Rigid Proctosigmoidos

RIGID PROCTOSIGMOIDOSCOPY
Pages with reference to book, From 192 To 194

Ziauddin Shamsi, Mohammad Aftab Anwar, Naeemuilah Khan ( G.I. Consultants, 5/15 Rimpa Plaza, Karachi. )
DEFINITION
Rigid Proctosigmoidoscopy is a procedure that directly visualizes the lumen (mucosal lining) of the
rectum and most of the sigmoid colon, using a rigid instrument.
INDICATIONS
Diagnostic
1. Unexplained symptoms like rectal bleeding, diarrhoea, constipation.
2. To confirm or diagnose abnormality seen in rectosiginoid on barium enema.
3. Diagnosis of inflammatory bowel diseases like ulcerative colitis.
4. Biopsy or cytology of a lesion.
Therapeutic
1. Polypectomy
2. Removal of foreign body.
3. Electrocoagulation of bleeding points.
4. Electric fulguration of small lesions.
PREPARATION
1. Procedure should be explained in simple words, and reassuted.
2.Generally no preparation of bowel is required. An enema may wash away blood, mucus and pus and
make it difficult to ascertain the level of bleeding. An enema, however may be necessary in certain pat-
ients with fecal impaction or where satisfactory examination is not possible inspite of swabbing and
suction of stool.
3. Premedication is generally not required. Topical anaesthetic lubricant may help in patients with
painful anal lesions.
4. Patients should be draped in a clean sheet wrapped in a circular manner to cover the back and legs to
expose only buttocks.
5. Instruments should be arranged within easy reach. An assistant usually a nurse, hands over
instruments to the examiner.
Place of Procedure
Examination can be done in endoscopy room with a special tilt table, doctor’s office or on patients bed.
Position of the Patient
Procto-sigmoidoscopy can be done in any of the following positions.
Left Lateral Position (SIM’S)
This position can be used to do sigmoidoscopy on patient’s bed or examination table in the office.
Patient lies on the straight table with left side down with hips fully flexed and knees drawn to 900 angle
with the body. The hipé are best kept at the edge of the bed to provide room for the examiner to
manipulate the instrument during examination. Examination in this position needs some experience and
is not recommended for beginners (Figure 1).
Knee Chest Position
Knee chest position may be used on a straight table or a multi- purpose tilt table (Jack knife prone
position) as shown in Figures 2 & 3.
Examination in this position is easy and one hardly needs to pump air during exantation as it spon-
taneously finds its way there.
MATERIAL
1. Rigid Sigmoidoscope.
2. Suction Machine and rubber tubing.
3. Gloves, Gauzes, Cotton rectal swabs.
4. Lubricant.
5. Biopsy bottles with fixatives.
6. Glass slide with cover slips.
7. 50cc syringe.
PROCEDURE
Instrument
A standard sigmoidoscope consists of a rigid tubular plastic or metallic instrument about 25cm long
(calibrated on its external surface) and 13 to 16mm in diameter alongwith an obturator. Newer scopes
have a brighter proximal fibreoptic light (in comparison to distal illumination in older scopes) with a
magnifying lens and a connection for air insufflation. A sigmoidoscopy set also includes air insufflation
bulb, grasping biopsy forceps and a suction cannula.
Technique
Procedure should be preceded by careful inspection of perineum. Palpation of peri-anal area with an
unlubricated finger and then careful and gentle digital examination of ano-rectal canal with a lubricated
finger in a systemic fashion, to detect any luminal or extra-luminal pathology and judge the tone of anal
sphincter. The well lubricated scope is held in right hand with the thumb pressed against the obturator
so that it does not slip back as the scope is introduced. The scope is placed at the opening of the anal
canal and held there for a moment, then with a gentle pressure with scope pointed towards umbilicus
scope is introduced into the anal canal. When tip of the scope reaches the ann-rectal ring it should be
deflected posteriorly to follow the lumen at the ano-rectal angle (Figure 4).
At this point obturator is removed and the scope is introduced with lumen in view all the time. Some air
insufflation may be necessary specially when examination is done in left lateral position (Figure 5 &
6).
In majority of cases (>75%)4~5,6 scope can be inserted upto 25cm without much discomfort to the
patient.1 The lumen is carefully examined as the scope is withdrawn with a circumferential movement
of the tip of the scope, while ironing out the valves of Houston. Lumen may need to be cleaned with
swab or suctioning liquid stool as needed. Normal recto-sigmoid mucosa is pink with a delicate
network of vessels visible. The first sign of oedema (inflammation) is blurring or loss of visibility of
these vessels. Mucosal friability can be judged by touching mucosa with cotton swabs. Appearance of
petechial spots is usually suggesfive of friability of mucosa. During examination neoplasms,
inflammation, its severity and extent are noted and its distance from anal verge should be recorded.
Biopsy is best performed from posterior wall below the peritoneal reflection. It should be avoided from
anterior wall and above 10cm. Bleeding from biopsy site can be avoided by holding tissue between the
jaws of forceps before cutting instead of tearing it away. Even if bleeding occurs, it usually stops by
applying pressure with a swab, with or without dilute epinephrine solution. Rarely bleeding points may
need cauterization.
COMPLICATION
1. Perforation2.
2. Bleeding (from biopsy or polypectomy site).
3. Infection (Bacteremia 3, specially in patients with endocarditis).
4. Arrhythmias (Transient 4).
5. Explosion (specially when electro-surgical instruments are used).
CONTRAINDICATIONS
Absolute
1. Imperforate anus.
Relative
1. Uncooperative patient.
2. Cardio-pulmonary diseases.
3. Acute fulminating inflammatory disease.
4. Acute inflammatory disease of the anus.
5. Incessant lower gastrointestinal bleeding.
6. Endocarditis (As it may cause bacteremia).
However, if the patient can give an informed consent and is cooperative, there is hardly any
contraindication to perform rigid procto-sigmoidoscopy.
ADVANTAGES
1. Sigmoidoscopy is a direct examination of the mucosa.
2. Diagnostic accuracy is greater.
3. Biopsies5 and cytology can be taken.
4. It can be performed by any trained professional person. 6,7,8
5. Morbidity and mortality is much less.
REFERENCES
1. NivatvOngs,S. and Fryd, D.S. Howfardoestheproctosigmoidoscope reach? A prospective study of
thousand patients. N. Engi. J. Med., 1980; 30:380.
2. Jackman, R.J. Rigid Tube Proctosigmoidoscopy. In Berry LH, ed. GI. Panendoscopy. Springfield,
(Thomas, 1974, p.439).
3. Lefrock, J.E., Ellis, C.A., Turchik, J.B. and Weinstein, L. Transient bacteremia associated with
sigmoidoscopy. N. Engi. J. Med., 1973;289:467.
4. Fletcher, G.F., Earnest, D.L, Shuford, W.F., et al. Electrocardiographic changes during routine
sigmoidoscopy. Arch. Intern. Med., 1968; 122:483.
5. Nivatvong. S. Technique of rectal biopsy. DiL Colon Rectum, 1981; 24:132.
6. Spencer, R.J> and Ready, R.L Utilization of nurse endoscopists for sigmoidoscopic examinations.
Dis. ColonRectum, 1977;20:94.
7. Spencer, R.J. and Winkels, R.J. Treatment of diminutive mucosal lesions of the terminal colon by
nurse endoscopists. Mayo Clin. Proc., 1978;53:391.

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RIGID PROCTOSIGMOIDOSCOPY

Pages with reference to book, From 192 To 194

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