A flexible sigmoidoscopy is a procedure to look at the inside of the left, lower part of the colon (large bowel) using a flexible telescope.  Your doctor has recommended a flexible sigmoidoscopy.  However, it is your decision to go ahead with the procedure or not.  This leaflet will give you information about the benefits and risks to help you make an informed decision.

If you have any questions that this document does not answer, you should ask your doctor or any member of the endoscopy team.

 Why do I need a flexible sigmoidoscopy?

Your doctor is concerned that you may have a problem in the large bowel.  A flexible sigmoidoscopy  is a good way of finding out if there is a problem or not.

If the endoscopist (the person doing the sigmoidoscopy) finds a problem, they can perform biopsies (removing small pieces of tissue) to help make the diagnosis. 

Sometimes a polyp is the cause of the problem and the endoscopist may be able to remove it during the procedure.

 Any there any alternatives to a flexible sigmoidoscopy?

A flexible sigmoidoscopy is recommended as it is the best way of diagnosing most problems with the large bowel. A colonoscopy is another option.  This is similar to a flexible sigmoidoscopy but the endoscopist looks all the way round the large bowel and has higher risks.

Other options include a barium enema (an x-ray test of the large bowel) or a CT Pneumocolon (a special scan of the large bowel).  However, if they find a problem, you may still need a colonoscopy to treat the problem or perform biopsies.

 What will happen if I decide not to have a flexible sigmoidoscopy?

Your doctor may not be able to confirm the cause of the problem.  If you decide not to have a flexible sigmoidoscopy, you should discuss this carefully with your doctor.

 What does the procedure involve?

• Before the procedure

Your doctor or a member of the endoscopy team will ask you to sign the consent form once you have read this leaflet and they have answered your questions.

The healthcare team will give laxatives or an enema to take the day before the procedure.  This is to make sure your bowel is empty so the endoscopist can have a clear view.  Follow the instructions carefully.  If you are diabetic, you will need special advice depending on the treatment you receive for your diabetes.  Let your doctor know as soon as possible if you are diabetic.

If you get severe abdominal pain, let the endoscopy team or your doctor know. 

• In the endoscopy room

Although the procedure is uncomfortable it should not be painful.  A sedative is not usually needed.  However if appropriate, the endoscopist may offer you a sedative or pain killer which they can give you through a small needle in your arm or the back of your hand.

The endoscopist will ask you to lie down on your left side in a comfortable position.  A member of the endoscopy team will monitor your oxygen levels and heart rate using a finger clip.  If you need oxygen, they will give it to you through a mask of small tube placed in your nose.

•  The procedure

A flexible sigmoidoscopy usually takes between quarter of an hour to twenty minutes.  The procedure involves placing a flexible telescope into the back passage and blowing some air into the large bowel to get a clear view.  The endoscopist will usually look up the splenic flexure. They will be able to perform biopsies and take photographs to help make the diagnosis.  If they find a polyp, it may be possible to remove it during the procedure.

 What complications can happen?

The healthcare team will try to make your procedure as safe as possible.  However, complications can happen.  Some of these can be serious and can cause death (risk: 1 in 15,000).

The possible complications of a flexible sigmoidoscopy are listed below.  Any numbers which relate to risk are from studies of people who have had this procedure.  Your doctor may be able to tell you if the risk of a complication is higher or lower for you.

• Allergic reaction to the equipment, materials or drugs.  The endoscopy team is trained to detect and treat any reactions that might happen.  Let the endoscopist know if you have any allergies or if you have reacted to any drugs or tests in the past.
• Breathing difficulties or heart irregularities, as a result of reacting to the sedation or overstretching of the bowel.  To help prevent this from happening, your oxygen levels and heart rate will be monitored.
• Making a hole in the colon (risk: 3 in 1,000).  The risk is higher if a polyp is removed.  This is a serious complication.  You may need surgery which can involve forming a stoma (bowel opening onto the skin).
• Bleeding from a biopsy site or from minor damage caused by an endoscope (risk: less than 1 in 1,000).  This usually stops on its own.
• Bleeding, if a polyp is removed (risk: 2 in 100).  Bleeding usually stops soon after a polyp is removed.  Sometimes bleeding can happen up to two weeks after the procedure.  Let the endoscopist know if you are on Warfarin, Clopidogrel or other blood-thinning drugs.  If you are on Warfarin or Clopidogrel and have a polyp, the endoscopist will not usually remove it.
• Incomplete procedure: This can happen due to a technical difficulty, blockage in the large bowel, complications during the procedure, or discomfort.  Your doctor may recommend another colonoscopy or a different test such as a barium enema.  You should discuss these possible complications with your doctor if there is anything you do not understand.

