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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]
Underlying systemic disease: tumor, chemotherapy/immunosuppression, radiation.
Probability of being sign of serious disease (liability issue): low.
Pathogenesis-Oriented Differential Diagnosis
1. Malformation
– lymphangioma, hemangioma
2. Vascular
– thrombosed external hemorrhoid
3. Inflammatory
– anal fissure
– perirectal abscess
– horseshoe abscess
– prostatitis
– herpes simplex infection
– HIV-associated anal ulcer
– proctitis
– perianal dermatitis, exulcerations
4. Neoplastic
– epithelial: anal SCC, rectal cancer (with muscle or bone infiltration)
– mesenchymal: GIST, etc
– neurogenic: melanoma
5. Degenerative/functional
– levator ani syndrome
– anismus
– proctalgia fugax
– rectocele
– intussusception
– spinal pathology with radicular pain
6. Traumatic/posttraumatic
– blunt/penetrating trauma
– autoeroticism, foreign body
– iatrogenic: eg, postsurgery, post–digital rectal exam
– coccygodynia
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Top of the List
1. Anal fissure.
2. Thrombosed external hemorrhoid.
3. Abscess.
Keys to Diagnosis
Patient history: association with defecation? Steadily increasing? Associated symptoms? Bowel function? Level of
activity? Previous interventions/ tests?
Clinical examination:
– External inspection: asymmetric appearance, erythema = abscess? bluish lump = thrombosed external
hemorrhoid?
– External palpation: exact pain localization, tissue induration?
– Lateral traction on buttocks: fissure visible?
– Only if diagnosis not yet made and exam tolerable to patient:
digital rectal exam (eg, tenderness/induration
in postanal space, palpation of prostate, levator muscles, etc), anoscopy/proctoscopy.
Cross-Reference
Anal fissure (565.0) (Ch. 4)
Hemorrhoids (455.X) (Ch. 4)
Perianal/-rectal abscess (566) (Ch. 4)
Functional anorectal pain—levator ani syndrome (569.42) (Ch. 4)
PROLAPSE
Highlights of the Symptom
Grading: extent of prolapse, spontaneous reduction, need for manual reduction, nonreducible, or immediately
reprolapsing.
Localization: anorectal, vaginal.
Associated symptoms: bleeding, pain, underlying bowel function (diarrhea/constipation), change in bowel habits,
incontinence (stool, gas, urine), weight loss.
Symptom evolution: acute, sporadic, recurrent, chronic.
Underlying systemic disease: wasting, malnutrition, tuberculosis, liver disease, neurologic disease (cerebral, spinal),
malignancy, cystic fibrosis, history of previous surgeries.
Probability of being sign of serious disease (liability issue): low.
Pathogenesis-Oriented Differential Diagnosis
1. Malformation/predisposition
– cystic fibrosis (mucoviscidosis)
– external skin tags/hemorrhoids
AccessSurgery | Print: Chapter 1. Symptoms and Differential Diagnosis
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2. Vascular
– internal hemorrhoids
3. Inflammatory
– solitary rectal ulcer syndrome
4. Tumor
– rectal neoplasm: may be lead point for intussusception/prolapse (Figure 1–1)
– anorectal neoplasm: true prolapse vs pseudoprolapse (fungating mass)
– large hypertrophic anal papilla
– external skin proliferation (condyloma, neoplasm, etc)
5. Degenerative/functional
– rectal mucosal prolapse
– full-thickness rectal prolapse
– vaginal prolapse
– cystocele
– rectocele
6. Traumatic/posttraumatic
– ectropion
Figure 1–1.
AccessSurgery | Print: Chapter 1. Symptoms and Differential Diagnosis
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Intussusception with cancer as lead point.
Top of the List
1. Skin tags.
2. Hemorrhoidal prolapse.
3. Rectal prolapse.
4. Tumor.
Keys to Diagnosis
AccessSurgery | Print: Chapter 1. Symptoms and Differential Diagnosis
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Patient's history: obstetric history (parity, etc), previous abdominal or spinal surgeries (hysterectomy, tumor, spinal
disc, etc), underlying bowel function (constipation/diarrhea).
Clinical examination:
– Patient's age and general condition (cachexia)?
– Anal configuration (tags, patulousness, pelvic floor descent, sphincter tone)? Presence/absence of
complications (incarceration, necrosis, ulceration, active bleeding)? Rectocele/cystocele?
– Visible prolapse? If no prolapse visible
patient instructed to perform Valsalva maneuver on the toilet to try
to trigger the prolapse:
Prolapse with radial pattern = hemorrhoidal prolapse.
Prolapse with concentric pattern = rectal prolapse.
– Anoscopy/proctoscopy: tumor (lead point), hemorrhoids, ulcerations and thickening (solitary rectal ulcer
syndrome).
