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PubMed1986

Sensitivity of fecal hemoccult testing and flexible sigmoidoscopy for colorectal cancer screening.

Fecal Hemoccult testing and flexible sigmoidoscopy have been proposed as means of screening for colorectal cancer in the general population, as well as in identified high-risk groups. A colorectal cancer screening program was conducted for the Pattern Makers' League of North America. A total of 1,473 white males were screened with fecal Hemoccult testing and flexible sigmoidoscopy during the period 1981 to 1983. The fecal Hemoccult test after diet restriction was positive in 38 workers (2.6%). Among 12 colorectal cancers, including in situ cases, only three were positive by this test. The sensitivity of this test for picking up cancer is only 25%. The positive predictive value was 7.9%. It is concluded that the Hemoccult test for the detection of colorectal cancer and polyps is not a valuable tool because of low sensitivity, whereas flexible sigmoidoscopy has a significant role in colorectal cancer screening of an asymptomatic population at risk.

Colonic Neoplasms↗
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↗
PubMed1998

Prospective evaluation of a teaching model to determine competency in performing flexible sigmoidoscopies.

OBJECTIVE: There are limited objective criteria for determining competency in performing flexible sigmoidoscopies. The authors developed a teaching model using eight objective criteria that measured both cognitive and technical skills in performing flexible sigmoidoscopies. The objective was to determine whether the teaching model was a valid method and then to compare it to a commonly used Overall Competence Score or independent observer method. METHODS: A total of 120 procedures with 10 residents were evaluated using the two methods. Eight objective parameters had been determined before validating the teaching model. Preset criteria determined competency on a single procedure, and competent performance on five procedures in a row determined certification to independently perform procedures. The teaching model was separately tested for validity and then compared with the independent observer method. RESULTS: A total of 120 procedures were graded using the teaching model method: 73 competent and 47 incompetent. Six of the seven objective parameters were associated with competency in the teaching model method. The eighth objective parameter was excluded because of lack of variation. Fifty of the 120 procedures were graded using the independent observer method: 36 competent and 14 incompetent. Two of the seven objective parameters were associated with competency in the independent observer method. Comparison of the two methods revealed seven discrepancies regarding competent and incompetent procedures. The correlation between the two methods was 0.71. CONCLUSION: The teaching model method offers objective criteria to evaluate skill in performing flexible sigmoidoscopies.

Clinical Competence↗
PubMed1999

A comparison of bowel preparations for flexible sigmoidoscopy: oral magnesium citrate combined with oral bisacodyl, one hypertonic phosphate enema, or two hypertonic phosphate enemas.

OBJECTIVE: Magnesium citrate with hypertonic enemas or oral bisacodyl provides superior preparation quality for sigmoidoscopy over enemas alone. We compared three magnesium citrate sigmoidoscopy preparations in a randomized, single-blind, controlled trial. METHODS: Two hundred and ninety-one adults scheduled for routine sigmoidoscopy were randomly assigned to receive one of three preparations containing oral magnesium citrate (296 cc) taken the night before the procedure in combination with the following: 1) oral bisacodyl (10 mg), given with the magnesium citrate the night before the procedure; 2) one hypertonic phosphate enema 1 h before the procedure; or 3) two hypertonic phosphate enemas, given singly at 2 and 1 h before the procedure. Endoscopists rated preparation quality, procedure duration, and depth of endoscopic insertion. Patients assessed preparation comfort and overall satisfaction. RESULTS: Preparation quality was rated as excellent or good for 80.6% in the bisacodyl group, 88.7% in the one-enema group, and 85.1% in the two-enema group (p = 0.30). Patients reported the oral bisacodyl regimen was better tolerated (p = 0.032). Although the three regimens were comparable in most side effects, the bisacodyl preparation was associated with more diarrhea (p = 0.0003). Mean procedure duration, mean insertion depth, and prevalence of diverticula and polyps were similar in all groups. Fewer than 4% of patients required repeat procedures due to poor preparation quality. CONCLUSIONS: There was no statistical difference between the quality of the three bowel preparations. Patients considered an oral bisacodyl and magnesium citrate regimen more easily tolerated, though it was associated with more diarrhea.

