ENDOSCOPY AND SPECIFIC CONDITIONS
Proctoscopy enables one to view and biopsy the whole of the
anal canal, but only a small part of the rectum is visible
at its lower end. Good lighting is essential. It is helpful
to obtain the patient’s confidence and cooperation.
Talk to them throughout the examination. Explain the procedure
and its purpose, emphasizing that it should cause only
minor discomfort. Do not administer an enema unless the
patient is constipated or unless sigmoidoscopy is also
a preliminary digital examination. Then, with the patient
in the same position, proceed to the proctoscopy to
view any lesions that you have just felt. Lubricate
and introduce the proctoscope, holding the handle with
the fingers and pressing the thumb firmly on the head
of the obturator (Figure 5.68). This grip will keep
the two parts of the instrument assembled. Point the
you introduce the scope to its full length (Figure
5.69), instruct the patient to take deep breaths with
the mouth open. Remove the obturator and direct the
light into the scope (Figure 5.70).
Remove any faecal material, mucus or blood. Align the scope
so that the lumen of the gut just beyond is clearly visible.
Slowly withdraw the instrument while maintaining its alignment
in the gut so that you can view any mucosal lesions, including
haemorrhoidal masses or polyps. Note the appearance of the
mucosa and assess its integrity.
reliable facilities for specimen examination exist,
take a biopsy sample from any obviously or possibly
abnormal area under direct vision, using special biopsy
forceps. Remove the tissue sample through the proctoscope.
Remember that taking a biopsy sample from the rectal
mucosa causes some discomfort and that removal of tissue
from the anal lining can produce severe pain. At this
examination, do not take tissue from a haemorrhoidal
mass or any other lesion that appears to be vascular.
after removal from the patient, fix the tissue sample
by total immersion in formaldehyde saline: 10 ml of
37% formaldehyde solution + 90 ml of physiological
saline; fixation takes about 48 hours. Alternatively,
use a fixative as directed by your local pathologist.
Sigmoidoscopy is indicated for patients who have symptomatic colorectal disease
and have had an inconclusive proctoscopy. It is also indicated following an abnormal
proctoscopy to detect additional lesions such as polyposis or rectal schistosomiasis.
For amoebic colitis, sigmoidoscopy is useful in assessing the response of proctocolitis
to treatment. It can also facilitate the introduction of a rectal tube to decompress
and reduce sigmoid volvulus. This examination normally follows a rectal examination
and a proctoscopy.
the patient to evacuate the rectum. If they cannot do
this spontaneously, give an enema. Check the equipment,
particularly the light-head, the eyepiece fitting (window)
and the inflation pump (bellows) to ensure that they
fit together and that enough light reaches the end of
the sigmoidoscope generously before you start and introduce
it with the obturator in position. In its initial stages,
sigmoidoscopy is similar to proctoscopy (Figure
Next, point the sigmoidoscope backwards and upwards as
you advance it (Figures 5.72, 5.73). Hold the obturator
firmly to prevent it being dislodged (Figure
introducing the sigmoidoscope about 10 cm, remove the
obturator (Figure 5.75). If there is any obstruction
before the sigmoidoscope has been inserted 10 cm, remove
the obturator at this point. Then attach the eyepiece,
which usually carries the light source and pump connections.
To view the gut wall and the bowel lumen, introduce a
little air and align the scope. Gently advance the instrument,
keeping it accurately within the lumen of the bowel.
Introduce air at intervals to open up the bowel lumen
gradually beyond the scope. Should the view be obscured
at any time by rectal contents, remove the eyepiece and
evacuate the material using dental rolls held firmly
with biopsy forceps.
change the direction of the scope to keep within the
lumen. Do not advance the scope unless the lumen of the
bowel is in view. The rectosigmoid junction may be difficult
to traverse, so do not rush the procedure. If there is
much difficulty advancing the scope beyond this level,
stop the procedure. Do not use force to introduce the
scope or to take a biopsy specimen from the wall of the
bowel. Injury or even perforation of the rectal wall
If the patient experiences discomfort during the
examination, check for proper alignment of the
sigmoidoscope, release air by removing the eyepiece
or by disconnecting the pump tubing, then reassemble
the instrument and continue the examination.
