Combined Flexible Sigmoidoscopy and Barium Enema Service One Stop Diagnostic Service

  • Reference Number: HEY-223/2018
  • Departments: Endoscopy

Introduction

This leaflet has been produced to give you general information about your procedure.  Most of your questions should have been answered by this leaflet.  It is not intended to replace the discussion between you and your doctor, but may act as a starting point for discussion.   If after reading it you have any concerns or require further explanation, please discuss this with a member of the healthcare team.

Endoscopy Department contact numbers: Hull Royal Infirmary (01482) 674790 (direct line) Castle Hill Hospital (01482 622069) (direct line)

PLEASE DETACH THE INFORMATION CHECKLIST AND BRING IT WITH YOU

What is a flexible sigmoidoscopy and Barium enema service?

This service involves two different examinations of the large bowel but performed on the same day, usually in one morning or afternoon.  The examinations are:

Flexible Sigmoidoscopy

This is an examination of the lower part of your large bowel using a flexible camera.

Barium Enema

This is the examination of your bowel under X-ray conditions using a barium contrast.

Benefits

One of the great benefits of this service is that the majority of your investigations are performed in one day and the bowel only has to be prepared once.  It reduces the amount of time coming to and from the hospital. It may also prevent time spent off work.  No sedative drugs are needed and you can resume your day-to-day activities quickly.

Why do I need these examinations?

A specialist will have seen you to discuss concerns about your bowels.  The symptoms you have described have caused some concern and they would like your bowel to be examined as soon as possible (within 0-3 months).  This is done to make sure there is nothing seriously wrong with your bowel.  Signs of disease may be found but the majority of these are not serious or life threatening.

The Bowel

The bowel is made up of two large sections of the gut.  A small bowel and the large bowel.  The small bowel absorbs nutrients from food and channel waste products from the food we eat to the outside of the body/large bowel.  The bowel lies in the tummy.  The term ‘bowel’ in the leaflet refers to the examination of the large bowel only. The large bowel is made up the colon and rectum.

The patient pictures are reproduced with the permission of Health Press Limited from Neild P, Gazzard B. Patient Pictures – Gastroenterology, Oxford Health Press, 1997.

Why use two examinations?

It is important that the whole of the large bowel is examined.  The barium enema will examine the whole of the large bowel but it sometimes does not see the left side of the bowel, especially if diverticular disease is present. The flexible sigmoidoscopy overcomes this limitation by looking at this part of the bowel.  This helps to ensure serious disease can be detected if it is present.

 These examinations have been arranged through the one stop service to make sure there is nothing seriously wrong with your bowel.  To this end the whole of the large bowel needs to be examined and reasonably quickly. Due to demands for alternative tests, both for urgent examinations and routine, if these were done separately, there is the possibility that the examination of the bowel will take much longer.

What if I refuse to have a Combined flexible sigmoidoscopy and barium enema examination?

If you decide not to have the examinations this will not alter the manner in which we treat you and your standard of care will not change. Please discuss this with your doctor/specialist team.

What are the limitations of this examination?

If a problem is found and biopsies are needed, then in the majority of cases this cannot be done at the same time.  This is because you are having a barium enema and there is some concern that the barium contrast will cause a problem if biopsies are taken.

Are there any alternatives to this examination?

The complete examination of the bowel only has one other alternative at the present time.  This is called colonoscopy and involves examining the bowel with a long flexible camera.  Its advantage is that the whole of the bowel is seen, biopsies can be taken and polyps dealt with at the same time.

It does require bowel preparation and the giving of sedative drugs.  The risks of complications occurring (although rare) are greater than the combined service. If you would like more information about this examination please ask your Endoscopy Department.

Who will perform the examinations?

An experienced and specially trained senior nurse – the nurse endoscopist, leads this service, with the support of the consultants and will usually perform the flexible sigmoidoscopy. An experienced radiographer performs the barium enema.  The x-rays are analysed and report by a specialist doctor – a radiologist.

Can there be any complications or risks?

