Добавил:
Sekretar
kiopkiopkiop18@yandex.ru
t.me/Prokururor I Вовсе не секретарь, но почту проверяю
Опубликованный материал нарушает ваши авторские права? Сообщите нам.
Вуз:
Предмет:
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]
Hemorrhoids (455.X) (Ch. 4)
Perianal/-rectal fistula (565.1) (Ch. 4)
Fecal incontinence (787.6) (Ch. 4)
Pruritus ani (698.0) (Ch. 4)
ULCERATION
Highlights of the Symptom
Localization/point of origin: anal verge, rectum, colon.
Appearance: solitary area, multifocal, diffuse.
Associated symptoms: rectal pain (with/without bowel movements), abdominal pain, urgency, tenesmus, and
cramping, abdominal distention, bleeding, altered bowel habits, diarrhea?
Time factor: relapsing, progressing, self-limited.
Symptom evolution: acute, intermittent, recurrent, chronic.
Severity: resulting in local symptoms only vs in general morbidity.
Underlying systemic disease: IBD (ulcerative colitis, Crohn disease), immunosuppression, HIV infection,
cytomegalovirus (CMV) infection/ flare-up, constipation, NSAID use, malignancy, history of previous surgeries,
anastomosis, implantation of foreign body (eg, mesh).
Probability of being sign of serious disease (liability issue): high.
Pathogenesis-Oriented Differential Diagnosis
1. Malformation
– congenital fistula opening
2. Vascular
– mesenteric ischemia (peripheral vascular disease, embolic disease, vasculitis)
– radiation injury with focal ulceration (caveat: don't biopsy anteriorly: risk to create rectovaginal fistula)
3. Inflammatory
– solitary rectal ulcer
– HIV-associated anal ulcer
– CMV colitis
– herpes colitis
– ulcerative colitis/Crohn disease
– caustic colitis (eg, result of bowel prep)
– around foreign body (eg, erosion, residual suture material, staples)
– STDs: lymphogranuloma venereum, herpes simplex, gonorrhea, syphilis, chancroid, granuloma inguinale
– tuberculosis
– Behçet disease
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]
4. Tumor
– primary anorectal or colorectal malignancy (cancer, lymphoma, etc)
– secondary involvement by extraintestinal cancer
5. Degenerative/functional
– stercoral ulcer
– solitary rectal ulcer syndrome
6. Traumatic/posttraumatic
– anoreceptive intercourse, foreign body, automanipulation
– iatrogenic injury (eg, instrumentation, biopsy)
Top of the List
ANORECTAL ULCERATION
1. Anal fissure.
2. Fistula opening.
3. HIV-associated anal ulcer: idiopathic or specific infection (STDs).
4. Solitary rectal ulcer syndrome.
5. Anorectal neoplasia: anal cancer, lymphoma, Kaposi sarcoma.
COLONIC OR RECTAL ULCERATION
1. IBD: ulcerative colitis, Crohn disease.
2. Neoplasia: rectal cancer (eg scirrhous subform).
3. CMV colitis.
4. Stercoral ulcerations.
5. Solitary rectal ulcer syndrome.
Keys to Diagnosis
Patient's surgical/medical history: personal/family history of IBD, underlying tumor diagnosis and treatments
(radiation, chemotherapy), immunosuppression (drug-induced, HIV)? Nature of anorectal symptoms?
Clinical examination: patient's general condition, descriptive parameters of ulcerations, eg,
– Painless anorectal ulcers: neoplasia, syphilis (= painless, indurated, clean-based ulcer/chancre), granuloma
inguinale.
– Painful anorectal ulcers: neoplasia, chancroid (= painful inguinal lymphadenopathy), HSV (= multiple tender
shallow ulcers/vesicular changes).
– Colonic/rectal ulcers: associated with mass, solitary vs multiple, condition of surrounding bowel, etc.
Biopsy: histopathology, special stains if necessary.
Endoscopy: defining the proximal extent of disease?
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]
Cross-Reference
Anal fissure (565.0) (Ch. 4)
Solitary rectal ulcer syndrome (SRUS, 569.41) (Ch. 4)
HIV-associated anorectal diseases (042) (Ch. 4)
Sexually transmitted diseases (STDs, 091, 098, 099) (Ch. 4)
IBD—ulcerative colitis (556.9) (Ch. 4)
IBD—Crohn disease (555.X) (Ch. 4)
VAGINAL AIR AND/OR STOOL PASSAGE
Highlights of the Symptom
Appearance: passage of gas, passage of stool through vagina, quality of material.
Evolution: continuous, intermittent, worsening, one-time, self-limited.
