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PubMed2005

Incomplete screening flexible sigmoidoscopy associated with female sex, age, and increased risk of colorectal cancer.

BACKGROUND: Several previous studies have found that females and older individuals are at greater risk of having incomplete flexible sigmoidoscopy. However, no prior study has reported the subsequent risk of colorectal cancer (CRC) following incomplete sigmoidoscopy. METHODS: Using data from 55 791 individuals screened as part of the Colon Cancer Prevention (CoCaP) programme of Kaiser Permanente of Northern California, we evaluated the likelihood of having an inadequate (<40 cm) examination by age and sex, and estimated the risk of distal CRC according to depth of sigmoidoscope insertion at the baseline screening examination. Multivariate estimation of risks was performed using Poisson regression. RESULTS: Older individuals were at a much greater risk of having an inadequate examination (relative risk (RR) for age 80+ years compared with 50-59 years 2.6 (95% confidence interval (CI) 2.3-3.0)), as were females (RR 2.3 (95% CI 2.2-2.5)); these associations were attenuated but remained strong if Poisson models were further adjusted for examination limitations (pain, stool, and angulation). There was an approximate threefold increase in the risk of distal CRC if the baseline sigmoidoscopy did not reach a depth of at least 40 cm; a smaller increase in risk was observed for examinations that reached 40-59 cm. CONCLUSIONS: Older individuals and women are at an increased risk of having inadequate sigmoidoscopy. Because inadequate sigmoidoscopy results in an increased risk of subsequent CRC, physicians should consider steps to maximise the depth of insertion of the sigmoidoscope or, failing this, should consider an alternative screening test.

Age Factors↗
PubMed1989

Olsalazine or sulphasalazine in first attacks of ulcerative colitis? A double blind study.

Olsalazine (2 g/day) and sulphasalazine (3 g/day) were compared in a double blind three centre trial in 37 patients presenting with first attack of distal colitis. Sigmoidoscopic appearances, rectal biopsies, and symptom and stool diary records were used to assess benefit and adverse effects. Both groups showed a similar decrease in stool frequency (p less than 0.001). The proportion of unformed stools was also decreased, but to a lesser extent (p less than 0.05) in those taking olsalazine (78% v 55%; p less than 0.001) compared with those taking sulphasalazine (72% v 28%; p less than 0.001). There was a diminution in the proportion of stools containing blood in both groups (olsalazine: 61% v 22%; p less than 0.001/sulphasalazine: 67% v 37%; p less than 0.001). Sigmoidoscopic and histological appearances and clinical activity improved significantly and to a similar extent in both groups. Intolerance was encountered in two patients on olsalazine and four on sulphasalazine; intolerance to sulphasalazine being even higher (five of seven patients) in a preliminary study using a dose of sulphasalazine releasing the same amount of 5-aminosalicylic acid as 2 g olsalazine. Olsalazine was at least as effective as sulphasalazine in the treatment of new patients with distal colitis, and in a dose releasing an equivalent amount of 5-aminosalicylic acid was better tolerated.

Adult↗
PubMed1993

Comparison of bismuth citrate and 5-aminosalicylic acid enemas in distal ulcerative colitis: a controlled trial.

An enema that contained a complex of bismuth citrate and polyacrylate was compared with 5-aminosalicylic acid (5-ASA) enemas for treatment of distal ulcerative colitis. The multicentre trial involving 63 patients was randomised and double blind with enemas given over four weeks; clinical, sigmoidoscopic, and histological assessments were made. Improvements were seen in both treatment groups. Clinical remission was seen in 18 of 32 patients treated with 5-ASA and 12 of 31 patients treated with bismuth citrate-carbomer (chi 2 1.94; p = 0.16). Sigmoidoscopic remission occurred in 20 of 32 patients in the 5-ASA group and 15 of 31 patients given bismuth (chi 2 1.27; p = 0.26). Improvement of rectal biopsy histology by at least one grade was seen in 16 of 32 patients in the 5-ASA group and 14 of 31 patients with bismuth (chi 2 0.15; p = 0.70). Analysis of covariance gave no significant difference between groups, although there was a trend favouring 5-ASA. There was no evidence of bismuth accumulation during the trial. Bismuth enemas may offer a new therapeutic option in distal ulcerative colitis.

Adult↗
PubMed1996

A randomised trial comparing mesalazine and prednisolone foam enemas in patients with acute distal ulcerative colitis.

