had done a total of 17,167 examinations. The average time of scope usage was nine months. Although additional supervised training was suggested at the time of the workshop, 68% of physicians began doing flexible sigmoidoscopy without it. A total of 465 polyps and 153 cancers were detected by the study group for an overall detection rate of 2.7% for polyps and 0.9% for cancers. Four complications were reported. This study indicates that the technique of flexible sigmoidoscopy is readily learned, is diagnostically productive, and is reasonably safe in the hands of primary care physicians.

Education, Medical, Continuing↗
PubMed1986

5-Aminosalicylic acid enemas in refractory distal ulcerative colitis: a randomized, controlled trial.

5-Aminosalicylic acid (5-ASA), the presumed active moiety of sulfasalazine, has shown clinical efficacy when administered per rectum as initial therapy to patients with distal ulcerative colitis. We report the results of a randomized double-blind trial comparing nightly retention of a 4-g 5-ASA enema with continued administration of hydrocortisone enemas in 18 patients with persistent active distal ulcerative colitis after at least a 3-wk course of treatment with 100-mg hydrocortisone enemas with or without oral sulfasalazine. Continuation of hydrocortisone enemas rather than placebo was used in the control group to reflect the realistic alternative therapy likely to be employed in current practice. Response to therapy was assessed after 3 wk by comparing pretreatment and posttreatment point scores of clinical, sigmoidoscopic, and histological severity. Improvement in clinical score was achieved in seven of nine 5-ASA enema-treated patients versus one of nine hydrocortisone enema-treated patients (p less than 0.05). Sigmoidoscopic and histological improvement generally paralleled clinical improvement. We conclude that in patients with distal ulcerative colitis unresponsive to standard therapy, treatment with 5-ASA enemas results in significant short-term clinical and sigmoidoscopic improvement in a majority of cases. Moreover, a significantly greater number of refractory patients improve when switched to 5-ASA enemas than when continued on standard therapy.

Adult↗
PubMed1986

Feasibility of 105-cm flexible sigmoidoscopy in family practice.

The 105-cm flexible sigmoidoscope was studied for the feasibility of its use in a family practice setting in screening for colorectal cancers and polyps. A total of 49 examinations were performed. The average length of colon examined was 71 cm. Insertion to 105 cm was accomplished in 14 patients (29 percent) and exceeded 65 cm in 28 patients (57 percent). No complications of the procedure were encountered. The study indicated that some patients, with no special preparation or medications and no additional discomfort, might benefit by the more thorough screening afforded by 105-cm flexible sigmoidoscope. What is not yet known is the efficacy of large-scale screening for cancers and polyps utilizing the 105-cm flexible sigmoidoscope in the family practice setting.

Colonic Neoplasms↗
PubMed1993

Mesalamine capsules for treatment of active ulcerative colitis: results of a controlled trial. Pentasa Study Group.

The efficacy of a capsule formulation of mesalamine was assessed in 374 patients with mild to moderately active ulcerative colitis. Patients, stratified to pancolitis or left-sided disease, received either placebo or mesalamine at 1, 2, or 4 g daily for 8 wk. Efficacy was assessed using clinical improvement--physician global assessment, sigmoidoscopic index, biopsy score, trips to the toilet, and clinical symptoms (abdominal pain, urgency, stool consistency, and rectal bleeding)--and induction of remission (more stringent criteria for physician global assessment, sigmoidoscopic index, and biopsy score). For physician global assessment of treatment benefit, 79% and 84% of patients on the 2-g and 4-g doses of mesalamine, respectively, received treatment benefit, compared with 54% on placebo (p < or = 0.0002). For the physician global assessment of treatment success, both the 2-g and 4-g doses of mesalamine were superior to placebo (57% and 59% of patients, p = 0.0021 and 0.0012, respectively), compared with 36% on placebo. Both the 2-g and 4-g doses produced statistically significant macroscopic (endoscopic) improvement compared with placebo (p < 0.004). The 4-g dose also produced a statistically significant microscopic (histologic) improvement compared to placebo (p < 0.002). Significant improvement compared to placebo was also observed at 2 g and 4 g for the four clinical symptoms and trips to the toilet (p < or = 0.003). Oral mesalamine capsules were significantly superior to placebo for inducing remission, with 29% of patients at 2 g and 29% at 4 g achieving remission by physician global assessment, compared with 12% on placebo. Forty-four percent and 48% of patients receiving 2 g and 4 g of mesalamine, respectively, achieved remission by sigmoidoscopic index (p < 0.05), compared with 31% on placebo. Thirty-nine percent of patients at 4 g daily achieved microscopic remission, compared with 23% on placebo (p < 0.03). Treatment response was not affected by extent of disease or prior steroid or sulfasalazine therapy. These data suggest that controlled-release mesalamine capsules are a safe and effective monotherapy in doses of 2-4 g daily for treating mild to moderately active ulcerative colitis, as well as for inducing remission, regardless of prior oral steroid or sulfasalazine therapy or extent of disease.

