Introduction

You have been advised by your GP or hospital doctor to have an investigation known as a flexible sigmoidoscopy.

If you are unable to keep your appointment, please notify the department as soon as possible. This will enable the staff to give your appointment to someone else and they will be able to arrange another date and time for you.

This patient information has been written to enable you to make an informed decision in relation to agreeing to the investigation therefore please read it carefully.

A flexible sigmoidoscopy requires your formal consent. 

Should you wish to change your mind and withdraw your consent you can do this at any time even when the procedure is taking place. The endoscopist will stop and clarify the problem with you. If you still wish and safe to do so the endoscopist will start to remove the endoscope. Please do note that this may not be done immediately as this needs to be removed in a safe manner.

Why do I need to have a flexible sigmoidoscopy?

You have been advised to undergo this investigation of the left side of your large bowel to help find the cause for your symptoms, thereby facilitating treatment, and if necessary to decide on further investigations.

There are many reasons for this investigation including
  • bleeding from the back passage
  • abdominal pain and diagnosing the extent of some inflammatory bowel disease.
  • follow-up inspection of previous disease
  • assessing the clinical importance of abnormalities found on x-ray
  • investigating the cause for diarrhoea.
What is a flexible sigmoidoscopy?

This test is a very accurate way of looking at the lining of the left side of your large bowel (colon). The instrument used in this investigation is called a colonoscope. Within each scope is an illumination channel which enables light to be directed onto the lining of your bowel, and another which relays images back on to a television screen. This enables the endoscopist to have a clear view and to check whether or not disease or inflammation is present.

Flexible sigmoidoscopy does not allow the endoscopist to see the entire colon. As a result, flexible sigmoidoscopy alone can't detect abnormalities further into the colon.

During the investigation the endoscopist may need to take some samples (biopsies) from the lining of your colon for analysis. These will be retained. Photographs can be taken for record and documentation purposes.

Preparation
Home preparation

The left side of your bowel can be cleaned properly using an enema. You have been sent an enema with clear instructions which will enable you to administer to yourself at home two hours before your appointment. Please try and retain the fluid in your bowel for as long as possible (for about 10 minutes) before going to the toilet.

You may eat and drink normally up until the time you have the enema, after that you may have only clear fluids until after the examination.

Instructions for using the enema are at the end of this leaflet.

Hospital preparation

In special circumstances we can arrange for the enema to be administered by the Nursing Staff at the hospital upon your arrival in the Endoscopy Department. This is more time consuming and will delay your early discharge home.

What about my medication?
Routine medication

Your routine medication should be taken. If you are taking iron tablets you must stop these 1 week prior to your appointment. If you are taking stool bulking agents (e.g. Fibogel, Regulan, Proctofibre), Loperamide (Imodium), Lomotil or codeine phosphate you must stop these 3 days prior to your appointment.

If you experience constipation please continue with your regular laxatives or obtain a laxative from your GP and take for 1 week prior to the procedure. This will enable improved views of your bowel following your enema, and a more successful investigation.

Anticoagulants/allergies

If you are taking anticoagulants or blood thinning medication such as apixaban, edoxaban, warfarin, clopidogrel, ticragelor, prasugrel, Dabigatran, Phenindione, or Rivaroxaban (Xarelto) and have not discussed this with your doctors or GP please contact the unit. Phone for information if you think you have a latex allergy.

Patients with implanted medical devices

If you have an implanted medical device such as a cardiac defibrillator or cochlear implant please bring any information about the type of device you have with you. We will need to know this information so that we can be aware of any precautions or provisions that we need to take whilst you are having your procedure.

How long will I be in the endoscopy department?

Overall you may expect to be in hospital for one to two hours. The time given on your letter is your admission time, not the time for your procedure.

The department also looks after emergencies and these can take priority over outpatient lists.

What happens when I arrive?

When you arrive in the department, you will be met by a trained member of staff who will ask you a few questions, one of which concerns your arrangements for getting home. You will also be able to ask further questions about the investigation.

The nurse will ensure you understand the procedure and discuss any further concerns or questions you may have.

The nurse will ask you some questions regarding your medical condition and any surgery or illnesses you have had to confirm that you are fit to undergo the investigation.

Your blood pressure and heart rate will be recorded and if you have diabetes, your blood glucose level will also be recorded. Should you suffer from breathing problems a recording of your oxygen levels will be taken.

