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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_1499_Библиотеки_им_академика_М_И_Перельмана.pdf
AccessSurgery | Print: Appendix I. Medications
file:///C|/...s/User/Desktop/ADRIANA/McGrawHillManual%20ColorectalSurgery%201stEdition/Appendix%20I_%20Medications.htm[9/5/2009 19:15:08]
Prednisone 1.0x 5–60 mg PO qd or 0.5 mg/kg Prednisone
Steroids, Local
Generic Name Typical Dosage Trade Name
Budesonide-oral 3–9 mg PO qd Entocort EC-oral
Budesonide-rectal 2 mg PR qd Entocort EC-rectal
Hydrocortisone acetate Analpram 1–2.5%, Cort Enemas, Cort Foam, ProctoCream 1%,
ProctoFoam 1%
Hydrocortisone topical 1 supp PR bid–tid Anusol-HC
Pramoxine 1 supp PR bid + post
BM
Anusol, ProctoFoam
Pramoxine +
hydrocortisone
1 supp PR bid–tid ProctoFoam HC
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McGraw-Hill Manual: Colorectal Surgery > Chapter 1. Symptoms and Differential Diagnosis >
ABDOMINAL DISTENTION
Highlights of the Symptom
Localization/point of origin: peritoneal cavity (ascites, bowel dilation), abdominal wall (hernia, obesity).
Associated symptoms: nausea, vomiting, abdominal pain and cramping, altered bowel function, bleeding?
Symptom evolution: acute/progressive, intermittent, recurrent, chronic.
Appearance: diffuse, focal area.
Grading: mild, severe.
Underlying systemic disease: congenital malformation, malignancy, cardiovascular disease, IBD, history of previous
surgeries.
Probability of being sign of serious disease (liability issue): high.
Pathogenesis-Oriented Differential Diagnosis
1. Malformation
– acquired: obesity, organomegaly (liver, spleen)
– cystic fibrosis (mucoviscidosis) with fecal impaction in the small bowel
– megacolon (Hirschsprung disease)
– colonic malrotation
– intestinal atresia
2. Vascular
– ischemia-related bowel obstruction (ischemic stricture)
3. Inflammatory
– inflammatory process with bowel obstruction (diverticulitis, Crohn disease)
– toxic megacolon
4. Tumor
– tumor-related bowel obstruction (neoplasm, endometriosis)
– carcinomatosis
– pseudomyxoma peritonei
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5. Degenerative/functional
– adhesion-related bowel obstruction
– Ogilvie syndrome
– hernia
– pseudohernia from denervation of abdominal wall musculature
– fecal impaction
– ascites (eg, liver cirrhosis)
6. Traumatic/posttraumatic
– hematoma
Top of the List
1. Constitutional: obesity.
2. Bowel obstruction (SBO, LBO).
3. Hernia.
4. Megacolon/pseudoobstruction.
5. Ascites.
Keys to Diagnosis
Patient's surgical/medical history: habitus, symptom progression, previous abdominal surgeries, tumor, etc.
Clinical examination: patient's general condition and habitus, presence/absence of (tympanitic) bowel sounds,
focal/diffuse tenderness to palpation, organomegaly, peritoneal signs, stool in rectal vault.
Imaging:
– Abdominal x-ray series, chest x-ray: evidence of bowel obstruction (SBO vs LBO), free air, distended loops of
bowel, air/fluid levels, gastric dilation, transition point, presence of air in distal colon, calcifications, pneumobilia.
– CT scan (if possible with oral and IV contrast): ascites, hernia, small or large bowel dilation, transition point,
extensive mucosal thickening, intestinal pneumatosis, pneumobilia, portal vein gas, suspicion of closed loop,
intraabdominal/retroperitoneal mass, extent and location of tumor burden, etc.
– Ultrasound: ascites, tumor.