Distal ulcerative colitis can be treated with oral or rectal mesalazine, or both. A foam enema preparation has been developed and its efficacy investigated. The aim of this study was to evaluate the efficacy and safety of mesalazine foam enemas compared with prednisolone foam enemas in the treatment of patients with acute distal ulcerative colitis. Patients aged over 18 years presenting with a relapse of distal ulcerative colitis were randomly allocated treatment with mesalazine foam enema (n = 149 evaluable patients) and prednisolone foam enema (n = 146 evaluable patients) for four weeks. A randomised multicentre investigator blind parallel group trial was conducted. It was found that after four weeks of treatment, clinical remission was achieved by 52% of mesalazine treated patients and 31% of patients treated with prednisolone (p < 0.001). There was a trend in favour of more patients in the mesalazine group achieving sigmoidoscopic remission (40% v 31%, p = 0.10). Histological remission was achieved by 27% and 21% of patients receiving mesalazine and prednisolone respectively. Symptoms improved in both treatment groups. Significantly more mesalazine patients had no blood in their stools after four weeks of treatment (67% v 40%, p < 0.001). Prednisolone treated patients had significantly fewer days with liquid stools than mesalazine patients, with a median of 0 and 1 days respectively by week 4 (p = 0.001). In this study mesalazine foam enema was superior to prednisolone foam enema with regards to clinical remission, this was supported by favourable trends in sigmoidoscopic and histological remission rates. Both treatments were well tolerated.

Acute Disease↗
PubMed1998

A simple clinical colitis activity index.

BACKGROUND: The appropriate medical treatment of patients with ulcerative colitis is determined largely by the severity of symptoms. Hospital assessment of the severity of disease activity includes investigation of laboratory indices and sigmoidoscopic assessment of mucosal inflammation. AIMS: To develop a simplified clinical colitis activity index to aid in the initial evaluation of exacerbations of colitis. METHODS: The information for development of the simple index was initially evaluated in 63 assessments of disease activity in patients with ulcerative colitis where disease activity was evaluated using the Powell-Tuck Index (which includes symptoms, physical signs, and sigmoidoscopic appearance). The new index was then further evaluated in 113 assessments in a different group of patients, by comparison with a complex index utilising clinical and laboratory data, as well as five haematological and biochemical markers of disease severity. RESULTS: The newly devised Simple Clinical Colitis Activity Index, consisting of scores for five clinical criteria, showed a highly significant correlation with the Powell-Tuck Index (r = 0.959, p < 0.0001) as well as the complex index (r = 0.924, p < 0.0001) and all laboratory markers (p = 0.0003 to p < 0.0001). CONCLUSIONS: This new Simple Colitis Activity Index shows good correlation with existing more complex scoring systems and therefore could be useful in the initial assessment of patients with ulcerative colitis.

Acute Disease↗
PubMed1983

Colon and rectal carcinoma: spatial distribution and detection.

Recent studies have challenged the concept that 50% of colon cancers are detectable by digital examination and two-thirds are within reach of the rigid sigmoidoscope. This is an important consideration because of the potential for failure of an otherwise appropriate screening method when evaluating a patient for carcinoma of the colon. An analysis of 2,298 cases of colorectal carcinoma diagnosed over 20 years showed that the most common sites were the rectum (34%) and sigmoid (25%). Over the 20 years, the incidence of cancer in the cecum increased and that in the rectum decreased. Cecal, ascending, and transverse colon cancers accounted for 34% of lesions - all beyond the range of the flexible sigmoidoscope. The changing site distribution emphasizes the need for an accurate and inexpensive technique to evaluate the entire colon. These data suggest that the barium pneumocolon examination should be included in the screening of high-risk patients.

Barium Sulfate↗
PubMed1984

A double-blind clinical trial to compare the effects of 4-aminosalicylic acid to 5-aminosalicylic acid in topical treatment of ulcerative colitis.

5-Aminosalicylic acid (5-ASA) is the active component of Salazopyrin and induces a prompt and excellent improvement, when administered as high dosage enema, in patients suffering from active ulcerative colitis. However, the high instability of this metabolite makes its large use difficult. We aimed at finding a more stable preparation and therefore wondered whether another similar molecule, i.e. 4-aminosalicylic acid (4-ASA, generally known as p-aminosalicylic acid, PAS), which differs from 5-ASA only for the position of the amino group, might be a valid alternative. Therefore, 4-ASA at 2 g dosage, administered as rectal enema, was compared to an equivalent preparation of 5-ASA. We carried out a double-blind therapeutical trial, in which 63 patients, similarly matched for age, sex and extent of disease, took part. The analysis of the final results showed that in the 5-ASA group, 26 (81%) out of 32 patients improved clinically, 25 (78%) sigmoidoscopically and 15 (46%) histologically. In the group of the 31 patients treated with 4-ASA, 24 (77%) improved clinically, 24 (77%) sigmoidoscopically and 13 (41%) histologically. Since no difference was registered between the two types of treatment (p = 0.141, X2 test), 4-ASA could be a possible form of treatment for active ulcerative colitis.

