DOCSLIB.ORG

Utility of the Digital Rectal Examination in the Emergency Department: a Review

Total Page：16

File Type：pdf, Size：1020Kb

Download full-text PDF Read full-text

Load more

The Journal of Emergency Medicine, Vol. 43, No. 6, pp. 1196–1204, 2012 Published by Elsevier Inc. Printed in the USA 0736-4679/$ - see front matter http://dx.doi.org/10.1016/j.jemermed.2012.06.015 Clinical Reviews UTILITY OF THE DIGITAL RECTAL EXAMINATION IN THE EMERGENCY DEPARTMENT: A REVIEW Chad Kessler, MD, MHPE*† and Stephen J. Bauer, MD† *Department of Emergency Medicine, Jesse Brown VA Medical Center and †University of Illinois-Chicago College of Medicine, Chicago, Illinois Reprint Address: Chad Kessler, MD, MHPE, Department of Emergency Medicine, Jesse Brown Veterans Hospital, 820 S Damen Ave., M/C 111, Chicago, IL 60612 , Abstract—Background: The digital rectal examination abdominal pain and acute appendicitis. Stool obtained by (DRE) has been reflexively performed to evaluate common DRE doesn’t seem to increase the false-positive rate of chief complaints in the Emergency Department without FOBTs, and the DRE correlated moderately well with anal knowing its true utility in diagnosis. Objective: Medical lit- manometric measurements in determining anal sphincter erature databases were searched for the most relevant arti- tone. Published by Elsevier Inc. cles pertaining to: the utility of the DRE in evaluating abdominal pain and acute appendicitis, the false-positive , Keywords—digital rectal; utility; review; Emergency rate of fecal occult blood tests (FOBT) from stool obtained Department; evidence-based medicine by DRE or spontaneous passage, and the correlation be- tween DRE and anal manometry in determining anal tone. Discussion: Sixteen articles met our inclusion criteria; there INTRODUCTION were two for abdominal pain, five for appendicitis, six for anal tone, and three for fecal occult blood. The DRE was The digital rectal examination (DRE) has a longstanding shown to add no additional diagnostic information and con- history as a mainstay component in a complete physical founded the diagnosis in acute, undifferentiated abdominal examination (1–3). However, evidence is rarely cited to pain. The sensitivity, specificity, positive predictive value, support its use or to substantiate the validity of the negative predictive value, and odds ratio for the DRE were too low to reliably diagnose acute appendicitis in children findings. The purpose of this review article is to search and adults. No statistical differences in the number of and review the literature for the utility of the DRE colonic pathologies were found between stool collection in evaluating acute, undifferentiated abdominal pain, methods in those with positive FOBT. The DRE correlation suspected appendicitis, fecal occult blood, and anal with anal manometry in determining resting and squeeze sphincter tone. The use of the DRE in colorectal neo- anal tone ranged from 0.405 to 0.82 and 0.52 to 0.97, plasm and benign prostatic hyperplasia screenings is be- respectively. Conclusion: We found the DRE to have yond the scope of this article and will not be included. a limited role in the diagnosis of acute, undifferentiated Acute, undifferentiated abdominal pain is a vague yet common chief complaint in the Emergency Department (ED). Some physicians routinely perform the DRE The work was previously presented at the 2011 Council of Emergency Medicine Residency Directors Scientific Assembly when evaluating abdominal pain even though the DRE in San Diego in February 2011. has been shown to be of little diagnostic value. Similarly, No grants or additional funding were associated with this the DRE has a history as a mainstay in diagnosing sus- article. pected appendicitis in children and adults with right RECEIVED: 2 August 2011; FINAL SUBMISSION RECEIVED: 2 February 2012; ACCEPTED: 28 June 2012 1196 Rectal Examination in the ED 1197 lower quadrant pain (4). However, its use for diagnosing Table 1. Search Terms suspected appendicitis has come into scrutiny. After per- Digital rectal examination NOT prostate NOT neoplasms forming a DRE, fecal occult blood testing (FOBT) by Digital rectal examination AND abdominal pain guaiac cards has become common practice throughout Digital rectal examination AND acute appendicitis Digital rectal examination AND appendicitis all medical services, such as in the ED to look for occult Digital rectal examination AND anal tone gastrointestinal (GI) bleeding (5). Testing for fecal occult Digital rectal examination AND anal manometry blood in DRE-obtained stool has been argued to be Digital rectal examination AND fecal occult blood Digital rectal examination AND hematochezia a ‘‘knee-jerk procedure’’ of little value (6). Longstreth Digital rectal examination AND bright red blood per rectum proposed that trauma to the anus or hemorrhoids during Digital rectal examination AND melena the