Sigmoidoscopy, flexible; with biopsy, single or multiple

CPT4 code

Name of the Procedure:

Sigmoidoscopy, Flexible; with Biopsy, Single or Multiple

Summary

A flexible sigmoidoscopy with biopsy is a diagnostic medical procedure that involves the use of a flexible tube with a camera to examine the sigmoid colon and rectum. If necessary, tissue samples (biopsies) are taken for further analysis.

Purpose

Addresses: Gastrointestinal issues, such as rectal bleeding, abdominal pain, and chronic diarrhea.
Goals: To determine the cause of symptoms, diagnose conditions like colorectal cancer, polyps, or inflammatory bowel disease, and gather tissue for biopsy analysis.

Indications

Symptoms: Rectal bleeding, unexplained abdominal pain, chronic diarrhea or constipation, changes in bowel habits.
Criteria: Patients with abnormal results from other tests (e.g., stool tests, imaging) or those at risk for colorectal diseases.

Preparation

Instructions: Follow a clear liquid diet 24 hours before the procedure, take prescribed laxatives or enemas to clean the bowel.
Tests: No specific diagnostic tests required before; however, a patient’s medical history and current medications will be reviewed.

Procedure Description

The patient lies on their side on an examination table.
A flexible sigmoidoscope is gently inserted through the rectum.
Air may be introduced to expand the colon for better visibility.
The scope transmits images to a monitor, allowing the doctor to view the colon lining.
If abnormal areas are seen, special tools can be passed through the scope to take biopsy samples.
The scope is carefully withdrawn.

Equipment: Flexible sigmoidoscope, air inflation device, biopsy forceps.
Anesthesia: Local anesthesia may be used; sedation rarely needed.

Duration

The procedure typically takes around 10-20 minutes.

Setting

Performed in an outpatient clinic or medical office.

Personnel

Involved: Gastroenterologist, nurse, and sometimes a technician.

Risks and Complications

Common: Mild cramping, bloating, minor bleeding at biopsy sites.
Rare: Perforation of the colon, excessive bleeding, infection.
Management: Antibiotics for infection, surgical repair for perforation.

Benefits

Benefits: Accurate diagnosis of gastrointestinal conditions, early detection of colorectal cancer.
Realization: Immediate preliminary results; biopsy results usually within a week.

Recovery

Care: Resume normal diet and activities almost immediately, may experience minor discomfort.
Time: Recovery is usually quick, within hours; follow-up depends on biopsy results.

Alternatives

Options: Colonoscopy (more comprehensive), stool tests, imaging studies (e.g., CT scan).
Comparison: Colonoscopy examines the entire colon but is more invasive; stool tests and imaging are non-invasive but may not be as diagnostic.

Patient Experience

During: Mild discomfort, feeling of fullness due to air inflation; usually not painful.
After: Minor cramping or bloating, manageable with over-the-counter pain relievers.