Aminosalicylic Acid↗
PubMed1980

The effect of topical N-acetyl-5-aminosalicylic acid in ulcerative colitis.

In a double-blind controlled therapeutic trial, retention enemas of N-acetyl-5-aminosalicylic acid (Ac-5-ASA) were compared with dummy enemas in the treatment of active ulcerative colitis. Forty patients were studied, each patient taking one test enema twice a day for 2 weeks. Seventeen of the patients had a mild clinical attack of the disease; the 23 others had sigmoidoscopic evidence of active inflammation although they were in clinical remission. Histological and sigmoidoscopic improvement were significantly commoner in the patients receiving the active treatment than in those taking the dummy preparation. Pronounced histological improvement was only seen in patients taking the Ac-5-ASA enemas. In those patients who had clinical attacks of ulcerative colitis at the start of the study, symptomatic improvement was commoner in the group treated with Ac-5-ASA enemas than in those who received placebo therapy. Ac-5-ASA resembles 5-aminosalicylic acid in its effect on the inflamed mucosa in ulcerative colitis. Further studies into other substituted salicylates may lead to the development of an effective oral agent that does not carry the side effects associated with the sulphapyridine moiety of sulphasalazine.

Aminosalicylic Acids↗
PubMed1989

A comparison of sucralfate and prednisolone enemas in the treatment of active distal ulcerative colitis.

Sucralfate is well established in the treatment of upper gastrointestinal inflammation and ulceration, and preliminary evidence suggests it may be of benefit in active colitis. We have therefore undertaken a clinical trial to compare enemas of sucralfate (4 g) and prednisolone metasulphobenzoate (20 mg) in the treatment of active distal ulcerative colitis. Forty-four patients were entered into a 4-week study. Two patients were withdrawn because of non-compliance, and five were unable to complete the study: two developed constipation (both allocated to sucralfate) and three were unable to retain the enemas (two prednisolone and one sucralfate). Intention-to-treat analysis showed significant within-treatment improvement in rectal bleeding, sigmoidoscopic grade, and histologic grade in the prednisolone-treated group, and in stool frequency, rectal bleeding, and sigmoidoscopic grade in the sucralfate-treated group. Between-treatment comparisons, however, showed greater resolution of rectal bleeding and more marked improvements in histologic grade in patients treated with prednisolone metasulphobenzoate enemas. Further studies using higher doses of sucralfate would be useful.

Adult↗
PubMedDate not supplied

Virtual reality flexible sigmoidoscopy simulator training: impact on resident performance.

BACKGROUND: Flexible sigmoidoscopy, a core skill for the primary care physician, requires learned hand-eye skills that can be difficult to master during residency training. With recent advances in virtual reality simulation technology, simulated flexible sigmoidoscopes are available to family medicine residents for training before their initial and subsequent live patient examinations. The purpose of the study was to determine whether a virtual reality flexible sigmoidoscope simulator would improve the hand-eye skills and various performance parameters in a live patient. METHODS: Residents were assigned to a control (n = 5) or experimental group (n = 5) in which the experimental group trained on a virtual reality sigmoidoscopy simulator before their first sigmoidoscopies on live patient volunteers. After the initial live patient sigmoidoscopies, both control and experimental groups trained on the simulator so that it was possible to evaluate presimulator and postsimulator training effects on live patient performance and to compare speed and skill between the groups at different levels of training. RESULTS: Training on the virtual reality simulator produced substantial improvements in examination times and hand-eye skill measures. After 6 to 10 hours of training on the simulator, the experimental group achieved significantly faster insertion times to 30 cm (119 versus 357 sec, P = 0.03), 40 cm (211 versus 518 sec, P = 0.03), and a shorter mean length of examination (323 versus 654 sec, P = 0.01). There was also significant improvement of hand-eye skill measures of the experimental group in directional errors (1.6 versus. 8.6, P < 0.01), percentage of colon visualized (79 versus 45 percent, P = 0.02), and viewing quality of examination when compared with the control group's initial performance on live patients. Resident survey findings after the study confirmed the trainee's perception of the benefit of the simulator training. CONCLUSIONS: This study shows the value of virtual reality simulator training for accelerating the development of the hand-eye skills to perform adequate sigmoidoscopy.

Clinical Competence↗
PubMed1976

Therapeutic evaluation of oxantel pamoate (1, 4, 5, 6-tetrahydro-1-methyl-2-[trans-3-hydroxystyryl] pyrimidine pamoate) in severe Trichuris trichiura infection.