Cross-Reference
Colorectal cancer—colon cancer (153.X) (Ch. 4)
Toxic megacolon (556.9) (Ch. 4)
Large bowel obstruction (LBO, 560.9) (Ch. 4)
Colonic pseudoobstruction (Ogilvie syndrome, 560.89) (Ch. 4)
BLEEDING PER RECTUM
Highlights of the Symptom
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Localization/point of origin: upper GI, mid-GI, lower GI, anorectal.
Associated symptoms: pain, pruritus, prolapse, altered bowel habits, constipation, diarrhea, dizziness, weakness,
weight loss?
Time factor: onset, constant, certain times, certain activity, link to menstrual cycle?
Symptom evolution: continuous, intermittent, worsening, one-time, self-limited.
Appearance: BRBPR, dark blood, melena, invisible/occult bleeding, false positive (nonhematogenous red color).
Severity: acute/massive, acute/moderate, sporadic, occult, anemia.
Underlying systemic disease: hematologic, liver disease, medications (ASA, warfarin).
Probability of being sign of serious disease (liability issue): high.
Pathogenesis-Oriented Differential Diagnosis
1. Malformation
– AV malformations, angiodysplasia, Osler disease
– Meckel diverticulum
– congenital aneurysms
2. Vascular
– ischemic colitis
– mesenteric ischemia
– vasculitis
– Osler disease
– rectal varices
– hemorrhoids
– anorectal Dieulafoy lesion
– acquired (pseudo-)aneurysms
– radiation injury
– esophageal varices
3. Inflammatory
– colitis (infectious, idiopathic, postradiation)
– SRUS
– fissure
– perianal dermatitis
– peptic ulcer disease, Mallory-Weiss syndrome
4. Tumor
– epithelial: cancer, adenomatous polyps
– mesenchymal: lymphoma, leiomyoma, GIST, etc
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– neurogenic: melanoma
– endometriosis
5. Degenerative/functional
– diverticulosis
– stercoral ulcers
– prolapse
– intussusception
– Mallory-Weiss syndrome
6. Traumatic/posttraumatic
– blunt/penetrating trauma
– anal intercourse, autoeroticism, foreign body
– iatrogenic
– paraplegia with need for manual stimulation
Top of the List
LOCAL BLEEDING SOURCE
1. Fissure.
2. Hemorrhoids.
3. Neoplasm.
4. Prolapse.
5. Trauma.
HIGHER BLEEDING SOURCE
1. Diverticulosis (distal > proximal).
2. Tumor.
3. Colonic AV malformation (proximal > distal).
4. IBD.
5. Ischemia.
6. Bleeding proximal to ileocecal valve (Meckel, Crohn, varices, Mallory-Weiss, peptic ulcer, etc).
Children:
1. Anal fissure
2. Intussusception
3. Meckel diverticulum
4. Polyps
Keys to Diagnosis
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Clinical examination: general condition, abdominal exam, rectal exam, anoscopy/rigid sigmoidoscopy.
Blood work: CBC, PT, PTT rule out coagulopathy.
Colonoscopy: limited by poor visibility (unprepped colon, strong light absorption of blood that results in darkness);
distribution of blood in the colon has only limited value in localization of bleeding source.
Tagged red blood cell scan: > 0.5 mL bleeding, particularly the first 15–30 min are meaningful for localization.
Angiography: > 1 mL/min bleeding.
Bleeding proximal to ileocecal valve: NGT insertion, EGD, capsule endoscopy.
Cross-Reference
Colonoscopy (Ch. 2)
Angiography with possible embolization (Ch. 2)
Nuclear scintigraphy (Ch. 2)
Anal fissure (565.0) (Ch. 4)
Hemorrhoids (455.X) (Ch. 4)
Colorectal cancer—colon cancer (153.X) (Ch. 4)
Acute lower GI bleeding (578.9) (Ch. 4)
COLITIS OR PROCTITIS
Highlights of the Symptom
Definition: visible inflammatory changes in colon or rectum (edema, ulcerations, friability).