Adult↗
PubMed1998

Factors associated with the use of flexible sigmoidoscopy as a screening test for the detection of colorectal carcinoma by primary care physicians.

BACKGROUND: Despite current recommendations of flexible sigmoidoscopy as a screening test for the detection of colorectal carcinoma, relatively few asymptomatic patients undergo this procedure. To enhance the use of sigmoidoscopy, differences in the use of screening, as well as barriers to screening among specific physician groups, should be defined. METHODS: The authors surveyed 1762 practicing primary care physicians to determine their self-reported ability to perform sigmoidoscopy and perceived obstacles to either initiating or enhancing screening. RESULTS: A total of 884 physicians (50%) responded. Ninety percent of primary care physicians reported that they offered sigmoidoscopic screening to their patients, with 46% referring patients and 44% performing the procedure themselves. Physician characteristics were not associated with the overall use of sigmoidoscopy. In contrast, compared with physicians who referred patients for the procedure, physicians who performed sigmoidoscopy themselves were more often board certified, male, and graduated from medical school after 1970 (P < 0.001). In a multivariate analysis, these characteristics were also independently associated with the ability to perform sigmoidoscopy. The barrier to sigmoidoscopy cited most often was poor patient acceptance, whether or not the physician performed or referred patients for sigmoidoscopic screening. Other barriers cited were lack of training, lack of equipment, and time required, each of which was identified most often by physicians who did not screen at all. CONCLUSIONS: Most physicians surveyed reported using sigmoidoscopic screening to some degree in their practice, although many did not perform the procedure themselves. Population-based interventions to increase screening may benefit from targeting specific physician subgroups and attempting to improve patient acceptance of the procedure.

Colorectal Neoplasms↗
PubMed1986

A comparison of the 25-cm rigid proctosigmoidoscope with the 65-cm flexible endoscope in the screening of patients for colorectal carcinoma.

A comparison of the rigid with the flexible sigmoidoscope was evaluated in 293 patients as part of a screening project for colorectal cancer at Roswell Park Memorial Institute. Patients with either a positive family history for colorectal cancer, a positive stool guaiac test result, a history of hematochezia, or a change in bowel habits were randomly assigned to either rigid or flexible sigmoidoscopy. The median distance of colon examined with the flexible instrument was significantly greater than with the rigid scope (55 versus 17 cm, respectively). A significantly greater number of malignant and premalignant lesions were found with the flexible instrument than with the rigid scope. It was concluded that the flexible sigmoidoscope is superior to the rigid scope in the process of screening for colorectal lesions.

Adolescent↗
PubMed2004

Small early tubular adenomas and mixed colonic polyps found on screening flexible sigmoidoscopy do not predict proximal neoplasia in males.

