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Use of rigid and flexible sigmoidoscopy by family physicians in the United States.

To investigate the incidence of use of the flexible and rigid proctosigmoidoscopes by family physicians, a questionnaire was mailed to 1,585 randomly selected members of the American Academy of Family Physicians. Of the total of 1,057 respondents, 48 percent performed sigmoidoscopy, with 30 percent performing flexible sigmoidoscopy, 31 percent performing rigid sigmoidoscopy, and 48 percent performing at least one of the procedures. Younger physicians were found to be more likely to perform flexible sigmoidoscopy, as were physicians who practice in communities of fewer than 500,000 population. Nationwide, more of the flexible procedures are performed in private offices than in the hospital. Physicians in communities of less than 500,000, however, are more likely to use the flexible sigmoidoscope in a hospital setting than are physicians in larger urban areas [corrected]. Board-certified physicians were more likely to perform one or both procedures than were noncertified physicians.

Family Practice↗

The long and short of flexible sigmoidoscopy: does it matter?

Physicians performing fiberoptic sigmoidoscopy may choose between a 35 and 60 cm instrument. Confusion and dispute exist concerning the advantages of one over the other. In an effort to resolve this question, 100 consecutive symptomatic patients were examined in an outpatient sigmoidoscopy clinic. Both the Olympus OSF-30 and Olympus OSF-60 flexible sigmoidoscopes were used on each patient alternately. Mean examination time, patient tolerance, diagnostic findings, instrument cost, physician training time, and insertion length were recorded and compared. The longer scope detected five more polyps and 25 additional cases of diverticulosis which were located beyond the reach of the shorter scope. The increased number of findings with the longer scope was expected; however, the increased number of polyps was not statistically significant. The additional number of findings with the longer scope was expected and with increased number of examinations the increased number of polyps may prove to be statistically significant. Neither instrument can substitute for colonoscopy in the overall management of colorectal neoplasms. We conclude that with adequate training and cost control, either instrument can be used for screening proctosigmoidoscopy; but the trend suggests a greater number of polyps are detected with the longer instrument.

Clinical Competence↗

Second-generation video sigmoidoscopy.

A newly developed 60-cm video sigmoidoscope has no image bundle or eyepiece. During scope manipulation, the instrument provides a real-time color endoscopic image on a video monitor as well as a permanent videotape record of the procedure. In a series of examinations performed by residents in family medicine, no complications occurred and patient acceptance was good. Consultations can be obtained using the videotapes. The video recording format overcomes many of the teaching limitations of conventional fiberoptic sigmoidoscopy and may play a role in documentation of procedures as well as certification of competence.

Family Practice↗

Flexible sigmoidoscopy: is it of value?

The use of 60 cm flexible fiberoptic sigmoidoscope increases the potential for finding significant colonic disease beyond the cutomary 25 cm. Patient comfort and cost effectiveness recommended the procedure for routine examination and for short operating colonoscopy.

Adult↗

Continued assessment of flexible sigmoidoscopy in a family practice residency.

The UCLA Family Practice Residency continues to use 60-cm flexible sigmoidoscopy in the care of patients. Between July 1980 and June 1983, 450 patients received an examination with the 60-cm flexible sigmoidoscope. One or more adenomatous polyps were detected in 21 patients. Adenocarcinoma was found in five patients. Four patients were found to have a villous adenoma, and four patients were determined to have inflammatory bowel disease. Of the 34 discrete lesions, 32 percent, 41 percent, and 27 percent were located between 0 and 20 cm, 21 and 35 cm, and 36 and 60 cm, respectively, from the anus. No complications were encountered. Sixty-four percent of the examinations were done by a family practice resident supervised by a full-time faculty member. The remaining 36 percent of the examinations were performed by full-time faculty. The overall detection rate for significant pathology was 8.0 percent. Most pathology by far was found in symptomatic patients. These results validate the safety and viability of 60-cm flexible sigmoidoscopy when performed by properly trained family physicians and family practice residents-in-training.

Adenocarcinoma↗

Impact of flexible sigmoidoscopy on physician compliance with colorectal cancer screening protocol.