Localization/point of origin: begin at the dentate line? Most distal segment disease-free or with limited disease
(caveat: distal begin of disease potentially masked by previous local therapy!).
Associated symptoms: altered bowel habits, diarrhea, bleeding, mucous discharge, urgency, tenesmus, weight loss,
pelvic or abdominal pain, abdominal distention, fever, toxic signs, urinary tract infections? Extraintestinal
manifestations?
Time factor: sudden onset, gradual onset, relapsing, one-time, continuous.
Symptom evolution: gradual worsening, on/off relapsing.
Appearance: diffuse involvement of affected segment, patchy/discontinuous involvement, very localized.
Severity: extent of involvement, chronic/acute/fulminant/toxic.
Underlying systemic disease: known IBD, status postcancer treatment (radiation, chemotherapy, bone marrow
transplantation, etc).
Probability of being sign of serious disease (liability issue): high.
Pathogenesis-Oriented Differential Diagnosis
1. Malformation
– cavernous hemangioma (
no true inflammation)
2. Vascular
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– ischemic colitis (peripheral vascular disease, embolic disease, vasculitis)
– radiation injury
3. Inflammatory
– IBD: ulcerative colitis, Crohn disease
– C difficile colitis, diverticulitis
– infectious colitis (amebic, shigella, enterohemorrhagic E coli, tuberculosis, cytomegalovirus, etc)
– STD proctitis: lymphogranuloma venereum, gonorrhea, etc
– side effect: bowel cleansing (aphthoid ulcers or diffuse), NSAIDs, etc
– eosinophilic colitis
4. Tumor
– colorectal cancer (eg, signet cell cancer results in diffuse infiltration with lack of mass effect)
– extraintestinal cancer
– lymphoma, Kaposi sarcoma
– endometriosis
5. Degenerative/functional>
– SRUS
– stercoral ulcerations (fecal impaction)
6. Traumatic/posttraumatic
– anal intercourse, autoeroticism, foreign body
– iatrogenic
Top of the List
1. IBD.
2. Specific proctitis/colitis (C difficile, infectious, STD).
3. Ischemic colitis (caveat: ischemic proctitis unlikely!).
4. Radiation proctitis/colitis.
Keys to Diagnosis
History: narration with specific details, identification of risk factors (family, travel, radiation, cardiovascular surgery,
anoreceptive intercourse, etc).
Clinical examination: anoscopy/rigid sigmoidoscopy or partial/full colonoscopy, endoscopic picture, and biopsies.
Histology: type of inflammation, granulomatous disease.
Stool analysis: cultures, C difficile toxin, ova and parasites, possible fecal WBCs.
Serum analysis: possible serum titers for viral/amebic pathogens.
Possible imaging studies, eg, small bowel follow-through or CT enterography: small bowel involvement?
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Cross-Reference
Colonoscopy (Ch. 2)
Ischemic colitis (557.X) (Ch. 4)
Pseudomembranous/Clostridium difficile colitis (008.45) (Ch. 4)
IBD—ulcerative colitis (556.9) (Ch. 4)
IBD—Crohn disease (555.X) (Ch. 4)
CONSTIPATION
Highlights of the Symptom
Appearance: decreased frequency of bowel movements, increased consistency of the stools, change in shape (pencil-
/pellet-like bowel movements), need for straining or manual support, incomplete evacuation; multiple/ repetitive small
bowel movements.
Localization/point of origin: intestinal transport, evacuation.
Associated symptoms: bleeding, weight loss, fever, dehydration (primary/ secondary), vaginal bulging, etc.
Time factor: acute vs chronic.
Symptom evolution: one-time, gradually worsening, lifelong.
Underlying systemic disease: tumor, cardiopulmonary disease, diabetes, renal disease, etc.
Probability of being sign of serious disease (liability issue): age-dependent.
