Adaptable Sigmoidoscopy

Presentation Transcript

Adaptable Sigmoidoscopy Scott M. Strayer, MD, MPH Assistant Professor University of Virginia Health System Department of Family Medicine

Colon Cancer 150,000 cases for each year. 50,000 passings yearly. #2 reason for disease mortality in non-smoking guys and females.

Screening Recommendations The USPSTF emphatically suggests that clinicians screen men and ladies 50 years old or more established for colorectal disease. ( A suggestion ) Good confirmation that intermittent fecal mysterious blood testing (FOBT) lessens mortality from colorectal growth and reasonable proof that sigmoidoscopy alone or in mix with FOBT diminishes mortality. Deficient confirmation that more current screening advancements (e.g., figured tomographic colography) are successful in enhancing wellbeing results.

Screening Recommendations AAFP-No distributed principles or rules for generally safe patients ACOG-After age 50, yearly FOBT (DRE ought to go with pelvic examination); sigmoidoscopy each 3 to 5 years ACS-After age 50, yearly FOBT in addition to adaptable sigmoidoscopy and DRE at regular intervals or colonoscopy and DRE like clockwork or twofold differentiation barium douche and DRE each 5 to 10 years

Screening Recommendations AMA-Annual FOBT starting at age 50, and adaptable sigmoidoscopy each 3 to 5 years starting at age 50 AGA-FOBT starting at age 59 (recurrence not determined); sigmoidoscopy like clockwork, twofold difference barium bowel purge each 5 to 10 years or colonoscopy like clockwork.

Screening Recommendations CTFPHC-Insufficient confirmation to suggest utilizing FOBT screening in the intermittent wellbeing examination of people more seasoned than age 40; lacking proof to prescribe sigmoidoscopy in the occasional wellbeing examination; deficient confirmation to prescribe screening with colonoscopy in the all inclusive community USPSTF-After age 50, yearly FOBT and additionally sigmoidoscopy (unspecified recurrence for sigmoidoscopy)

The Evidence Screening for colorectal tumor lessens disease related mortality at costs practically identical to other malignancy screening programs. Given a normal screening consistence rate of 60% and current expenses of the different methodology, yearly rehydrated fecal mysterious blood testing in addition to sigmoidoscopy like clockwork is most practical. On the off chance that the cost of colonoscopy is diminished by at least 25%, screening at regular intervals with colonoscopy is favored by this model (LOE: 2b). Frazier AL, Colditz GA, Fuchs CS, Kuntz KM. Fetched adequacy of screening for colorectal malignancy in the overall public. JAMA 2000;284:1954-61.

More Evidence 16% of colorectal growths avoided with FOBT. 34% of colorectal tumors averted with flex sig. 75% avoided with colonoscopy. Colonoscopy q 10 years was more practical than flex sigs q 5-10 (LOE:?). Sonnenberg An, et al. Taken a toll adequacy of colonoscopy in screening for colorectal growth. Ann Intern Med October 17, 2000;133:573-84.

Even More Evidence Screening with sigmoidoscopy: There is confirmation from case control studies, to prescribe that adaptable sigmoidoscopy be incorporated into the intermittent wellbeing examination of patients over age 50 [B, II-2, III]. There is deficient confirmation to make suggestions about whether just 1 or both of fecal mysterious blood testing and sigmoidoscopy ought to be performed [C, I]. CMAJ 2001 Jul 24;165(2):206-8 [20 references]

Indications Mostly to screen. Ought to consider colonoscopy if: past polyps, family history of colon tumor, rectal dying, hemoccult positive stools, change in gut propensities, extended looseness of the bowels, reconnaissance in UC/Crohn's, frailty, unexplained wt. Misfortune/fevers, stomach torment.

Contraindications ABSOLUTE Acute, serious cariopulmonary infection. Deficient entrail prep. Dynamic diverticulitis Acute belly. History of SBE or prosthetic valves with no prophylaxis. Checked draining dyscrasia.

Contraindications RELATIVE Recent stomach surgery (inside or pelvic). Dynamic contamination Pregnancy.

Equipment

Additional Equipment Light source Suction mechanical assembly Biopsy forceps K-Y Jelly 4X4 inch bandage cushions Nonsterile gloves Water holder (for suction)

More hardware Video unit and screen Anoscope Basin of water Formalin jugs Disinfecting cleaner

Complications Bowel aperture (1/10000) Bleeding (expanded hazard with biopsy) Abdominal enlargement and agony Infection (SBE, contamination from another pt.) Vasovagal side effects Missed sickness

Increased Complications Watch out for patients with past inside or pelvic surgery, illumination, or diverticulosis. Alert with visually impaired headway (just restricted separations).

Patient Preparation Signed educated assent 2 armadas douches (one a hour and a half earlier, and one 30 minutes) before system Clear fluids subsequent to night feast Take diuretic if perpetual clogging Take typical drugs (alert with diabetics)

Clear Liquid Diet Beverages: carbonated, espresso, kool-help (evade red), tea. Treats: Jello, clear popsicles Fruit: Apple juice, cranberry juice, grape juice Soups: Beef bouillon, clear juices Sweets: hard confection, sugar.

Anatomy Review

The Procedure Pt. Put in left sidelong decubitus position Rectal examination first Lubrication is vital, don't spread the focal point Either straightforwardly embed degree, or flex pointer behind the extension. Hold scope in left hand, utilize thumb for here and there, utilize right hand for right-left (or can likewise utilize thumb).

Rectum Insert scope 7-15cm, insufflate or potentially pull back to picture lumen Normal rectal mucosa is a nonfriable, vascular system. Proctitis delivers an erythematous, friable mucosa, frequently with dying. Semilunar valves of Houston show up as sharp edges jutting into the lumen (there are 3) with shadows noted behind them.

Rectum Ulcerative colitis will create erythema, friability, and mucosal dying.

Rectal Colon CA

Sigmoid Redundant folds, hard to picture lumen May need to: insufflate, broad turning, torquing, accordionization, or dithering Avoid bowing out.

FIGURE 1. Snaring and rectifying procedure used to go through a convoluted sigmoid colon. (A) The extension is embedded to the calculated sigmoid. (B) The extension tip is swung to a sharp point, and the sigmoid is snared as the degree is pulled back. (C) The sigmoid is rectified as the extension is pulled back. The degree can then be embedded through to the slipping colon. Procedures

FIGURE 2. Paradoxic inclusion. (A) The degree is bowing out the sigmoid colon, which has a versatile mesenteric connection. (B) Paradoxic addition depicts the inclusion of the tube without headway of the extension tip. Paradoxic addition can be exceptionally awkward for the patient. Different Techniques

Descending Colon Long, straight tube with concentric haustrae. Vascularity is arbitrary, reticular. Polyps can either be hill like (sessile) or on a long stalk (pedunculated). Try not to mix up suction polyps or mucous for polyps!!

Pedunculated Polyp

Diverticulosis

Crohn's Colitis

C. Difficile Colitis

The Final Step-Retroflexion Accomplished by turning inward handle the distance "up" and external handle the distance "right" while tenderly embeddings and pivoting 180 degrees. Ensure you are in rectum, and not to a long way from inside sphincter.

Retroflexion with Hemorrhoid and Small Polyp

Be pleasant to your patient Suction let some circulation into before ending methodology!