The flexible sigmoidoscope may represent a partial solution to the longstanding problem of physician and patient noncompliance with sigmoidoscopy for the detection of colorectal cancer. A three-year longitudinal audit of medical records revealed at least a sevenfold increase in the number of sigmoidoscopies performed after the introduction of flexible sigmoidoscopy to a salaried medical group. This procedure has made a significant contribution to patient care and resident education in the UCLA family practice residency program.

Adult↗

Flexible fiberoptic sigmoidoscopy.

The 35-cm flexible fiberoptic proctosigmoidoscope is a cost-effective instrument for the family physician. Nonendoscopists have mastered its use with no reported complications. Patient tolerance is high compared to tolerance for the rigid scope. The pathology yield per procedure is two to four times greater than that reported with the rigid sigmoidoscope. Yields with the 35-cm instrument have matched those documented with the 65-cm fiberoptic instrument.

Aged↗

Fiberoptic pansigmoidoscopy. An evaluation and comparison with rigid sigmoidoscopy.

A flexible 60-cm fiberoptic sigmoidoscope was evaluated in 139 patients. In 120 patients flexible sigmoidoscopy was compared with routine rigid sigmoidoscopy with respect to patient tolerance, distance of inspection, procedure time, and diagnostic yield. All patients were prepared with a single cleansing enema, and given no analgesia. Despite the fact that the flexible instrument was inserted nearly 3 times as far into the colon (55 cm versus 20 cm), more patients preferred the flexible examination. Significant pathological lesions were discovered by the flexible examination in 39% of patients, whereas rigid sigmoidoscopy discovered lesions in only 13%. Fluoroscopy performed during flexible sigmoidoscopy in 19 additional patients revealed that the instrument tip had reached the descending colon or beyond in 84% of patients. There were no complications. The flexible fiberoptic pansigmoidoscope offers promise as a practical diagnostic tool for a rapid and complete examination in patients with suspected colorectal diseases.

Adolescent↗

[Colorectal cancer mortality can be reduced. Fecal blood screening is an efficient test].

Findings in large randomised studies in Europe and America show that colorectal cancer mortality can be reduced by faecal occult blood screening. Moreover, in the American study it was shown for the first time that the risk of colorectal cancer is reduced by removal of benign polyps larger than 9 mm. Partly as a result of uncontrolled studies showing repeat examination with the rigid rectoscope and removal of benign adenomas to reduce the risk of cancer, flexible sigmoidoscopy has been adopted in two controlled studies, one British the other American, though the problem remains of diagnosing the 30-40 per cent of tumours that are inaccessible to the sigmoidoscope. Together, the two types of hereditary colorectal cancer, familial adenomatous polyposis and hereditary non-polyposis colon cancer, account for only 5-10 per cent of all colorectal cancer, the overwhelming majority of cases being sporadic.

Adenomatous Polyposis Coli↗

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↗

Sigmoidoscopy. Is it a general practice procedure?

Sigmoidoscopy can readily be learnt and practised by a general practitioner interested in looking after patients with colorectal problems. Examination with a rigid sigmoidoscope has advantages over use of the flexible instrument for the frequent user. Details of the equipment needed for sigmoidoscopy as well as a method, precautions and some typical findings are described.

Colorectal Neoplasms↗

Use of flexible sigmoidoscopy to screen for colorectal cancer in HIV-infected patients 50 years of age and older.

BACKGROUND: Although many patients with human immunodeficiency virus (HIV) infection are now living well beyond 50 years of age, there are no data available on colorectal cancer screening in this population. The aim of this study was to determine the utility of screening flexible sigmoidoscopy in patients with HIV. METHODS: Consecutive patients at average risk for colorectal cancer who were referred for screening flexible sigmoidoscopy were prospectively identified. A detailed medical history was obtained from all patients before flexible sigmoidoscopy, and colonoscopy was recommended for all subjects with positive sigmoidoscopic findings. RESULTS: A total of 2382 patients were enrolled in the study; 165 were HIV positive. The prevalence of neoplastic lesions (adenomas or adenocarcinomas) in the distal colon was significantly higher in HIV-infected patients than in control subjects (25.5% vs 13.1%, P<.001), and the odds of HIV-infected patients having a neoplastic lesion was significantly higher even after adjustment for potential confounding variables (odds ratio, 2.34; 95% confidence interval, 1.60-3.44). The prevalence of adenomas of any size (25.5% vs 12.9%, P<.001) and advanced neoplasia (7.3% vs 3.8%, P = .03) in the distal colon was significantly higher in HIV-infected patients. Among individuals with positive results on flexible sigmoidoscopy, proximal colonic neoplastic lesions on follow-up colonoscopy were more common in HIV-infected patients after adjustment for age, sex, and race/ethnicity (odds ratio, 1.88; 95% confidence interval, 1.02-3.46). CONCLUSIONS: Patients infected with HIV are more likely to have colonic neoplasms on screening flexible sigmoidoscopy than those without HIV, and these individuals should be offered colorectal cancer screening.

