Please read, contains important information about your procedure and fasting

Your doctor has advised you to have a special camera test to help find the cause of your symptoms. The test is called a Flexible Sigmoidoscopy. This leaflet has been designed to tell you how to prepare for the examination and also to answer some commonly asked questions, if you have any concerns please contact the Endoscopy Unit.

Airedale General Hospital, Endoscopy Unit – 01535 292341

Please inform the unit if you are unable to keep your appointment as it may be given to someone else.
The Endoscopy Unit deals with out-patients and in-patients including emergencies from wards and other departments.

The appointment time you are given for the day of your procedure is the time we would like you to arrive at the Endoscopy Unit and not the time you should expect to have your procedure performed. Please expect to be in the Endoscopy Unit for 2-4 hours.

If a relative or friend is collecting you after the procedure, it is advisable that you provide the nurse with their contact telephone number so that we can call them when you are nearly ready to leave the Unit; this will prevent them waiting for a long period of time. The Endoscopy waiting room has limited seating; if your relative or friend wishes to remain in the hospital until you are ready to go home please ask them to wait in another area such as the cafeteria so that patients have access to the seats.

The hospital has a training commitment and the Endoscopy Unit is a training unit.

Your procedure may be performed by a trainee endoscopist who will be supervised by an experienced endoscopist. If you do not wish to have your procedure performed by a trainee, then please inform the nurse who carries out your pre-assessment.

A Flexible Sigmoidoscopy is a test which allows the Endoscopist (a doctor or a specialist nurse who performs these procedures) to look directly at the lining of the left side of the large bowel (colon). A long flexible tube about the width of your finger is inserted into the back passage (anus). The tube is passed around the left side of the colon and pictures are displayed on a television screen allowing the Endoscopist to detect any abnormal areas. The test takes approximately 15 minutes to complete but can take a little less and in some cases longer than this.

Having a flexible sigmoidoscopy can be uncomfortable and you may wish to have some form of pain relief or sedation. The pre-assessment nurse will explain your options to you.

Sedation / Pain relief

Many patients choose not to have any sedation or pain relief for this procedure. Even with sedation or pain relief, you may still feel some discomfort and even pain at times during the procedure.

Entonox – Entonox is a medical gas; it is a mixture of 50% Oxygen and 50% Nitrous Oxide. Entonox is used for pain relief during childbirth, acute trauma such as broken bones and other medical procedures and it is very effective for pain relief during Flexible Sigmoidoscopy.

If you choose to have Entonox you will be given a mouthpiece through which to breathe in the Entonox. The mouthpiece is connected to a demand valve system which only delivers Entonox to you as you breathe in. Entonox will begin to take effect after 2 or 3 inhalations of the gas. You should take these initial breaths just before the procedure begins and you can continue to breathe the Entonox as much as you need throughout the procedure, you are in control of how little or how much you take. You will still be able to hear and talk with the staff and follow instructions.

The advantage of Entonox is that the effects wear off quickly once you stop taking it so you will be able to take yourself home after your procedure and you do not need anybody to look after you. You can drive 30 minutes after taking Entonox and continue your day as normal.

Possible side effects – Like all medicines, Entonox may cause side effects, although not everybody will experience these.

Common side effects that are generally minor and rapidly reversible are: dizziness, light-headedness, sickness, tingling, and disorientation.

Less common side effects are: problems with the ear due to increased pressure inside the ear, tiredness, bowel enlargement due to trapped gas.

You cannot use Entonox if you have a condition where air may be trapped in some part of your body, collapsed lung, decompression sickness (the bends), or if you have been diving within 48 hours, severe lung disease such as bullous emphysema, head injury within 24 hours, colonic volvulus or blockage, suspected or known increased pressure on the brain, an inability to hold the apparatus or understand how to use it, decreased levels of consciousness, if you have had a laryngectomy or if you have had recent surgery to your eyes or ears where injections of gas have been used. It should also be avoided if you are taking Methotrexate

Conscious Sedation – is given via a cannula, a little plastic tube that is inserted into one of your veins. Sedation helps to relax you but it does not put you to sleep. You will still be able to hear and talk with the staff and follow instructions. After the procedure you will be taken to the recovery area to rest. Following recovery some patients don’t remember having the test, but many patients remember part or all of the procedure.

If you have sedation you must have a responsible adult to collect you from the Endoscopy Unit to take you home and stay with you for 24 hours as the medication stays in your system. You cannot drive, drink alcohol, look after small children by yourself, operate heavy machinery or sign legal documents during this 24 hour period. You will not  be able to travel home on public transport. If you do not have a responsible adult to take you home AND stay with you for 24 hours, you cannot have sedation.

Side effects and risks – because the sedative tends to make your breathing slower and shallower, your oxygen levels can drop. You will be given extra oxygen and your oxygen levels will be monitored during and after the procedure. It can also cause irregularities in your heart beat, therefore your pulse will also be monitored.

Biopsy – Tissue samples can be taken and sent to the laboratory for analysis. You will not usually feel any pain when this is done.