If necessary, reintroduce the scope and repeat
the examination. At the end of each examination,
let out the air from the gut before withdrawing
Perianal haematoma is usually associated with considerable pain. The inflamed
area is tense, tender and easily visible upon inspection of the anal verge as
a small, tender swelling about the size of a pea.
Management consists mainly of relieving the pain by local or oral administration
of analgesics and by helping the patient to avoid constipation. The lesion will
resolve slowly over several days or weeks. This can be expedited with hypertonic
saline compresses. During this time, the haematoma may spontaneously rupture
through the overlying skin, discharging blood clots and providing some pain relief.
In the early stages of haematoma formation, surgical evacuation of the clot under
local anaesthesia can rapidly relieve pain and discomfort. Drainage is not recommended
in the sub-acute or chronic stages of perianal haematoma.
An anal fissure is a tear in the mucosa of the lower anal canal. It is usually
associated with intense pain, especially during and just after defecation. Hard
stools precipitate and aggravate the condition.
The anus is tightly closed by spasm, so that the application of a local anaesthetic
gel, or occasionally even general anaesthesia, is necessary to allow an adequate
examination. The fissure may be acute or chronic, the latter having fibrotic
Non-operative management is recommended, especially for an acute fissure. It
should include prescription of a high-fibre diet and administration of a local
anaesthetic ointment or suppository. A chronic fissure can be treated by manual
dilatation of the anus.
Anal dilatation: technique
proceeding, empty the rectum by administering an enema.
Give the patient a general anaesthetic without a muscle
relaxant and use the tone in the anal sphincter to judge
the extent to which the anal sphincter should be stretched.
Perform a digital, and then proctoscopic, examination
to confirm the presence of haemorrhoids (Figure
The success of the treatment depends largely on adequate dilatation of the anus
in the region of the “constricting bands”. This is achieved by applying
pressure with the fingers but, to avoid over-dilatation and other complications,
use no more than four fingers. Do not use any instruments.
insert the index and middle fingers of the left hand
into the anus and press against the wall to assess the
degree of constriction caused by the bands in the anal
wall (Figure 5.78). Now, dilate the anus by inserting
the right index finger and pressing it against the anal
wall in the opposite direction to the other two fingers
(Figure 5.79). Insert the middle finger of the right
hand and repeat the procedure.
insert into the anus a sponge or gauze swab, soaked in
a non-irritating antiseptic or saline and wrung out,
or a piece of petrolatum gauze. Leave one end of the
sponge or gauze protruding.
aftercare, administer analgesics when indicated. Give
the patient a mild laxative, such as liquid paraffin
(mineral oil), to encourage the regular passing of soft,
bulky stools. Instruct the patient to sit in warm water,
preferably in which some salt has been dissolved, for
about 15–30 minutes at least once a day for 14
Complications can include haematoma formation, incontinence and mucosal prolapse.
Provided that no more than four fingers are used for dilatation, no significant
complications should arise.
The main symptoms of haemorrhoids are bleeding on passing stools and prolapse
of the varicose masses. Pain is not always a significant feature. Haemorrhoids
are graded according to whether they prolapse and whether the prolapsed mass
reduces spontaneously or must be replaced manually. Rectal examination, proctoscopy
and sigmoidoscopy are necessary in diagnosing haemorrhoids and in checking for
any associated conditions, in particular carcinoma of the rectum.
Complications of haemorrhoids are anaemia and thrombosis.
Many patients benefit from a high-fibre diet which encourages regular, soft,
bulky motions and the local application of an analgesic ointment or suppository.
This non-operative management is sufficient for the majority of patients.
Patients whose haemorrhoids prolapse (and either return spontaneously or can
be replaced) and patients in whom the above regimen has failed to give adequate
relief can be treated by manual dilatation of the anus (see anal fissure). This
is the only form of surgical treatment recommended for the non surgical specialist.
Haemorrhoidectomy undertaken by the inexperienced can be complicated with anal
stenosis. If haemorrhoidectomy is required, refer the patient to a qualified
Never perform haemorrhoidectomy or anal dilatation on a pregnant or postpartum
patient. Hypertonic saline compresses will temporize the discomfort and the haemorrhoids
will improve dramatically several weeks after delivery.