It is important to say that serious complications during these examinations are rare. Complication rates, that is, how often complications occur, vary across the United Kingdom. If you would like to know our rates for serious complications this can be discussed with you during your consultation. Complications can be described as minor (mild) or major (serious):

Minor complications:

These complications are common and expected but do not last for long and do not cause serious harm.

They include feeling bloated after the examination because of trapped wind, feeling faint and dizzy, cold sweats and occasionally feeling sick.  Constipation and difficulty going to the toilet after barium enema is something which can occur, but will subside as long as the advice mentioned in this leaflet is taken.

There is a small risk of bleeding from the bottom after sigmoidoscopy. The entrance to your bottom, the anus, does have a very good blood supply and this is where piles are often found. The insertion of the camera can cause a little bleeding. This should only be ‘spotting’ on the toilet paper or drops in the toilet bowl. It may take a few days for this to subside.

Major complications:

These are complications, which can be serious, may lead to admission to hospital and sometimes an operation.

It is important to stress major and serious complications are rare.

Complications, which can become serious and life threatening include:

Perforation of the bowel

A small tear may be made through the bowel wall. This can especially occur in thin, diseased bowel or when polyps have been removed. If it occurs you may begin to feel unwell, feel nauseous or vomit, your tummy may become hard, swollen and painful. You may feel hot and shivery. These symptoms can occur within minutes of the perforation or may slowly develop over days.

If you have any of these symptoms YOU MUST CONTACT your doctor or the hospital Endoscopy Department or Ward 7 HRI (out of hours) as soon as possible.

Bleeding

This can occur especially after the removal of polyps. Although great care is taken to ensure there is no sign of bleeding after a polyp is removed, the contraction of the bowel after sigmoidoscopy when getting rid of wind or when the bowels are next opened can cause the area where the polyp was to bleed.

You should expect a little bleeding, such as ‘spotting’ on the toilet paper or small drops in the toilet bowl. This usually subsides as already described.  If bleeding begins to increase where large clots of blood are seen and /or you begin to feel unwell or faint, please contact your doctor immediately for advice and help. Recent evidence puts the risk of perforation between 1 in 1000 to 1 in 3000. This can sometimes be accompanied by bleeding. This can be more common with the removal of large or difficult polyps.

Will I need this examination again?

For some, despite following instructions and taking the bowel preparation to empty the bowel, the view with the camera is poor. The endoscopist cannot be certain that the large bowel has been adequately seen.

Where will I have these examinations?

The examinations are performed in the Endoscopy Department and X-ray Department.

It will be done at Hull Royal Infirmary or Castle Hill Hospital depending on where your consultant is based.  Please make sure you go to the correct Endoscopy department.  Directions will be given with your appointment letter.

How do I prepare for the examination?

Please read all the information sent to you by the Endoscopy Department. Share the information, if you wish, with your partner and family so that they can be of help and support. There may be information they need to know.

With your appointment, a health questionnaire will be sent. Please complete this to the best of your ability. This forms an important part of assessing your ‘fitness’ for sigmoidoscopy and the potential for complications to occur, so that action can be taken to eliminate or reduce these risks.

To be able to see the lower part of the large bowel, this part will need to be free of faeces.  To do this we will send you sachets (usually two) of a special powder to mix with water and drink.  Instructions for this and how to use should have come with your appointment time.  If not, contact your Endoscopy Department – see contact numbers.

This bowel preparation will cause you to have loose and gradually more watery bowel actions – diarrhoea.  Sometimes it works within 1-2 hours; but both sachets need to be taken to be effective.  You must drink plenty of fluid during this time.  Avoid ‘fizzy drinks’.  You can lose a lot of fluid and you can become easily dehydrated making you feel unwell if you do not drink fluid to replace this.

If you have diabetes (especially taking insulin) or you have serious heart, lung or kidney problems, or concerned that a health problem you have may be affected, then contact the Endoscopy Department at the hospital where you are having your examination (see contact numbers).

