Diagnosis of Fecal incontinence
Diagnostic Test list for Fecal incontinence:
The list of medical tests
mentioned in various sources as
used in the diagnosis of Fecal incontinence
includes:
Fecal incontinence Diagnosis: Book Excerpts
Tests and diagnosis discussion for Fecal incontinence:
The doctor will ask health-related questions and do a physical exam and
possibly other medical tests.
- Anal manometry checks the tightness of the anal sphincter and its
ability to respond to signals, as well as the sensitivity and function
of the rectum.
- Anorectal ultrasonography evaluates the structure of the anal
sphincters.
- Proctography, also known as defecography, shows how much stool the
rectum can hold, how well the rectum holds it, and how well the rectum
can evacuate the stool.
- Proctosigmoidoscopy allows doctors to look inside the rectum for
signs of disease or other problems that could cause fecal incontinence,
such as inflammation, tumors, or scar tissue.
- Anal electromyography tests for nerve damage, which is often
associated with obstetric injury.
(Source: excerpt from
Fecal Incontinence: NIDDK)
Diagnosis of Fecal incontinence: medical news summaries:
The following medical news items
are relevant to diagnosis and misdiagnosis issues for Fecal incontinence:
Diagnostic Tests for Fecal incontinence: Online Medical Books
16 MEDICAL BOOKS ONLINE!
Review excerpts from medical books online, free, without registration,
for more information about diagnostis of Fecal incontinence.
CONSTIPATION:
Ask the following questions:
(Algorithmic Diagnosis of Symptoms and Signs)
- Is the constipation acute or chronic? If the constipation is acute and there is abdominal pain or vomiting, one must consider the possibility of intestinal obstruction. An examination may disclose an empty rectum, in which case it is more likely complete intestinal obstruction, or there may be some feces in the rectum, in which case there may be incomplete intestinal obstruction. If the constipation is a chronic problem, one should investigate the patient's diet and emotional status and toilet habits over the life span.
- What kind of a diet is the patient on? Many patients today eat on the run, and they eat mostly fast foods, which are devoid of fiber. Frequently, they don't take the time to go to the bathroom. Some patients are on special diets to lose weight or have a fear of gaining weight; therefore, they don't eat well at all. If what the patient labels as constipation is simply infrequent bowel movements, but the bowel movements are normal in consistency, this is not really true constipation.
- Does the patient take drugs of any kind? Patients should be questioned first about chronic use of laxatives. Americans have the misconception that they must have a bowel movement every day and, therefore, they get in the habit of using something to stimulate the bowels, which can lead them to believe they have chronic constipation. Chronic narcotic use can lead to constipation, as can the use of antispasmodics for ulcer or urinary incontinence.
- Associated symptoms: We have already mentioned that abdominal pain and vomiting may be a sign of acute intestinal obstruction, and occasionally this is a sign of a chronic intestinal obstruction. If there is alternating diarrhea and constipation, one must consider the possibility of irritable bowel syndrome or a colon carcinoma. Blood in the stool along with painful defecation may indicate hemorrhoids and anal fissure. A person who is suffering from these conditions may delay moving his bowels for fear of the pain that accompanies this situation, and the hard stool that caused the hemorrhoids and anal fissure in the first place perpetuates the condition because it contributes to the constipation. If blood is found in the stool, well mixed with the stool, and defecation is basically painless, then colon carcinoma and diverticulitis must be considered. Blood and mucus in the stool would indicate an irritable bowel syndrome.
- What are the findings on physical examination? The finding of an empty rectum indicates an intestinal obstruction. A finding of an abdominal mass or a rectal mass certainly would indicate carcinoma of the colon. Rectal examination may disclose hemorrhoids or anal fissure as causing the chronic constipation and allow one to test the stool for occult blood.
DIAGNOSTIC WORKUP
If the constipation is acute, a flat plate of the abdomen and a CBC would be in order to determine if the patient has intestinal obstruction. The workup of chronic constipation should include stool for occult blood, sigmoidoscopy, barium enema, or a colonoscopy. A chemistry panel and other diagnostic studies may be necessary to rule out systemic causes of constipation such as diabetes, hypothyroidism, and various conditions associated with hypercalcemia. If diagnostic tests yield no positive findings, referral to a psychiatrist or a gynecologist may be in order. A trial of a fiber diet may be helpful. At the same time, one should eliminate chronic laxative usage. Anorectal manometry will help diagnose rectal and anal sphincter dysfunction. Defecography will help diagnose anorectal dysfunction also. A neurologist should be consulted if urinary retention is also a problem.
» READ BOOK EXCERPT ONLINE »
Source: Algorithmic Diagnosis of Symptoms and Signs, 2003
INCONTINENCE OF FECES:
Ask the Following Questions:
(Algorithmic Diagnosis of Symptoms and Signs)
- Is the stool volume small or large? A small volume of stool should suggest anal fissure; hemorrhoids, diarrhea, or postoperative incontinence from a fistulectomy; or other types of surgery in the perirectal area.
- Is the incontinence intermittent? Intermittent incontinence suggests epilepsy or organic brain syndrome.
- Are there hyperactive reflexes in the lower extremities? Presence of hyperactive reflexes in the lower extremities should suggest a spinal cord tumor or trauma to the spinal cord, multiple sclerosis, a parasagittal meningioma, transverse myelitis, and syringomyelia.
- Are there hypoactive reflexes in the lower extremities? The presence of hypoactive reflexes in the lower extremities should suggest tabes dorsalis, a cauda equina tumor, spinal stenosis, and other conditions of the lumbar spine and lumbosacral area.
DIAGNOSTIC WORKUP
Routine studies include a CBC, sedimentation rate, chemistry panel, and VDRL test. A sigmoidoscopy and barium enema are needed to exclude malignancy. The anorectal area should be carefully inspected for lesions and the sphincter competence determined by a digital exam. If these findings are normal, it would be wise to consult a neurologist. If one is not available, further workup may be done.
If there are hyperactive reflexes with cranial nerve signs, a CT scan or MRI of the brain should be done. If there are hyperactive reflexes of all four extremities with no cranial nerve signs, MRI of the cervical spine should be done. With hyperactive reflexes of the lower extremities only, MRI of the thoracic cord should be done. If there are hypoactive reflexes in the lower extremities, MRI or CT scan of the lumbar spine should be done. If increased intracranial pressure has been excluded, a spinal tap may be done to help diagnose multiple sclerosis or tabes dorsalis. Anorectal manometry and defecography may be used to detect anal and rectal muscle dysfunction.
If the general physical examination and neurologic examination are negative, psychogenic causes should be considered, and cystometric studies might be helpful. The patient should be referred to a psychiatrist.
» READ BOOK EXCERPT ONLINE »
Source: Algorithmic Diagnosis of Symptoms and Signs, 2003
INCONTINENCE OF URINE:
Ask the Following Questions:
(Algorithmic Diagnosis of Symptoms and Signs)
- Is the volume of urine large or small? If the volume of urine released is small, stress incontinence and vesicovaginal fistula should be considered. If the amounts released are large, one should consider a neurologic condition or an enlarged prostate with bladder neck obstruction as the cause.
- Are there abnormalities on the neurologic examination? Neurologic disorders to be considered are spastic neurogenic bladder due to multiple sclerosis, spinal cord tumor, and spinal cord trauma, as well as incompetent sphincter due to cauda equina syndrome, spinal stenosis, poliomyelitis, diabetic neuropathy, and tabes dorsalis.
- Are there hyperactive reflexes? This helps distinguish the disorders of the spinal cord and parasagittal area, such as spastic neurogenic bladder due to multiple sclerosis, spinal cord tumor, spinal cord trauma, and parasagittal meningioma.
- Are the reflexes hypoactive? Hypoactive reflexes suggest poliomyelitis, cauda equina syndrome, spinal stenosis, diabetic neuropathy, and tabes dorsalis.
- Is there an enlarged bladder or prostate? If an enlarged bladder or prostate is palpated, one should consider overflow incontinence from bladder neck obstruction, prostatic hypertrophy, and tuberculosis of the bladder.