The efficacy of oxantel pamoate (1, 4, 5, 6-tetrahydro-2-[trans-3-hydroxystyryl]-1-methyl pyrimidine pamoate) was evaluated in 25 children with severe Trichuris infection. The presence of chronic dysentery and sigmoidoscopic demonstration of whipworms in the intestinal mucosa were the criteria for inclusion in the trial. Most of these patients had severe anemia, rectal prolapse, digital clubbing, hypoproteinemia, and growth retardation. There were a high incidence of concomitant parasitism with other intestinal helminths and with Entamoeba histolytica and Giardia lamblia. Sigmoidoscopic grading of Trichuris load and egg count in the feces were carried out prior to treatment and 2 days after each course of oxantel therapy. Oxantel was administered at a dose of 10 mg/kg body weight twice daily for a 3-day course. Satisfactory response, as judged by relief of dysentery and absence of whipworms from the mucosa at sigmoidoscopy, was achieved in 17 patients after the first course and in the remaining 8 patients after a second course of oxantel. The drug was well tolerated and no side effects were noted during or after treatment. It is concluded that oxantel is a safe and effective anthelmintic for severe clinical trichuriasis.

Child↗
PubMed1998

Treatment of sigmoid volvulus: experience in Gondar, north-west Ethiopia.

A retrospective study of 145 patients with sigmoid volvulus (SV) seen over a three year period is presented. Sigmoid volvulus (SV) was the commonest cause of emergency admissions with intestinal obstruction (56%). The mean age was 55 +/- 13 years, (range 10-80), and the male to female ratio was 13.5:1. The presence or absence of a previous attack makes a significant difference in the occurrence of gangrenous bowel. Eighteen out of 75 patients (24%) with no previous attack had gangrenous bowel compared with 2 out of 57 (4%) after recurrence. A conservative sigmoidoscopic detorsion was successful in the majority of the cases (63%). Elective surgery after bowel preparation was associated with a mortality rate of 3% in comparison to 12.5 mortality rate in patients with viable bowel operated on an emergency basis (p < 0.05). Sigmoidoscopic detorsion should be the first measure in patients with viable bowel.

Adult↗
PubMed2000

Improving the view in the rectal clinic: a randomised control trial.

BACKGROUND: Rigid sigmoidoscopy forms an integral part of the out-patient assessment of patients with colorectal symptoms. However, the value of this of this examination is often diminished by faecal loading of the rectum. This trial aimed to determine the ability of a single self-administered glycerine suppository to clear the rectum in preparation for rigid sigmoidoscopy, and considered patient acceptability of this practice. METHODS: Consecutive patients were randomly allocated to receive suppository or no suppository prior to out-patient rigid sigmoidoscopy. Assessment was made of patient compliance, the effectiveness of rectal examination, and the depth to which the sigmoidoscope was inserted. RESULTS: 131 patients were randomised into suppository (n = 66) or control groups (n = 65). The number of patients deemed to have good views of the rectum (> 75% of rectal mucosa seen) was significantly greater in suppository than control groups (79% versus 26.2%, P < 0.05 Chi square test), whilst that of poor examinations (< 50% of rectal mucosa seen) was significantly greater in control than suppository groups (44.6% versus 4%, P < 0.05). The depth of insertion of the sigmoidoscope was significantly greater in those receiving suppositories (54.5% versus 21.5% undergoing evaluation to 18 cm or more, P < 0.05). Compliance amongst those who received suppositories was high with only 3 of 53 (4.5%) patients in the suppository group evaluated by questionnaire reporting difficulty or concerns over their use. CONCLUSION: Self-administered suppositories are acceptable to patients and significantly improve the efficiency of outpatient rigid sigmoidoscopy. Their usage should become routine.

Adult↗
PubMed2001

Flexible sigmoidoscopy.

Flexible sigmoidoscopy remains a common tool used for the periodic screening of colorectal cancer. Most organizations recommend screening at three- to five-year intervals beginning at age 50 for persons with average risk. Extensive training in endoscopic maneuvering, colorectal anatomy and pathologic recognition is required. Most physicians report comfort performing the procedure unsupervised after 10 to 25 precepted sessions. The procedure involves the insertion of the sigmoidoscope through the anus and distal rectum and advancement of the scope tip to an average depth of 48 to 55 cm in the sigmoid colon. Once the sigmoidoscope has been appropriately advanced, the scope is slowly withdrawn, allowing for the inspection of colon mucosa during withdrawal. Polyps less than 5 mm in diameter should be biopsied. Polyps 5 to 10 mm or greater can be assumed to be adenomatous, and follow-up colonoscopy for complete polypectomy is required. Diverticulosis, hemorrhoids, nonspecific colitis and pseudomembranes may also be encountered during inspection. Use of preprocedural benzodiazepines can be helpful in reducing patient discomfort. 2001;63:1375-80,1383-4,1385-8.)