LATEX – Please inform the department if you have a confirmed latex allergy as this will affect your appointment time.

Creutzfeldt-Jakob disease/variant Creutzfeldt-Jakob disease (CJD) commonly known as mad cow disease – Please inform the department if you have been notified that you are at risk of CJD/vCJD for public health reasons.

PACEMAKER – Please contact the department if you have a pacemaker.

CLOPIDOGREL (PLAVIX) – Please inform the department if you are taking these tablets as these may need to be stopped prior to your procedure.

PREGNANCY – It is important that you inform us if there is a possibility that you may be pregnant.  Any information you share with us will be kept strictly confidential.

Private changing facilities are provided and if you have a dressing gown, please bring this with you.  If your health has changed whilst waiting for this examination, please inform your Endoscopy department.

Should I take my tablets during my bowel preparation and before coming for my examination?

Yes, please take all your tablets as normal. There are some medications that may need to be stopped or reduced for a period of time before your examinations. If you are taking any of the following medications, please contact your Endoscopy Department for further advice and instructions.

If you take warfarin tablets, please let your Endoscopy Department know, special arrangements are sometimes needed.

Insulin

If you take insulin, it may be best for you to come into hospital the day and night before the test because there is a risk that the bowel preparation for the examination and restricted diet could make the control of your blood sugar difficult and make your diabetes unstable. 

Iron Tablets

Iron tablets are usually stopped for one week before the examinations.  Iron coats the inside of your large bowel making it very difficult for the endoscopist to see the lining of the bowel.  It is important to stop taking iron tablets.  If they are not stopped it is best that you contact us so that we can rearrange the appointment.

If you take any of the following blood thinning tablets please contact the Endoscopy Department before your appointment for further advice: APIXABAN, RIVAROXABAN, DABIGATRAN, ARGATROBAN, OR EDOXABAN

Will I be able to eat before these examination?

Some foods such as chicken (not cooked in a sauce), rice, clear soups and Bovril-like drinks may be taken – please refer to the dietary advice contained in your bowel preparation information leaflet. Please avoid red jelly as this will show up on your examination

On the day of examination we advise that you only drink clear fluids.  Once the examinations are over, you will be able to eat and drink normally again.

What happens to me in the Endoscopy Department?

Our friendly reception staff will greet you on arrival.  They will let a nurse know that you have arrived.  Occasionally there may be a delay in your appointment time due to an emergency taking place.  If there are any delays you will be notified as soon as possible and be kept informed. A nurse will collect you from the waiting room and explain what will happen next. You will be given an approximate time of when you may be collected to go home. It is advisable to leave any valuables at home.

Due to the nature of the examination we ask you to undress. A private changing area is provided. Although a gown and privacy shorts are provided, you may also wish to bring a dressing gown with you.

We will ask you questions about your general health and work through the health questionnaire you have completed for us. Please feel free to ask questions.

We will check your blood pressure, pulse, and oxygen levels, before your sigmoidoscopy.

The endoscopist will meet you and explain the examination to you. You will both sign a consent form. This is to show you understand what will happen and agree to the procedure being performed.  At any point during the procedure you can withdraw your consent and ask for the procedure to stop. If this happens the endoscopist or radiographer will stop the test. If you have any queries or worries, please tell us.

If you need glasses to read, please keep them with you at all times. Do not leave them with a relative or tucked away in a bag or pocket.

You are then taken through to the examination room and asked to lie on your left side on the examination trolley. Your belongings will be put in a plastic bag and will be with you all the time.  There will be a nurse or assistant in the room with you. You may not have met this person until you get in the examination room. Once on the examination trolley you will be asked and helped to lie on your left side with your knees tucked up as close as you can get, to your chest. This will help the camera get passed the first few bends. You can watch the examination on the TV screen if you wish. Do not hesitate to ask questions during the examination.

How will I feel during the flexible sigmoidoscopy? Will it be painful?

The endoscopist will examine you first with a finger.  Lubricating jelly is applied (which may feel cold) to the bottom but also allows the endoscopist to feel the first few centimetres of the bowel.  This part is sometimes not seen by the camera.