DIAGNOSTIC WORKUP
Routine laboratory tests include a CBC, a urinalysis, a urine culture and sensitivity, a chemistry panel, and a VDRL test. An intravenous pyelogram and a voiding cystogram may be helpful. A Q-tip test or stress test may be helpful in diagnosing stress incontinence. The bladder may be catheterized for residual urine, or abdominal ultrasonography may be employed to evaluate residual urine. Fifty milliliters or more is considered abnormal. Cystoscopy may also be necessary to determine if there is chronic bladder inflammation or bladder neck obstruction. Office cystometrography can be considered, but it is usually best to refer the patient to a urologist for cystometric studies. Prostatic size can be determined by transrectal prostatic ultrasonography.
The simplest and most cost-effective approach is to refer the patient to a neurologist if there are abnormalities on the neurologic examination, or refer the patient to a urologist if there are not. If there is stress incontinence and a cystocele is found on vaginal examination, the patient should be referred to a gynecologist. It is not cost-effective to begin ordering MRIs or CT scans of the brain and spinal cord without the assistance of these specialists.
» READ BOOK EXCERPT ONLINE »
Source: Algorithmic Diagnosis of Symptoms and Signs, 2003
STRESS INCONTINENCE:
DIAGNOSTIC WORKUP
(Algorithmic Diagnosis of Symptoms and Signs)
In most cases, the diagnosis will be obvious. You can ask the patient to cough during a vaginal examination, and the urine will trickle out. If that does not establish the diagnosis, have the patient drink a lot of water and not void until he or she returns to the office. Then you can have him or her cough in the recumbent or erect position, and the urine will be released. This is called the stress test. In the Q-tip test, a Q-tip is inserted in the tip of the urethra, and the patient is asked to cough or strain. The Q-tip will move at least 30 degrees above the horizontal in cases of stress incontinence. For further discussion of incontinence, see
page 264
.
» READ BOOK EXCERPT ONLINE »
Source: Algorithmic Diagnosis of Symptoms and Signs, 2003
DIARRHEA, ACUTE:
Ask the following questions:
(Algorithmic Diagnosis of Symptoms and Signs)
- Is there blood in the stool? From the algorithm, blood in the stool should indicate that there is
Salmonella
,
Shigella
,
Campylobacter jejuni
, ulcerative colitis, and amebic dysentery. Without blood in the stool, it is more likely that the acute diarrhea is due to a staphylococcal toxin, giardiasis, traveler's diarrhea, a virus, or contaminated food.
- Is there a fever? Fever, especially with an elevated white count and blood in the stool, would suggest
Salmonella
,
Shigella
,
Campylobacter jejuni
, or ulcerative colitis in its acute stage. The absence of fever would suggest amebic dysentery or giardiasis, although there may be fever in amebic dysentery in the severe cases. Even traveler's diarrhea and toxic staphylococcal gastroenteritis do not usually give more than a low-grade temperature at best. Pseudomembranous colitis may result in a significant elevation of the temperature once the patient becomes severely dehydrated.
- Is there severe vomiting? Severe vomiting is seen in toxic staphylococcal gastroenteritis! This follows 2 to 4 hr after eating food poisoned with the toxin. Traveler's diarrhea and viral gastroenteritis may also cause severe vomiting, as may food that is contaminated. On the other hand, there is little or no vomiting in giardiasis and pseudomembranous colitis.
- Did several members of the family experience acute diarrhea also? This is a key question because it indicates whether there is a possibility of toxic staphylococcal gastroenteritis or the possibility of a contagious condition such as infection with
Salmonella
,
Shigella
, or
Campylobacter
. If only one member of the family was suffering from diarrhea and everyone is eating the same food, then it is less likely to be a contagious condition, and one must consider ulcerative colitis, pseudomembranous colitis, and conditions listed under chronic diarrhea.
- Was there recent foreign travel? Recent foreign travel would suggest the possibility of traveler's diarrhea, cholera, shigellosis, salmonellosis, and giardiasis.
- Is there neurologic symptomatology? This should point one in the direction of botulism, and generally a little epidemiologic research will disclose that other people in the community have been suffering from the same condition.
DIAGNOSTIC WORKUP
The first thing to do is a stool for occult blood. This will help distinguish those patients who are having obvious infectious disease of the large intestine or maybe even the small intestine. It will also make one suspicious of ulcerative colitis. All patients need a stool culture and stool for ova and parasites. A stool for
Giardia
antigen can also be done. Serologic studies will not be of much help in the acute condition, but they may help later on in cases of salmonellosis and amebiasis. The clinician himself should do a methylene blue smear for leukocytes and examine a wet saline preparation of the stool. If there is a history of antibiotic uses, a stool should be tested for
Clostridium difficile
toxin B. Leukocytes on a smear suggest bacterial cause and a culture should be done. The laboratory should be alerted if
Campylobacter
or
Yersinia
are suspected because special culture media are needed. If the diarrhea persists or if there is blood, sigmoidoscopy or colonoscopy should be performed. It is always important to examine the rectum for hemorrhoids and anal fissures that may be causing the positive stool for occult blood. When the diarrhea persists and becomes chronic, the diagnostic workup should include the studies that are listed under chronic diarrhea.
» READ BOOK EXCERPT ONLINE »
Source: Algorithmic Diagnosis of Symptoms and Signs, 2003
DIARRHEA, CHRONIC:
Ask the following questions:
(Algorithmic Diagnosis of Symptoms and Signs)
- Is there a positive drug or alcohol history? It is well known that alcohol can cause diarrhea, as do drugs in common use, such as digitalis, diuretics, beta-blockers, aspirin, colchicine, and other nonsteroidal anti-inflammatory drugs. Perhaps there is overuse of laxatives. Remember, patients may lie about the use of laxatives.
- Is there blood in the stool? Blood in the stool certainly is significant for ulcerative colitis, carcinoma, and diverticulitis, but it is also found in amebiasis and the Zollinger-Ellison syndrome.
- Is there a lot of mucus in the stool? Mucus is often found in ulcerative colitis, Crohn's disease, and irritable bowel syndrome.
- Is there evidence of steatorrhea? Large volumes of stools that are partially formed or formed and float in the commode suggest steatorrhea. Stool analysis can be done, as is discussed later.
- Is there an abdominal mass? A mass in the right lower quadrant would suggest carcinoma or diverticulitis. Tenderness in the left lower quadrant with or without a significant mass would be suggestive of ulcerative colitis, diverticulitis, and irritable bowel syndrome. A mass in the area of the ascending or descending colon or the transverse colon should be looked for also, as these would suggest carcinoma.
- Are there signs of systemic disease? Many systemic diseases may cause diarrhea. Among them are thyrotoxicosis, in which case one would be looking for a thyroid tumor and a tremor and tachycardia; carcinoid syndrome, which would cause considerable flushing; Addison's disease, which would cause hyperpigmentation of the skin; and pellagra, which may cause dermatitis and dementia.
- Does significant diarrhea persist on fasting? Diarrhea that persists after fasting suggests a secretory diarrhea from a polypeptide-secreting tumor, such as villous adenoma, a gastrinoma, or a carcinoid tumor.
DIAGNOSTIC WORKUP
Most patients will be diagnosed by a stool culture, stool for occult blood, and stool for ovum and parasites, along with a sigmoidoscopy and barium enema. Giardiasis may be best diagnosed by the finding of
Giardia
antigen in the stool. In patients who have been on antibiotics, the stool should be tested for
C. difficile
toxin B. If a systemic disease is suspected, CBC, sedimentation rate, chemistry panel, and thyroid profile should be done. An HIV antibody test may be indicated depending on the history. A urine test for 5-HIAA will uncover a carcinoid syndrome. A serum gastrin will usually reveal a gastrinoma. If these tests do not provide a diagnosis, the most cost-effective approach at this point is to refer the patient to a gastroenterologist, who will undoubtedly perform a colonoscopy as part of the workup. Small bowel aspiration and biopsy will be useful in diagnosing
Giardia
infection or celiac sprue; angiography will confirm mesenteric ischemia or infarcts.
