Synonym/Acronym:
Anoscopy (anal canal), proctoscopy (rectum), flexible fiberoptic sigmoidoscopy, flexible proctosigmoidoscopy, sigmoidoscopy (sigmoid colon).

Common Use:
To visualize and assess the colon, rectum, and anus to assist in diagnosing disorders such as cancer, inflammation, prolapse, and evaluate the effectiveness of medical and surgical therapeutic interventions.

Area Of Application:
Anus, rectum, colon.

Contrast:
Air.

Description

Proctosigmoidoscopy allows direct visualization of the mucosa of the anal canal (anoscopy), rectum (proctoscopy), and distal sigmoid colon (sigmoidoscopy). The procedure can be performed using a rigid or flexible fiberoptic endoscope, but the flexible instrument is generally preferred. The endoscope is a multichannel device allowing visualization of the mucosal lining of the colon, instillation of air, removal of fluid and foreign objects, obtainment of tissue biopsy specimens, and use of a laser for the destruction of tissue and control of bleeding. The endoscope is advanced approximately 60 cm into the colon. This procedure is commonly used in patients with lower abdominal and perineal pain; changes in bowel habits; rectal prolapse during defecation; or passage of blood, mucus, or pus in the stool. Proctosigmoidoscopy can also be a therapeutic procedure, allowing removal of polyps or hemorrhoids or reduction of a volvulus. Biopsy specimens of suspicious sites may be obtained during the procedure.

Indications

• Confirm the diagnosis of diverticular disease
• Confirm the diagnosis of Hirschsprung’s disease and colitis in children
• Determine the cause of pain and rectal prolapse during defecation
• Determine the cause of rectal itching, pain, or burning
• Evaluate the cause of blood, pus, or mucus in the stool
• Evaluate postoperative anastomosis of the colon
• Examine the distal colon before barium enema (BE) x-ray to obtain improved visualization of the area, and after a BE when x-ray findings are inconclusive
• Reduce volvulus of the sigmoid colon
• Remove hemorrhoids by laser therapy
• Screen for and excise polyps
• Screen for colon cancer

Potential Diagnosis

Normal Findings In:

• Normal mucosa of the anal canal, rectum, and sigmoid colon

Abnormal Findings In:

• Anal fissure or fistula
• Anorectal abscess
• Benign lesions
• Bleeding sites
• Bowel infection or inflammation
• Crohn’s disease
• Diverticula
• Hypertrophic anal papillae
• Internal and external hemorrhoids
• Polyps
• Rectal prolapse
• Tumors
• Ulcerative colitis
• Vascular abnormalities

Critical Findings

N/A

Interfering Factors

This procedure is contraindicated for:

• Patients with bleeding disorders, especially disorders associated with uremia and cytotoxic chemotherapy.
• Patients with cardiac conditions or arrhythmias.
• Patients with bowel perforation, acute peritonitis, ischemic bowel necrosis, toxic megacolon, diverticulitis, recent bowel surgery, advanced pregnancy, severe cardiac or pulmonary disease, recent myocardial infarction, known or suspected pulmonary embolus, large abdominal aortic or iliac aneurysm, or coagulation abnormality.

Factors that may impair clear imaging:

• Inability of the patient to cooperate or remain still during the procedure because of age, significant pain, or mental status.
• Strictures or other abnormalities preventing passage of the scope.
• Barium swallow or upper gastrointestinal (GI) series within the preceding 48 hr.
• Severe lower GI bleeding or the presence of feces, barium, blood, or blood clots.

Other Considerations:

• Failure to follow dietary restrictions before the procedure may cause the procedure to be canceled or repeated.
• Use of bowel preparations that include laxatives or enemas should be avoided in pregnant patients or patients with inflammatory bowel disease unless specifically directed by a health-care provider (HCP).

Nursing Implications Procedure

Pretest

• Positively identify the patient using at least two unique identifiers before providing care, treatment, or services.
• Patient Teaching: Inform the patient this procedure can assist in evaluating the rectum and lower colon for disease.
• Obtain a history of the patient’s complaints, including a list of known allergens, especially allergies or sensitivities to latex, iodine, seafood, contrast medium, and anesthetics.
• Obtain a history of the patient’s gastrointestinal system, symptoms, and results of previously performed laboratory tests and diagnostic and surgical procedures.
• Note any recent procedures that can interfere with test results. Ensure that this procedure is performed before an upper GI study or barium swallow.
• Record the date of the last menstrual period and determine the possibility of pregnancy in perimenopausal women.
• Obtain a list of the patient’s current medications, including anticoagulants, aspirin and other salicylates, herbs, nutritional supplements, and nutraceuticals (see Effects of Natural Products on Laboratory Values). Such products should be discontinued by medical direction for the appropriate number of days prior to a surgical procedure. Note time and date of last dose.
• Note intake of oral iron preparations within 1 wk before the procedure because these cause black, sticky feces that are difficult to remove with bowel preparation.
• Review the procedure with the patient. Address concerns about pain related to the procedure and explain that some pain may be experienced during the test, and there may be moments of discomfort. Explain that a sedative and/or analgesia will be administered to promote relaxation and reduce discomfort prior to insertion of the anoscope. Inform the patient that the procedure is performed in a GI lab by an HCP specializing in this procedure, with support staff, and takes approximately 30 to 60 min.
• Sensitivity to social and cultural issues, as well as concern for modesty, is important in providing psychological support before, during, and after the procedure.
• Instruct the patient that a laxative may be needed the day before the procedure, with cleansing enemas on the morning of the procedure, depending on the institution’s policy.
• Inform the patient that the urge to defecate may be experienced when the scope is passed. Encourage slow, deep breathing through the mouth to help alleviate the feeling.
• Inform the patient that flatus may be expelled during and after the procedure owing to air that is injected into the scope to improve visualization.
• Instruct the patient to eat a low-residue diet for 3 days prior to the procedure. Consume clear liquids only the evening before, and restrict food and fluids for 8 hr prior to the procedure. Protocols may vary among facilities.
• Make sure a written and informed consent has been signed prior to the procedure and before administering any medications.