Associated symptoms: pelvic or abdominal pain, bleeding, altered bowel habits, diarrhea, urinary tract infections?
Time of occurrence: recent child birth or anorectal surgery? History of abdominal pain or change in bowel habits?
Underlying systemic disease: Crohn disease, malignancy, history of radiation treatment, history of previous surgeries
(anorectal, bowel resection, hysterectomy, other GYN).
Localization: high, mid-level, low rectovaginal fistula.
Probability of being sign of serious disease (liability issue): high.
Pathogenesis-Oriented Differential Diagnosis
1. Malformation
– congenital rectovaginal fistulae (eg, in conjunction with imperforate anus)
2. Vascular
– radiation injury
3. Inflammatory
– Crohn disease
– perirectal abscess
– Bartholin abscess
– specific infections: tuberculosis, LGV, actinomycosis
– diverticulitis
– intra-abdominal/pelvic abscess postanastomotic leak (LAR, bowel resection)
– endometritis, vaginitis (without fistula)
4. Tumor
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]
– pelvic (anorectal or GYN) or abdominal tumor
– endometriosis
5. Degenerative/functional
– pseudofistula: passage of vaginal air without true intestinal communication
6. Traumatic/posttraumatic
– obstetric injury
– penetrating trauma
– anal intercourse, autoeroticism, foreign body
– iatrogenic (instrumentation, surgeries: eg, hemorrhoidectomy, rectocele repair, LAR, hysterectomy,
enterotomy, etc)
Top of the List
COLOVAGINAL (OR ENTEROVAGINAL) FISTULA
1. Diverticulitis.
2. Cancer.
3. Crohn disease.
4. Postsurgical (eg, anastomotic leak, enterotomy).
RECTOVAGINAL FISTULA
1. Obstetric injury.
2. Perirectal or Bartholin abscess.
3. Crohn disease.
4. Anorectal surgery.
5. Malignancy.
6. Radiation injury.
Keys to Diagnosis
Patient's narration: believe her even if fistula not immediately visible.
History: previous diseases, previous surgeries, timing.
Clinical examination: rectovaginal exam, anoscopy/rigid sigmoidoscopy, colposcopy, air-water test, tampon test.
Possible imaging studies: barium enema, colpography, CT scan.
Cross-Reference
Colovaginal and colovesical fistula (619.1, 596.1) (Ch. 4)
Rectovaginal fistula (619.1) (Ch. 4)
Copyright © The McGraw-Hill Companies. All rights reserved.
Privacy Notice
. Any use is subject to the Terms of Use and Notice. Additional Credits and Copyright Information.
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]
AccessSurgery | Print: Chapter 2. Evaluation Tools
file:///C|/...esktop/ADRIANA/McGrawHillManual%20ColorectalSurgery%201stEdition/Chapter%202_%20Evaluation%20Tools.htm[9/5/2009 19:15:25]
Print | Close Window
Note: Large images and tables on this page may necessitate printing in landscape mode.
McGraw-Hill Manual: Colorectal Surgery > Chapter 2. Evaluation Tools >
LIABILITY IN COLORECTAL SURGERY
Overview
Practice of colorectal surgery opens numerous vulnerabilities for lawsuits:
Failure to timely diagnose disease: eg, colorectal cancer is the second most common type of cancer cited in
malpractice lawsuits.
Sphincter injury with fecal incontinence after anorectal surgery or midline episiotomy.
Failure to offer continence-preserving procedure.
Iatrogenic medical complications/death during diagnosis or treatment.
Sponges/instruments left in the patient.
Iatrogenic organ injury of nontarget structures (eg, colon, small bowel, ureter, major vessels, spleen, vagina).
Lack of informed consent regarding extent or risks of procedures/endoscopies.
Specific challenges to physicians cited in malpractice cases arise from:
Type or sequence of diagnostic procedures, eg, failure to recommend colonoscopy.
Missing or insufficient documentation for medical rationale to recommended treatment, patient education, follow-up.
Lack of follow-up on test results, initiation of follow-up tests (eg, after incomplete colonoscopy).
Lack of communication.
Risk of lawsuit can never be completely eliminated but can be dramatically reduced, if the outlook of success for the plaintiff
is lower, due to the fact that systematic preventive steps are undertaken:
1. To reduce misconceptions, miscommunications.
2. To follow recommended medical guidelines.
3. To adhere to excellent documentation in the chart, informed consenting process, and documentation of refusal to
undergo recommended test/procedure.
Key Elements
DELAYS TO PROMPT DIAGNOSTIC EVALUATION IN PATIENTS WITH SYMPTOMS
Routine screening not recommended.
Routine screening recommended but not scheduled.