How soon will I recover?

After the procedure you will be transferred to the recovery area where you can rest and have a drink.  If you were given sedation, you will normally recover in about two hours.  However, this depends on how much sedation you were given.  You may feel a bit bloated for a few hours but his will pass.

If you were given sedation, a responsible adult should take you home in a car or taxi, and stay with you for at least 12 hours.  You must also not drive, operate machinery, sign legal documents or drink alcohol for 24 hours.

Your doctor will tell you what was found during the flexible sigmoidoscopy and will discuss with you any treatment or follow-up you need.  Results from biopsies will not be available for a few days so they may ask you to come back to the clinic for these results.

Once at home, if you get pain in your abdomen, significant or continued bleeding from your back passage, or a high temperature, contact the endoscopy unit, or your GP.  If your symptoms are severe, go to your nearest Accident and Emergency department or call an ambulance.

You should be able to go back to work the day after the colonoscopy unless you are told otherwise.

 Summary

A flexible sigmoidoscopy is usually a safe and effective way of finding out if you have a problem with your large bowel.  However, complications can happen.  You need to know about them to help you make an informed decision about the procedure.  Knowing about them will also help to detect and treat any problems early.

PPH stands for Procedure for Prolapse and Haemorrhoids and is the name of the specific surgical procedure that has been recommended for you.  Thousands of people in the UK have had their haemorrhoids treated using PPH and is proven to be as effective as conventional surgery.  Patients who have undergone this operation report that their post-operative pain levels are very low and say that they feel able to resume normal activities within a few days of going home.

What does the procedure involve?

The surgery is usually performed under a light general anaesthetic or sometimes even under a regional anaesthetic.  A circular stapling device is used to gently pull the prolapsed haemorrhoids back into their normal position inside the body and excise a ring of tissue at the base of haemorrhoids.

How will I feel after surgery?

You will probably experience some discomfort in the first few days after your operation, such as tenderness and aching.  You may also have a little light bleeding, this is perfectly normal and will settle on its own.  Additionally you may feel an urgent need to open your bowels, even if there is ‘nothing to come’.  This condition should pass quite quickly.

How long will I have to stay in hospital?

This is your surgeon’s decision, but because there is much less post-operative pain associated with PPH procedure than with traditional haemorrhoidectomy, you may be able to leave hospital the same day or next one to two days.

What should I do when I get home?

You should try to go about your normal activity as much as you feel able to.  Resting in bed is not necessary.

What will happen when I go to toilet?

You will probably have your first bowel motion a couple of days after the operation and it may be quite tender.  There may also be some bleeding.  Try not to force the motion.

How long will the bleeding and tenderness last?

This varies from person to person, but should not be longer that a few days.  If you are still experiencing bleeding two weeks after surgery, you should arrange to see your GP.

Are there any side effects?

Rarely patients may experience difficulty with passing urine immediately after the operation and may require the passing of tube (catheter) into the bladder for a brief period.

What happens to the staples?

From time to time staples may be expelled naturally.  This is quite normal.  It is possible that you may notice them as tiny ‘B’ shapes about 3mm wide in your stool but this is no cause for alarm.  Occasionally their passage may cause slight bleeding but his perfectly normal.

How long will it take before I can return to work and normal activity?

Most people who undergo the PPH procedure feel able to go back to work and resume normal activity within a few days.  This is much quicker than with traditional surgical techniques where the post-operative recovery period is around few weeks or more.

Will the haemorrhoids come back?

You may have undergone other types of treatment or surgery in the past and your haemorrhoids have returned.  However, thousands of people in the UK and abroad had their haemorrhoids permanently cured with the PPH procedure.  Occasionally patients continue to be troubled by external skin tags, left after haemorrhoid treatment.  If these are troublesome a minor procedure can remove these.  In less than 5% of cases further haemorrhoid treatment may be required.

Preventing the return of Haemorrhoids

There are also few simple dietary changes you can make to help prevent haemorrhoids form occurring in the future.  The most important thing is to avoid constipation and straining when you open bowels, so a careful look at what you eat is important.  Try to increase the amount of fibre in your diet-eat more whole grain cereals, fruit and vegetables, preferably with skin still on and drink plenty of water.  The fibre and liquid will add bulk to your stools which helps the waste move through the intestines and results in soft stools which are quick and easy to pass.