The sigmoidoscopy flexible tube for viewing the bowel is gently inserted into the back passage.  Air opens up the bowel so that the endoscopist can see where they are going.  This will cause the bowel to stretch.  To help get around the bowel; air is gently passed into the bowel through special channels within the tube.

The tube in the bowel makes you feel that you want to go to the toilet.  Please do not worry that you will do so.  The sensation is caused by the stretching of the bowel and usually settles down as the tubes moves in the bowel, sometimes a bloated feeling and a cramp like tightening of the tummy muscles may occur.

Please try to breathe normally and steadily during this procedure. The feeling does not last very long and disappears once the examination is finished.

Some people find the procedure uncomfortable.  If you find this is the case we can stop, remove some air and then carry on to finish.  Most people find this works and are able to tolerate the examination until it is finished.

Some people do not tolerate this test very well due to a variety of reasons. The test may be too painful.  You do have the right to withdraw your consent at any time. If you wish us to stop, tell us and the examination will be stopped.

Sometimes because of the importance of the examination, the endoscopist will stop and discuss your decision with you. If you still wish not to proceed, then your wishes will be respected.

How long will the examination take?

This examination usually takes about 5-10 minutes. The shape of the bowel varies from person to person and for some it can be difficult to get round. If this is the case, it may take longer.

What happens when the flexible sigmoidoscopy is finished? 

Once finished, the endoscopist will give you the result of the examination. Your nurse will then take you to the ‘recovery’ area where you can rest for some 5-10 minutes.

You will feel the need to pass wind this is a natural response to the examination.  We do understand that this can be embarrassing and there may be worries and concerns.  In the majority of patients, the bowel preparation is very good and the only thing you will pass is air.  For some people, air can become ‘trapped’ for a short time.

Please do not resist the urge to pass wind.  This will cause bloating and discomfort which could become painful.  This will delay your barium enema examination.

What happens in the X-ray Department?

You will be escorted to the X-ray Department where you will meet the radiographer. This is the person who will perform the examination.

A needle will be placed into the back of the hand.  This is so that medication can be given to help relax the bowel.  This is important so that good quality x-ray pictures can be taken.  If you are diabetic please let the radiographer know.

Initially you will be asked to lie on your left side.  The radiographer will insert a tube into your bottom.  This tube is attached to a bag containing the barium solution.

During the examination, the barium is slowly introduced into your bottom and you will be helped to change position from side to side.  This helps the barium wash around the bowel.  Some air is introduced at the same time to help show all the areas of the bowel.  This enables good quality x-ray pictures to be taken.

During the above X-rays will be taken at intervals until the examination is finished.  The examination takes about 20-30 minutes.

What happens when the X-ray is finished?

Unlike the sigmoidoscopy, the results of this will not be available until they have been seen and analysed (reported) by the radiologist.  This is a specially trained doctor who has experience and expertise with these types of X-rays.

We will ask you to use the toilet and you will need to pass any barium left in the bowel.  You will find that you will get rid of most of the barium at this time.  However, over the next 7-10 days you may still pass barium when you open your bowels and your motions will look cream or pale in colour.  Your motions will gradually return to their normal consistency and colour.

It is very important that you drink plenty of fluids over the next few days otherwise the barium can cause constipation.

 The results to the X-ray are usually given at your next appointment with your consultant and his team.  They will also discuss the meaning of the test results with you and what the next steps will be.

Sometimes if the examinations are normal, no other investigations are needed and you may be discharged back to the care of your doctor.  You will be notified of this either in writing or by telephone.

Will I need these examinations again?

This will depend on the results.  Some people will require repeat examinations but in these cases it is usually the sigmoidoscopy which is repeated. This is usually to remove polyps which were found or to take biopsies (samples of tissue from the bowel which are sent to a laboratory).

It is rare for the barium enema to be repeated.  The most common cause is due to poor preparation of the bowel before the first examination.