DRE and the lack of dietary restrictions before stool Digital rectal examination AND gastrointestinal hemorrhage collection can cause potential false-positive results of FOBT, prompting needless, invasive investigations (6). In the emergent setting, assessing anal tone by DRE can agreement between the two authors for inclusion or ex- be performed during the trauma survey and during neuro- clusion of articles, we discussed the articles and more logic examination, yet it has largely been assumed that strictly applied the inclusion and exclusion criteria to the DRE provides good estimation of anal tone. reach an agreement. Methods RESULTS We identified four inclusion criteria to apply to the data- A total of 380 articles were found after searching all da- base searches. First, the study participants must have been tabases. Duplicate search results were not excluded in the adults, children, or both. Second, the participants must final counts of the articles found from the database have had symptoms of, or a chief complaint of abdominal searches. Some articles were found with more than one pain, acute appendicitis, anal sphincter tone, or fecal oc- search and on more than one database. After applying cult blood. Third, the participants had to have a digital the inclusion and exclusion criteria, 332 articles were ex- rectal examination performed with the outcome docu- cluded, leaving 48 articles. The bibliographies of the 48 mented. Fourth, the DRE had to be the major outcome included articles were searched, yielding an additional in the article and had to be compared to a true or final di- 65 articles. A total of 113 articles were included for full agnosis or compared to another reported outcome. Ran- text review with further application of inclusion criteria. domized controlled trials, meta-analyses, observational Ninety-seven articles were excluded for failing to meet studies, clinical guidelines, editorials, and letters to the inclusion criteria or for the DRE not being the major out- editor were considered for inclusion. Review articles, come of the study. Of the 16 articles left for inclusion, case reports, and abstracts were not considered for inclu- there were two for abdominal pain, five for appendicitis, sion. The exclusion criteria were any study using the DRE six for anal tone, and three for fecal occult blood. A flow to screen for benign prostatic hyperplasia or colorectal diagram of the search strategy can be found in Figure 1, neoplasia. and a summary of the included articles can be found in The following electronic databases were searched us- Table 2 (3,7–21). ing multiple phrases (Table 1) to ensure a comprehensive search of the literature: MEDLINE (PubMed; 1950 to Abdominal Pain present), EMBASE (1988 to present), Cochrane Library, and National Guidelines Clearinghouse. If a search term Two studies were found investigating physicians’ use of was not available in the Medical Subject Headings the DRE in medical management of acute, undifferenti- (MeSH) search function in PubMed, then PubMed was ated abdominal pain in the ED (7,8). The evaluating searched without using MeSH terms. Only the EMBASE physicians performed DREs at their discretion and database was searched; MEDLINE was not researched completed evaluation forms indicating whether the using the EMBASE search function. All of the searches DRE results altered their diagnosis (7,8). Quaas et al. from PubMed were searched in EMBASE, with no new found that the DRE results altered management of articles. The limits for the searches were: English and Hu- acute abdominal pain in only 7% of patients, in which man. No publication date restrictions were applied. The the alteration of management was as likely to bibliographic references of all the articles identified by diagnostically help (either indicate correct diagnosis or the database screening were examined to identify new ar- refute incorrect diagnosis) as it was to diagnostically ticles not identified in the searches. Although review arti- harm (either indicate incorrect diagnosis or refute cles and case reports were excluded, their bibliographies correct diagnosis) (7). Similarly, Manimaran and Galland were searched for applicable articles. If there was a dis- showed that the DRE did not change management of 1198 C. Kessler and S. J. Bauer Literature Search diagnostic information to the evaluation of RLQ pain (11). Databases: PubMed, EMBASE, Dickson et al. found a 90% diagnostic accuracy of acute The Cochrane Library, The National Guidelines Clearing House appendicitis based on history and physical examination Limits: Humans, English alone (12). Right-sided rectal tenderness or mass was present in 61 of 103 children with histologically proven appendicitis and in 12 of 98 children without appendicitis Search results combined (n = 380) (12). Similarly,
Recommended publications
  • Table 1 Table 2 Table 3 Table 4 Colonoscopy-Related Costs