Adenocarcinoma↗

A second look at colonoscopy: indications, failures, and costs.

Results of colonoscopy and colonoscopic polypectomy in 599 patients have been reviewed. Added experience has not decreased the number of failures--failure to examine the entire colon, polyps not retrieved for histological examination ("lost polyps"), undetected ("missed") lesions, and false-negative biopsy specimens. The incidence of invasive carcinoma in polyps measuring under 1 cm is less than 1%; polypectomy should be reserved for larger lesions or demonstrated growth of small polyps. Diagnostic colonoscopy in selected patients (those with persistent gross or occult rectal bleeding but normal results from sigmoidoscopic and barium enema studies) demonstrates a causative lesion in greater than 25% and detects a cancer in 5% to 10% of patients.

Biopsy↗

Argon laser treatment of radiation proctitis.

Radiation therapy for malignant gynecologic disease and prostatic cancer has resulted in increased survival and cure rates. This modality has unfortunately produced debilitating radiation proctitis. Recently, five patients were seen with continuous rectal bleeding secondary to radiation disease of the rectum. Four of these patients were women who were being treated for cervical carcinoma and one was a man with prostatic cancer. These patients were refractory to steroid retention enemas, iron therapy, and benproperine enema therapy. Treatment was accomplished using the argon laser with a 300-micron fiber passed via flexible fiberoptic sigmoidoscope. The most proximal areas were treated first. One and a half watts at 0.5 pulses was used. Up to 50 pulses were delivered per therapy session. The fiber was placed in contact with the lesion and circumferentially for 0.5 cm surrounding each suspected area. Bleeding stopped in the four women after two sessions and in the man after four sessions.

Ambulatory Surgical Procedures↗

Predicting advanced proximal colonic neoplasia with screening sigmoidoscopy.

CONTEXT: Indications are not well defined for follow-up colonoscopy for all patients with distal colonic tubular adenomas (TAs) found at screening sigmoidoscopy. OBJECTIVE: To determine whether distal adenoma size, number, and villous histology, along with family history and age, are predictors of advanced proximal colonic neoplasia. DESIGN: Cross-sectional analysis conducted between January 1, 1994, and December 31, 1995. SETTING: Large group-model health maintenance organization in northern California. PATIENTS: A total of 2972 asymptomatic subjects aged 50 years or older undergoing colonoscopy as follow-up to a screening sigmoidoscopy. MAIN OUTCOME MEASURE: Based on sigmoidoscopy, colonoscopy, and pathology reports, occurrence of advanced proximal neoplasia, defined as adenocarcinoma or TAs 1 cm or larger or with villous features or severe dysplasia located beyond sigmoidoscopic view. RESULTS: The prevalence of advanced proximal neoplasia was similar among patients with no TAs at sigmoidoscopy, those with TAs less than 1 cm in diameter, and those with TAs 1 cm in diameter or larger (prevalence, 5.3%, 5.5%, and 5.6%, respectively). Of patients with a distal tubulovillous or villous adenoma, 12.1% had advanced proximal neoplasia. In multivariate analyses, having a distal tubulovillous adenoma or villous adenoma was the strongest predictor of advanced proximal neoplasia (odds ratio, 2.30; 95% confidence interval, 1.69-3.14). Age of 65 years or older, having more than 1 adenoma, and a positive family history of colorectal cancer were also significant predictors. Distal adenoma size was not a significant predictor in any multivariate analyses. CONCLUSIONS: Advanced proximal neoplasia is not uncommon in subjects with or without distal TAs, but subjects with advanced distal histology and those older than 65 years are at increased risk. Age-specific screening using sigmoidoscopy starting at ages 50 to 55 years and colonoscopy after age 65 years may be justified.