Intratest

• Observe standard precautions, and follow the general guidelines in Patient Preparation and Specimen Collection. Positively identify the patient.
• Ensure that the patient has complied with food, fluid, and medication restrictions and pretesting preparations.
• Administer two small-volume enemas 1 hr before the procedure.
• Have emergency equipment readily available.
• Instruct the patient to void prior to the procedure and change into the gown, robe, and foot coverings provided.
• Record baseline vital signs and continue to monitor throughout the procedure. Protocols may vary among facilities.
• Place the patient on an examination table in the left lateral decubitus position or the knee-chest position and drape with the buttocks exposed. The buttocks are placed at or extending slightly beyond the edge of the examination table or bed, preferably on a special examining table that tilts the patient into the desired position.
• The HCP visually inspects the perianal area and then performs a digital rectal examination with a well-lubricated, gloved finger. A fecal specimen may be obtained from the glove when the finger is removed from the rectum.
• A lubricated anoscope (7 cm in length) is inserted, and the anal canal is inspected (anoscopy). The anoscope is removed, and a lubricated proctoscope (27 cm in length) or flexible sigmoidoscope (35 to 60 cm in length) is inserted.
• The scope is manipulated gently to facilitate passage, and air may be insufflated through the scope to improve visualization. Suction and cotton swabs also are used to remove materials that hinder visualization.
• The patient is instructed to take deep breaths to aid in movement of the scope downward through the ascending colon to the cecum and into the terminal portion of the ileum.
• Examination is done as the scope is gradually withdrawn. Photographs are obtained for future reference.
• At the end of the procedure, the scope is completely withdrawn, and residual lubricant is cleansed from the anal area.
• Place fecal or tissue samples and polyps in properly labeled specimen containers, and promptly transport the specimen to the laboratory for processing and analysis.

Post Test

• A report of the results will be made available to the requesting HCP, who will discuss the results with the patient.
• Monitor vital signs and neurological status every 15 min for 1 hr, then every 2 hr for 4 hr, and then as ordered by the HCP. Monitor temperature every 4 hr for 24 hr. Monitor intake and output at least every 8 hr. Compare with baseline values. Notify the HCP if temperature changes. Protocols may vary among facilities.
• Monitor for any rectal bleeding.
• Instruct the patient to resume diet, medication, and activity, as directed by the HCP.
• Instruct the patient to expect slight rectal bleeding for 2 days after removal of polyps or biopsy specimens, but heavy rectal bleeding must be immediately reported to the HCP.
• Instruct the patient that any abdominal pain, tenderness, or distention; pain on defecation; or fever must be reported to the HCP immediately.
• Inform the patient that any bloating or flatulence is the result of air insufflation.
• Encourage the patient to drink several glasses of water to help replace fluid lost during test preparation.
• Recognize anxiety related to test results, and be supportive of perceived loss of independence and fear of shortened life expectancy. Discuss the implications of abnormal test results on the patient’s lifestyle. Provide teaching and information regarding the clinical implications of the test results, as appropriate. Educate the patient regarding access to counseling services.
• Reinforce information given by the patient’s HCP regarding further testing, treatment, or referral to another HCP. Decisions regarding the need for and frequency of occult blood testing, colonoscopy, or other cancer screening procedures should be made after consultation between the patient and HCP. The most current guidelines for colon cancer screening of the general population as well as of individuals with increased risk are available from the American Cancer Society (www.cancer.org) and the American College of Gastroenterology (www.gi.org). Answer any questions or address any concerns voiced by the patient or family.
• Depending on the results of this procedure, additional testing may be needed to evaluate or monitor progression of the disease process and determine the need for a change in therapy. Evaluate test results in relation to the patient’s symptoms and other tests performed.

Related Monographs

• Related tests include barium enema, capsule endoscopy, colonoscopy, CBC, CT abdomen, fecal analysis, fecal fat, GI blood loss scan, MRI abdomen, US prostate transrectal.
• Refer to the Gastrointestinal System table at the end of the book for related tests by body system.