    Table 1 Table 2 Table 3 Table 4 Colonoscopy-Related Costs

    Digestive Health Network, Inc. List of Tables Top 10 Physician Specialties Performing Colonoscopies, Medicare Fee-for- Table 1 Service, 2015 Colonoscopy-related Costs, Medicare Fee-for-Service Beneficiaries who Table 2 Received a Screening or Diagnostic Colonoscopy, 2015 Colonoscopy-related Costs, Medicare Fee-for-Service Beneficiaries who Table 3 Received a Colonoscopy in an Ambulatory Surgical Center (ASC), Hospital Outpatient Department, or Physician Office, 2015 Proportion of Medicare Fee-for-Service Medicare Beneficiaries who Received Table 4 a Colonoscopy and were Treated in the Emergency Department within 7 Days of the procedure, 2015 Digestive Health Network, Inc. Responses to Questions Among Medicare beneficiaries, how many colonoscopies are performed in the US, by type of Q1 physician? Nearly 2 million screening and diagnostic colonoscopies were performed in 2015. Of these, over 78% were performed by a gastroenterologist. Nearly 10% were performed by a general surgeon and about 6% were performed by an internal medicine specialist. These results are shown in Table 1. Q2 What proportion of spending on colonoscopies is accounted for by physician services? In 2015, Medicare expenditures associated with colonoscopies totaled over $1.3 billion. (This excludes anesthesiology, pathology, radiology, and other costs identified in Table 2.) Approximately 31% of this amount, or $416 million was associated with professional fees. Q3 What share of Part B Medicare spending is accounted for by colonoscopies? Medicare Part B expenditures in 2015 totaled over $131 billion (data not shown). Colonoscopy costs accounted for approximately 1.03% of this total. Q4 What are the costs associated with colonoscopies for the different settings of care? Costs associated with colonoscopies in ambulatory surgical centers (ASC), hospital outpatient departments (HOPD), and physician offices are shown in Table 3.
  • International Journal of Medical and Health Sciences

    International Journal of Medical and Health Sciences

    International Journal of Medical and Health Sciences Journal Home Page: http://www.ijmhs.net ISSN:2277-4505 Review article Examining the liver – Revisiting an old friend Cyriac Abby Philips1*, Apurva Pande2 1Department of Hepatology and Transplant Medicine, PVS Institute of Digestive Diseases, PVS Memorial Hospital, Kaloor, Kochi, Kerala, India, 2Department of Hepatology, Institute of Liver and Biliary Sciences, D-1, Vasant Kunj, New Delhi, India. ABSTRACT In the current era of medical practice, super saturated with investigations of choice and development of diagnostic tools, clinical examination is a lost art. In this review we briefly discuss important aspects of examination of the liver, which is much needed in decision making on investigational approach. We urge the new medical student or the newly practicing physician to develop skills in clinical examination for resourceful management of the patient. KEYWORDS: Liver, examination, clinical skills, hepatomegaly, chronic liver disease, portal hypertension, liver span INTRODUCTION respiration, the excursion of liver movement is around 2 to 3 The liver attains its adult size by the age of 15 years. The cm. Castell and Frank has elegantly described normal liver liver weighs 1.2 to 1.4 kg in women and 1.4 to 1.5 kg in span in men and women utilizing the percussion method men. The liver seldom extends more than 5 cm beyond the (Table 1). Accordingly, the mean liver span is 10.5 cm for midline towards the left costal margin. During inspiration, men and 7 cm in women. During examination, a span 2 to 3 the diaphragmatic exertion moves the liver downward with cm larger or smaller than these values is considered anterior surface rotating to the right.
  • Fecal Incontinence/Anal Incontinence