If a gastroenterologist is not available, the clinician may proceed with a quantitative 24-hr stool analysis for fat. If there is 10 g or more of fat in the stool in a day, then steatorrhea can be diagnosed and one can proceed with the workup of steatorrhea. If there is less than 7 g of fat per day in the stool, the stool volume after fasting should be done. If it is large and we have ruled out surreptitious laxative abuse, a polypeptide-secreting tumor should be considered. Here again, it would be best to refer the patient to a gastroenterologist. If the volume after a fast is small, the problem is most likely lactose or other food intolerance or an irritable bowel syndrome. Occasionally, the problem is dysfunction of the anal sphincter. Once again, a GI specialist is probably best consulted for workup of a dysfunctional anal sphincter.
» READ BOOK EXCERPT ONLINE »
Source: Algorithmic Diagnosis of Symptoms and Signs, 2003
Constipation:
Differential Diagnosis
(In a Page: Signs and Symptoms)
-
Medications
–Narcotic analgesics
–Antihypertensives (e.g., calcium channel blockers)
–Tricyclic antidepressants
–Aluminum hydroxide in antacids
–Iron supplements
-
Inadequate dietary fiber or liquid intake
-
Neurological dysfunction
–Diabetes mellitus
–Multiple sclerosis
–Hirschsprung's disease
-
Mechanical difficulties
–Colorectal cancer
–Hernia
–Diverticulitis
–Inflammatory bowel syndrome
–Adhesion
–Stricture
–Torsion
–Volvulus
-
Metabolic and endocrine
–Hypothyroidism
–Hypercalcemia
–Hypokalemia
-
Chronic laxative abuse
Workup and Diagnosis
- History and physical examination
–Specific attention to medication history, diet, and thyroid examination
–Abdominal examination: Note any surgical scars, palpate for masses (stool) and hepatosplenomegaly, check for hernias; however, note that examination results are often normal
–Rectal examination: Determine presence of stool, masses, hemorrhoids, fistulas, abscesses, or fissures; resting and squeezing sphincter tone; when patient bears down, relaxation of anal tone and perineal descents should be palpable (the absence of relaxation or inadequate perineal descents raises the suspicion of obstructive defecation)
-
Initial laboratory testing may include CBC, electrolytes, BUN/creatinine, glucose, calcium, phosphate, thyroid function tests, and fecal occult blood test
-
Consider a stool examination for ova and parasites, and flexible sigmoidoscopy or colonoscopy (colonoscopy if age greater than 50, new onset of constipation without cause, or blood in stool)
» READ BOOK EXCERPT ONLINE »
Source: In a Page: Signs and Symptoms, 2004
Incontinence:
Differential Diagnosis
(In a Page: Signs and Symptoms)
Transient, acute incontinence (DIAPPERS)
-
Delirium
-
Infections of urinary tract
-
Atrophic urethritis or vaginitis
-
Pharmaceuticals [e.g., diuretics, sedatives, anxiolytics, alcohol, β-blockers (cause urethral relaxation), ACE inhibitors (chronic cough increases abdominal pressure), antidepressants, antipsychotics]
-
Psychiatric conditions (e.g., depression)
-
Endocrine disorders (e.g., hypercalcemia, hyperglycemia)
-
Restricted mobility or (urinary)
-
Retention
-
Stool (fecal impaction)
Persistent, chronic incontinence - Stress incontinence
–Loss of urine upon increases in intra-abdominal pressure (e.g., laughing, coughing, change in position, exercise)
–Women <60 years after vaginal births
–Urethral trauma (e.g., prostate surgery)
- Urge incontinence (“overactive bladder”)
–Strong urge to urinate before reaching the toilet; usually in people >60
–Commonly associated with reversible causes, increased fluid intake, or poor bladder contractility
–Idiopathic causes, neurologic causes, hyperreflexia, neuropathies, poor bladder contractility, increased sphincter relaxation, and reversible causes (e.g., UTI, increased fluid intake)
-
Overflow incontinence
–Outlet obstruction: BPH, GU prolapse, tumors
–Bladder contractility dysfunction: Neurologic disorder (e.g., diabetic or alcoholic neuropathy), sacral spinal cord lesions, anticholinergic medications
-
Functional incontinence
–Normal urinary system affected by external factors (e.g., age, mental status decline, poor mobility)
-
Mixed incontinence
–Combined elements of stress and urge incontinence is common in older females
–Combined elements of overflow and urge incontinence are most common in men and frail nursing-home patients
Workup and Diagnosis
-
History should include whether the patient has problems holding urine versus emptying bladder; leakage of urine with cough, exercise, sneezing, laughing, lifting; frequency of urination; nocturnal urination; strong urge to urinate; loss of urine before reaching toilet; hesitancy, dribbling, slow stream, incomplete voiding, dysuria; bowel habits (e.g., constipation); medications; fluid intake; and medical and surgical history
-
Physical exam should include full neurologic and mental status examinations, assessment of physical frailness (e.g., use of walking aids, dysfunction secondary to stroke), abdominal exam (e.g., lower quadrant distension, pregnancy, fecal impaction), and genital and rectal exam (evaluate for cystocele, vaginal atrophy, strength of pelvic muscles in women; rectal tone, abnormalities of glans penis and prostate in men)
-
Cough stress test: Immediate leakage indicates stress incontinence; delayed leakage indicates urge incontinence
-
Voiding diaries may be used to track urinary habits
-
Initial labs may include electrolytes, calcium, glucose, urinalysis, and urine culture
-
Measurement of postvoid residual volume by catheterization and/or pelvic ultrasound (>100 mL of residual urine is abnormal)
-
Specialized urodynamic tests are reserved for ambiguous results or treatment failure
>
» READ BOOK EXCERPT ONLINE »
Source: In a Page: Signs and Symptoms, 2004
Diarrhea - Acute:
Differential Diagnosis
(In a Page: Signs and Symptoms)
- Infectious etiologies
–Acute (viral) gastroenteritis
–“Traveler's diarrhea”: Shigella, Salmonella,
enterotoxigenic E. coli, Campylobacter
–Rotavirus
–Norwalk virus
–Yersinia enterocolitica
–Clostridium difficile (pseudomembranous
enterocolitis): Follows antibiotic use
–Giardiasis: Foul-smelling, explosive diarrhea
–Enterovirus
-
Lactose intolerance
-
IBS: Alternating diarrhea and constipation
-
Ischemic colitis: Associated with history of atherosclerotic disease (CAD, PVD, AAA)
-
Inflammatory bowel disease (ulcerative colitis, Crohn's disease)
-
Medications (e.g., laxatives, antibiotics, anticholinergics, chemotherapy, metformin)
-
Malabsorption syndromes
-
Vasculitis
-
Neoplasia
-
Appendicitis
-
Adrenal insufficiency
-
Hyperthyroidism
-
HIV
-
Less common etiologies include E. coli O157:H7 (commonly associated with raw meat; invasive, bloody diarrhea), Cryptosporidium, Cyclospora, Isospora belli, typhoid fever
Workup and Diagnosis
- History and physical examination
–Proper history should include travel history, woodland
exposure (Giardia), immune status, and sick contacts
–Blood pressure and pulses, including orthostatics
–Full abdominal examination
–Back, genital, and rectal examinations
–Skin examination (e.g., jaundice, turgor)
–Signs of dehydration (e.g., loss of jugular pulsations,
dry mucous membranes, skin tenting, orthostasis)
- Stool examination and culture are usually indicated
–Fecal leukocytes suggest for infectious causes
–Fecal lactoferrin suggests laxative abuse
–Ova and parasites (for Giardia and Cryptosporidium)
should be considered in at-risk patients with persistent diarrhea
–Stool cultures may identify Salmonella, Shigella,
Campylobacter, Yersinia, or E. Coli
–Test stool for C. difficile toxin, if suspected
–Stool osmolar gap is elevated in osmotic and
malabsorptive diarrhea and decreased in
