Physician Assistant Exam Review

You are here: Home / Podcasts / S2 E087 Colon & Rectum & 3 Words That Might Change Everything

S2 E087 Colon & Rectum & 3 Words That Might Change Everything

Podcast: Play in new window | Download

Polyps

  • An abnormal growth of soft tissue projecting from a mucous membrane
  • They may be flat, sessile or pedunculated
  • 95% of adenocarcinoma of the colon are thought to come from polyps

Clinical Presentation

  • Surveillance
    • According to the American Cancer society all patients of average risk should begin screening at age 45 with
      • Fecal occult blood test every year
      • One of the following
        • Colonoscopy every 10 years
        • CT colonography (virtual colonoscopy) every 5 years
        • Flexible sigmoidoscopy (FSIG) every 5 year
  • Bright red blood per rectum

Lab & Studies

  • CT colonography (virtual colonoscopy) every 5 years
  • Flexible sigmoidoscopy (FSIG) every 5 years
  • Colonoscopy

Treatment

  • Resection at the time of colonoscopy
  • Surgical resection for lesions > 2-3 cm
  • Patients with a history of polypectomy should have more frequent follow up, but the exact recommendation is unclear.

Neoplasms

Risk Factors

  • History of colon polyps
  • History of Crohn’s disease or ulcerative colitis
  • Increasing age
  • Family history of colorectal cancer
  • African Americans are at an increased risk compared with caucasian

Clinical Presentation

  • If the lesion is found on the right side
    • Iron deficiency anemia
    • Fatigue
  • If the lesion is found on the left side
    • Abdominal pain
    • Constipation
    • Diarrhea
    • Bloody stool
  • If lesion is found in the rectum
    • Tenesmus – feeling that you need to pass stool when your bowels are empty
    • Hematochezia – passing of blood in the stool

Labs, Studies & Physical Exam Findings

  • Usually normal physical exam
  • CBC
  • Iron panel
  • Fecal occult blood test
  • Carcinoembryonic antigen (CEA) – Not for screening, but for monitoring
  • Barium enema
  • CT/MRI
  • Colonoscopy is the gold standard

Treatment

  • Adjuvant chemotherapy
  • Radiation
  • Surgical resection

Constipation

  • More common in women
  • More common in people with psychosocial disorders

Clinical Presentation

  • Less than two bowel movements per week
  • Excessive straining
  • Need for digital manipulation
  • Decreased appetite
  • Abdominal pain
  • Bloating

Labs, Studies and Physical Exam Findings

  • You may be able to palpate stool in the LLQ
  • CBC
  • BMP
  • Thyroid panel
  • Fecal occult blood
  • Colonoscopy
  • Barium enema

Treatment

  • Fiber supplements
  • Mineral oil
  • Osmotic or stimulant laxatives
  • Digital disimpaction
  • Enema

Fecal impaction

  • A solid mass of fecal material secondary to chronic constipation

Clinical Presentation

  • Chronic constipation
  • Overflow diarrhea – liquid stool leaks around the solid mass from higher in the bowel

Treatment

  • Laxatives
  • Water or oil enema
  • Manual disimpaction
  • Prevention of a second occurrence
    • Increase in fiber
    • Increase fluids
    • Daily exercise
    • Regular bowel habits
    • Avoid opiates

Anal Fissures

  • Ulcers near the rectum
  • Very painful
  • Most commonly found in the posterior midline
  • If found off the midline it may be indicative of Crohn’s, TB, Syphilis or Cancer

Clinical Presentation

  • Extreme pain especially during a bowel movement
  • Bright red blood in the stool

Labs, Studies and Physical Exam Findings

  • Visualization of the ulcers on physical exam

Treatment

  • Increase in fiber
  • Stool softeners
  • Sitz baths
  • Topical nitroglycerin
  • Botox injection into the anal sphincter
  • Sphincterotomy

Rectal Abscess and Fistula

  • An abscess forms when a gland gets blocked
  • A fistula is the tract that forms from the abscessed anal gland to the skin

Clinical Presentation

  • PAIN
  • Purulent discharge from fistula

Labs, Studies and Physical Exam Findings

  • Tender, red, swollen area
  • The opening of the fistula may be seen on physical exam
  • A fistula probe may be used to explore the fistula

Treatment

  • Surgical drainage of fistula
  • Surgical repair of the fistula

Hemorrhoids

  • Internal or external rectal veins which normally act as a cushion to help control stool but can become inflamed, enlarged or prolapsed.
  • The dentate line divides internal from external

Clinical Presentation

  • #1 Cause of bright red blood per rectum
  • A protrusion from the anus
  • Pain – especially if thrombosed though normally internal hemorrhoids are painless

Labs, Studies and Physical Exam Findings

  • Often visible on physical exam
  • Anoscopy

Treatment

  • High fiber diet
  • Increase in fluids
  • Sitz bath
  • Grade I-III (Hemorrhoids may be manually reduced)
    • Sclerotherapy
    • Rubber band ligation
    • Electrocoagulation
  • Grade IV (Can not be manually reduced) or thrombosed
    • Surgical excision