    Fecal Incontinence/Anal Incontinence

    Fecal Incontinence/Anal Incontinence What are Fecal incontinence/ Anal Incontinence? Fecal incontinence is inability to control solid or liquid stool. Anal incontinence is the inability to control gas and mucous in addition to the inability to control stool. The symptoms range from mild release of gas to a complete loss of control. It is a common problem affecting 1 out of 13 women under the age of 60 and 1 out of 7 women over the age of 60. Men can also be have this condition. Anal incontinence is a distressing condition that can interfere with the ability to work, do daily activities and enjoy social events. Even though anal incontinence is a common condition, people are uncomfortable discussing this problem with family, friends, or doctors. They often suffer in silence, not knowing that help is available. Normal anatomy The anal sphincters and puborectalis are the primary muscles responsible for continence. There are two sphincters: the internal anal sphincter, and the external anal sphincter. The internal sphincter is responsible for 85% of the resting muscle tone and is involuntary. This means, that you do not have control over this muscle. The external sphincter is responsible for 15% of your muscle tone and is voluntary, meaning you have control over it. Squeezing the puborectalis muscle and external anal sphincter together closes the anal canal. Squeezing these muscles can help prevent leakage. Puborectalis Muscle Internal Sphincter External Sphincter Michigan Bowel Control Program - 1 - Causes There are many causes of anal incontinence. They include: Injury or weakness of the sphincter muscles. Injury or weakening of one of both of the sphincter muscles is the most common cause of anal incontinence.
  • General Signs and Symptoms of Abdominal Diseases

    General Signs and Symptoms of Abdominal Diseases

    General signs and symptoms of abdominal diseases Dr. Förhécz Zsolt Semmelweis University 3rd Department of Internal Medicine Faculty of Medicine, 3rd Year 2018/2019 1st Semester • For descriptive purposes, the abdomen is divided by imaginary lines crossing at the umbilicus, forming the right upper, right lower, left upper, and left lower quadrants. • Another system divides the abdomen into nine sections. Terms for three of them are commonly used: epigastric, umbilical, and hypogastric, or suprapubic Common or Concerning Symptoms • Indigestion or anorexia • Nausea, vomiting, or hematemesis • Abdominal pain • Dysphagia and/or odynophagia • Change in bowel function • Constipation or diarrhea • Jaundice “How is your appetite?” • Anorexia, nausea, vomiting in many gastrointestinal disorders; and – also in pregnancy, – diabetic ketoacidosis, – adrenal insufficiency, – hypercalcemia, – uremia, – liver disease, – emotional states, – adverse drug reactions – Induced but without nausea in anorexia/ bulimia. • Anorexia is a loss or lack of appetite. • Some patients may not actually vomit but raise esophageal or gastric contents in the absence of nausea or retching, called regurgitation. – in esophageal narrowing from stricture or cancer; also with incompetent gastroesophageal sphincter • Ask about any vomitus or regurgitated material and inspect it yourself if possible!!!! – What color is it? – What does the vomitus smell like? – How much has there been? – Ask specifically if it contains any blood and try to determine how much? • Fecal odor – in small bowel obstruction – or gastrocolic fistula • Gastric juice is clear or mucoid. Small amounts of yellowish or greenish bile are common and have no special significance. • Brownish or blackish vomitus with a “coffee- grounds” appearance suggests blood altered by gastric acid.
  • The Differences Between ICD-9 and ICD-10

    The Differences Between ICD-9 and ICD-10

    Preparing for the ICD-10 Code Set: Fact Sheet 2 October 1, 2015 Compliance Date Get the Facts to be Compliant Alert: The new ICD-10 compliance date is October 1, 2015. The Differences Between ICD-9 and ICD-10 This is the second fact sheet in a series and is focused on the differences between the ICD-9 and ICD-10 code sets. Collectively, the fact sheets will provide information, guidance, and checklists to assist you with understanding what you need to do to implement the ICD-10 code set. The ICD-10 code sets are not a simple update of the ICD-9 code set. The ICD-10 code sets have fundamental changes in structure and concepts that make them very different from ICD-9. Because of these differences, it is important to develop a preliminary understanding of the changes from ICD-9 to ICD-10. This basic understanding of the differences will then identify more detailed training that will be needed to appropriately use the ICD-10 code sets. In addition, seeing the differences between the code sets will raise awareness of the complexities of converting to the ICD-10 codes. Overall Comparisons of ICD-9 to ICD-10 Issues today with the ICD-9 diagnosis and procedure code sets are addressed in ICD-10. One concern today with ICD-9 is the lack of specificity of the information conveyed in the codes. For example, if a patient is seen for treatment of a burn on the right arm, the ICD-9 diagnosis code does not distinguish that the burn is on the right arm.
  • HIGH-SENSITIVITY GUAIAC-BASED FECAL OCCULT BLOOD TEST (HSGFOBT) Anyone Can Get Colon Cancer