Administration, Oral↗
PubMed2003

Female gender and other factors predictive of a limited screening flexible sigmoidoscopy examination for colorectal cancer.

OBJECTIVE: Flexible sigmoidoscopy (FS) screening for colorectal cancer (CRC) is associated with reduced mortality from CRC. It is unknown whether FS is equally effective in men and women, but differences in anatomy and perception of pain may increase the difficulty of performing FS in women. The aim of this study was to determine factors associated with a shorter or limited screening FS. METHODS: Patients referred by their primary care provider were eligible for screening sigmoidoscopy if they were 50 yr or older with negative fecal occult blood tests and no first-degree relative with colorectal cancer at age 55 yr or younger. A detailed questionnaire regarding demographic characteristics and risk factors for CRC, aspirin and multivitamin use, and previous abdominal surgery was completed by the patient on a standardized form before their procedure. The histologic type (hyperplastic, adenoma, normal mucosa, or carcinoma) of each polyp was recorded. Depth of examination (in cm) was recorded based on the standardized markings on the shaft of the sigmoidoscope when it was thought to be in a straight position. Limitations to the examination (angulation, pain, and poor preparation), other mucosal findings, and complications were also noted. RESULTS: A total of 3980 patients (52% female) were prospectively enrolled in a screening program over a 22-month period. Women were more likely than men to report previous pelvic or abdominal surgery (OR = 2.64, 95% CI = 2.29-3.05) and were less likely to have had a previous sigmoidoscopy (OR = 0.71, 95% CI = 0.61-0.83). Females were almost twice as likely as males to have a procedure limited in some way (angulation, spasm, or pain) (OR = 1.86, 95% CI = 1.63-2.13). When defined by depth of examination, females were significantly more likely than males to have a procedure of <50 cm (OR = 1.93, 95% CI = 1.63, 2.29) and were less likely to have an adenomatous polyp or cancer detected (OR = 0.55, 95% CI = 0.42-0.71). The average endoscopy distance for women was 52.3 cm, compared with 55.2 cm in men (p < 0.0001), and the average number of polyps detected in women was 1.4, compared with 1.56 in men (p = 0.003) among patients with at least one polyp. Using multivariable analysis, females were more likely to have an examination of <50 cm compared with men, controlling for age, spasm or pain on examination, previous surgery, angulation of the colon, and type of endoscopist-MD or nonphysician endoscopist (OR = 1.67, 95% CI = 1.41-1.99). CONCLUSIONS: Women are more likely than men to have a shorter and more limited FS. This is partly owing to increased colonic angulation and pain during the examination. Methods aimed at reducing pain and improving maneuverability in an angulated colon during FS may improve the effectiveness of CRC screening in women.

Colorectal Neoplasms↗
PubMed2000

Single blind, randomised trial of efficacy and acceptability of oral picolax versus self administered phosphate enema in bowel preparation for flexible sigmoidoscopy screening.

OBJECTIVE: To compare the acceptability and efficacy of two methods of self administered bowel preparation for flexible sigmoidoscopy screening: a single phosphate enema and a single sachet of Picolax. DESIGN: Single blind, randomised trial. SETTING: Endoscopy units of two general hospitals. PARTICIPANTS: 1442 men and women aged 55-64 years who had agreed to be screened by flexible sigmoidoscopy. MAIN OUTCOME MESURESs: Attendance rates, compliance with allocated preparations, adverse effects, quality of bowel preparation, procedure time, and yield of neoplasia. RESULTS: Compliance with the enema was higher than with the Picolax (608 (84%) v 566 (79%); difference 6%, 95% confidence interval 2% to 10%). Almost half of those who refused Picolax used an enema at home. Wind, incontinence, and sleep disturbance were more frequent in the Picolax group than the enema group; bottom soreness was more frequent in the enema group. Around 30% (187) found the diet restriction required by Picolax difficult; 78% (471) found the enema easy to administer. The quality of preparation was better with the enema; the proportion of procedures complete to the descending colon was greater and the mean duration of the procedure was shorter. There was no significant difference in polyp detection rates. CONCLUSION: A single phosphate enema self administered around one hour before leaving home is a more acceptable and effective method of preparing the distal bowel for flexible sigmoidoscopy than Picolax.