infectious/secretory diarrhea
-
Initial laboratory studies may include CBC, electrolytes, BUN/creatinine, glucose, urinalysis, liver function tests, and hepatitis serologies
-
Therapeutic trial of a lactose-free diet or lactose intolerance testing may be useful
-
Barium enema, colonoscopy, and/or flexible sigmoidoscopy may be indicated
-
Consider HIV testing
» READ BOOK EXCERPT ONLINE »
Source: In a Page: Signs and Symptoms, 2004
Diarrhea - Chronic:
Differential Diagnosis
(In a Page: Signs and Symptoms)
- Diarrhea due to deranged motility presents with alternating diarrhea and constipation, bloating, mucus or blood in the stool, relief of abdominal pain upon defecation, worsening diarrhea with stress
–IBS: Usually presents in the morning, seldom at night; more common in women; rectal urgency
–Diabetic neuropathy: Uncontrolled, explosive, postprandial diarrhea; usually seen in patients with neurologic dysfunction and uncontrolled blood sugar
–Hyperthyroidism
–Postileal resection
–Scleroderma
–Carcinoid syndrome: Diaphoresis and
diarrhea - Secretory diarrhea will persist even after a
48–72 hour fast; stool osmotic gap <50
–Bacterial gastroenteritis
–Bile acid malabsorption
–Colitis
–Hyperthyroidism
–Collagen vascular diseases (SLE, MCTD,
scleroderma)
–Neuroendocrine tumors (e.g., VIPoma, gastrinoma, carcinoid)
-
Osmotic diarrhea will cease upon fasting; stool osmotic gap >100 mOsm/kg
–Malabsorption (celiac sprue, nontropical sprue, Whipple's disease)
–Nonabsorbable substances (e.g., laxatives, lactose, magnesium)
Inflammatory diarrhea presents with blood and
mucus in the stools, urgency, fevers
–Inflammatory bowel disease
–Behçet syndrome
–Invasive bacterial disease (Campylobacter
jejuni)
–Intestinal neoplasm
Workup and Diagnosis
-
History should include appearance of bowel movements (e.g., bloody, mucusy, greasy, color, consistency), recent travel history, associated symptoms (e.g., abdominal pain), and timing
-
Physical examination
–Blood pressure and pulses, including orthostatics
–Abdominal, back, genital, and rectal examinations
–Skin examination (e.g., jaundice, turgor)
–Signs of dehydration (e.g., loss of jugular pulsations,
dry mucous membranes, tenting, orthostatics)
- Stool examination
–Blood suggests an inflammatory process
–WBCs suggest an inflammatory or infectious process
–72-hour stool collection for fecal fat with Sudan stain will diagnose malabsorption or oil-containing laxatives
–Stool electrolytes should be measured to calculate stool osmolality [2(K++Na+)] and osmotic gap [calculated stool osmolality
– 300 ×(normal stool osmolality)]
–Stool culture (including culture for parasites) is
indicated if infectious causes are suspected
–Stool pH
-
Initial lab tests may include CBC, electrolytes, LFTs, BUN/creatinine, calcium, glucose, urinalysis, and TSH
-
Endoscopy (flexible sigmoidoscopy, colonoscopy with biopsy, or EGD for small bowel biopsy)
-
Breath hydrogen test for lactose intolerance
-
Abdominal CT, small bowel series, and/or barium enema may be indicated
'>
» READ BOOK EXCERPT ONLINE »
Source: In a Page: Signs and Symptoms, 2004
Constipation:
Differential Diagnosis
(In A Page: Pediatric Signs and Symptoms)
- Functional constipation
–By far the most common etiology
–Rome II criteria define chronic functional constipation in infants and young children as at least 2 weeks of scybalous, pebble-like, hard stools for the majority of stools, or firm stools two or fewer times per week
–Presents with stool-withholding behavior
–Often due to inadequate fluid/fiber intake
-
Drugs: Antacids (with aluminium and calcium), anticholinergics, antidepressants, bismuth, calcium antagonists, cough suppressants, opioid analgesics, phenobarbitol
-
Irritable bowel syndrome
-
Endocrine disorders
–Hypercalcemia
–Hypothyroidism
–Hyperparathyroidism
–Pregnancy
–Reduction of steroid hormones in luteal and follicular phases of menstrual cycle
-
Hirschsprung disease
–1/5,000 births, male to female ratio 4:1
–94% do not pass meconium within 24 hours of birth
–61% diagnosed by 12 months of life
-
Neurologic disease
–Myelomeningoce
–Hypotonia (e.g., Down, myopathies, prune-belly syndrome)
–Cerebral palsy
-
Celiac disease
-
Cystic fibrosis
-
Inflammatory bowel disease
-
Lead toxicity
- Structural abnormalities
–Anal disorders (imperforate anus, anteriorly displaced anus, perianal fissures, strep infection, anal stenosis)
–Colonic strictures (primary or secondary)
–Pelvic masses (sacral teratoma)
-
Infectious disease
–Infantile botulism
–Chagas disease
-
Metabolic disorders
–Uremia
–Hypokalemia
–Amyloid neuropathy
-
Ogilvie syndrome
Workup and Diagnosis
- History and physical exam are often diagnostic for functional constipation
- History
–Age at onset, duration, stool frequency/consistency, pain/bleeding with defecation, abdominal pain, toilet training, fecal soiling, stool-withholding behavior, appetite change, nausea/vomiting, weight loss, attempted treatments, dietary intake of fluid and fiber
–Medical history: Gestational age, time of meconium passage, existing medical conditions, surgeries, delayed growth and development, sensitivity to cold, coarse hair, medications, association with stress
-
Physical exam
–Vital signs (including growth parameters), abdominal exam for fecal mass, anal inspection (position of anus, soiling, sacral dimple, skin tags, perianal fissures; rectal examination: anal wink, anal tone, presence/consistency of stool, fecal mass, other masses, explosive stool on withdrawal of finger, occult blood), and neurologic examination (tone, strength, cremasteric reflex, DTRs)
-
KUB may demonstrate fecal mass in uncooperative patients
-
Labs rarely needed, but may include thyroid (TSH, free T4), electrolytes (including Ca++, Mg+++, Ph+++), lead level, and celiac testing (tissue transglutaminase IgA)
-
Rectal biopsy, manometry, or BE for Hirschsprung
-
Spinal MRI for sacral anomalies
» READ BOOK EXCERPT ONLINE »
Source: In A Page: Pediatric Signs and Symptoms, 2007
Diarrhea – Chronic, No Blood or Weight Loss:
Differential Diagnosis
(In A Page: Pediatric Signs and Symptoms)
-
Osmotic: Presence of nonabsorbable solute, pH <5, volume <200 mL/day, normal electrolytes, stops with fasting
-
Secretory: Mostly due to toxins, pH >6, volume >200 mL/day, no response to fasting, stool Na >70 mEq/L, negative reducing substances
-
Toddler's diarrhea: Chronic nonspecific diarrhea, onset 3 months to 3 years of age, average 4–6 stools daily, due to excessive juice intake or low-fat diet
-
Excessive intake of nonabsorbable solutes (lactulose, sorbitol, magnesium hydroxide)
-
Congenital lactose deficiency: Very rare in infancy, but may occur in extremely premature infants; adult-onset type of hypolactasia may be seen in older children (over age 5), autosomal recessive, 15% white adults, 85% of black adults, 90% of Asian adults
-
Secondary lactase deficiency: Follows a viral gastroenteritis, most commonly rotavirus, may persist for months
-
Fructose intolerance
-
Sucrase-isomaltase deficiency: Autosomal recessive, found in 0.2% of North Americans, symptoms commence on starting sucrose or glucose polymer-containing foods
-
Glucose-galactose malabsorption: Rare, autosomal recessive disorder
-
Infections
–Giardiasis (most common infectious cause of
chronic diarrhea in toddlers)
–Cryptosporidium
–Microsporidium
-
Irritable bowel syndrome (IBS)
–Abnormality of intestinal motility and pain perception with no organic basis
–Abdominal pain associated with intermittent diarrhea or constipation
-
Bacterial overgrowth: Enteric bacteria colonizes the upper small intestine
-
Trehelase deficiency (trehelose is the sugar found in mushrooms)
-
Zinc deficiency
–Acrodermatitis enteropathica is typical rash
-