Imaging:
– Defecating proctogram: only needed if diagnosis in doubt or co-pathology suspected.
– Dynamic MRI: assessment of coexisting pelvic floor dysfunction.
Cross-Reference
Hemorrhoids (455.X) (Ch. 4)
Colorectal cancer—colon cancer (153.X) (Ch. 4)
Pelvic floor dysfunction (618.X) (Ch. 4)
Rectal prolapse (569.1) (Ch. 4)
SMALL BOWEL OBSTRUCTION (SBO)
Highlights of the Symptom
Grading: partial SBO, complete SBO.
Localization: proximal jejunum, mid-small bowel, ileum.
Associated symptoms: time of last bowel activity, nausea, vomiting, abdominal pain and cramping, abdominal
distention, high ileostomy output of watery (tealike) quality, bleeding, altered bowel habits, diarrhea, urinary tract
infections?
Evolution: acute, intermittent, recurrent, chronic.
Underlying systemic disease: Crohn disease, malignancy, cardiovascular disease, history of previous surgeries.
Probability of being sign of serious disease (liability issue): moderate to high.
Pathogenesis-Oriented Differential Diagnosis
1. Malformation
– atresia
AccessSurgery | Print: Chapter 1. Symptoms and Differential Diagnosis
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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)
4. Tumor
– peritoneal carcinomatosis (various primary tumors)
– desmoid
– lymphoma, mesenchymal tumors
– endometriosis
– primary small bowel cancer: rare
5. Degenerative/functional
– ileus (postoperative)
– internal wrapping of small bowel around ostomy-bearing bowel segment
– intussusception
– fecoliths/fecal impaction in small bowel of patients with cystic fibrosis
– gallstone ileus
– hernia (external, internal)
6. Traumatic/posttraumatic
– blunt abdominal trauma
– abdominal compartment syndrome (post-trauma, post–burn injury, etc)
– retroperitoneal/spinal pathology (hematoma, fracture, etc)
Top of the List
1. Adhesions.
2. Herniation (external, internal).
3. Tumor (eg, carcinomatosis).
4. Crohn disease.
Keys to Diagnosis
Patient's surgical/medical history: symptom characterization, previous abdominal surgeries, tumor, history of
AccessSurgery | Print: Chapter 1. Symptoms and Differential Diagnosis
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previous SBOs.
Clinical examination: patient's general condition, abdominal distention (may be absent if very proximal obstruction),
presence of incarcerated hernia, presence/absence of (tympanitic) bowel sounds, focal/diffuse tenderness to palpation,
peritoneal signs, stool in rectal vault.
Imaging:
– Abdominal x-ray series, chest x-ray: SBO vs LBO, free air, air/fluid levels, gastric dilation, small bowel dilation
(> 2.5 cm) with plicae circulares, transition point, presence of air in the distal colon, calcifications, pneumobilia.
– CT scan (if possible with oral and IV contrast): small bowel dilation, transition point, extensive mucosal
thickening, intestinal pneumatosis, pneumobilia, portal vein gas, suspicion of closed loop, tumor burden, etc.
– Contrast studies: small bowel follow-through: (a) with barium if chronic partial SBO, (b) Gastrografin or
50%/50% Gastrografin/barium if more acute partial SBO.
Cross-Reference
Complications—postoperative ileus (546.3) (Ch. 4)
Adhesiolysis (laparoscopic vs open) (Ch. 5)
SEPSIS
Highlights of the Symptom
Grading: subfebrile vs febrile, hemodynamically stable/unstable.
With/without sepsis-like symptoms: tachycardia, decrease of peripheral vascular resistance, hypotension, high cardiac
output, thrombocytopenia, hypophosphatemia, coagulopathy/DIC.
Organ dysfunction: pulmonary, cardiovascular, renal, neurologic, hepatic, bone marrow, GI.
Associated abdominal symptoms: nausea, vomiting, abdominal pain and cramping, distention, wound infection,
wound discharge, altered drain output, GI dysfunction?
Postoperative timing:
– 1–3 days: atelectasis/pulmonary.
– 3–6 days: wound infection/fascial dehiscence.
– 5–7 days: anastomotic leak.
Evolution: acute, fulminant, persistent/smoldering.
Underlying systemic disease: immunosuppression, malignancy, other systemic disease, single- or multiorgan
dysfunction, coagulopathy.
Probability of being sign of serious disease (liability issue): high.