Polypectomy – polyps (abnormal growths) can also be removed during Flexible Sigmoidoscopy and sent for analysis. This is done by tightening a thin wire around the polyp to cut it away, sometimes diathermy (use of an electric current) is used to do this. You will not usually feel pain when this is done.

Endoscopic Mucosal Resection (EMR) – when larger or flatter polyps need removing a procedure called EMR may be necessary to reduce the risk of damage to the bowel wall. This involves injecting fluid underneath the polyp to lift it away from the bowel wall. A thin wire is then tightened around the polyp and diathermy is applied to remove the polyp, sometimes the polyp is removed in a few pieces. EMR does increase the risk of perforation (causing a hole or a tear) but is still considered to be a safe procedure.

Flexible Sigmoidoscopy is an established and safe procedure but very rarely it can result in complications. Some of these can be serious and can even cause death (1 in 15,000). The possible complications are listed below.

Pain – the test can be uncomfortable and even painful at times, but every patients experience will be different. Options for pain relief are discussed later in this booklet and staff will aim to keep you as comfortable as possible.

Making a hole in the colon (perforation) (risk: less than 1 in 30,000). The risk is higher if a polyp is removed (risk: less than 1 in 500 for small polyps and 1 in 50 for removal of large polyps). 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 the endoscope (risk: less than 1 in 3,000). This usually stops on its own.

Bleeding, if a polyp is removed (risk: 1 in 400). Bleeding usually stops soon after a polyp is removed. Sometimes bleeding can happen up to two weeks after the procedure. Let the Endoscopist or nurse know if you are taking Warfarin, Clopidogrel or any other blood-thinning medication.

You may need to stop your medication before having a polyp removed. If you have not been given instructions about your medication please contact the Endoscopy Unit.

Failed or limited procedure. This can happen due to technical difficulty, blockage in the large bowel, incomplete emptying of the bowel, complications during the procedure or discomfort. Your doctor or the Endoscopist may recommend another Flexible Sigmoidoscopy or a different test.

Missed pathology – a very small percentage of the bowel that is examined is not seen during Flexible Sigmoidoscopy so there is a 3-5% risk that abnormalities could be missed. However, this is still a reliable examination.

There are alternatives to this test e.g. radiological examinations, however these tests are considered slightly less accurate, specimens cannot be taken and if an abnormality is seen you may still need to have a Flexible Sigmoidoscopy.

Pre-assessment
Prior to the day of your procedure, you will have a telephone pre-assessment appointment. The nurse will ask you a number of questions about your health to ensure you are able to prepare safely for your procedure. If you are having full bowel preparation for your procedure the nurse will explain how to take this correctly. You will also be told if it’s necessary to stop any of your medication. The pre-assessment is also an opportunity for you to ask any questions you may have about the procedure.

Interpreters – Family members and friends cannot be used to interpret. Please inform the Endoscopy Unit if you require an interpreter before you attend for your appointment. Failure to do this can result in cancellation or delay.

Pacemakers or Implanted defibrillators – If you have one of these devices you must tell the nurse at the pre-assessment appointment as your pacemaker or defibrillator will need to be checked before the procedure and arrangements need to be made for this. Failure to do this can result in delay or cancellation. Please bring your pacemaker/device identification card with you.

Medication – Please ensure you are aware of all the medication you are taking as the pre-assessment nurse will ask you about this. If you are unsure you can contact your GP surgery who will be able to provide you with an up to date list of all your medication.

• Blood thinning medication – If you are taking medication to ‘thin’ your blood e.g. Warfarin, Clopidogrel, Ticagrelor, Rivaroxaban or Dabigatran please inform the pre-assessment nurse as you may need to stop this prior to your procedure. The nurse at pre-assessment will advise you about this.
• Bulking agents – If you are taking bulking agents such as bran or Fybogel you should stop taking these one week prior to the test. Ask the nurse in pre-assessment if you are unsure about this.
• Iron tablets (ferrous sulphate) – If you are taking iron tablets you should stop taking these one week before your test. Please ensure you inform the nurse at pre-assessment. If your doctor has told you that your procedure is urgent and will take place within two weeks, stop your iron tablets immediately and inform the nurse in pre-assessment. If you are unsure, contact the Endoscopy Unit.
• Diabetic patients – If you have diabetes, the nurse in pre-assessment will give you advice and a written information sheet about your diet and medication.
• Other medication – You may take any other medication as normal even on the day of the test. It is particularly important that you take your medication if you suffer from conditions such as epilepsy, heart problems or hypertension (high blood pressure) as your procedure may be cancelled if your blood pressure is too high or your heart rate is irregular.

Bowel preparation – for a flexible sigmoidoscopy you will either have an enema on the day of your test or full bowel preparation which has to be taken the day before your procedure. The pre-assessment nurse will inform you which of these you will have and give you specific information on how to take or administer the preparation.

Enema – An enema involves the administration of fluid via the rectum to make you open your bowels. This will be sent out to your home for you to self administer or administered on the endoscopy unit on the day of your procedure.