BACKGROUND & AIMS: Distal colonic adenomas found on flexible sigmoidoscopy are associated with proximal neoplasias, thus requiring a complete colonoscopic examination, but data regarding the association of distal mixed polyps with proximal neoplasia are lacking. We conducted this study to elucidate the significance of distal mixed colonic polyps in predicting proximal neoplasia. METHODS: We retrospectively analyzed data from patients who underwent a flexible sigmoidoscopic examination for colorectal cancer screening and a follow-up colonoscopic examination because of distal colonic polyps. Distal index polyps were classified by a pathologist as early tubular adenoma (ETA), serrated, or true mixed categories. Index polyps also were immunostained with a monoclonal antibody, Adnab-9, a marker for the colorectal adenoma carcinoma sequence. RESULTS: In 636 patients with distal index polyps, 6% were malignant, 55% were adenomas, 13% were ETAs, 6% were serrated, 4% were true mixed, and 17% were hyperplastic. Compared with distal hyperplastic index polyps, distal malignant polyps (P = 0.0006) and adenomas (P = 0.001) were associated with a significantly increased number of synchronous proximal neoplasia, but the small distal mixed, serrated, or ETA did not predict the increased incidence of proximal neoplasia. Large distal polyps of each category were significantly associated with an increased number of synchronous proximal neoplasias. In support of these findings, immunostaining of distal polyps with Adnab-9 showed predictability for proximal neoplasia only in the adenoma category (P < 0.05). CONCLUSIONS: Small ETAs, serrated, or mixed polyps found on flexible sigmoidoscopic examination do not increase the probability of synchronous proximal neoplasia.

Adenomatous Polyps↗
PubMed1998

A randomized trial comparing three methods of bowel preparation for flexible sigmoidoscopy.

OBJECTIVE: The aim of this study was to assess the optimum method of bowel preparation for flexible sigmoidoscopy. METHODS: A total of 164 adults undergoing flexible sigmoidoscopy at an ambulatory clinic were randomized to receive one of three preparations: a single hyperphosphate enema 1 h before the procedure; a hyperphosphate enema given 1 and 2 h before the procedure; or a hyperphosphate enema administered 1 and 2 h before the procedure, preceded by a 296 ml bottle of magnesium citrate taken p.o. the night before. Patients completed surveys on preparation and procedure comfort and satisfaction. The performing endoscopist assessed preparation quality, procedure duration, and depth of sigmoidoscope insertion. RESULTS: All three preparations were equally well tolerated with slightly more diarrhea reported among patients receiving magnesium citrate (p = 0.007). The addition of magnesium citrate resulted in more procedures rated by the endoscopist as excellent or good (RR 1.5, 95% CI: 1.3-1.9), deeper sigmoidoscope insertion (56 vs 51 cm, p = 0.0036), fewer procedures requiring repeat preparation (RR: 0.21, 95% CI: 0.04-0.98) and more procedures rated by patients as discomfort free (RR: 2.2, 95% CI: 1.39-3.60). Excellent and good preparations were associated with shorter procedure duration (19 vs 14 min, p = 0.008) and greater depth of insertion (56 vs 50 cm, p = 0.003). Fewer diverticuli were noted with a single enema than the two enema preparation (p = 0.006) with the remaining outcomes equal between these two groups. CONCLUSION: The addition of bottle of magnesium citrate to a 2-hyperphosphate enema preparation is well tolerated and improves bowel preparation for flexible sigmoidoscopy.

Abdominal Pain↗
PubMed2004

Screening flexible sigmoidoscopy using an upper endoscope is better tolerated by women.

