Department Name

Fecal Occult Blood Test (FOBT)                         

FOBT is a simple chemical test that can detect blood in the stool, which may be a symptom of colorectal cancer. Patients can perform this test in the privacy of their own home by using a small stick from a test kit to apply to a test card a thin layer of stool from three consecutive bowel movements. After the samples have been collected, the patient sends the test card to their colorectal surgeon's office where it is checked for hidden blood. If blood is found, your colorectal surgeon will recommend a follow up colonoscopy.

Recommended testing: Beginning at age 40, all adults should have an FOBT once every year.

Flexible Sigmoidoscopy

A flexible sigmoidoscopy is a visual examination of the rectum and lower portion of the colon, where most colorectal polyps and cancers occur. To perform the test, a colorectal surgeon inserts a thin flexible tube with a tiny camera on the end into the rectum and up into the colon to look for abnormalities or polyps. Although tissue samples and polyps can be removed with the endoscope, a follow-up colonoscopy generally is necessary if polyps or other abnormalities are found. Flexible sigmoidoscopy exams usually are performed in a hospital or doctor's office, and the patient may be given some light sedation.

For the procedure, you will lie on your left side on the examining table. The physician will insert a short, flexible, lighted tube into your rectum and slowly guide it into your colon. The tube is called a sigmoidoscope (sig-MOY-duh-skope). The scope transmits an image of the inside of the rectum and colon, so the physician can carefully examine the lining of these organs. The scope also blows air into these organs, which inflates them and helps the physician with the examination.

If anything unusual is in your rectum or colon, like a polyp or inflamed tissue, the physician can remove a piece of it using instruments inserted into the scope. The physician will send that piece of tissue (biopsy) to the lab for testing.

Flexible sigmoidoscopy takes 10 to 20 minutes. During the procedure, you might feel pressure and slight cramping in your lower abdomen. You will feel better afterward when the air leaves your colon.

Preparation:

The colon and rectum must be completely empty for flexible sigmoidoscopy to be thorough and safe, so the physician will probably tell you to drink only clear liquids for 12 to 24 hours prior. A liquid diet means fat-free bouillon or broth, gelatin, strained fruit juice, water, plain coffee, plain tea, or diet soda. The night before or right before the procedure, you may also be given an enema, which is a liquid solution that washes out the intestines. Your physician may give you other special instructions.

Recommended testing: Beginning at age 50, a flexible sigmoidoscopy should be conducted every 5 years.

Double-contrast Barium Enema (DCBE) or Barium X-ray:

The DCBE is an x-ray examination of the rectum and entire colon performed in a hospital or clinic. With this procedure, the colorectal surgeon gives the patient an enema containing white dye or barium followed by an injection of air. The barium outlines the intestine and enables the surgeon to take x-rays of the lower intestine.

Recommended testing: Beginning at age 50, all adults should have a DCBE once every 5-10 years.

Colonoscopy

A colonoscopy is a visual examination of the rectum and entire colon, performed by a colorectal surgeon in a hospital or clinic. This exam is similar to the flexible sigmoidoscopy, except that the thin tube is inserted into the rectum and through the entire length of the colon. If polyps are found, they can be removed during this procedure. Because this exam is more invasive than the flexible sigmoidoscopy, a colorectal surgeon will sedate the patient before performing the procedure. The bowel must be completely empty for this visual examination, so patients must adhere to a clear liquid diet for 1-2 days prior to the test. During that time, patients also must cleanse their colon by drinking a purifying solution.

Procedure

For the colonoscopy, you will lie on your left side on the examining table. You will be given pain medication and a moderate sedative to keep you comfortable and help you relax during the exam. The doctor and a nurse will monitor your vital signs, look for any signs of discomfort, and make adjustments as needed.

Your doctor will then insert a long, flexible, lighted tube into your rectum and slowly guide it into your colon. This tube is referred to as a colonoscope. The scope transmits an image of the inside of the colon onto a video screen so your doctor can carefully examine the lining of the colon. The scope bends so the doctor can maneuver it around the curves of your colon.

You may be asked to change positions during the procedure so that your doctor can more easily move the scope to see the different parts of your colon. The scope gently blows air into your colon and inflates it, which helps give the doctor a better view. Most patients do not remember the procedure afterwards.

The doctor can remove most abnormal growths in your colon, like a polyp, which is a growth in the lining of the bowel. Polyps are removed using tiny tools passed through the scope. Most polyps are not cancerous, but they could turn into cancer. Visualization of a polyp is not enough to determine if it is cancerous. Biopsied polyps are sent to a lab for testing. By identifying and removing polyps, a colonoscopy likely prevents most cancers from forming.