High fibre foods

• Wholemeal pasta
• Wholemeal bread
• Pulses, lentils and beans
• Vegetables fruits with skin

Videos of Interest

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This is a common condition that usually affects your sigmoid colon (in the lower left hand corner of your abdomen), although any part of your small or large be affected.  A divertculum (plural diverticula) in a small bulge.  When there are many diverticula in a part of the bowel this is called diverticulosis.  If these are causing symptoms or problems, it becomes diverticular disease.  These pockets are caused by increased pressure within the bowel itself.

Diverticulitis occurs when these pockets become inflamed.

How common is it?

Diverticular disease is common, particularly in western countries, and is linked with advancing age.  In the UK, the number of people affected by diverticular increases from 1 in 20 at the age of 50 to 1 in 4 at the age of 85.  It affects both men and women.

In some families there is an increased risk of diverticular disease.  The reason that some people with diverticulosis go on to develop diverticular disease whilst others do not is not understood.

What are the symptoms?

Many people with diverticular disease don’t have symptoms, although you may experience abdominal pain, bloating or wind.  You may also have a variable bowel habit and feel that you are not able to completely empty your bowels.

Diverticulitis ranges from mild attacks of discomfort, pain and tenderness to more serious of peritonitis (inflammation of the whole abdomen) that will need hospital treatment.  The main symptoms include:

• Changes in bowel habit
• Fever
• Pain in the lower left side of your abdomen that may feel quite colicky
• Distension (bloating) of your abdomen
• Occasional severe pain
• Occasionally, passing blood

How is diverticular disease diagnosed?

Tests are needed to confirm the diagnosis as other bowel disorders may cause the same symptoms.  These tests include:

• Barium enema – your colon is first cleared by taking a strong laxative.  A tube is inserted into your rectum (back passage), and barium (a white fluid) is passed through the tube into your bowel. Air is then blown so that it can be seen clearly.  X-rays are taken from different positions and directions.  The test takes around 30 minutes.

• Colonoscopy – this is a telescope examination of your bowel.  Your colon is first cleared by taking strong laxative.  You are given medication to make you relaxed and sleepy.  A thin camera tube connected to a camera is inserted into your rectum and along your colon.  A colonoscopy is not usually painful, but may cause discomfort because of the air being blown into your bowel and the many twists and turns that the camera needs to negotiate.

• CT scan – this is a type of x-ray that may show the presence of diverticular disease or complications.  No special preparation is needed for an ordinary CT scan but if you need a CT pneumocolon, your colon is first cleared by taking strong laxative.

How can I help myself?

If you have early \rticular disease, you can help prevent future problems through some lifestyle changes:

• Choose a diet that is high in fibre and low in fat, containing plenty of fruit, vegetables, wholemeal bread and wholegrain cereals.
• Try to avoid medications that can make you constipated (including opiate-containing painkillers)
• Drink plenty of liquid throughout the day; don’t become dehydrated.
• Take daily exercise. Regular exercise encourages normal bowel movement.  Around 30 minutes of brisk walking at least five times a week is a good start.

What complications could occur?

• A diverticulum may burst and cause either an abscess or peritonitis(an infection through the abdomen).  Peritonitis can be life threatening and requires immediate treatment in hospital.
• Occasionally, diverticulitis may result in a stricture (narrowing) in your bowel.
• Infection or inflammation may cause bleeding.
• Sometimes after an attack of diverticulitis and abdominal connection (called a fistula) with either the bladder or vagina can occur.

What treatments are available?

A high fibre diet should reduce the chances of developing diverticular disease later in life.  Your diet should be balanced and include at least five daily portions of fruit and vegetables, plus wholegrains.  However, once these pockets have formed they never go away.  You may benefit from:

• A change in fibre in your diet
• Taking laxatives to treat constipation
• Antispasmodic tablets which help abdominal discomfort and bloating
• Antibiotics for flare-ups
• An operation to remove the diseased part of  your bowel.

Diverticulitis may require admission to hospital for treatment where you may be nil per mouth (nothing to eat or drink), instead having intravenous fluids and antibiotics.  An abscess may require radiologial drainage.  Peritonitis or obstructions are usually treated with an operation.  The aim of the surgery is to treat the infections and remove diseased part of the bowel.  This normally involves either a sigmoid colectomy or a Hartmann’s procedure.

Sigmoid Colectomy

This operation is performed with an incision (cut) to the middle of your abdomen, or by keyhole surgery (laparoscopically).  Your sigmoid colon is removed and the two ends of your bowel are joined back together.