Diagnostic test recommended but not scheduled.
Diagnostic test scheduled but not performed.
AccessSurgery | Print: Chapter 2. Evaluation Tools
file:///C|/...esktop/ADRIANA/McGrawHillManual%20ColorectalSurgery%201stEdition/Chapter%202_%20Evaluation%20Tools.htm[9/5/2009 19:15:25]
Ordering or follow-up of screening or diagnostic procedures not documented.
NARROW DIAGNOSTIC FOCUS
Inadequate evaluation of abnormal findings.
Failure to convey to patient the importance of keeping test and follow-up appointments.
LACK OF COMMUNICATION
Multiple providers for the same patient fail to properly communicate important information.
Patient not notified of test results.
POOR DOCUMENTATION
Informed refusal not documented.
Important clinical information missing from clinical note.
Documentation
BASELINE DOCUMENTATION
Adequate documentation of current history elements; clarification of patient's vague terminology (eg, "occasional,"
"frequent")
reduce misinterpretation of self-reported symptoms.
Key statements must be documented by selected outside medical records, eg, pathology report (cancer, IBD),
colonoscopy report (clearance of rest of the colon), operative notes (definition of anatomy, problems/adhesions during
previous surgeries), medical clearance.
Amendments to existing chart/medical record: if an addendum is absolutely necessary, it should be made after the
last entry, noting current date and time, with both entries cross-referenced. Inappropriately amended medical records
render a case indefensible if plaintiff's attorneys demonstrate in court that the note was written or typed after the fact.
No addendum in anticipation of claim or legal action.
Medical record: "what is not documented has not happened" record should reflect in appropriate detail what was
done for patient and demonstrate quality of care given
provide defense against allegations of inadequate care.
INTERACTIONS WITH PATIENT OR FAMILY
Document all phone conversations, including those in which compliance issues are stressed.
PATIENT COMPLIANCE AND NONCOMPLIANCE
To ensure that screening tests are performed: schedule before patient leaves office, or at least document discussion
with patient of the recommendation for the test.
Document all follow-up efforts to reach patient or to reschedule a test/procedure.
Document discussions/conversations with patient and witnesses about recommended action, risks and benefits of
proposed testing, as well as alternatives.
Document patient's refusal to undergo recommended test or lifesaving procedure, preferably on a specific informed
refusal form signed by patient.
Make it a routine for high-risk patients who fail to keep appointments or when responding to phone calls to
reschedule:
– To use a form for tracking details.
– To contact them by registered mail (with return receipt).
AccessSurgery | Print: Chapter 2. Evaluation Tools
file:///C|/...esktop/ADRIANA/McGrawHillManual%20ColorectalSurgery%201stEdition/Chapter%202_%20Evaluation%20Tools.htm[9/5/2009 19:15:25]
Cross-Reference
Patient history (Ch. 2)
Clinical examination (Ch. 2)
Complications—ureteral injury (997.5) (Ch. 4)
PATIENT HISTORY
Overview
Obtaining the patient's accurate and detailed history is the most important tool to direct the subsequent examination, to
create a list of possible differential diagnoses, and eventually to establish the final diagnosis without wasting valuable
resources. It is further crucial in tailoring the best choice among various treatment options to the patient's individual
situation. Preferably, the history is taken from the patient, often from accompanying individuals (family, translators, referring
physicians): risk of "loss in translation."
Particularly in colorectal surgery, it is a high art to take a patient's history in an unprejudiced, sensitive, but nonetheless
thorough manner. Efficient questioning consists of a problem-oriented focus and systematic expansion of areas, depending on
the responses. It is advantageous to start by letting the patient describe the key symptoms in an open end–type narration,
which is subsequently complemented with specific problem-oriented questions. Even in "simple" cases, a systematic checklist
of relevant background information should be followed to ensure a complete context and hence avoid legal glitches.
Key Elements
SYMPTOMS
Rectal bleeding: amount, color (bright red vs dark red), onset, pattern, mixed into the stool, triggering factors, etc.
Discharge: quality, associated symptoms, etc.
Pain: location, onset, pattern, triggering factors, etc.
Itching: hygiene habits, incontinence, discharge, medications applied, etc.
Prolapse: what, how much, where? Spontaneous or manual reduction, nonreducible?
Lump/mass: always there or protruding with bowel movements, pain?
Bowel movements: stool quality, sudden change in bowel habits, complete/ incomplete evacuation, necessary
counterpressure/digital maneuvers.
Incontinence: stool, gas, urine.
Nausea/vomiting, weight loss, fevers/chills.
Associated symptoms.
PAST MEDICAL/SURGICAL HISTORY
Baseline bowel and anorectal function (prior to onset of presenting symptom).