The investigation

Your consent to the procedure will be confirmed and you will be given the opportunity to ask any further questions before you are escorted to the treatment room.

The nurse looking after you may ask you to remove or lower your lower garments and ask you to lie on the trolley then cover you with a sheet to respect your dignity. Alternatively they may ask you to get changed into a gown. The nurse will then place the oxygen monitoring probe on your finger. The examination takes 10 – 20 minutes to complete, you will be fully awake. At some point during the procedure you may be asked to change position to help improve the views in the bowel.

Some patients experience slight discomfort within the left side of the abdomen but this is rarely distressing enough to stop the examination.

During the procedure samples may be taken from the lining of your bowel for analysis in our laboratories. These will be retained. Any photography will be recorded in your notes.

In some cases it may be advisable to extend the examination further along the length of the bowel. This will only be done if you are comfortable and if the endoscopist feels it appropriate and safe to do so. Should you have any concerns or questions regarding this possibility please discuss these with the endoscopist before the procedure.

Please note that occasionally the test may need to be abandoned or may be incomplete. This can happen if you find the procedure too uncomfortable or if the bowel preparation did not empty your bowel completely. In this case, the test may need to be repeated.

Intravenous sedation and Entonox explained

Most patients find this test quite tolerable without sedation, so we do not give it routinely. If this is necessary it will be administered into a vein in your hand or arm which will make you lightly drowsy and relaxed but not unconscious. You will be in a state called cooperative sedation. This means that although drowsy, you will still hear what is said to you and therefore will be able to follow simple instructions during the investigation. Sedation often prevents you from remembering much about the examination.

Please note if you have had sedation you must not drive, take alcohol, operate heavy machinery or sign legally binding documents for 24 hours following the procedure and you must have someone to accompany you home and stay with you for at least 12 hours.

Entonox is a short acting painkiller which you inhale. It is a mixture of nitrous oxide and oxygen. The effects last no more than 10 minutes. If you do not have someone to stay with you after the procedure you may find this a good alternative to intravenous sedation. Following the use of entonox you would need to remain in the unit for a short while and you would not be able to drive for at least 30 minutes.

During the procedure we will monitor your breathing and heart rate so changes will be noted and dealt with accordingly. For this reason you will be connected by the finger probe to a pulse oximeter which measures your oxygen levels and heart rate during the procedure. Your blood pressure may also be recorded.

Risks of the procedure

Lower gastrointestinal endoscopy is classified as an invasive investigation and because of that it has the possibility of associated complications. These occur extremely infrequently; we would wish to draw your attention to them and so with this information you can make your decision.

The doctor who has requested the test will have considered this very carefully before recommending that you have it and as with every medical procedure, the risk must be compared to the benefit of having the procedure carried out.

The risks are small but can be associated with the procedure itself and with administration of the sedation.

The endoscopic procedure

The main risks are of mechanical damage

  • Perforation (risk approximately 1 in every 1,500 examinations) or making a hole in the wall of the bowel. An operation is nearly always required to repair the hole. Whilst this is a serious and potentially life threatening complication, we emphasise it is extremely rare. The risk of perforation is however higher with polyp removal.
  • Bleeding may occur at the site of biopsy or polyp removal (risk approximately 1 for every 100-200 examinations where this is performed). Typically minor in degree, such bleeding may either simply stop on its own or if it does not, be controlled by cauterization or injection treatment.
  • There are other extremely rare complications which can occur during a procedure. Most of these are related to specific people or conditions. Should you have any particular concerns or worries regarding this please discuss this with your endoscopist when you attend and before you sign your consent form.
  • There are occasions when the endoscopist may fail to detect abnormalities in the bowel. This most often occurs when the bowel preparation is inadequate although small lesions can also be missed in a fully cleansed bowel.
Sedation

Sedation can occasionally cause problems with breathing, heart rate and blood pressure. If any of these problems do occur, they are normally short lived. Careful monitoring by a fully trained endoscopy nurse ensures that any potential problems can be identified and treated rapidly.

Older patients and those who have significant health difficulties may be assessed by a doctor before being treated.

What is a polyp?

