Office Endoscopy

James Church

Perioperative Considerations

A full armamentarium of endoscopes maximizes the effectiveness of the office consultation, with each potentially utilized in different situations.
Before you scope: Although endoscopy should always be thorough, the examination is directed by the provisional diagnosis reached as a result of history and physical examination.
Patients with an obvious diagnosis on physical examination do not need endoscopy in the office. Examples include a patient presenting with anal pain and a lump that is an obvious thrombosed external hemorrhoid, or a perianal abscess. Treat the thrombosis or abscess. Patients with rectal bleeding, rectal pain, or dysfunctional defecation are good candidates for endoscopy.
Judge the mental state of the patient sitting before you. They are usually expecting some sort of anal examination and are often dreading it. In their minds, it will be painful, embarrassing, and involve complete loss of their personal dignity. This dread and anxiety demands a very relaxing and respectful examination.
Limit the number of people in the room. This is no time to have multiple observers and students.
Make sure the patient’s anus is covered most of the time.
Tell the patient exactly what is going to happen before it happens.
Be gentle at all times.
Use plenty of lubricant.
Use lidocaine jelly if there is anal excoriation.
Infiltrate the anus with local anesthetic if immediate anoscopy is important and you suspect an anal ulcer or fissure.

Anoscopes (short and long, adult and pediatric) (Fig. 7-1)
Proctoscopes (pediatric, adult standard, and adult large) (Fig. 7-2)
Flexible sigmoidoscopes (adult and narrow) (pediatric gastroscope = “ileoscope”)
Cotton-tip applicators
Suction device
Enemas
Gloves and lubrication
Local anesthetic with corresponding betadine, 5- or 10-mm syringe, and a 27-guage needle, when required
Biopsy forceps (open and endoscopic)

Technique

Position

The easiest way to examine the anus is with the patient in knee-chest position, on a Ritter table, tipped forward to raise the anus and lower the head.
The examiner and an assistant on the other side of the patient spread the buttocks.
A left lateral position can also be used and, in fact, is preferred if there is a question of pelvic floor nonrelaxation.

FIGURE 7-1 ▪ A selection of closed anoscopes for office anoscopy, including adult-sized scopes of different lengths and a pediatric-sized anoscope.

FIGURE 7-2 ▪ Selection of instruments for rigid anorectal endoscopy.

Inspection

The anus is then inspected for symmetry, scars, the degree of closure, the state of the surrounding skin of the perineum, tags, masses, or other abnormalities.

Digital Examination

The skin beside the anus is gently touched with a Q-tip to elicit an anal “wink,” a contraction of the corrugator cutis ani muscle that is evidence of intact anal innervation. The “Open Sesame” technique follows.
“Open Sesame”: This technique of anal examination is based on the tendency of many patients (especially young patients) to have a tight anal sphincter that resists attempts at examination.
- To achieve intubation, the anus has to be encouraged to relax. This means a gentle approach with a well-lubricated finger circling the anus and gradually inserting itself. If the anus is surprised by
  an attempt at forceful insertion, there will be spasm and pain. A gradual, intermittent insertion will avoid the spasm.
- The key to comfort is asking the patient to bear down during insertion. This relaxes the internal sphincter and allows full insertion of the examining digit or scope.
- In addition, bearing down will bring the contents of the lower rectum down on to the finger, allowing detection of masses that might otherwise be unreachable. This technique is useful for inserting an anoscope or a sigmoidoscope, either rigid or flexible. ¹
- If an initial reconnaissance reveals a very tight sphincter muscle, it is better to examine with a fifth digit and a pediatric anoscope.
- If these do not provide enough information because of the limited vision afforded by the narrow instrument, then an examination with the patient under a general anesthetic is warranted.