Low-fat diet
Workup and Diagnosis
- History
–Weight loss
–Daycare setting, ill contacts
–Diet history: Type and amount of fluids daily (intake
of >150 mL/kg/day with normal weight and height
suggests toddler's diarrhea)
–Frequency of stool and consistency
–Associated symptoms: Abdominal pain, bloating,
flatulence, rash, fever, or vomiting
–Onset of symptoms and relation to ingestion of milk,
sucrose, or glucose
–Worsening with stress (typical for IBS)
–Exposure to lakes, well water (suggestive of parasite)
–Travel history
–Excessive “sugar free” gum chewing (sorbitol)
-
Stool examination
–Gross examination (blood, mucus, undigested food)
–Color is not helpful
–Occult blood test (not detected in IBS)
–pH: Stool pH <5 indicates osmotic diarrhea from reducing sugars (sucrose and trehelose are nonreducing)
–Stool cultures, O&P, Clostridium difficile toxin
-
More studies only if all of above failed to reveal cause
-
Hydrogen breath test
–Detects carbohydrate malabsorption (lactose, sucrose, fructose, glucose) and bacterial overgrowth
-
Stool electrolytes if secretory diarrhea is suspected
>>>
» READ BOOK EXCERPT ONLINE »
Source: In A Page: Pediatric Signs and Symptoms, 2007
Diarrhea – Chronic, with Weight Loss:
Differential Diagnosis
(In A Page: Pediatric Signs and Symptoms)
-
Allergic enteritis: Typically cow's milk or soy in infants
-
Inflammatory bowel disease (IBD)
-
Cystic fibrosis (CF)
–Chronic diarrhea may be the only sign
–90% have pancreatic insufficiency (PI)
-
Celiac disease (CD): Gluten sensitivity, increased incidence in selective IgA deficiency, DM, and Down syndrome
-
Immune deficiency (e.g., hypogammaglobulinemia)
-
Sucrase-isomaltase deficiency: Autosomal recessive, symptoms with starting sucrose or glucose polymer-containing diet
-
Microvillus inclusion disease: Most common cause of persistent diarrhea in the neonatal period
-
Schwachman-Diamond syndrome
–Pancreatic insufficiency, neutropenia, short stature, skeletal abnormalities
-
Johannson-Blizzard syndrome
–Pancreatic insufficiency, scalp defects, agenesis of nasal cartilage, deafness, imperforate anus
-
Whipple disease:
–Tropheryma whippelii (actinomycete)
–Diagnosed mainly in adults
–Weight loss, diarrhea, and arthropathy
-
Tropical sprue: Common in developing countries; folate deficiency and diarrhea
-
Neural crest tumors: Pheochromocytoma, VIPoma, Zollinger-Ellison syndrome, carcinoid tumors
-
Mastocytoma
-
Neuroblastoma
-
Abetalipoproteinemia
-
Giardiasis, Strongyloides, coccidia
-
AIDS
-
Acrodermatitis enteropathica: Zinc deficiency, acral perioral and perianal rashes, consider underlying cystic fibrosis
-
Mutational defects in ion transport proteins
–Chloride-losing diarrhea: Rare, ileal chloride
transport defect, maternal polyhydramnios
–Congenital sodium diarrhea
-
Tufting enteropathy (epithelial dysplasia)
-
Enterokinase deficiency
Workup and Diagnosis
- History and physical exam
–Diet history and nutritional assessment, onset, frequency, and consistency, history of foreign travel
–Associated symptoms: Vomiting, irritability, and rashes (dermatitis herpetiformis) with CD; frequent infections in CF and Schwachman-Diamond; digital clubbing in CF, CD, and IBD
–Hypertension, tachycardia, anxiety, flushing, and sweating with pheochromocytoma; peptic ulcers with Zollinger-Ellison; wheezing, abdominal pain, flushing with carcinoid tumors; pruritus, flushing, and apnea with mastocytoma
-
Stool examination: Oily, bulky, and foul-smelling with fat malabsorption; massive watery stools with secretory diarrhea; blood and mucus seen with colitis; stool for ova and parasites or antigen test for Giardia; WBC, eosinophils in allergic disease; occult blood test, stool pH, electrolytes, osmolarity, reducing substances
-
PI proven by 72-hour fecal fat, stool elastase, secretin stimulation test, fat-soluble vitamin deficiency (ADEK)
-
CBC, ESR, electrolytes, LFT, albumin (low in CD or IBD)
-
Sucrose breath test for sucrase-isomaltase deficiency
-
Sweat test to rule out CF
-
Endoscopic biopsy: CD, IBD, Whipple diagnosis, microvillus inclusion (abetalipoproteinemia)
-
Hormonal assay: Gastrin, vasocative intestinal peptide
-
Anti-tissue transglutaminase IgA antibodies for CD
» READ BOOK EXCERPT ONLINE »
Source: In A Page: Pediatric Signs and Symptoms, 2007
Diarrhea – Acute:
Differential Diagnosis
(In A Page: Pediatric Signs and Symptoms)
-
Viral gastroenteritis
–Rotavirus, most common (winter)
–Norwalk-like virus
–Calcivurus
–Enteric adenovirus
–Astrovirus
-
Bacterial gastroenteritis
–Campylobacter jejuni (associated with
Guillain-Barré syndrome)
–Salmonella
–Shigella: May cause seizures (up to 30%),
HUS
–Escherichia coli (various types): Enteropathogenic, enterohemorrhagic (O157:H7) verotoxin can cause HUS (6–8% of cases), enterotoxigenic (traveler's diarrhea), enteroinvasive
–Clostridium difficile (toxin A or B)
–Yersinia enterocolitis (mimics acute
appendicitis)
–Vibrio cholerae
–Aeromonas hydrophila
–Toxin-mediated food poisoning: Bacillus
cereus, Staphylococcus aureus, Clostridium perfringens
-
Parasitic infestations
–Giardia lamblia
–Cryptosporidium (severe in AIDS patients)
–Entamoeba histolytica
-
Food allergies
–Cow's milk and soy protein allergy are most common in infancy
-
Malbasorption (celiac disease, CF)
-
Lactose or fructose intolerance
-
Overfeeding (relative lactase deficiency)
-
Vitamin deficiency (e.g., niacin )
-
Zinc deficiency
-
Laxative abuse
-
Irritable bowel syndrome
-
Constipation with encopresis
-
Bacterial overgrowth
-
Antibiotics
-
Hirschsprung toxic colitis
-
Adrenogenital syndrome
Workup and Diagnosis
- History
–Duration of diarrhea
–Frequency and consistency of stool
–Vomiting, weight loss
–Diet history
–History of sick contact
–Fever and blood mixed in stool more common with
invasive pathogens: Salmonella, Shigella, Campylobacter, Yersinia, E. coli O157:H7, and E. histolytica
-
Physical exam
–Vital signs, look for signs of dehydration
–Severe cases may present in hypovolemic shock
-
Labs
–Urinalysis: Specific gravity and ketones
–Serum electrolytes: Acidosis, hyper- or hyponatremia,
hypoglycemia
–Stool for Rotazyme
–Stool culture: Salmonella, E. coli, Shigella,
Campylobacter, and Yersinia
–Stool ELISA for C. difficile toxin A and B
–Stool for ova and parasites
–Blood culture indicated in the presence of fever
–CBC may reveal high bandemia with shigellosis
–Stool for occult blood and WBC is of little value in
differentiating viral from bacterial causes
» READ BOOK EXCERPT ONLINE »
Source: In A Page: Pediatric Signs and Symptoms, 2007
CONSTIPATION:
Approach to the Diagnosis
(Differential Diagnosis in Primary Care)
Rectal examination for a fecal impaction and subsequent enemas if no contraindication exists are the first steps. This may disclose a fissure, inflamed hemorrhoid, or abscess. Pelvic examination must be done in all females. If nothing is found here a proctoscopic examination and barium enema would be indicated, provided the neurologic examination and a flat plate of the abdomen are normal. Careful inquiry about diet, drugs, and emotional stress should be made.
» READ BOOK EXCERPT ONLINE »
Source: Differential Diagnosis in Primary Care, 2007
DIARRHEA:
Approach to the Diagnosis
(Differential Diagnosis in Primary Care)
Whichever method is applied (anatomic or physiologic), most causes of diarrhea can be recalled before interviewing the patient. Then one can proceed to ask the right questions to eliminate each suspected cause. Combinations of symptoms and signs will assist greatly in narrowing the differential diagnosis. For example, chronic diarrhea and copious mucous without blood suggests irritable bowel syndrome. Chronic diarrhea with mucous and blood suggests ulcerative colitis.