A polyp is a protrusion from the lining of the bowel into the lumen caused by an abnormal multiplication of cells. Some polyps are pedunculated (look like a grape) and are attached to the intestinal wall by a stalk and some are sessile polyps which attach directly onto the intestinal wall without a stalk. Polyps when found are generally removed or sampled by the endoscopist as they may grow and cause problems.

Polypectomy

Various removal techniques are available to remove polyps in the large bowel. Most involve removing them with a wire loop or biopsy forceps, sometimes using an electric current. This is called a polyp resection or polypectomy.

It will depend on the size of the polyp, the location of the polyp in the bowel and the appearance of the polyp as to what method the endoscopist uses to perform the polypectomy.

For large polyps with a stalk, a snare (wire loop) is placed around the stalk of the polyp, a high frequency current is then applied and the polyp is removed.

Flat polyps (without any stalk) may need to be lifted up from the lining of the bowel. This involves injecting the lining of the bowel that surrounds the flat polyp. This raises the area and allows the wire loop snare to capture the polyp.

For smaller polyps biopsy forceps (cupped forceps) may be used.

The risk of making a hole in the bowel during a polypectomy can be as high as one in every 750 examinations.

After the procedure

Nearly all patients will be free to leave after discussing their results. However, the nurse may recommend a short rest in the recovery area if, for example, you are still very uncomfortable at that stage. Before you leave the department, the nurse or doctor will explain the findings and any medication or further investigations required. They will also inform you if you require further appointments.

If you have had sedation you will be allowed to rest for as long as necessary. Your blood pressure, oxygen levels and heart rate will be recorded. Once you have recovered from the initial effects of any sedation (which normally takes 30 minutes) you may be moved to a comfortable chair and offered a drink.

Any sedation is likely to affect your memory, so it is a good idea to have a member of your family or friend with you when you are given this information although there will be a short written report given to you.

If you have had sedation you may feel fully alert following the investigation, but however, the drug remains in your blood system for about 24 hours and you can intermittently feel drowsy with lapses of memory. If you live alone, you will need to arrange for someone to stay with you for at least 12 hours after the procedure or, if possible, arrange to stay with your family or a friend for this time.

The nursing staff will telephone the person collecting you when you are ready for discharge.

What if I choose not to have this procedure?

If you decide not to proceed with the examination, your doctors will still treat your symptoms, however they may find it harder to identify the underlying cause of your problems. This may affect their ability to provide a long-term solution or treatment for your condition or exclude conditions like cancers.

Ready to use enemas – directions for use
  • Lie on left side with both knees bent, arms at rest.
  • Remove protective shield. Pull shield gently while holding bottle upright and grasping grooved bottle cap with fingers. With steady pressure, gently insert enema into rectum with tip pointing towards navel.
  • Squeeze bottle until nearly all liquid is expelled. Discontinue use if resistance is encountered. Forcing the enema can result in injury.
General points to remember
  • If you are unable to keep your appointment please notify the endoscopy department as soon as possible.
  • It is our aim for you to be seen and investigated as soon as possible after your arrival. However, the department is very busy and your investigation may be delayed. If emergencies occur, these patients will be given priority over the less urgent cases.
  • The hospital cannot accept any responsibility for the loss or damage to personal property during your time on these premises.
  • If you are having sedation, please arrange for someone to collect you.
  • If you have any problems with persistent abdominal pain or bleeding please contact your GP immediately informing them that you have had an endoscopy.
  • If you are unable to contact or speak to your doctor, you must contact the A&E department.
Contact details 

Cumberland Infirmary Endoscopy Unit: 01228 814289

West Cumberland Endoscopy Unit: 01946 523061

Endoscopy booking/appointments: 01228 210430

Confidentiality

‘The Trust’s vision is to keep your information safe in our hands.’ We promise to use your information fairly and legally, and in-line with local and national policies. You have a right to understand how your information is used and you can request a copy of the information we hold about you at any time.

For further information on confidentiality contact the Information Governance Team:

Information.Governance@ncic.nhs.uk | 01228 603961

Feedback

We appreciate and encourage feedback, which helps us to improve our services. If you have any comments, compliments or concerns to make about your care, please contact the Patient, Advice & Liaison Service:

pals@ncic.nhs.uk | 01228 814008 or 01946 523818

If you would like to raise a complaint regarding your care, please contact the Complaints Department:

complaints@ncic.nhs.uk | 01228 936302