Administration, Oral↗
PubMed1979

Value of sigmoidoscopy and biopsy in detection of carcinoma and premalignant change in ulcerative colitis.

Of 111 carcinomas developing in 73 patients with ulcerative colitis, 46 (41.5%) arose in the rectum where they are directly accessible to sigmoidoscopy. Fifty-eight per cent of single carcinomas developed in the rectum. The extent and frequency of rectal dysplasia was assessed by examining slides of rectal mucosa with an eyepiece micrometer. Slides from 46 patients with carcinoma and 22 patients with dysplasia but no carcinoma in whom proctectomy or proctocolectomy had been carried out were examined by this method. Thirteen of 15 patients with carcinoma of the colon (87%) and 21/22 patients (95%) with large bowel dysplasia showed evidence only of rectal dysplasia. However, there was marked variability in the proportion of dysplastic rectal mucosa even in those patients with rectal carcinoma, while in some patients dysplasia was limited to a small focus. Because of the possibility of false negative biopsies due to sampling error, multiple biopsies should be taken to detect dysplasia. Their state should be recorded and deliberately varied at subsequent visits. Careful sigmoidoscopy and multiple biopsies in this study had potential value as an aid in the detection of 85-90% of all carcinomas. In practice the figure would almost certainly be lower due to intrinsic bias (see discussion) so that, although regular sigmoidoscopy and biopsy would be of great value when colonoscopy is not available, the latter should be included in any long-term programme of carcinoma prevention.

Biopsy↗
PubMed1996

Self-administered disposable micro-enemas before outpatient sigmoidoscopy.

Many colorectal carcinomas can be diagnosed by rigid sigmoidoscopy. One important limiting factor in the usefulness of this investigation is the presence of faeces; another is inability to negotiate the recto-sigmoid bend. 101 patients (47 men) were sent a Microlax enema with instruction to use it before their first attendance in the outpatient department. The grade of preparation [on a scale of 0 (empty rectum) to 3, with grades 0 and 1 providing an adequate view], height achieved with the sigmoidoscope and whether or not the extent of the examination was limited by faeces were recorded. These data were compared with results in 78 patients (38 men) who did not receive any special preparation. There were no serious difficulties with self-administration. An adequate view was obtained in 89 (88%) of those who had received an enema and in 41 (53%) of those who were unprepared (P < 0.001, chi 2 test). The height achieved and the percentage of patients in whom the sigmoidoscopy was not limited by faeces were also significantly increased. The mailing of micro-enemas to patients who are likely to need sigmoidoscopy is a cheap measure that increases diagnostic yield and saves reattendances.

Ambulatory Care↗
PubMed1992

[Utility of SCG (screening colonography) and combined sigmoidoscopy-SCG in thorough physical checkups].

Given the increasing incidence of colon cancer in recent years, it is important to establish a diagnostic system for early detection and introduce it into clinical practice. A double contrast examination that uses a disposable tip and tube with an enema reservoir filled with 200 ml of 60 w/v% barium sulfate, known as SCG (screening colonography) was used in this study. In order to assess its utility SCG was performed on 1,554 patients, and 2,004 patients were examined by a within 24 hours combination of sigmoidoscopy and SCG by way of screening for colon cancer. Given the brief duration of SCG, which ranged from 10 to 13 min in most patients in the study, the efficiency of the examinations was considered to be rather high. Furthermore, the barium reached the cecum in as many as 98.7% of the patients. Overall, SCG proved to have an excellent diagnostic capability. Sigmoidoscopy-SCG, on the other hand, detected colon cancer in 114 patients (5.7%) and colon polyps in 658 patients (32.8%). The rates of detection of colon cancers and polyps were higher in the patients who tested positive in immunological fecal examinations for occult blood. Judging from our results, it may be said that for many patients receiving thorough physical checkups to screen for colon cancer, our system will provide for efficient screening whereby patients are first examined for fecal occult blood and those who test positive undergo sigmoidoscopy and SCG within the same day.

