Evaluation of flexible sigmoidoscopy as an investigation for “left sided” colorectal symptoms

Abstract

Background: Colonoscopy is the best way of imaging the colon with concurrent biopsy and treatment. However it is expensive, requires full bowel preparation, and carries a risk of complications. Flexible sigmoidoscopy is an alternative way to investigate symptoms that raise the suspicion of a lesion of the rectum or left colon. Aim of the study: To evaluate flexible sigmoidoscopy as the main investigation for ''left sided'' colorectal symptoms. Methods: The clinical records of 317 patients who were assessed at a colorectal specialist clinic and were thought to have a suspicion of a lesion of the rectum or left colon were retrospectively reviewed. All patients had flexible sigmoidoscopy as the primary investigation. Primary outcome was the diagnostic yield of flexible sigmoidoscopy and secondary outcomes were any additional colonic investigations required, failure rates, and complication rates. Results: Three hundred and sixteen patients who had flexible sigmoidoscopy with the above criteria were retrospectively analysed. Twenty four procedures (7.6%) had to be abandoned because of poor bowel preparation. The examination was considered complete when it reached the splenic flexure, which was the case in 205 cases (65%).In 137 flexible sigmoidoscopies (43.3%) there were no abnormal findings. Of the remaining 179 a carcinoma of the rectum or colon was found in 28 cases (8.8%) and one or more polyps was found in 57 (18%) cases. On the basis of the findings it was calculated that 31% of the patients would require an additional investigation for further imaging of the right colon. Discussion: Although flexible sigmoidoscopy has a high yield of pathologies when carried out by a specialist colorectal clinic, the presence of those pathologies makes the full imaging of the whole colon with an additional investigation necessary. Therefore the cost efficiency of flexible sigmoidoscopy is questionable. Although flexible sigmoidoscopy is indicated for certain patients, it cannot replace colonoscopy as the main investigation used by a specialist colorectal clinic.

Investigating the frail elderly patient with lower bowel symptoms: what do we do now and can we improve?

“…10,11 This is largely because a negative FS does not exclude right-sided colon pathology (such as malignancy), thus necessitating further investigation by either radiology or colonoscopy.…”

Is whole-colon investigation by colonoscopy, computerised tomography colonography or barium enema necessary for all patients with colorectal cancer symptoms, and for which patients would flexible sigmoidoscopy suffice? A retrospective cohort study

“…29,32,34,71 There have been calls for further clarity in this area, particularly in relation to diagnostic protocols for patients presenting with bowel symptoms alone without IDA and/or a palpable abdominal mass. 32,34 In 2011, we proposed the Symptoms of Colorectal Cancer Evaluation Research (SOCCER) study as an add-on study to the SIGGAR randomised controlled trials.…”

“…In studies in lower-risk patients, or when criteria for WCI referral after FS were more tightly controlled, referral rates were slightly lower, ranging from 16% to 31%. 71,94,95 It is not possible to determine the proportion of patients referred for WCI after FS in the SOCCER cohort, as patients were eligible for the SIGGAR trials on the basis that they required a WCI. Very few studies report reasons for referral for WCI after FS, but clearly this is an important question, as it profoundly affects the cost-effectiveness of offering FS.…”

“…Very few studies report reasons for referral for WCI after FS, but clearly this is an important question, as it profoundly affects the cost-effectiveness of offering FS. In the few studies that do provide details, the reasons provided include the presence of distal pathology (neoplastic and non-neoplastic), 71,89,[94][95][96][97] suboptimal bowel preparation and/or incomplete FS, 89,94,95,97 symptoms not adequately explained at FS 32,57,97 and the presence of symptoms/signs (anaemia, abdominal pain, weight loss and faecal occult blood) that are suggestive of proximal pathology. 89,95,96 In the Thompson et al 33 series, the yield of proximal cancer in patients receiving WCI after FS was particularly low in patients with distal symptoms when FS yielded no clear indication for further investigation.…”

The role of flexible sigmoidoscopy in the evaluation of patients presenting with a lump at anus

“…Studies have been done to assess the yield of flexible sigmoidoscopy in patients presenting with per-rectal bleeding and other colorectal symptoms [3,4]. However, there are no published data particularly on the yield of flexible sigmoidoscopy in those presenting with a lump at anus, with or without fresh per rectal bleeding.…”