Hartmann’s procedure

This operation is performed to remove disease which affects all or part of your small bowel.  A cut is made in your abdomen to remove the large bowel and a colostomy is formed on your abdomen.  The rectal stump is left in place and either closed or brought up to your abdomen as a mucous fistula.  Body waste will be collected from the colostomy pouch (stoma bag) which will need to be emptied.

What are the risks and complications of surgery?

These are major operations, which may be done when you are very ill.  Post-operative complications arise, including:

• Reactions to anaesthetic
• Bleeding
• Infection-includes possible wound infection, infection deep inside, bladder infection, chest infection
• Bruising
• Blood clot in the legs (DVT) which may lead to a blood clot I the lungs(PE)
• A stroke or heart attack
• Breakdown of the join in the bowel(anastomotic leak)
• Occasionally, the bowel may be slow to start working again (ileus) which requires patience
• Incisional or parastomal hernia, narrowing, retraction or ischemia or the stoma

There is an increased risk of complications if you are overweight or if you smoke.

How do I prepare for my operation?

Try to get fit, stop smoking and get your weight down.  If you have problems with your blood pressure, your heart, or your lungs, ask your GP to check that these are under control.

Your bowels may need to be empty for your operation; if so, we will give you some medication for this before your operation.

Before you are admitted to hospital for your operation you will need to have a pre-operative assessment.  This is an assessment of your operation.  Check the hospital’s advice about taking pill or hormone replacement therapy (HRT); this will be discussed at your pre-assessment appointment.  Also ensure that you have a relative or friend who can bring you to the hospital and take you home.  Please also bring all your medication with you to the hospital

You will be advised when to stop eating or drinking before your operation.  It is important that your stomach is empty to avoid the risk of vomiting during the anaesthetic.

You should also bath or shower before coming into hospital.

On the day of your operation

The nurses will admit you and answer any questions.  You will be asked to change into a theatre gown and the surgeon and anaesthetist will visit you, and answer any questions that you may have.  You will also need to sign a consent form.

You will be give blood thinning injections and need to wear special stockings to help prevent blood clots.  You will also be given antibiotics to reduce the risk of injection.

What happens afterwards?

After your operation you will return to the ward area, and your vital signs (blood pressure, breathing and pulse) will be monitored.  You will be encouraged to take deep breaths and cough, and sit out of bed.  You may have a:
•    CVP line (a drip that is in your neck)
•    Naso-gastric tube ( a thin tube that comes out of your nose and is connected to a plastic bag) to drain your stomach
•    Catheter (tube) to drain your bladder
•    Dressing on your wounds-these may show some blood stain, which is normal
•    Wound drain
•    Either an epidural or PCA for pain relief
The day after your operation, you will be encouraged to get out of bed and become mobile as soon as possible.  Increasing your mobility and daily activity will help your recovery, and although it may feel uncomfortable, you will not harm your wound.

Your drains and tubes will be removed over the next few days.  Your eating and drinking should return to normal after three or four days.

During your stay in the hospital, if you or your family have any questions or concerns, please feel free to ask the ward nurses or doctors, who will be glad to help.

Will I have pain or discomfort?

Following your operation, expect to have some pain around your wound site.  You will be given painkillers to keep you comfortable; please ask for more if you need them.

You may find swallowing uncomfortable due to naso-gastric tube.

Will I need any stitches removing?

You may have stitches or staples in your skin.  If these are not dissolvable they will need removing10-14 days after your operation.  This may be done in hospital, at your GP surgery, or by district nurses at home.

When can I resume normal activities?

When you go home, you are likely to feel very tired and will notice that you are quickly fatigued after activity.  This will improve gradually and by three months you will have returned to your normal levels of activity.  You may drive when you have fully recovered from your anaesthetic and operation and can make an emergency stop without discomfort and maintain full control of the vehicle.  It is advisable to let your car insurance company know that you have had surgery and check that you are covered.

What should I look out for?

If you have any of the following symptoms:

• Persisting nausea and vomiting
• Bleeding at the wound site
• Infection in the wound site.  Symptoms will influde:
• fever (temperature)
• fluid oozing, redness, swelling at the wound site
• increased pain
• red and inflamed skin around the wound site
• No bowel movement after four day
• prolonged bloating of your stomach
• increased abdominal pain

It is important to seek advice from your GP.

A pilonidal sinus is a problem in the natal cleft (area just above the buttocks), which can cause infection.  The condition usually affects young adults, happening in 1 in 100 young men.  It is less common in women.