Adult↗
PubMedDate not supplied

[Colonoscopy or sigmoidoscopy: risk of isolated right colon lesions].

BACKGROUND: Colorectal cancer is an important cause of death in western countries. Screening methods are based on flexible sigmoidoscopy, a cheap, effective, and less painful procedure, but some important lesions on the right colon can be missed. AIM: Evaluate how many important lesions would be missed if colonoscopy indicated only for patients with distal lesions identified during flexible sigmoidoscopy. MATERIAL AND METHODS: All consecutive colonoscopy performed in the Endoscopy Unit of the Gastroenterology Division of Federal University of São Paulo, SP, Brazil, with polyps and cancer suspicious lesions were reviewed. Patients with a second procedure, inflammatory bowel disease or colonic surgery were excluded. RESULTS: We reviewed 101 patients with 38 possible cancer lesions and 70 polyps. The mean age was 62 years (SD 13.7 years) and 45 were male. Forty five lesions were in the right colon, namely 23 adenomas, 10 adenocarcinomas, 1 lymphoma and 11 benign lesion. Among such lesions, 28 were isolated in the right colon (16 adenomas and 7 adenocarcinomas). CONCLUSION: In our study 23 patients (22.77%) had adenomas or adenocarcinomas isolated in the right colon, that would be missed if flexible sigmoidoscopy was used alone.

Colonic Neoplasms↗
PubMed1996

Flexible sigmoidoscopy screening for colorectal cancer in average-risk subjects: a community-based pilot project.

OBJECTIVE: To test a pilot screening program for colorectal cancer. DESIGN: Subjects, chosen at random and recruited by mail, were examined by flexible sigmoidoscopy. PARTICIPANTS AND SETTING: Normal-risk, asymptomatic men and women aged 55-59 years recruited from the community, July to December, 1995. MAIN OUTCOME MEASURES: Number of polyps detected and cancers diagnosed, and compliance with screening. RESULTS: Letters of invitation were sent to 3500 subjects; of these, 2881 were eligible for inclusion in the study and 342 (12%) consented to participate. A further 3.5% of non-compliant subjects attended the screening program after a telephone survey assessing reasons for non-attendance. Common reasons for non-attendance were a lack of interest (30%) or a lack of time, mainly due to work commitments (28%). A third of subjects had polyps and 46% of these were adenomas. Three subjects were found to have adenocarcinoma: in two the cancer was confined to a polyp and treated with polypectomy, and one subject underwent anterior resection (overall prevalence of cancer, 0.9%). The median depth of insertion achieved with flexible sigmoidoscopy was 55 cm (range, 25-100 cm). Median pain level (on a scale of 0 = no pain to 10 = worst pain imaginable) was 2 (range, 0-8.5), and 99% of the subjects would have the test again if required. CONCLUSIONS: Flexible sigmoidoscopy was well tolerated and had an acceptable detection rate of adenomatous polyps and early cancer. Subject compliance emerged as a major issue which requires further evaluation to maximise participation in future programs.

Adenocarcinoma↗
PubMed1999

Flexible sigmoidoscopy: screening for colorectal cancer.

Flexible sigmoidoscopy is an important screening procedure because of its ability to detect early changes in the distal colon. The 60-cm flexible sigmoidoscope provides excellent visualization with minimal discomfort to patients. Successful sigmoidoscopy requires adequate patient preparation, proper equipment and an experienced examiner who can recognize both normal and abnormal findings. Complications arising from sigmoidoscopy are rare, but patients may experience some cramping, gas or watery stools. Screening and primary preventive measures, including regular exercise and increased dietary fiber intake, can lower the morbidity and mortality associated with colorectal cancer.