BACKGROUND: Flexible sigmoidoscopy (FS) is a commonly used method for colorectal cancer screening. Women are more likely than men to have a FS with a limited depth of insertion, in part due to differences of anatomy and perception of pain. AIM: The objective of this prospective single-blinded randomized clinical study is to assess satisfaction in women undergoing screening FS using an upper endoscope (E, diameter 9.8 mm) versus a standard sigmoidoscope (S, diameter 13.3 mm) as measured by pain and discomfort and overall satisfaction using a validated survey instrument. Secondary endpoints of FS efficacy included the depth of insertion of the instrument, frequency of polyp detection, and complication rate. RESULTS: A total of 160 asymptomatic women undergoing screening FS were entered over a 4-month period (July through November 2002). All procedures were performed by two experienced physician assistants. The two groups were of similar age (E = 57.5, S = 58.2, p= 0.579) and had a similar rate of previous abdominal surgery (E = 51.2%, S = 45.0%, p= 0.428) or hysterectomy (E = 34.2%, S = 26.3%, p= 0.274). Depth of insertion of the scope was 54.5 cm (+/-9.2 cm) with the E and 51.6 cm (+/- 10.3 cm) with the S (p= 0.058). Polyps were found more frequently in the study group (18.3%) compared with the control group (p= 10.2%) though this did not reach statistical significance (p= 0.131). Overall satisfaction with FS was similar in both groups (p= 0.694) but pain and discomfort were less in the patients undergoing FS using the E (p= 0.006). Controlling for age and previous surgery the differences in pain scores remained significant (p= 0.035). Endoscopist assessment of procedure difficulty (p= 0.726) and complication rates (p= 0.614) was equivalent. Controlling for the presence of polyps, the total duration for the procedure was 7.2 min in the E group and 5.7 min in the S group (p= 0.008). There were no significant differences between women with and without hysterectomy on either overall satisfaction or pain and discomfort. CONCLUSION: Screening FS in women using an upper endoscope is a feasible approach to colorectal cancer screening. Patients screened with an upper endoscope reported less pain and discomfort compared to standard sigmoidoscope while overall satisfaction did not differ. The trend toward increased polyp detection in patients undergoing FS with an upper endoscope may be related to a more thorough examination due to less patient discomfort and/or an increased depth of insertion of the upper endoscope. Thinner, more flexible endoscopes should be considered when performing screening FS in women.

Aged↗
PubMed2000

EndoSheath endoscopic system.

To address the problems inherent in reprocessing endoscopes--the time required (about an hour per use), the difficulty of the process, and the adverse consequences of endoscope contamination--Vision Sciences Inc. introduced the EndoSheath endoscopic system. It consists of a disposable sheath that fits over a specially designed reusable fiberoptic endoscope. When an endoscopic procedure is completed, the sheath is discarded, and the endoscope is wiped with alcohol and reused. We evaluated one of the EndoSheath products--a sheathed sigmoidoscope--for its suitability in an endoscopy suite. We examined the unit and surveyed a number of users. We found that, although it would considerably shorten the time between endoscopic procedures, the unit was not well suited for an endoscopy suite because it provided no more protection than would be afforded by a carefully followed reprocessing protocol. However, users informed us that the sigmoidoscope and one other product--a nasopharyngo-laryngoscope--would likely be useful in a doctor's office or a hospital clinic.

Cost-Benefit Analysis↗
PubMed1985

Physician compliance with colorectal cancer screening (1978-1983): the impact of flexible sigmoidoscopy.

Physician compliance with widely recommended colorectal cancer screening methods was studied over a five-year period in a university-based family medicine residency program. Indicated examinations were being avoided in symptomatic as well as asymptomatic patients aged over 50 years. The introduction of flexible sigmoidoscopy created significant change in previously documented poor resident and faculty compliance. Baseline measurement of outcomes was noted by audit of 189 adult medical records (year 1). Educational reemphasis by lecture and intragroup commitment produced no change by the end of year 2 (n = 189). Introduction of the flexible sigmoidoscope yielded a sevenfold increase in physician compliance in year 3 (n = 192). This compliance increased as measured by chart audit in years 4 (n = 166) and 5 (n = 190). All audited groups were mutually exclusive. The documented diagnostic superiority of this instrument was readily obtainable by family physician faculty and residents in training. With Papanicolaou smear activity serving as a control group, the findings indicated a significant and sustained effect. Two additional primary care training programs were audited during the final year of the study period. These control audits revealed continued poor compliance with rigid sigmoidoscopy. The flexible sigmoidoscope is an important addition to the diagnostic and screening armamentarium of a family medicine residency program.

Adult↗
PubMed1984

Flexible fiberoptic sigmoidoscopy in family medicine.

Flexible fiberoptic sigmoidoscopy is easily mastered by family physicians. Self-study, along with a minimal amount of supervision, seems to provide adequate training. Patient preparation is essential and is best accomplished with enemas "until clear" rather than with the standard two enemas. Patients prefer the flexible sigmoidoscope to the rigid instrument, and the greater depth of penetration achieved with the former--even with the 35-cm sigmoidoscope--enables the physician to detect significantly more pathologic lesions.

Colonic Polyps↗