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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_1499_Библиотеки_им_академика_М_И_Перельмана.pdf
AccessSurgery | Print: Chapter 1. Symptoms and Differential Diagnosis
file:///C|/...illManual%20ColorectalSurgery%201stEdition/Chapter%201_%20Symptoms%20and%20Differential%20Diagnosis.htm[9/5/2009 19:15:13]
– celiac disease
4. Tumor
– neuroendocrine tumor (eg, VIPoma)
5. Degenerative/functional
– contrast-induced
– IBS (diarrhea predominant)
– dietary (eg, artificial sweeteners, enteral tube feeding)
– drug-induced (eg, laxatives, bowel cleansing, HAART, chemotherapy, etc)
– bile acid–induced (eg, postileal resection, Crohn disease)
– malabsorption
– pancreatic insufficiency
– stress-induced
– paradoxical diarrhea (in fecal impaction)
6. Traumatic/posttraumatic
– loss of bowel
Top of the List
ACUTE DIARRHEA
1. Infectious enterocolitis (including traveler's diarrhea).
2. Iatrogenic (contrast-induced, drugs, cleansing).
3. Antibiotic-associated diarrhea.
4. IBD.
CHRONIC DIARRHEA
1. IBS.
2. IBD.
3. Malabsorption.
4. Collagenous/microscopic colitis.
Keys to Diagnosis
Patient's surgical/medical history: exposure (travel, foods, oral–anal intercourse, etc)? Other family members
affected? Previous endoscopies? Previous abdominal surgeries, tumor, antibiotic treatment, immunosuppression (HIV,
drug-induced), current medications, etc.
Clinical examination: patient's general condition (hydration, hemodynamic status), abdominal distention, hyperactive
bowel sounds, focal/diffuse tenderness to palpation, peritoneal signs, stool in rectal vault (fecal impaction?), etc.
Further testing (typically not needed for acute self-limited diarrhea):
AccessSurgery | Print: Chapter 1. Symptoms and Differential Diagnosis
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– Stool analysis: cultures, toxins, O&P, 24-hour fat content.
– Blood/urine tests: celiac disease, 5-HIAA, etc.
– Endoscopy:
Colonoscopy with biopsies (even if macroscopically normal assess for collagenous or microscopic colitis).
EGD consider small bowel biopsy to rule out celiac disease?
Capsule endoscopy?
– Imaging:
Contrast studies: small bowel follow-through, CT enterography.
Response to empirical treatment (antidiarrheals, cholestyramine, etc).
Cross-Reference
HIV-associated anorectal diseases (042) (Ch. 4)
Sexually transmitted diseases (STDs, 091, 098, 099) (Ch. 4)
Carcinoid tumors (235.2) (Ch. 4)
Infectious enterocolitis (002-009.X) (Ch. 4)
IBD—ulcerative colitis (556.9) (Ch. 4)
Functional disorders—irritable bowel syndrome (IBS, 564.1) (Ch. 4)
DISCHARGE
Highlights of the Symptom
Localization/point of origin: per rectum, perianal, per vagina?
Associated symptoms: perianal/perineal moisture ( skin irritation), odor, bleeding, pain, itching, tenesmus, urgency,
prolapse, altered bowel habits, diarrhea, weight loss, pulmonary symptoms?
Time factor: onset, constant, cyclic, certain time, certain activity?
Symptom evolution: continuous, intermittent, worsening, one-time, self-limited.
Appearance: aqueous; clear, colorless mucus; brownish; feculent; purulent.
Underlying systemic disease: fistula-in-ano, fecal incontinence/soiling, rectovaginal fistula, IBD (ulcerative colitis,
Crohn disease), HIV, STDs, tuberculosis.
Probability of being sign of serious disease (liability issue): moderate.
Pathogenesis-Oriented Differential Diagnosis
1. Malformation
– ectropion (eg, post–Whitehead hemorrhoidectomy)
2. Vascular
– prolapsing internal hemorrhoids
AccessSurgery | Print: Chapter 1. Symptoms and Differential Diagnosis
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– radiation proctitis
3. Inflammatory
– proctitis/colitis (infectious, idiopathic, postradiation)
– SRUS
– abscess
– fistula-in-ano
– anastomotic leak
– dermatitis (eczema, contact allergy, etc)
4. Tumor
– large adenoma (particularly villous adenoma)
– anorectal tumors (cancer, Paget disease, Bowen disease)
5. Degenerative/functional
– IBS
– rectal prolapse/intussusception
– fecal incontinence
– transpiration
– inadequate local hygiene
6. Traumatic/posttraumatic
– anal intercourse, autoeroticism, foreign body
– rectourinary fistula
Top of the List
1. Abscess/fistula.
2. Incontinence/transpiration.
3. Prolapse (rectal, hemorrhoidal).
4. Villous adenoma.
5. IBS.
6. Neoplasm.
7. Proctitis.
8. Trauma.
Keys to Diagnosis
Patient history: precipitating/risk factors, characterization of symptoms.