Colorectal Neoplasms↗
PubMed2000

Training in sigmoidoscopy: the experience of trainees in elderly medicine in East Anglia.

To assess the standard of training in postgraduate sigmoidoscopy in East Anglia, a questionnaire was prepared and distributed to pre-registration house officers (JHOs), senior house officers (SHOs) and specialist registrars (SpRs) in eight hospitals. The results suggest that practical instruction in technique is inadequate, and that most trainees perform too few sigmoidoscopies to become competent at either examining or recognising lesions. Many JHOs have not performed sigmoidoscopies or even witnessed important lesions in their early training. The training improved little during the SHO grade, with few trainees feeling happy with their training. The SpRs felt they were competent, although their training was thought inadequate. The current training programme needs detailed reassessment and improvement.

Aged↗
PubMedDate not supplied

Flexible sigmoidoscopy as a colorectal cancer screening test in the general population: recruitment phase results of a randomized controlled trial in Lombardia, Italy.

UNLABELLED: A two arm multicentre randomized controlled trial is in progress to evaluate the efficacy of flexible sigmoidoscopy (FS) as a screening test for colorectal cancer in the general population. AIMS: To determine the acceptance rate and feasibility of FS as a colorectal cancer screening test in average-risk asymptomatic volunteers. Average-risk, asymptomatic subjects, aged 55-64 years and assisted by 244 general practitioners (GPs) in Lombardy, Italy, were invited by postal questionnaire (PQ) to enter a study for the prevention of colorectal cancer and asked to indicate their interest in, and willingness to undergo, screening: those responding positively were randomized to the intervention or control arms. GPs were trained in colorectal cancer screening and proposed free FS to their patients randomized to the intervention arm. All sigmoidoscopies were performed by experienced endoscopists. Small polyps were removed at FS. Colonoscopy was indicated for high risk polyps (size more than 5 mm, more than two adenomas, villous histology, severe dysplasia or malignancy). 40,945 subjects were invited. 667 PQs were returned undelivered due to postal failure. 7,892 (19.59%) subjects responded, 2,116 of whom (26.81%) were not included, presenting 1 or more exclusion criteria. We randomized 5,778 volunteers and performed 1,582 sigmoidoscopies out of 2,885 subjects in the intervention arm (54.84% acceptance rate). Although the screening procedure had a good attendance rate in the intervention group, involvement of the people invited was lower than expected. Future FS screening programmes will require a keener focus on recruitment strategies, mainly with participation of GPs.

Colorectal Neoplasms↗
PubMedDate not supplied

The interval between flexible sigmoidoscopy screening examinations can be expanded beyond five years.

BACKGROUND/AIMS: As one of the methods for colorectal cancer screening, asymptomatic average-risk persons aged > or = 50 years are recommended to undergo flexible sigmoidoscopy screening every 5 years. We evaluate whether the interval between examinations can be extended beyond 5 years. METHODOLOGY: A total of 192 asymptomatic average-risk subjects were studied, all of whom had undergone a initial negative examination on a flexible sigmoidoscopy screening at age > or = 50 years and a second examination at least 3 years later. The study population was divided into three groups according to the interval between examinations, which was 3-5 years in Group A, 5-6 years in Group B, and 6-8 years in Group C. RESULTS: The incidence of neoplasms was compared among the three subjects groups, and it was found to be similar: 11/96 (11.5%) in group A, 4/55 (7.3%) in group B, and 5/41 (12.2%) in group C. All detected adenomas were less than 10 mm in diameter, and none contained a villous component or high-grade dysplasia. No cancers were found in the study. CONCLUSIONS: The results suggest that the interval for screening sigmoidoscopy may be extended beyond 5 years in persons showing negative results on an initial examination.

Adenoma↗
PubMedDate not supplied

Technical competency in flexible sigmoidoscopy.