Pathogenesis-Oriented Differential Diagnosis
1. Malformation
– atresia
– Hirschsprung disease
2. Vascular
– ischemic stricture
3. Inflammatory
– Crohn diseaes with stricture
– chronic diverticulitis with stricture
– anastomotic stricture
4. Tumor
– tumor-related obstruction
5. Degenerative/functional
– dietary
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– social (poor habits)
– drug-induced
– immobility
– endocrine/metabolic: hypothyroidism, diabetes, hyperparathyroidism
– psychiatric/neurologic (Parkinson disease, multiple sclerosis, etc)
– constipation-predominant IBS
– slow transit constipation (colonic inertia)
– pelvic floor dysfunction: functional outlet obstruction, intussusception, prolapse, rectocele
– Chagas disease
– pregnancy (pelvic/abdominal lack of space, endocrine-induced decrease of motility, insufficient fluid intake)
6. Traumatic/posttraumatic
– spinal injury, paraplegia
– retroperitoneal/spinal pathology (hematoma, fracture, etc)
Top of the List
1. Habits.
2. Drug-induced.
3. Functional (IBS, slow transit constipation).
4. Morphologic obstruction (tumor, stricture etc).
5. Pelvic floor dysfunction.
Keys to Diagnosis
Patient's surgical/medical history: habits, daily routine (diary), alarm symptoms, previous abdominal surgeries,
tumor, systemic disease, etc. Previous colonic evaluations?
Clinical examination: patient's general condition, abdominal distention, palpable mass, tenderness to palpation?
Digital rectal exam: perineal descent, stool in rectal vault, stool quality, rectocele, sphincter and puborectalis muscle
tone, etc?
Based on evidence from H&P, the likelihood of a morphologic problem has to be determined in order to decide on
further tests:
– Colonic evaluation.
– Colonic function tests: colonic transit time, defecation proctogram.
– CT scan.
– Contrast studies.
Cross-Reference
Anophysiology studies (Ch. 2)
Colonic transit study (Sitzmark) (Ch. 2)
Defecating proctogram (defecography) (Ch. 2)
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Colorectal cancer—colon cancer (153.X) (Ch. 4)
Large bowel obstruction (LBO, 560.9) (Ch. 4)
Pelvic floor dysfunction (618.X) (Ch. 4)
Functional disorders—chronic constipation (564.0X) (Ch. 4)
Functional disorders—irritable bowel syndrome (IBS, 564.1) (Ch. 4)
DIARRHEA
Highlights of the Symptom
Localization/point of origin: intestinal, colonic, systemic.
Associated symptoms: nausea, vomiting, abdominal pain and cramping, abdominal distention, high ileostomy output
of watery (tealike) quality, bleeding, altered bowel habits, diarrhea, urinary tract infections?
Time factor: acute vs chronic.
Symptom evolution: single episode (self-limited).
Appearance: increased frequency, decreased consistency (loose, watery, etc), added components (blood, mucus),
etc.
Severity: decompensated dehydration; compensated preserved hydration and organ function.
Underlying systemic disease: IBD, celiac disease, history of previous abdominal surgeries, antibiotic use, etc.
Probability of being sign of serious disease (liability issue): moderate.
Pathogenesis-Oriented Differential Diagnosis
1. Malformation
– short bowel syndrome (postresection)
– internal fistula (eg, gastrocolic, enterocolonic, enteroenteric fistula)
2. Vascular
– acute mesenteric ischemia (first stage)
– chronic intestinal ischemia
– massive GI bleeding
3. Inflammatory
– infectious enteritis/enterocolitis (viral, bacterial, parasites, fungal, STDs, etc)
– toxic colitis (eg, C difficile colitis, chemotherapy)
– collagenous colitis (abortive form of ulcerative colitis?)
– microscopic colitis (abortive form of ulcerative colitis?)
– IBD (ulcerative colitis, Crohn disease)
– pouchitis
– radiation enteritis