Clinical examination: careful anorectal exam including inspection, palpation, anoscopy/rigid sigmoidoscopy.
Colonoscopy: (a) for diagnostic purposes if diagnosis not clear from local exam; (b) colonic evaluation per guidelines.
AccessSurgery | Print: Chapter 1. Symptoms and Differential Diagnosis
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Functional studies: anophysiology testing, defecating proctogram, etc.
Cross-Reference
Hemorrhoids (455.X) (Ch. 4)
Perianal/-rectal fistula (565.1) (Ch. 4)
Fecal incontinence (787.6) (Ch. 4)
Sexually transmitted disease (STDs, 091, 098, 099) (Ch. 4)
Colorectal cancer—colon cancer (153.X) (Ch. 4)
Rectal prolapse (569.1) (Ch. 4)
EXTRALUMINAL AIR
Highlights of the Symptom
Radiologic finding: conventional x-ray, CT scan.
Associated abdominal symptoms: nausea, vomiting, abdominal pain and cramping, distention, GI dysfunction, tissue
crepitans?
Evolution: primary progression/regression, temporary resolution (eg, postoperative) with secondary recurrence?
Location: peritoneal, retroperitoneal, mediastinal, abdominal wall/soft tissue.
Probability of being sign of serious disease (liability issue): high.
Pathogenesis-Oriented Differential Diagnosis
1. Malformation
– Chilaiditi syndrome, situs inversus: pseudo–free air
2. Vascular
– portal vein gas: sign of ischemic bowel necrosis
3. Inflammatory
– perforated viscus (colon, peptic ulcer, appendicitis, etc):
confined or free perforation
– anastomotic leak
confined or free perforation
– abscess
small pocket of extraluminal air
– appendicitis: rarely leading to pneumoperitoneum
– emphysematous cholecystitis
– necrotizing soft tissue infection
4. Tumor
– perforated tumor
confined or free perforation
5. Degenerative/functional
AccessSurgery | Print: Chapter 1. Symptoms and Differential Diagnosis
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– spontaneous pneumoperitoneum without peritonitis: aspiration of air, eg, through vagina and tubes
– peritoneal dialysis
6. Traumatic/postsurgical
– postoperative pneumoperitoneum: normal resolution expected within 7 days, sporadically taking up to 2½–3
weeks (however, worsening not compatible with delayed absorption
new pathology has to be suspected)
– postoperative while nonvacuum drains still in place
– postcolonoscopy: small amounts of gas possible even without perforation
– colonoscopic/endoscopic perforation
generally massive pneumoperitoneum and/or retroperitoneal air (due to
insufflation of pressured gas)
– post–transanal endoscopic microsurgery (TEM): extensive retroperitoneal gas expected.
– postcardiopulmonary resuscitation: air leak from pressured ventilation
pneumomediastinum/pneumothorax
with abdominal extension; rib fractures
sharp injury to lung/diaphragm
– pneumobilia: status post-ERCP/sphincterotomy, status post-hepaticojejunostomy
Top of the List
1. Perforated viscus.
2. Normal postoperative.
3. Anastomotic leak.
4. Abscess.
Keys to Diagnosis
Patient's immediate surgical/medical history: type and time frame of previous abdominal surgeries or procedures,
prodromal symptoms (eg, epigastric or LLQ pain, etc).
Clinical examination: patient's general condition, vital signs, abdominal distention, tenderness to
percussion/palpation, peritoneal signs (involuntary guarding, rebound tenderness), bowel sounds, drains, etc.
Context synthesis: combination of radiologic data with information from H&P.
Additional imaging: eg, water-soluble contrast study.
Cross-Reference
Conventional x-rays (plain films) (Ch. 2)
Computed tomography (CT scan) (Ch. 2)
Colorectal cancer—colon cancer (153.X) (Ch. 4)
Toxic megacolon (556.9) (Ch. 4)
Diverticular disease (diverticulosis, diverticulitis, 562.1X) (Ch. 4)
Complications—leak (997.4) (Ch. 4)
FISTULA
AccessSurgery | Print: Chapter 1. Symptoms and Differential Diagnosis
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Highlights of the Symptom
Localization/point of origin (primary opening): stomach, small bowel, colon, rectum, anal canal.