Adenocarcinoma↗

Colorectal carcinoma screening attitudes and practices among primary care physicians in counties at extremes of either high or low cancer case-fatality.

BACKGROUND: To the authors' knowledge, physician attitudes and reported practices regarding colorectal carcinoma screening have not been studied in areas of highest risk for cancer death. METHODS: Medicare claims were used to calculate colorectal carcinoma 2-year case-fatality rates for counties with >100 incident cases of colorectal carcinoma between 1991-1993. All 2682 practicing primary care physicians in 20 counties with the lowest case-fatality rates (mean of 29.9%) and 19 counties with the highest case-fatality rates (mean of 47.8%) were surveyed regarding their screening procedures and attitudes. RESULTS: Among the 972 respondents (36.1%), the reported use of fecal occult blood testing (FOBT) and flexible sigmoidoscopy was similar in the low and high case-fatality counties. However, physicians who practiced in the high case-fatality counties were less likely to be trained in and to perform sigmoidoscopy themselves (37.0% vs. 45.6%; P<0.01). Moreover, practitioners in the high case-fatality counties were more likely than the other physicians to consider or plan enhanced FOBT and sigmoidoscopic screening in the near future. FOBT and sigmoidoscopy screening rates at the county level were associated negatively with cancer incidence rates, case-fatality rates, and metastatic disease rates, suggesting a potentially protective effect. CONCLUSIONS: Geographically targeted interventions are a potentially cost-effective strategy for focusing additional screening services on the highest risk populations. The primary care clinicians in these high risk areas are logical partners for these interventions by virtue of their high degree of readiness to change their current screening practices.

Attitude to Health↗

Colorectal cancer--Prevention and detection.

The American Cancer Society estimates that during 1980, there will be approximately 114,000 new cases of colorectal cancer in the United States--second only to lung cancer (an expected 117,000 cases) in incidence for internal malignant neoplasms. There will be 53,000 deaths this year from colorectal cancer. The low five-year survival rate of 42% in related primarily to late diagnosis. Therefore effective methods of making an earlier diagnosis are important. The use of fecal occult blood testing and sigmoidoscopic examination (rigid or flexible) appear to be tools that will make earlier diagnoses of colorectal cancer. Colonoscopy and barium enema are indicated if symptoms of colorectal cancer are present or if indicated from findings noted on fecal occult blood testing or sigmoidscopy. Determinations of carcinoembryonic antigen levels are of no practical value in colorectal cancer screening. In asymptomatic patients, fecal occult blood testing is recommended annually beginning at age 50, while sigmoidoscopy should be performed at age 50, repeat in one year, then performed every three years. The two chief areas of interest in colorectal cancer prevention are the removal of neoplastic polyps at the time of endoscopy, and the role of nutrition to decrease fat and increase fiber in the diet.

Adenoma↗

Severe pseudomembranous colitis after lincomycin and clindamycin.

Four cases of severe pseudomembranous colitis following the use of lincomycin and clindamycin are described; 2 required emergency total colectomy and 2 died. Cases of such gravity after the use of these drugs have not been previously reported. On hundred and fifty-six orthopaedic cases where clindamycin and lincomycin were used postoperatively are reviewed; 34 had diarrhoea (22 per cent), and 3 of the severe cases occurred in this group. The diagnosis of pseudomembranous colitis may be difficult as the latent period from initiation of drug therapy to commencement of diarrhoea may be as much as 18 days, and that from cessation of drug therapy may be as much as 11 days. The value of early sigmoidoscopy in cases of diarrhoea of obscure aetiology is emphasized, and the characteristic sigmoidoscopic and histological appearances of pseudomembranous colitis are described. As these drugs may produce a lethal condition it is suggested that they should be used with appropriate discretion, especially in the elderly female who appears to be most at risk.

Aged↗