    HIGH-SENSITIVITY GUAIAC-BASED FECAL OCCULT BLOOD TEST (HSGFOBT) Anyone Can Get Colon Cancer

    GET SCREENED: DETECT ANDDETECT PREVENT AND PREVENT COLON CANCER COLON CANCER TEST TYPE: HIGH-SENSITIVITY GUAIAC-BASED FECAL OCCULT BLOOD TEST (HSGFOBT) Anyone can get colon cancer. It can affect people of all racial and ethnic groups. Routine screening can help your health care provider find cancers earlier, when they are easier to treat. Screening may also prevent cancer, by finding and removing polyps or abnormal growths from the colon. COLON CANCER SCREENING There are different test options for screening. Talk with your provider to choose FACT SHEET the test that’s right for you. WHO? Adults who are at average risk for colon WHERE? You do this test at home. cancer may have an HSgFOBT. Talk with your health WHY? HSgFOBT detects signs of colon and rectal care provider about your risk and what age to begin cancer. It can also detect some polyps, which are screening. If you are at an increased risk of colon growths that could become cancer later. cancer, you may need screening early or this test may not be right for you. Discuss your medical and family HOW? You may have a restricted diet starting a medical history with your provider before choosing a few days before the test. You will get a kit from your test. Tell them if you have any of these risk factors: provider with instructions about how to take a sample A history of colon cancer or precancerous polyps of stool from three bowel movements in a row that A parent, sibling or child with colon cancer or you collect into a clean container.
  • Unenhanced Areas Revealed by Contrast-Enhanced Abdominal Ultrasonography with Sonazoidtm Potentially Correspond to Colorectal Cancer

    Unenhanced Areas Revealed by Contrast-Enhanced Abdominal Ultrasonography with Sonazoidtm Potentially Correspond to Colorectal Cancer

    4012 EXPERIMENTAL AND THERAPEUTIC MEDICINE 12: 4012-4016, 2016 Unenhanced areas revealed by contrast-enhanced abdominal ultrasonography with SonazoidTM potentially correspond to colorectal cancer MINORU TOMIZAWA1, MIZUKI TOGASHI2, FUMINOBU SHINOZAKI3, RUMIKO HASEGAWA4, YOSHINORI SHIRAI4, MIDORI NORITAKE2, YUKIE MATSUOKA2, HIROAKI KAINUMA2, YASUJI IWASAKI2, KAZUNORI FUGO5, YASUFUMI MOTOYOSHI6, TAKAO SUGIYAMA7, SHIGENORI YAMAMOTO8, TAKASHI KISHIMOTO5 and NAOKI ISHIGE9 Departments of 1Gastroenterology; 2Clinical Laboratory; 3Radiology and 4Surgery, National Hospital Organization, Shimoshizu Hospital, Yotsukaido City, Chiba 284-0003; 5Department of Molecular Pathology, Chiba University Graduate School of Medicine, Chiba City, Chiba 260-8670; Departments of 6Neurology; 7Rheumatology; 8Pediatrics and 9Neurosurgery, National Hospital Organization, Shimoshizu Hospital, Yotsukaido, Yotsukaido City, Chiba 284-0003, Japan Received September 18, 2015; Accepted September 22, 2016 DOI: 10.3892/etm.2016.3868 Abstract. The present study investigated the potential utility of Introduction contrast-enhanced abdominal ultrasonography (CEUS), using SonazoidTM, in colorectal cancer (CRC). Three patients were Colorectal cancer (CRC) is commonly observed in clinical subjected to CEUS with SonazoidTM. Surgical specimens were settings (1). To improve the prognosis in patients with CRC, immunostained for CD31. Numbers of blood vessels positive prompt and accurate diagnosis is essential. Screening for CRC for CD31 were analyzed in each of five fields at x400 magnifi- is performed using fecal occult blood testing, and is diagnosed cation and averaged to determine blood vessel density. Blood with colonoscopy (2). vessel density was compared between non-tumorous and Abdominal ultrasound (US) is useful for the safe and tumorous areas. Prior to the administration of SonazoidTM, easy diagnosis of patients (3-6). During US screening of the CRC was illustrated as irregular-shaped wall thickening.
  • The American Society of Colon and Rectal Surgeons' Clinical Practice