Age Factors↗
PubMed1989

Sigmoid volvulus. A four-decade experience.

During the 40 years from 1945 to 1984, 159 occurrences of sigmoid volvulus in 140 patients were diagnosed and managed. Treatment modalities gradually evolved from primarily operative decompression in the first 20 years to selective, sigmoidoscopic, nonoperative reduction in the most recent 10-year period. Operative reduction was associated with a 10 per cent mortality, while no deaths were associated with nonoperative reduction. A 60 per cent mortality was noted when gangrenous bowel was present. In the most recent 10-year period, 71 per cent of cases were associated with neuropsychiatric diseases, and one third had a previous episode of sigmoid volvulus. The diagnosis was made on the initial plain abdominal radiograph in 60 per cent, and nonoperative sigmoidoscopic reduction attained in 95 per cent. Following nonoperative reduction, elective resection was performed during the same hospitalization with a 5 per cent mortality. Initial management of sigmoid volvulus should consist of nonoperative attempts at reduction with operative reduction reserved for refractory cases or those with ischemic bowel. Elective resection can be safely performed during the same hospitalization.

Adult↗
PubMed1988

Lack of association between skin tags and colon polyps in a primary care setting.

Cutaneous skin tags (acrochordons) have recently been proposed as markers for adenomatous polyps of the colon among symptomatic patients referred for colonoscopy. To ascertain the utility of skin tags as a predictor of colonic polyps in a primary care setting, 492 patients, with a mean age of 58 +/- 13.3 years (241 with signs or symptoms and 251 for screening), were evaluated for the presence of skin tags and then examined using a 60-cm fiberoptic sigmoidoscope by an examiner "blinded" to the skin findings. Among patients with skin tags, 23 (10.2%) of 226 had polyps, whereas among patients without skin tags, 20 (7.5%) of 266 had polyps. The predictive value of the presence of a skin tag was 10.2%. Contrary to studies done in more selected populations with a higher prevalence of adenomatous polyps, the results using a 60-cm flexible sigmoidoscope in a primary care population suggest that cutaneous skin tags are not a marker for adenomatous polyps of the colon.

Adolescent↗
PubMed1986

Continuing medical education for flexible sigmoidoscopy--toward a conceptual model for procedural skills training.

Participants in two one-day continuing medical education courses on flexible sigmoidoscopy were surveyed before, immediately after and ten months after the courses. 52 (29.5% of 176) participants completed all three survey forms. Before the course 32 (61.5%) expected to immediately use the flexible sigmoidoscope without further training. Ten months after the course 33 (63.4%) were using the flexible sigmoidoscope; four additional respondents were expecting to begin using the instrument. Twenty three of these (69.7%) had only attended the course without additional training. Those who found the instrument more difficult to use, or decided immediately after the course that more education was necessary, were less likely to use the instrument. Those not using the instrument also were older, more likely to be in solo practice and more likely to be surgeons. The course altered the educational plans of 23.1% of the respondents. This one-day format combining didactic and laboratory work with the instrument proved to be an efficient and effective means of education for using the instrument.

Adult↗
PubMed1986

Establishing a flexible sigmoidoscopy/colonoscopy program for surgical residents. The University of Illinois experience.

The clinical value of lower gastrointestinal endoscopy and the requirement of the American Board of Surgery for endoscopic training mandate establishing a program in flexible sigmoidoscopy and colonoscopy for all surgical residents. In a 12-month period, the surgical residents at the authors' institution performed 599 flexible sigmoidoscopic and 116 total colonoscopic examinations under the supervision of two attending colorectal surgeons, with no mortality and a 0.03 per cent morbidity. There was an average of 42 endoscopic examinations per resident for the 3-week training period. Three hundred seventy (62%) of the flexible sigmoidoscopic examinations were for screening and 229 (38%) were for the evaluation of symptomatic patients. Colorectal polyps were identified in 68 patients (11.4%) and carcinoma in 14 patients (1.9%). Forty-nine per cent of the colonoscopic examinations were for endoscopic polypectomy. Sixty-four per cent of patients with more than one adenomatous polyp harbored polyps in different surgical segments of the colon. Every resident was able to perform flexible sigmoidoscopy safely by the end of the 3-week training period, and in addition, the residents rated their endoscopic experience as a valuable part of their surgical training.

Colonoscopy↗