The doctor can also remove tissue samples to test in the lab for diseases of the colon (biopsy). In addition, if any bleeding occurs in the colon, the doctor can pass a laser, heater probe, electrical probe, or special medicines through the scope to stop the bleeding. The tissue removal and treatments to stop bleeding usually do not cause pain. In many cases, a colonoscopy allows for accurate diagnosis and treatment of colon abnormalities without the need for a major operation.

During the procedure you may feel mild cramping. You can reduce the cramping by taking several slow, deep breaths. When the doctor has finished, the colonoscope is slowly withdrawn while the lining of your bowel is carefully examined. Bleeding and puncture of the colon are possible but uncommon complications of a colonoscopy.

A colonoscopy usually takes 30 to 60 minutes. The sedative and pain medicine should keep you from feeling much discomfort during the exam. You may feel some cramping or the sensation of having gas after the procedure is completed, but it usually stops within an hour. You will need to remain at the colonoscopy facility for 1 to 2 hours so the sedative can wear off.

Preparation

You will be given instructions in advance that will explain what you need to do to prepare for your colonoscopy. Your colon must be completely empty for the colonoscopy to be thorough and safe. To prepare for the procedure you will have to follow a liquid diet for 1 to 3 days beforehand. The liquid diet should be clear and not contain food colorings, and may include:

• fat-free bouillon or broth
• strained fruit juice
• water
• plain coffee
• plain tea
• diet soda
• gelatin

Thorough cleansing of the bowel is necessary before a colonoscopy. You will likely be asked to take a laxative the night before the procedure. In some cases you may be asked to give yourself an enema. An enema is performed by inserting a bottle with water and sometimes a mild soap in your anus to clean out the bowels. Be sure to inform your doctor of any medical conditions you have or medications you take on a regular basis such as:

• aspirin
• arthritis medications
• blood thinners
• diabetes medication
• vitamins that contain iron

The medical staff will also want to know if you have heart disease, lung disease, or any medical condition that may need special attention. You must also arrange for someone to take you home afterward, because you will not be allowed to drive after being sedated.

Recommended testing: A colonoscopy is considered a follow-up exam that is performed when abnormalities are found during an FOBT, flexible sigmoidoscopy, or barium x-ray. Generally, colonoscopies are performed once every 10 years on adults 50 years and older.

When and how often should testing be done?

For people who have none of the risks described earlier, digital rectal examination and testing of the stool for hidden blood are recommended annually beginning at age 40. Flexible sigmoidoscopy is recommended every 5 years at age 50 or older. A double contrast barium enema should be administered every 5 to 10 years, and colonoscopy every 10 years are also acceptable.

Surveillance is recommended for people in the following high-risk groups:

o        Patients who have had any pre-cancerous polyps found and removed should have colonoscopy 1 to 3 years after their first examination.

o        Patients with a close relative, such as sibling, parent, or child who has had colorectal cancer or a pre-cancerous polyp should have the same screening as people of average risk, but it should begin at age 40; or 5 years before the age at which the youngest was diagnosed.

o        Patients with a family history of colorectal cancer in several close relatives and over several generations, especially cancers occurring at a young age, should receive genetic counseling and consider genetic testing for a condition called hereditary non-polyposis colorectal cancer. People with this family medical history should have a colonoscopy every 2 years starting between the age of 20 and 30, and every year after age 40.

o        People with a family history of an inherited disease called familial adenomatous polyposis (FAP) should receive counseling and consider genetic testing to see if they are carriers for the gene that causes the disease. People with this gene or whose tests are inconclusive should have a flexible sigmoidoscopy annually beginning at puberty to see if they are expressing the gene. If polyposis is present, they should discuss with their physician the need for total colectomy, which involves removing all the colon and rectum.

o        People with a personal history of colorectal cancer should have a complete examination of the colon within 1 year after the cancer is initially detected and surgically removed. If this exam is normal, they should have a follow-up exam within 3 years. Examinations to evaluate the entire colon include colonoscopy or flexible sigmoidoscopy with a double-contrast barium enema.

o        People with a history of extensive inflammatory bowel disease for 8 or more years should consider having a colonoscopy examination of their colon conducted every 1-2 years.

o        Women with a personal history of breast or female genital cancer (ovary or uterine) have a 15% lifetime risk (1 in 6) of developing colon cancer. They should undergo colonoscopy every 5 years, beginning at age 40.