Physical examination is often unrewarding but it may disclose a hepatic, rectal, or pelvic source for the diarrhea; it may also indicate that the diarrhea is a sign of a systemic disease (e.g., scleroderma or hyperthyroidism). Rectal examination may reveal a fecal impaction. A warm stool examination for pus, pH (acid stool suggests lactase deficiency), fat and meat fibers, blood, ova, and parasites is most essential. A stool culture is done. Proctoscopy (immediately if there is blood) followed by colonoscopy, barium enema, and upper gastrointestinal (GI) series is usually necessary in all cases.
» READ BOOK EXCERPT ONLINE »
Source: Differential Diagnosis in Primary Care, 2007
INCONTINENCE, URINARY:
Approach to the Diagnosis
(Differential Diagnosis in Primary Care)
First, exclude stress incontinence with a pad test. Perineal pads are weighed before and after walking and stress for 30 minutes. An increase in weight identifies urine loss. Catheterization and examination, smear, and culture of the urine are essential at the outset. Cystoscopy and cystometric studies are often needed. Surgical repair of a cystocele or a parasympathomimetic drug in cases of a flaccid neurogenic bladder and propantheline bromide (ProBanthine), a parasympatholytic drug, for spastic neurogenic bladders may be all that is necessary. A neurologist and urologist often need to cooperate in the diagnosis and treatment of these unfortunate individuals.
» READ BOOK EXCERPT ONLINE »
Source: Differential Diagnosis in Primary Care, 2007
Constipation:
History and physical examination
(Handbook of Signs & Symptoms (Third Edition))
Ask the patient to describe the frequency of his bowel movements and the size and consistency of his stools. How long has he had constipation? Acute constipation usually has a physiological cause such as an anal or rectal disorder. In a patient older than age 45, a recent onset of constipation may be an early sign of colorectal cancer. Conversely, chronic constipation typically has a functional cause and may be related to stress.
Does the patient have pain related to constipation? If so, when did he first notice the pain, and where is it located? Cramping abdominal pain and distention suggest obstipation — extreme, persistent constipation due to intestinal tract obstruction. Ask the patient if defecation worsens or helps relieve the pain. Defecation usually worsens pain, but with such disorders as irritable bowel syndrome, it may relieve it.
Ask the patient to describe a typical day's diet; estimate his daily fiber and fluid intake. Ask him about changes in eating habits, medication or alcohol use, or physical activity. Has he experienced recent emotional distress? Has constipation affected his family life or social contacts? Also, ask about his job and exercise pattern. A sedentary or stressful job can contribute to constipation.
Find out whether the patient has a history of GI, rectoanal, neurologic, or metabolic disorders; abdominal surgery; or radiation therapy. Then ask about the medications he's taking, including opioids and over-the-counter preparations, such as laxatives, mineral oil, stool softeners, and enemas.
Inspect the abdomen for distention or scars from previous surgery. Then auscultate for bowel sounds, and characterize their motility. Percuss all four quadrants, and gently palpate for abdominal tenderness, a palpable mass, and hepatomegaly. Next, examine the patient's rectum. Spread his buttocks to expose the anus, and inspect for inflammation, lesions, scars, fissures, and external hemorrhoids. Use a disposable glove and lubricant to palpate the anal sphincter for laxity or stricture. Also, palpate for rectal masses and fecal impaction. Finally, obtain a stool sample and test it for occult blood.
As you assess the patient, remember that constipation can result from several life-threatening disorders, such as an acute intestinal obstruction and mesenteric artery ischemia, but it doesn't herald these conditions.
» READ BOOK EXCERPT ONLINE »
Source: Handbook of Signs & Symptoms (Third Edition), 2006
Diarrhea:
History and physical examination
(Handbook of Signs & Symptoms (Third Edition))
If the patient isn't in shock, proceed with a physical examination. Evaluate hydration, check skin turgor and mucous membranes, and take blood pressure with the patient lying, sitting, and standing. Inspect the abdomen for distention, and palpate for tenderness. Auscultate bowel sounds. Check for tympany over the abdomen. Take the patient's temperature, and note any chills. Also, look for a rash. Conduct a rectal examination and a pelvic examination if indicated.
Explore signs and symptoms associated with diarrhea. Does the patient have abdominal pain and cramps? Difficulty breathing? Is he weak or fatigued? Find out his drug history. Has he had GI surgery or radiation therapy recently? Ask the patient to briefly describe his diet. Does he have any known food allergies? Last, find out if he's under unusual stress.
» READ BOOK EXCERPT ONLINE »
Source: Handbook of Signs & Symptoms (Third Edition), 2006
Fecal incontinence:
History and physical examination
(Handbook of Signs & Symptoms (Third Edition))
Ask the patient with fecal incontinence about its onset, duration, and severity and about any discernible pattern — for example, does it occur at night or only with episodes of diarrhea? Note the frequency, consistency, and volume of stools passed within the past 24 hours and obtain a stool sample. Focus your history taking on GI, neurologic, and psychological disorders.
Let the history guide your physical examination. If you suspect a brain or spinal cord lesion, perform a complete neurologic examination. (See
Neurologic control of defecation.) If a GI disturbance seems likely, inspect the abdomen for distention, auscultate for bowel sounds, and percuss and palpate for a mass. Inspect the anal area for signs of excoriation or infection. If not contraindicated, check for fecal impaction, which may be associated with incontinence.
» READ BOOK EXCERPT ONLINE »
Source: Handbook of Signs & Symptoms (Third Edition), 2006
Urinary incontinence:
History and physical examination
(Handbook of Signs & Symptoms (Third Edition))
Ask the patient when he first noticed the incontinence and whether it began suddenly or gradually. Have him describe his typical urinary pattern: Does incontinence usually occur during the day or at night? Does he have any urinary control, or is he totally incontinent? If he is occasionally able to control urination, ask him the usual times and amounts voided. Determine his normal fluid intake. Ask about other urinary problems, such as hesitancy, frequency, urgency, nocturia, and decreased force or interruption of the urine stream. Also ask if he’s ever sought treatment for incontinence or found a way to deal with it himself.
Obtain a medical history, especially noting urinary tract infection, prostate conditions, spinal injury or tumor, stroke, or surgery involving the bladder, prostate, or pelvic floor. Ask a woman how many pregnancies she has had and how many childbirths.
After completing the history, have the patient empty his bladder. Inspect the urethral meatus for obvious inflammation or anatomic defect. Have female patients bear down; note any urine leakage. Gently palpate the abdomen for bladder distention, which signals urine retention. Perform a complete neurologic assessment, noting motor and sensory function and obvious muscle atrophy.
» READ BOOK EXCERPT ONLINE »
Source: Handbook of Signs & Symptoms (Third Edition), 2006
Constipation:
History and physical examination
(Professional Guide to Signs & Symptoms (Fifth Edition))
Ask the patient to describe the frequency of his bowel movements and the size and consistency of his stools. How long has he had constipation? Acute constipation usually has an organic cause, such as an anal or rectal disorder. In a patient over age 45, a recent onset of constipation may be an early sign of colorectal cancer. Conversely, chronic constipation typically has a functional cause and may be related to stress.
Does the patient have pain related to constipation? If so, when did he first notice the pain, and where is it located? Cramping abdominal pain and distention suggest obstipation—extreme, persistent constipation due to intestinal tract obstruction. Ask the patient if defecation worsens or helps relieve the pain. Defecation usually worsens the pain, but in disorders such as irritable bowel syndrome, it may relieve it.
Ask the patient to describe a typical day’s menu; estimate his daily fiber and fluid intake. Ask him, too, about any changes in eating habits, medication or alcohol use, or physical activity. Has he experienced recent emotional distress? Has constipation affected his family life or social contacts? Also, ask about his job. A sedentary or stressful job can contribute to constipation.
Find out whether the patient has a history of GI, rectoanal, neurologic, or metabolic disorders; abdominal surgery; or radiation therapy. Then ask about the medications he’s taking, including over-the-counter preparations, such as laxatives, mineral oil, stool softeners, and enemas.