Your surgeon has recommended an operation for your pilonidal sinus.  However, it is your decision to go ahead with the operation or not.  This leaflet will give you information about the benefits and risks to help you make an informed decision.

How does pilonidal sinus happen?

Loose hairs fall off the neck or back and collect in the natal cleft.  The hairs can cause small holes to form in the skin or can get into existing holes.

As the hairs carry bacteria, the holes can become infected.  This causes an abscess to orm or a discharge that is released through a tunnel (sinus) out into the skin.  Sometimes the sinus can be quite widespread, with branches and pockets of infection. 

 What are the benefits of surgery?

Surgery is the most dependable way to remove the pilonidal sinus.  Once the area has been fully healed, the infection and any discharge do not usually come back.

 Are there any alternative to surgery?

If an abscess has not formed and you have not had any discharge for the sinus for a while, there is not an immediate need to have the operation.

You can treat an occasional discharge with antibiotics.  However, the infection is likely to come back.

 What will happen if I decide not to have the operation?

You may not have any further problems.  However the area can keep on getting infected, causing an abscess or a persistent discharge that can continue for years.

What does the operation involve?

The operation is performed under a general anaesthetic and usually takes about an hour.  your surgeon will remove the sinus and infected tissue, sometimes over a large area

At the end of the operation, your surgeon will decide either to close the wound with stitches or leave it to open. If your surgeon closes the wound with stitches, they will usually place a drain (small tube) in the wound for a day or two.  If your surgeon leaves the wound open, they will place a pack in the wound.

Before the operation, your surgeon can discuss with you if closing the wound with stitches is likely.

 What should I do about my medication?

You should continue your normal medication unless you are told otherwise.  Let your surgeon know if you are on Warfarin or Clopidogrel.  Follow your surgeon’s advice about stopping this medication before the operation.

 What complications can happen?

The healthcare team will try to make your operation as safe as possible.  However, complications can happen.  Some of these can be serious and you can cause death. You should ask your surgeon if there is anything you do not understand.  Any numbers which relate to risk are from studies of people who have had this operation.  Your surgeon may be able to tell you if the risk of a complication is higher or lower for you.

 The future

Occasionally the pilonidal sinus comes back (risk: 1 in 9).  It is important to keep the area free from hairs and as clean as possible to reduce this risk.

 Summary

Pilonidal sinus is a common problem in young people and is best treated by surgery.  It can cause an abscess or persistent discharge.

Surgery is usually safe and effective.  However, complications can happen.  You need to know about them to help you make an informed decision about surgery.  Knowing about them will also help to detect and treat any problems early.

What leads to irritable bowel?

• Overactivity of nerves- stress
• Intolerance to foods

What should you do?

• See your GP!
• Exclude sinister cause-Cancer/ colitis/ coeliac

Treatment

• Food products- Caffeine rich drinks/ dairy products/ wheat
• Avoid Alcohol/ Smoking
• Regular exercise
• Lifestyle diary
• If constipated- 2 litres of fluids/ fibre
• Diarrhoea-loperamide

*  Please see power point presentation/ weblink on the links section on irritable bowel syndrome

Lesions continuous – superficial

Rectum always involved

• Terminal ileum involved in 10%
• Granulated ulcerated mucosa
• Fibrous strictures rare
• Fistulae rare
• Anal lesions in <20%

Crohns

• Lesions patchy – penetrating
• Rectum normal in 50%
• Terminal ileum involved in 30%
• Discretely ulcerated mucosa
• Strictures common
• Enterocutaenous or intestinal fistulae in 10%
• Anal lesions in 75%

Assessment of disease severity

• Mild = < 4 stools per day.  Systemically well
• Moderate = > 4 stools per day.  Systemically well
• Severe = > 6 stools per day.  Systemically unwell
• Systemic features include tachycardia, fever, anemia, hypoalbuminaemia

Indications for surgery – Ulcerative colitis

• 20% of patients with ulcerative colitis require surgery at some time
• 30% of those with total colitis require colectomy within 5 years

Emergency

• Total colectomy with ileostomy and mucus fistula

Elective

• Panproctocolectomy and Brooke ileostomy
• Panproctocolectomy and Kock continent ileostomy
• Total colectomy and ileorectal anastomosis

–     Maintains continence but proctitis persists

• Restorative proctocolectomy with ileal pouch

–     Need adequate anal musculature

–     Need for mucosectomy unclear

–      May need defunctioning ileostomy

Videos

J pouch- first 2 weeks patient experience

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* For further information see power point presentation on UC and Crohns/Role of surgery in colitis