Localization of secondary openings: abdominal skin, small bowel, colon, rectum, vagina/uterus, bladder/urethra,
perirectal skin.
Associated symptoms: drainage (stool, pus, gas, urine), incontinence, fever, sepsis, abscess, abdominal or perirectal
pain, bleeding, skin irritation, change in bowel habits (eg, diarrhea), malnutrition, weight loss.
Time factor: onset with acute presentation, onset without memorable episode of acute event, associated with
preceding event (abdominal/perianal) or procedure.
Symptom evolution: worsening, improving, one-time episode with complete/incomplete resolution, high-/low-output
or alternating, recurrent, sporadic cyclic.
Appearance: diameter, length, visible mucosa, perifocal induration/erythema, tenderness.
Severity: severe (with sepsis, malnutrition), moderately symptomatic (manageable, not manageable), asymptomatic
except for abnormal passage, completely asymptomatic.
Underlying systemic disease: Crohn disease, cancer, radiation enteropathy, adhesions, preceding surgery, systemic
infection (tuberculosis, actinomycosis, etc), hidradenitis suppurativa, chronic LGV.
Probability of being sign of serious disease (liability issue): low to high.
Pathogenesis-Oriented Differential Diagnosis
1. Malformation
– pilonidal cyst
– congenital anogenital malformations
– urachus fistula
2. Vascular
– radiation injury (acute, chronic)
– incarcerated hernia
3. Inflammatory
– Crohn disease (intestinal)
– diverticulitis
– massive adhesions
– cryptoglandular disease
– hidradenitis suppurativa
– burrowing fissure
– tuberculosis
– actinomycosis
– chronic LGV
4. Tumor
AccessSurgery | Print: Chapter 1. Symptoms and Differential Diagnosis
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– advanced neoplasm (cancer, lymphoma, etc)
5. Degenerative/functional
– diverticulosis
– giant hernia with loss of domain
6. Traumatic/posttraumatic
– Iatrogenic: eg, postsurgical leak, stapler injury, enterotomies, instrument perforation, implant, etc
– blunt/penetrating trauma (eg, impalement)
– anal intercourse, autoeroticism, foreign body
– obstetric injury
– iatrogenic (postsurgery, instrument perforation, enterotomies, etc)
Top of the List
ANAL/PERIRECTAL
1. Cryptoglandular fistula.
2. Hidradenitis suppurativa.
3. Crohn disease.
4. Posttraumatic/postsurgical.
ABDOMINAL
1. Diverticulitis.
2. Cancer.
3. Crohn disease.
4. Postsurgical (eg, enterotomy, leak, infected implant).
Keys to Diagnosis
Patient history: events/interventions preceding onset, exact description of symptoms and severity, underlying
diseases, evidence for FRIEND (foreign body, radiation, infection, epithelialization, neoplasm, distal obstruction)?
Clinical examination: anorectal exam including anoscopy/sigmoidoscopy, vaginal exam if needed, abdominal exam,
general condition, and nutritional status.
Further testing:
– Anorectal: assessment in clinic as tolerated, complete during surgery, imaging only under selected
circumstances.
– Abdomen: CT abdomen/pelvis, colonoscopy vs barium enema, small bowel follow-through, fistulogram,
assessment of nutritional status
ultimately surgical exploration to give best assessment of the problems.
Cross-Reference
Computed tomography (CT scan) (Ch. 2)
Perianal/-rectal fistula (565.1) (Ch. 4)
AccessSurgery | Print: Chapter 1. Symptoms and Differential Diagnosis
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Hidradenitis suppurativa (705.83) (Ch. 4)
Sexually transmitted diseases (STDs, 091, 098, 099) (Ch. 4)
Colorectal cancer—colon cancer (153.X) (Ch. 4)
IBD—Crohn disease (555.X) (Ch. 4)
Diverticular disease (diverticulosis, diverticulitis, 562.1X) (Ch. 4)
Enterocutaneous fistula (569.81) (Ch. 4)
Complications—leak (997.4) (Ch. 4)
INCONTINENCE
Highlights of the Symptom
Quality of incontinence: stool, gas, urine.
Location: anal, vaginal, urethra.