Further information

If you require further information about your test your GP, consultant, and the Endoscopy Department is a valuable source of information.

Further information about your rights with regards to consent can be found in the following documents: These are free of charge.

  • Department of Health (2001), Guide to Consent for Examination or Treatment
  • Department of Health (2001), Consent – What you have a right to expect
  • A Guide for Adults. (Available from the Endoscopy Department)
  • A Guide for Relatives and Carers. (Available from the Endoscopy Department)

Visit the Department of Health’s website at: www.doh.gov.uk and, for consent: www.doh.gov.uk/consent

 Useful contact numbers:

The Endoscopy Department, Castle Hill Hospital (01482) 622069 Monday – Friday: 8.00am – 5.00pm

The Endoscopy Department, Hull Royal Infirmary (01482) 674790 Monday – Friday: 8.00am – 5.00pm

Ward 100 Hull Royal Infirmary Out of hours  (01482) 674860

What do the words in the leaflet mean?

  • Barium enema: The examination of the bowel using a special liquid containing barium.  It involves the use of X-rays to take pictures of the bowel outlined with the barium.
  • Biopsy: A sample of tissue is taken for analysis.
  • Colon: This is the part of the large bowel above the rectum.
  • Consent: This is the agreement between you and the endoscopist.  You are agreeing to have investigations or treatment and that you understand the purpose, benefits, alternatives and risks. You and the endoscopist during this process usually sign a consent form.
  • Endoscopy Department: The place where your procedure takes place.
  • Endoscopist: This can either be your consultant, an experienced and trained doctor or an experienced and specially trained practitioner.
  • Perforation: A rare, but possible risk in which a hole or tear is made through the large bowel.
  • Polyp: A common, benign (not cancer) growth arising from the lining of the large bowel. They take some years to develop. Some polyps, depending on their size and type, have the potential to turn cancerous.
  • Polypectomy: The removal of a polyp usually performed at the same time as the sigmoidoscopy.
  • Radiographer: The specially trained person who performs the barium enema examination and takes the X-rays.
  • Radiologist: Specially trained senior doctor who has experience and expertise in analysing and reporting the findings of the barium enema X-rays.
  • Sigmoidoscopy: The examination of the inside of the large bowel using a long, flexible camera.

This leaflet has been written with the help, support, advice and collaboration of:

  • Consultants of the Department of Gastroenterology
  • Consultants of the Surgical Department
  • Staff of the Endoscopy Department at Castle Hill Hospital and Hull Royal Infirmary
  • Patients attending the Endoscopy Department

General Advice and Consent

Most of your questions should have been answered by this leaflet, but remember that this is only a starting point for discussion with the healthcare team.

Consent to treatment

Before any doctor, nurse or therapist examines or treats you, they must seek your consent or permission. In order to make a decision, you need to have information from health professionals about the treatment or investigation which is being offered to you. You should always ask them more questions if you do not understand or if you want more information.

The information you receive should be about your condition, the alternatives available to you, and whether it carries risks as well as the benefits. What is important is that your consent is genuine or valid. That means:

  • you must be able to give your consent
  • you must be given enough information to enable you to make a decision
  • you must be acting under your own free will and not under the strong influence of another person

Information about you

We collect and use your information to provide you with care and treatment. As part of your care, information about you will be shared between members of a healthcare team, some of whom you may not meet. Your information may also be used to help train staff, to check the quality of our care, to manage and plan the health service, and to help with research. Wherever possible we use anonymous data.

We may pass on relevant information to other health organisations that provide you with care. All information is treated as strictly confidential and is not given to anyone who does not need it. If you have any concerns please ask your doctor, or the person caring for you.

Under the General Data Protection Regulation and the Data Protection Act 2018 we are responsible for maintaining the confidentiality of any information we hold about you. For further information visit the following page: Confidential Information about You.

If you or your carer needs information about your health and wellbeing and about your care and treatment in a different format, such as large print, braille or audio, due to disability, impairment or sensory loss, please advise a member of staff and this can be arranged.