History of IBD, IBS, cancer (abdominal/extraabdominal), etc.
Previous abdominal surgeries.
Previous anorectal/pelvic surgeries or radiation treatment.
Previous vaginal deliveries, obstetric injuries.
AccessSurgery | Print: Chapter 2. Evaluation Tools
file:///C|/...esktop/ADRIANA/McGrawHillManual%20ColorectalSurgery%201stEdition/Chapter%202_%20Evaluation%20Tools.htm[9/5/2009 19:15:25]
Previous colonic evaluations (colonoscopy, etc).
HIV status (if relevant for disease).
General medical history: cardiopulmonary, vascular, diabetes, cancer, liver, neurologic, kidney.
WHEN INTERVENTION IS PLANNED
Documentation of preexisting symptoms (incontinence to stool/gas, sexual dysfunction, rectovaginal fistula, etc).
FAMILY HISTORY
Particularly risk of polyps/cancer and IBD.
GENERAL HISTORY
Medications (current and recent past).
Allergies.
Review of systems.
Profession/disability, socioeconomic environment, habits, caregivers.
Documentation
Adequate documentation of current history elements is absolutely necessary. Key statements in a patient's history must be
documented by selected outside medical records, eg, pathology report (cancer, IBD), colonoscopy report (clearance of rest of
the colon), operative notes (definition of anatomy, problems/adhesions during previous surgeries), medical clearance.
Cross-Reference
Liability in colorectal surgery (Ch. 2)
Clinical examination (Ch. 2)
CLINICAL EXAMINATION
Overview
The clinical examination is the cornerstone and the most distinguishing skill for the initial and follow-up assessments of an
overwhelming part of colorectal patients, particularly patients with anorectal problems. Nothing should be taken for granted
even if there are respective statements in outside records. It is an art and special privilege to examine a patient in the most
intimate area of the body and requires an unprejudiced, sensitive, but nonetheless thorough manner. To optimize the exam,
it is important in the short time between the history taking and the actual exam to digest the information and prepare a
working array of possible, likely or unlikely findings.
Key Findings
GENERAL EXAM
Habitus including weight and height calculation of body mass index as weight (in kg) divided by square height (in
m).
Vital signs: heart rate, blood pressure, respiratory rate, temperature.
Mobility and performance status.
AccessSurgery | Print: Chapter 2. Evaluation Tools
file:///C|/...esktop/ADRIANA/McGrawHillManual%20ColorectalSurgery%201stEdition/Chapter%202_%20Evaluation%20Tools.htm[9/5/2009 19:15:25]
Mental/intellectual status: eg, inquisitive vs passive vs manipulative nature; anxiety, mood.
Nutritional and hydration status.
ANORECTUM
Inspection:
– Presence/absence of external/internal stool, blood, mucus, secretions (eg, pus).
– Anal configuration: appearance/location/asymmetries of anus, perineal body, vagina. Circumferential presence
of radial folding, or absence in area of sphincter defect?
– Perianal skin: intact, irritation (symmetric, asymmetric), erythema, discoloration, focal pathology.
– Visible evidence of pelvic floor dysfunction: perineal descent, flattened anal verge, patulous anus, gapping of
anus to lateral traction.
– Spreading of buttocks to the anal verge: search for visible pathologic openings, eg, fistula, fissure, ulcer.
– Visible "tissue addition": lumps, bumps, prolapse (posterior vs anterior/vaginal).
– Visible "tissue diminution": weakened/absent perineal body.
Palpation, including digital rectal exam:
– Focal external tenderness to palpation.
– Bidigital palpation (index finger inside, external counterpressure with thumb): focal induration, eg, perirectal
or ischioanal fat, deep postanal space.
– Focal tenderness: exact location, including coccyx, prostate, levator muscles, cervical motion.
– Sacrum palpable: if not
suspect presacral mass/abscess/hematoma/scar!
– Palpable mass (endorectal, prostate, extraluminal).
– Sphincter tone at rest/squeeze, intersphincteric groove, focal defects, use of auxiliary muscles for squeezing.
– Length of anal canal.
– Anastomosis, anastomotic leak.
– Stricture, stenosis: length, angulation, passable?
– Presence/absence of stool, assessment of stool quality.
– Palpable defect (eg, rectovaginal fistula).
Vaginal exam:
– Palpable defect or mass.
– Assessment of strength of rectovaginal septum.
Anoscopy:
– Evaluation of anal canal: internal hemorrhoids, dentate line, distal defect or mass.
Rigid sigmoidoscopy:
– Evaluation of distal rectum and anal canal.
– Characterization of visible stool.