Warning symptoms: urgency ("reduced time to bathroom"), inappercept episodes.
Descriptive severity: staining < soilage < seepage < accidents.
Grading of severity and impact: scoring systems: eg, CCF/Wexner fecal incontinence score (frequency of five
parameters), Fecal Incontinence Quality of Life (FIQL) score.
Associated symptoms: bleeding, prolapse (rectal, vaginal, bladder), altered bowel habits, diarrhea/constipation,
urinary incontinence, urinary tract infections, abdominal discomfort?
Evolution: acute-limited, progressive, sporadic, persistent.
Timing: interval since original injury?
Underlying systemic disease: IBD, IBS, malignancy, history of previous surgeries, diabetes, neurologic including
spinal disease, history of chemoradiation?
Probability of being sign of serious disease (liability issue): low.
Pathogenesis-Oriented Differential Diagnosis
1. Malformation
– meningomyelocele
neurogenic incontinence
– imperforate anus (postreconstructive pull-through procedure)
– cloaca-like deformity (acquired, congenital)
– keyhole deformity (acquired)
2. Vascular
– radiation injury with stricture formation
3. Inflammatory
– IBD
AccessSurgery | Print: Chapter 1. Symptoms and Differential Diagnosis
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– fistula-in-ano
4. Tumor
– anorectal cancer
5. Degenerative/functional
– age-related
– idiopathic sphincter dysfunction
– rectal/hemorrhoidal prolapse
– pelvic floor dysfunction
– pelvic organ prolapse syndrome
– neuropathy (eg, diabetes, drug-induced)
– functional fecal incontinence (normal sphincter and nerve function)
6. Traumatic/posttraumatic
– obstetric injury
– surgical injury (hemorrhoidectomy, fistulotomy, sphincterotomy)
– post-sphincter–salvaging coloanal or ileoanal reconstruction
– spinal injury
– brain injury
Top of the List
1. Obstetric injury (10% known at time of delivery, 30% occult).
2. Anorectal surgeries (hemorrhoidectomy, fistulotomy, sphincterotomy).
3. Altered bowel habits (IBS, IBD, diet intolerance, constipation with overflow incontinence).
4. Status post colo-/ileoanal reconstruction.
Keys to Diagnosis
Patient's surgical/medical history: gravity/parity, obstetric injuries, previous anorectal, vaginal or abdominal
surgeries, malignancy, radiation treatment; underlying diseases, bowel function.
Clinical examination: anal configuration, sphincter function (sphincter complex, auxiliary muscles), evidence for
morphologic changes (inflammation, mass, stricture, etc).
Investigations:
– Anophysiology studies including endorectal ultrasound: sphincter defect, manometry, neuropathy, anorectal
sensation, rectal compliance.
– Endoscopy.
Cross-Reference
Anophysiology studies (Ch. 2)
AccessSurgery | Print: Chapter 1. Symptoms and Differential Diagnosis
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Fecal control (continence) (Ch. 3)
Fecal incontinence (787.6) (Ch. 4)
INTESTINAL STRICTURE
Highlights of the Symptom
Localization/point of origin: proximal/mid/distal small bowel, large bowel.
Associated symptoms: nausea, vomiting, abdominal pain and cramping, abdominal distension, high ileostomy output
of watery (tealike) quality, bleeding, altered bowel habits, diarrhea, urinary tract infections? Dehydration,
hemodynamic instability, sepsis?
Symptom evolution: asymptomatic, acute, intermittent/recurrent, chronic.
Appearance: endoscopic, radiologic, during surgery.
Severity: no functional impact, causing mild/moderate/severe symptoms (partial SBO/LBO, complete SBO/LBO).
Underlying systemic disease: Crohn disease, malignancy, history of previous surgeries.
Probability of being sign of serious disease (liability issue): moderate to high.
Pathogenesis-Oriented Differential Diagnosis
1. Malformation
– atresia
– anastomotic stricture
2. Vascular
– mesenteric ischemia (peripheral vascular disease, embolic disease, vasculitis)
– portal vein thrombosis
– radiation injury with stricture formation
3. Inflammatory
– peritoneal adhesions
– Crohn disease
– diverticulitis/appendicitis with inflammatory encasement of small bowel loop(s)
– pancreatitis (mixture of direct inflammation and mid-colic ischemia)
4. Tumor
– peritoneal carcinomatosis (various primary tumors)
– desmoid
– lymphoma, mesenchymal tumors
– endometriosis
– primary small bowel cancer: rare
5. Degenerative/functional