Inspect the abdomen for distention or scars from previous surgery. Then auscultate for bowel sounds, and characterize their motility. Percuss all four quadrants, and gently palpate for abdominal tenderness, a palpable mass, and hepatomegaly. Next, examine the patient’s rectum. Spread his buttocks to expose the anus, and inspect for inflammation, lesions, scars, fissures, and external hemorrhoids. Use a disposable glove and lubricant to palpate the anal sphincter for laxity or stricture. Also palpate for rectal masses and fecal impaction. Finally, obtain a stool specimen and test it for occult blood.
As you assess the patient, remember that constipation can result from several life-threatening disorders, such as acute intestinal obstruction and mesenteric artery ischemia, but it doesn’t herald these conditions.
» READ BOOK EXCERPT ONLINE »
Source: Professional Guide to Signs & Symptoms (Fifth Edition), 2006
Diarrhea:
History and physical examination
(Professional Guide to Signs & Symptoms (Fifth Edition))
If the patient isn’t in shock, proceed with a brief physical examination. Evaluate hydration, check skin turgor and mucous membranes, and take blood pressure with the patient lying, sitting, and standing. Inspect the abdomen for distention, and palpate for tenderness. Auscultate bowel sounds. Check for tympany over the abdomen. Take the patient’s temperature, and note any chills. Also, look for a rash. Conduct a rectal examination and a pelvic examination if indicated.
Explore signs and symptoms associated with diarrhea. Does the patient have abdominal pain and cramps? Difficulty breathing? Is he weak or fatigued? Find out his drug history. Has he had GI surgery or radiation therapy recently? Ask the patient to briefly describe his diet. Does he have any known food allergies? Lastly, find out if he’s under unusual stress.
» READ BOOK EXCERPT ONLINE »
Source: Professional Guide to Signs & Symptoms (Fifth Edition), 2006
Fecal incontinence:
History and physical examination
(Professional Guide to Signs & Symptoms (Fifth Edition))
Ask the patient with fecal incontinence about its onset, duration, and severity and about any discernible pattern—for example, at night or with diarrhea. Note the frequency, consistency, and volume of stools passed within the last 24 hours and obtain a stool specimen. Focus your history taking on GI, neurologic, and psychological disorders.
Let the history guide your physical examination. If you suspect a brain or spinal cord lesion, perform a complete neurologic examination. (See Neurologic control of defecation, page 334.) If a GI disturbance seems likely, inspect the abdomen for distention, auscultate for bowel sounds, and percuss and palpate for a mass. Inspect the anal area for signs of excoriation or infection. If not contraindicated, check for fecal impaction, which may be associated with incontinence.
» READ BOOK EXCERPT ONLINE »
Source: Professional Guide to Signs & Symptoms (Fifth Edition), 2006
Urinary incontinence:
History and physical examination
(Professional Guide to Signs & Symptoms (Fifth Edition))
Ask the patient when he first noticed the incontinence and whether it began suddenly or gradually. Have him describe his typical urinary pattern: Does incontinence usually occur during the day or at night? Does he have any urinary control, or is he totally incontinent? If can control urination occasionally, ask him the usual times and amounts voided. Determine his normal fluid intake. Ask about other urinary problems, such as hesitancy, frequency, urgency, nocturia, and decreased force or interruption of the urine stream. Also ask if he’s ever sought treatment for incontinence or found a way to deal with it himself.
Obtain a medical history, especially noting urinary tract infection (UTI), prostate conditions, spinal injury or tumor, stroke, or surgery involving the bladder, prostate, or pelvic floor. Ask a woman how many pregnancies and childbirths she has had.
After completing the history, have the patient empty his bladder. Inspect the urethral meatus for obvious signs of inflammation or an anatomic defect. Have female patients bear down, and note any urine leakage. Gently palpate the abdomen for bladder distention, which signals urine retention. Perform a complete neurologic assessment, noting motor and sensory function and obvious muscle atrophy.
» READ BOOK EXCERPT ONLINE »
Source: Professional Guide to Signs & Symptoms (Fifth Edition), 2006
Constipation:
History
(The 10-Minute Diagnosis Manual: Symptoms and Signs in the Time-Limited Encounter)
The assessment and evaluation of the constipated patient begins with the history.
A. What is the patient’s description of the onset, duration, and frequency of constipation? Constipation of recent onset is suggestive of tumor.
B. Is rectal bleeding, melena, or narrowing of the stool caliber (all suggesting neoplasia) present (Chapter 9.11)?
C. What over-the-counter (OTC) medications are being used? (Is this patient potentially abusing OTC laxatives or taking OTC “cold” medicine containing an antihistamine?) Does the onset of constipation coincide with the taking of any of the medications listed in the MADE-O-FUN acrostic?
D. Does the past medical history, past surgical history, systems review, or chart review suggest any of the associated systemic illness listed in MADE-O-FUN? Is the patient known to have parkinsonism, renal failure, diabetes mellitus, hypertension (possibly treated with medications such as clonidine, calcium channel blockers, or potassium depleting diuretics, or other medications potentially causing decreased colonic tone), or hypothyroidism? Is there a history of cancer (potentially associated with hypercalcemia)?
Physical examination
Undertake a general physical examination looking for the stigmata of the associated constitutional illnesses mentioned in the MADE-O-FUN acrostic. Target the abdominal examination specifically for masses or abdominal tenderness and the rectal examination for fecal occult blood, rectal tone, rectal masses, rectal foreign body, impaction, anal fissure, hemorrhoids, or rectocoele—essential parts of the evaluation.
Diagnostic testing
Laboratory evaluation should consist of fecal occult blood testing (FOBT) looking for rectal bleeding; serum potassium and calcium to rule out hypokalemia and hypercalcemia (both associated with decreased colonic tone); serum glucose to evaluate possible diabetes; complete blood count looking for anemia (possibly related to chronic GI blood loss from tumor); blood urea nitrogen, serum creatinine, or both to rule out renal failure; and thyroid stimulating hormone to evaluate for hypothyroidism.
Visualize the lower colon via flexible sigmoidoscopy in patients aged more than 40 years whose constipation is of recent origin. Flexible sigmoidoscopy alone is insufficient for patients whose findings could suggest colonic neoplasia (melena, positive FOBT, hematochezia, abdominal mass, unexplained weight loss, or unexplained anemia). These patients should be offered either (a) colonoscopy or (b) barium enema plus flexible sigmoidoscopy.
Diagnostic assessment
The key diagnostic task in adults presenting with constipation is identifying those occasional patients whose constipation is caused by colorectal cancer. Because survival from colon cancer is directly related to the stage of the disease at time of diagnosis (3), patients whose history, examination, or laboratory findings are more suggestive of this diagnosis merit prompt investigation, including referral if necessary.
For patients whose constipation can be related to a particular systemic disease (e.g., hypercalcemia or hypothyroidism) or the use of particular medications (e.g., clonidine or an aluminum-containing antacid), identifying that link can be instrumental in ensuring that inciting issues are appropriately addressed in the management of the patient as a whole entity and not just as “a colon.”
In that greater host of patients whose initial evaluation suggests a more benign cause of constipation, or for whom constipation seems to be an incidental feature in an otherwise well individual, the decision to proceed with colonic visualization, or to begin a search for more unusual causes (the “U” in the MADE-O-FUN acrostic) will depend on the degree to which the constipation subjectively has an impact on the patient’s ability to live a fulfilling, happy, and rewarding life.
References
1. Drossman DA, McKee DC, Sandler RS, et al. Bowel patterns among subjects not seeking health care. Use of a questionnaire to identify a population with bowel dysfunction. Gastroenterology 1982;83:529–534.
2. Sonnenberg A, Koch TR. Physician visits in the United States for constipation: 1958–1986. Dig Dis Sci 1989;34:606–611.
3. Steele G. Colorectal cancer. In: Murphy GP, Lawrence W, Lenhad RE, eds. American Cancer Society textbook of clinical oncology, 2nd ed. Atlanta: The American Cancer Society, 1995:Chap 14.