Pathogenesis-Oriented Differential Diagnosis
1. Malformation
– valvular heart disease (bicuspid aortic valve, mitral valve prolapse)
bacterial endocarditis
– atrial myxoma
2. Vascular
AccessSurgery | Print: Chapter 1. Symptoms and Differential Diagnosis
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– ischemic necrosis
– thromboembolic
– herniation, strangulation
– line sepsis
3. Inflammatory
– anastomotic leak
– abscess: pelvic, paracolonic, interloop, subhepatic, subdiaphragmatic, etc
– wound infection
– fascial dehiscence/evisceration
– superimposed infection: cholecystitis, pancreatitis, C difficile colitis, diverticulitis, appendicitis, line sepsis
– pneumonia (including malinspiration, aspiration, ARDS)
– urinary tract infection
– endocarditis, septic thrombus
4. Tumor
– extensive tumor load (with tumor necrosis)
– hematologic and lymphatic proliferations
– treatment- or tumor-induced neutropenia
5. Degenerative/functional
– atelectasis
– ileus (postoperative)
– sacral decubitus (with/without osteomyelitis)
– factitious fever
6. Traumatic/posttraumatic
– sepsis-like syndrome
– fat embolism
Top of the List
1. Infection: surgery-related > pulmonary > non–surgery-related.
2. Neoplasm.
3. Autoimmune disease.
Keys to Diagnosis
Patient's surgical/medical history: type and time frame of previous abdominal surgeries (particularly
contaminated/dirty), aspiration, central lines, tumor extent, etc; recovery progress, ie, bowel function, respiratory
function, pain control, urination, etc.
AccessSurgery | Print: Chapter 1. Symptoms and Differential Diagnosis
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General clinical examination: patient's general condition, vital signs, arrhythmias, respiratory excursions,
oxygenation, abdominal distention, wound appearance, excessive amber drainage (ie, sign of fascial dehiscence),
bowel sounds, focal/diffuse tenderness to careful percussion, peritoneal signs, appearance of drains.
Gentle digital rectal exam (if anastomosis in reach): obvious or subtle evidence for leak?
Cultures: blood, sputum, urine, wounds/drains.
Imaging:
– Abdominal x-ray series, chest x-ray: persistent or recurrent free air, air/fluid levels, gastric dilation.
– Chest x-ray: atelectasis, pulmonary consolidations, effusions.
– Ultrasound or CT scan (abdomen/pelvis, or inclusion of chest) with possible CT-guided drainage: evidence for
abscess, leak, free air, etc.
– Water-soluble contrast studies, particularly if relatively distal anastomosis: evidence for anastomotic leak.
Cross-Reference
Colorectal cancer—colon cancer (153.X) (Ch. 4)
Diverticular disease (diverticulosis, diverticulitis, 562.1X) (Ch. 4)
Complications—leak (997.4) (Ch. 4)
Sigmoid resection (open, anastomosis versus Hartmann) (Ch. 5)
SKIN RASH
Highlights of the Symptom
Localization/distribution pattern: perianal, groin, diffuse.
Associated symptoms: itching, pain, bleeding, fever/chills, edema, moisture, incontinence, drainage, prolapse, etc.
Time factor: constant, one-time, recurrent.
Symptom evolution: progressive, worsening, on/off, triggered by certain treatment/activity.
Appearance: symmetric, asymmetric, circumscribed with sharp demarcation, border enhancement, dry/wet,
elevation/lump, underlying induration.
Underlying skin disease: atopic eczema, psoriasis, lichen, lupus erythematosus.
Probability of being sign of serious disease (liability issue): low.
Pathogenesis-Oriented Differential Diagnosis
1. Malformation
– acanthosis nigricans
2. Vascular
– radiation injury (acute, chronic)
3. Inflammatory
– unspecific perianal skin irritation
AccessSurgery | Print: Chapter 1. Symptoms and Differential Diagnosis
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– fungal infection
– erythrasma
– allergic contact dermatitis
– irritant contact dermatitis
– atopic dermatitis
– erythema (phlegmon)
– perirectal abscess
– lichen sclerosus
– psoriasis
4. Tumor
– Paget disease
– Bowen disease
– eczematoid squamous cell carcinoma
– lentigo, melanoma
5. Degenerative/functional
– chronic steroid abuse
– pseudorash: change in pigmentation (hyperpigmented scar, vitiligo, pityriasis versicolor, etc)
6. Traumatic/posttraumatic
– scratch-induced (eg, scratch excoriations)
– hematoma
Top of the List
1. Unspecific perianal dermatitis.
2. Fungal infection.
3. Allergic or toxic contact dermatitis.
4. Systemic skin disease (eg, psoriasis).
Keys to Diagnosis
Patient history: symptom characterization, previous anorectal surgeries, tumor treatment (eg, radiation treatment),
current bowel function (diarrhea?), incontinence, antibiotic use, current perianal skin management (creams,
ointments, hygiene, aggressive washing), etc.
Clinical examination: patient's general condition, symmetric vs asymmetric rash, excoriations, exact localization
(perianal, groins, intertriginous areas, etc), underlying induration, digital rectal exam (reduced sphincter tone?).
Biopsy (with/without cultures): all asymmetric or otherwise suspicious lesions, symmetric lesions without complete
resolution after limited period of empirical treatment.
Cross-Reference