    The American Society of Colon and Rectal Surgeons' Clinical Practice

    CLINICAL PRACTICE GUIDELINES The American Society of Colon and Rectal Surgeons’ Clinical Practice Guideline for the Evaluation and Management of Constipation Ian M. Paquette, M.D. • Madhulika Varma, M.D. • Charles Ternent, M.D. Genevieve Melton-Meaux, M.D. • Janice F. Rafferty, M.D. • Daniel Feingold, M.D. Scott R. Steele, M.D. he American Society of Colon and Rectal Surgeons for functional constipation include at least 2 of the fol- is dedicated to assuring high-quality patient care lowing symptoms during ≥25% of defecations: straining, Tby advancing the science, prevention, and manage- lumpy or hard stools, sensation of incomplete evacuation, ment of disorders and diseases of the colon, rectum, and sensation of anorectal obstruction or blockage, relying on anus. The Clinical Practice Guidelines Committee is com- manual maneuvers to promote defecation, and having less posed of Society members who are chosen because they than 3 unassisted bowel movements per week.7,8 These cri- XXX have demonstrated expertise in the specialty of colon and teria include constipation related to the 3 common sub- rectal surgery. This committee was created to lead inter- types: colonic inertia or slow transit constipation, normal national efforts in defining quality care for conditions re- transit constipation, and pelvic floor or defecation dys- lated to the colon, rectum, and anus. This is accompanied function. However, in reality, many patients demonstrate by developing Clinical Practice Guidelines based on the symptoms attributable to more than 1 constipation sub- best available evidence. These guidelines are inclusive and type and to constipation-predominant IBS, as well. The not prescriptive.
  • Appendectomy: Simple Appendicitis

    Appendectomy: Simple Appendicitis

    Appendectomy: Simple Appendicitis Your child has had an appendectomy (ap pen DECK toe mee). This is the surgical removal of the appendix. The appendix is a small, narrow sac at the beginning of the large intestine (Picture 1). The appendix has no known function. What to Expect After Surgery . Your child will awaken in the Post Anesthesia Care Unit (PACU) near the surgery area. He or she may be in the PACU for 1 to 2 hours. After your child wakes up in the PACU, he or she will return to a hospital room or be Esophagus transferred to the Surgery Unit. Discharge will be directly from the Surgery Unit. Liver Stomach . Your child will have 3 to 4 small incision Large sites (see Helping Hand HH-I-283, Intestines Laparoscopic Surgery (colon) ). Small . Your child will receive fluids and pain intestines medicine through an intravenous line (IV). Rectum When your child can take liquids by mouth, pain medicine will also be given by mouth. Appendix . Your child will need to cough and deep-breathe often to help keep the lungs clear. He or she may use a plastic device called an incentive Picture 1 The appendix inside the body. spirometer to help with this. Your child will need to get up and walk soon after surgery. Walking will help "wake up" the bowels; it will also help with breathing and blood flow. Your child will be able to go home on the same day of the surgery if he or she is: o able to drink clear liquids like water, clear soft drinks, broth, and fruit punch o taking pain medicine by mouth and his or her pain is controlled, and o able to walk.
  • 16. Questions and Answers

    16. Questions and Answers

    16. Questions and Answers 1. Which of the following is not associated with esophageal webs? A. Plummer-Vinson syndrome B. Epidermolysis bullosa C. Lupus D. Psoriasis E. Stevens-Johnson syndrome 2. An 11 year old boy complains that occasionally a bite of hotdog “gives mild pressing pain in his chest” and that “it takes a while before he can take another bite.” If it happens again, he discards the hotdog but sometimes he can finish it. The most helpful diagnostic information would come from A. Family history of Schatzki rings B. Eosinophil counts C. UGI D. Time-phased MRI E. Technetium 99 salivagram 3. 12 year old boy previously healthy with one-month history of difficulty swallowing both solid and liquids. He sometimes complains food is getting stuck in his retrosternal area after swallowing. His weight decreased approximately 5% from last year. He denies vomiting, choking, gagging, drooling, pain during swallowing or retrosternal pain. His physical examination is normal. What would be the appropriate next investigation to perform in this patient? A. Upper Endoscopy B. Upper GI contrast study C. Esophageal manometry D. Modified Barium Swallow (MBS) E. Direct laryngoscopy 4. A 12 year old male presents to the ER after a recent episode of emesis. The parents are concerned because undigested food 3 days old was in his vomit. He admits to a sensation of food and liquids “sticking” in his chest for the past 4 months, as he points to the upper middle chest. Parents relate a 10 lb (4.5 Kg) weight loss over the past 3 months.
  • High Resolution Anoscopy Overview