BACKGROUND: Family practice residencies offer training in flexible sigmoidoscopy; however, there are no objective recommendations for determining competency in learners. We describe a longitudinal study designed to determine the mean procedure time and depth of insertion for family practice residents. METHODS: During a 21-month period, data were collected for 421 patients undergoing flexible sigmoidoscopy. Second- or third-year family medicine residents supervised by family medicine faculty did all procedures. The data were analyzed with simple descriptive statistics, t test, and linear and logistic regression. RESULTS: The mean procedure time was 18+/-9.3 minutes (17.2 - 19.6, 95% confidence interval [CI]). The mean insertion depth was 51.4+/-12.4 cm (50.4 - 52.6 cm, 95% CI). Performing a biopsy was associated with an increase in procedure time (17.0 vs 27.3 minutes, P < .0001). Women with a history of pelvic surgery had less depth of insertion than did those who had no history of pelvic surgery (47 vs 53 cm, P = .002, t test). CONCLUSION: Procedural competency consists of knowledge, technical skills, and attitudes. Knowledge and attitudes can be assessed with other items, such as examinations and observation. Primary care faculty can now use these standards of insertion depth and procedure time when determining technical skill proficiency for their residents in flexible sigmoidoscopy.

Attitude of Health Personnel↗
PubMed2001

[Sigmoidoscopy as primary examination in patients with bowel symptoms].

INTRODUCTION: Flexible sigmoidoscopy is recommended in the literature and is now officially recommended as the primary diagnostic method in patients with symptoms consistent with colorectal cancer. Sigmoidoscopy can detect two-thirds of all colorectal cancers. MATERIAL AND METHODS: We carried out a retrospective analysis of prospective data on symptoms and findings at FS in 682 patients, above the age of 40 years, referred to a private specialist for rectal bleeding, change in bowel habits, or unspecific abdominal symptoms. The chi 2-test and logistic multivariate regression analysis were used to estimate the predictive value of symptoms for neoplasia. RESULTS: Carcinoma was found in 31 (5%) and adenoma in 76 (11%), i.e., neoplasia in 16%. Logistic multivariate regression showed that bleeding in or on the faeces (p < 0.0001, OR 10.6 and 11.6), mucous discharge (p = 0.02, OR 3.0), and change in bowel habits (p = 0.02, OR 3.0) were independent risk factors of cancer, and bleeding on the faeces (p = 0.0002, OR 3.2) or in the faeces (p = 0.02, OR 2.7) were independent risk factors of adenoma. DISCUSSION: On the basis of the literature and the present results, we conclude that sigmoidoscopy is a suitable primary diagnostic method for the detection of neoplasia in the rectum and left colon in patients with bowel symptoms. Bleeding, mucous discharge, and change in bowel habits are independent risk factors for carcinoma and bleeding for adenoma.

Adult↗
PubMedDate not supplied

Comparison of three forms of bowel preparations for screening flexible sigmoidoscopy.

Our initial attempts at implementing a high-volume clinic were impeded by the quality of colon preparation. While two Fleet enema preparations were generally easy to administer and well tolerated, the results were frequently poor. Current studies are limited and opinions vary regarding the most effective bowel preparation. The purpose of this study was to compare three forms of bowel preparation for screening flexible sigmoidoscopy. All patients scheduled for screening flexible sigmoidoscopy were given one of three colon preparations: two Fleet enemas; magnesium citrate orally the evening before, clear liquid diet and two Dulcolax suppositories the day of the exam; or magnesium citrate orally the evening before, clear liquid the day of the exam, and two Fleet enemas 1 hour before the procedure. Examinations were performed using a video flexible sigmoidoscopy by specialty trained gastroenterologists. Physicians were asked to rate the preparations as excellent, good, fair, or poor according to explicit criteria, and to document depth of insertion. Results showed that the magnesium citrate and Fleet enema preparation was excellent for 70% of patients, allowing for greater depth of insertion. Need for repeat examination due to poor preparation was infrequent with this group and patient tolerance of the preparation was acceptable.

Analysis of Variance↗