Full bowel prep – if you are to have full bowel prep the pre-assessment nurse will arrange for you to collect this from the hospital. This is to be taken prior to your procedure and the pre-assessment nurse will explain fully how and when to take it. The purpose of the bowel preparation is to clear your bowel, diarrhoea is to be expected therefore you will need quick access to a toilet. We would advise you not to work during this period. You will also be told about dietary restrictions. It is important that you follow these instructions carefully. Failure to do so may result in an unsuccessful examination.

Please follow the bowel preparation instructions on the information sheet given to you by the pre-assessment nurse. This may be different to the instructions in the box containing the bowel preparation.

Some people find the drinks unpleasant; you can add fruit cordial to them to make them more palatable, do not add red or purple cordial as this can look like blood in your bowel. It is also better to sip the fluids rather than drinking them down very quickly and it can help to drink it through a straw. Whilst taking the preparation and following the dietary restrictions it is important to increase your intake of clear fluids. This is important to stop you becoming dehydrated and will also help to clean the bowel. You can continue to take clear fluids up to 2 hours before your appointment time. If you suffer from renal problems, you should inform the nurse at pre-assessment clinic.

If you feel lethargic it may help to take sugary drinks to give you energy. Diabetic patients should monitor their blood sugar and follow advice on the  separate diabetic information sheet provided.

Side effects of the bowel preparation include nausea, vomiting, bloating, abdominal pain, anal irritation and sleep disturbance. If you experience severe vomiting, severe diarrhoea with dizziness, headache and confusion or feel generally unwell, please either contact the Endoscopy Unit or your GP.

You have been sent a copy of the consent form; please take the time to read the form in conjunction with this information so that you fully understand what you are agreeing to. The nurse at pre-assessment will go over the form with you and explain the risks and benefits of the procedure and answer any questions you may have. You will sign your consent form on the day of your procedure.

If you are caring for someone who is unable to give consent for the procedure themselves, you will not be able to sign the consent form for them even if you are their next of kin. The consent form should have been completed with the Consultant in clinic after discussion with the patient and ideally the next of kin or other family member. If this has not taken place, please contact the Endoscopy Unit as soon as possible, ideally before the pre-assessment appointment as cancellation on the day may occur if there are problems with the consent process.

Withdrawal of consent – you can withdraw your consent at any point. If you withdraw your consent, the test will not end immediately as we will need to safely remove the instrument. If you have had sedation, you may not remember withdrawing your consent after the procedure.

Arriving at the Endoscopy Unit

Report directly to the Reception Desk in the Endoscopy Unit, do not take a seat until you have given your name to the receptionist. If you need to speak to the receptionist in a more private area, please ask.

On the unit

A nurse will check your details with you and complete a short questionnaire, check your pulse and blood pressure and place an identification band on your wrist. If you have chosen to have sedation and have not already given the name and contact number of a responsible adult who will be collecting you, you will be asked for this at this point. During your admission you will be able to ask the nurse any questions you may have about the test. You will then be asked to get changed into a gown. You will be given the option of a pair of shorts to wear to maintain your dignity, the shorts have a split at the back so you can keep them on during your procedure. If you require an enema before your procedure and you have not already administered this yourself, this will then be given.

After your procedure you will be taken to the recovery area. If you have not had sedation you will be quickly offered something to eat and drink and will be able to leave the Unit on your own as soon as you wish.

If you have had Entonox, you need to wait 30 minutes after your last inhalation before driving, but you can leave the unit.

If you opt to have sedation, you will be taken into the recovery area and observed for approximately 30-40 minutes. You will then be offered something to eat and drink before you go home. A responsible adult will need to collect you from the Endoscopy Unit, take you home and stay with you for the next 24 hours. The effects of the sedation can last 24 hours, therefore it may be necessary to take the following day off work. During this 24 hour period you must not drive, drink alcohol, operate heavy machinery, sign any legal documents or look after small children on your own.

On discharge the nurse will tell you as much as we can about the outcome of  the procedure but we may not be able to give you the full result. If specimens are taken, these need to go to the lab to be analysed and it can take a few weeks for these results to be available. If you have had sedation you may not remember what the nurse or doctor has said to you. If you would like a friend or relative with you when you are being given your results, please ask.

Q. Will the test hurt?

A. The test can be uncomfortable and even painful at times even with pain relief or sedation. If you are finding the procedure very painful you can tell the staff who will try to reduce your discomfort and the procedure can be stopped if you wish.

Q. Will I be asleep if I have sedation?

A. No, you will not be asleep. The sedative helps to relax you, but does not put you to sleep.

Q. Will my relative be able to come in the room when I have my procedure?

A. No. Your relative or friend will not be able to go into the procedure room with you.

Q. What if I don’t have a responsible adult to look after me following sedation?

A. You will not able to have sedation if you do not have a responsible adult to look after you following your procedure.  If you are very keen to have the sedative injection you will need to be admitted to hospital overnight.

Q. Will I need to get changed?

A. Yes, you will need to remove your lower clothing including your underwear. You will be given the option of wearing a pair of shorts to maintain your dignity, they have a split at the back so you can wear them during the procedure.

Q. Will I get my results on the day of the test?

A. We will tell you as much as we can after the procedure but we may not be able to give you the full result. If specimens are taken, these need to go to the lab to be analysed and it can take a few weeks for these results to be available.