    High Resolution Anoscopy Overview

    High Resolution Anoscopy Overview Naomi Jay, RN, NP, PhD University of California San Francisco Email: [email protected] Disclosures No Disclosures Definition of HRA Examination of the anus, anal canal and perianus using a colposcope with 5% acetic acid and Lugol’s solution. Basic Principles • Office-based procedure • Adapted from gynecologic colposcopy. • Validated for anal canal. • Similar terminology and descriptors. may be unfamiliar to non-gyn providers. • Comparable to vaginal and vulvar colposcopy. • Clinicians familiar with cervical colposcopy may be surprised by the difficult transition. Anal SCJ & AnTZ • Original vs. current SCJ less relevant. • TZ features less common, therefore more difficult to appreciate. • SCJ more subtle, difficult to see in entirety requires more manipulation & acetic acid. • Larger area of metaplastic changes overlying columnar epithelium compared to endocervix. • Most lesions found in the AnTZ. Atypical Metaplasia • Atypical metaplasia may indicate the presence of HSIL. • Radiate over distal rectum from SCJ. • Thin, may wipe off. • Features to look for indicating potential lesions: • Atypical clustered glands (ACG) • Lacy metaplastic borders (LM) • Epithelial Honeycombing (EH) Lugol’s. Staining • More utility in anus compared to cervix. • Adjunctive to help define borders, distinguish between possible LSIL/HSIL. • Most HSIL will be Lugol’s negative • LSIL may be Lugol’s partial or negative • Applied focally with small cotton swabs to better define an acetowhite lesion. •NOT a short cut to determine presence or absence of lesions, acetic acid is used first and is applied frequently. Anal vs. Cervical Characteristics • Punctation & Mosaic rarely “fine” mostly “coarse”. • Mosaic pattern mostly associated with HSIL. • Atypical vessels may be HSIL or cancer • Epithelial honeycombing & lacy metaplasia unique anal descriptors.
  • Diagnostic Approach to Chronic Constipation in Adults NAMIRAH JAMSHED, MD; ZONE-EN LEE, MD; and KEVIN W

    Diagnostic Approach to Chronic Constipation in Adults NAMIRAH JAMSHED, MD; ZONE-EN LEE, MD; and KEVIN W

    Diagnostic Approach to Chronic Constipation in Adults NAMIRAH JAMSHED, MD; ZONE-EN LEE, MD; and KEVIN W. OLDEN, MD Washington Hospital Center, Washington, District of Columbia Constipation is traditionally defined as three or fewer bowel movements per week. Risk factors for constipation include female sex, older age, inactivity, low caloric intake, low-fiber diet, low income, low educational level, and taking a large number of medications. Chronic constipa- tion is classified as functional (primary) or secondary. Functional constipation can be divided into normal transit, slow transit, or outlet constipation. Possible causes of secondary chronic constipation include medication use, as well as medical conditions, such as hypothyroidism or irritable bowel syndrome. Frail older patients may present with nonspecific symptoms of constipation, such as delirium, anorexia, and functional decline. The evaluation of constipa- tion includes a history and physical examination to rule out alarm signs and symptoms. These include evidence of bleeding, unintended weight loss, iron deficiency anemia, acute onset constipation in older patients, and rectal prolapse. Patients with one or more alarm signs or symptoms require prompt evaluation. Referral to a subspecialist for additional evaluation and diagnostic testing may be warranted. (Am Fam Physician. 2011;84(3):299-306. Copyright © 2011 American Academy of Family Physicians.) ▲ Patient information: onstipation is one of the most of 1,028 young adults, 52 percent defined A patient education common chronic gastrointes- constipation as straining, 44 percent as hard handout on constipation is 1,2 available at http://family tinal disorders in adults. In a stools, 32 percent as infrequent stools, and doctor.org/037.xml.