» READ BOOK EXCERPT ONLINE »
Source: The 10-Minute Diagnosis Manual: Symptoms and Signs in the Time-Limited Encounter, 2000
Diarrhea:
History
(The 10-Minute Diagnosis Manual: Symptoms and Signs in the Time-Limited Encounter)
A. General. How long has the diarrhea been present? Most cases of acute diarrhea are secondary to infection (Table 9.1) (2). The overwhelming majority of cases of acute diarrhea are benign and self-limited. Diarrheal illnesses lasting longer than 3 weeks are classified as chronic and should be clinically investigated (Table 9.2) (3,4). Other symptoms to inquire about include associated nausea, vomiting, chills, fever, or abdominal pain. Bloody or melanotic stools and weight loss are red flags that should prompt further diagnostic testing (Chapters 2.13 and 9.11).
B. Acute diarrhea. Has the patient recently traveled, tried new foods, used any medications, or had recent illness? Traveler’s diarrhea commonly begins 3 to 7 days after arrival in a foreign location after exposure to foods or water contaminated with enterotoxigenic Escherichia coli, Salmonella spp., or Giardia spp. Diarrhea that develops within 12 hours of food ingestion is most likely caused by a bacterial preformed toxin. If diarrhea occurs in the setting of a recent course of antibiotic therapy, pseudomembranous colitis caused by Clostridium difficile toxin should be suspected. A thorough medication history includes all products, including over-the-counter agents, alcohol, and caffeine.
C. Chronic diarrhea. In patients with chronic diarrhea, the history should focus on the characterization of the stools and the pattern of the diarrhea. Diarrhea at night favors an organic cause. Associated periods of constipation can be a clue to irritable bowel syndrome (Chapter 9.3). Is there a family history of diarrhea? Family history can provide clues to a diagnosis of irritable bowel syndrome, inflammatory bowel disease, or a multiple endocrine neoplastic disorder. Concurrent diarrheal illness among family members suggests the possibility of shared pathogens (e.g., Giardia) with a contaminated water source. The history should also detail other medical problems, prior surgeries, and allergies. A sexual history should be sought. Homosexual individuals are at higher risk for exposure to infectious agents, including amebiasis, giardiasis, and shigellosis. In patients with acquired immune deficiency syndrome, infectious agents may include Candida spp., cytomegalovirus, and Cryptosporidium spp. A careful medication history should also screen for laxative abuse.
Physical examination
A. Focused physical examination. Obtain vital signs (notably temperature) and include orthostatic blood pressure measurements. Assess the patient’s weight and general nutritional status. The abdomen should be examined for bowel sounds, localized tenderness, and organomegaly. A rectal examination may demonstrate a fistula or abscess that can be a clue to Crohn’s disease. Occult or gross blood can indicate an invasive inflammatory diarrheal illness, diverticular disease, or an ischemic bowel.
B. Additional physical examination. The history may lead to a more specific examination (e.g., thyroid for thyrotoxicosis) or a search for lymphadenopathy in an immunocompromised patient.
» READ BOOK EXCERPT ONLINE »
Source: The 10-Minute Diagnosis Manual: Symptoms and Signs in the Time-Limited Encounter, 2000
Urinary Incontinence:
History
(The 10-Minute Diagnosis Manual: Symptoms and Signs in the Time-Limited Encounter)
A. Voiding history. It is important to fully characterize the patient’s problem by taking a detailed history, including the duration of the symptoms, timing of voluntary or involuntary voiding, amounts voided involuntarily, and the relationship to voluntary voiding. Focus on the following areas:
1. Need for pads or diapers (measure of severity)
2. Loss of urine with coughing or laughing (suggests stress type)
3. Inability to hold urine after having the urge to urinate (suggests urge type)
4. Pain or discomfort (suggests infection or inflammation) (Chapter 10.1)
5. Inability to fully empty bladder (suggests obstruction)
6. Decreased urinary stream (suggests obstruction)
7. What impact does UI have on the patient’s life?
8. What does the patient think is going on?
B. Major medical problems. Does the patient have any known condition that is associated with UI? These include diabetes, heart failure, menopause, and neurologic problems. Does the patient have other genitourinary symptoms? In female patients, be sure to take a detailed obstetric history.
C. Medication history. Since medications are a major cause of incontinence, a thorough medication history is essential. Offending agents include diuretics, older antidepressants, antihypertensives, narcotics, and alcohol.
D. Special concern. Central and nephrogenic diabetes insipidus can present with UI because of increased urine output (many liters per day). These patients frequently have a concomitant polydypsia that closely matches their water loss (Chapter 14.5). Consider this diagnosis when the patient gives a history of voiding large volumes of urine.
Physical examination
The physical examination is often normal in cases of UI. Focus efforts in an attempt to uncover the underlying cause(s):
A. General. Is the patient physically capable of getting to the toilet?
B. Mental status. Can the patient understand and act on the urge to void?
C. Neurologic, including the anal reflex; focal signs suggest a neurologic cause.
D. Abdominal examination. Is the bladder distended?
E. Rectal or prostate. Does the patient have a fecal impaction or an enlarged prostate?
F. Pelvic examination. Look for atrophic vaginitis, uterine prolapse, or a pelvic mass.
» READ BOOK EXCERPT ONLINE »
Source: The 10-Minute Diagnosis Manual: Symptoms and Signs in the Time-Limited Encounter, 2000
Constipation:
Differential Overview
(Field Guide to Bedside Diagnosis)
❑ Lifestyle
❑ Drugs
❑ Depression
❑ Irritable bowel syndrome
❑ Pelvic floor dysfunction
❑ Hypothyroidism
❑ Hypokalemia
❑ Colon cancer
❑ Anorectal pathology
❑ Voluntary retention
❑ Megacolon
❑ Mechanical obstruction
❑ Spinal cord pathology
❑ Hypercalcemia
❑ Scleroderma
Diagnostic Approach
Determine what the patient means by constipation. Patients are bothered by straining, excessively hard stools, unproductive urges, infrequency, and a feeling of incomplete evacuation.
With recent-onset constipation, seek an obstructing lesion, such as colon cancer, stricture, diverticular disease, inflammatory bowel disease, or foreign body. Hard stool in the vault rules out mechanical obstruction and suggests impaired emptying of the rectal vault. A change in stool caliber is more often caused by a tight sphincter than an “apple core” lesion.
» READ BOOK EXCERPT ONLINE »
Source: Field Guide to Bedside Diagnosis, 2007
Urinary Incontinence:
Differential Overview
(Field Guide to Bedside Diagnosis)
❑ Cystitis
❑ Benign prostatic hypertrophy
❑ Pelvic floor relaxation
❑ Drugs
❑ Prostatitis
❑ Diabetes
❑ Cough
❑ Multiple sclerosis
❑ Spinal cord compression
❑ Decreased cortical inhibition
❑ Vesicovaginal fistula
Diagnostic Approach
On examination, test for stress-induced leakage with a full bladder, palpate for bladder distension after voiding, and check for post-void residual. Do a pelvic examination looking for pelvic floor laxity, atrophic vaginitis, urethritis, or pelvic mass, and a rectal examination for tone, fecal impaction, and prostate nodule. Check perineal sensation and neurosacral reflexes including volitional anal contraction, anal wink (anal contraction in response to a light scratch of the perineal skin), and bulbocavernosus reflex (anal contraction in response to a light squeeze of the penis or clitoris). An intact reflex arc but absent perineal sensation suggests a cord lesion or multiple sclerosis.
Urge incontinence: Due to detrusor overactivity. Urine loss is accompanied by a strong desire to void. Incontinence is preceded by a warning of seconds to minutes. Leakage is periodic but frequent, and nocturnal incontinence is common. Voluntary control of the anal sphincter is intact, and sacral sensation and reflexes are preserved. The post-void residual is low. It is usually a result of detrusor instability caused by stroke, Alzheimer dementia, brain tumor, Parkinson disease, bladder outlet obstruction, spinal cord lesion, or interstitial cystitis.
Reflex incontinence: Due to an excessive pressure response to bladder filling. Voiding occurs without stress or warning. Sacral reflexes are preserved, but voluntary sphincter control and perineal sensation are impaired. Post-void residual is increased. Usually caused by a spinal cord lesion, incontinence may be mimicked by cortical damage with decreased awareness of signals to void.
Stress incontinence: Due to failure of the sphincter to remain closed during bladder filling. Incontinence of small amounts of urine occurs with increased abdominal pressure (e.g., coughing, laughing, sneezing). Stress-induced detrusor instability is suggested by a 5 to 15 second delay between stress and leakage, and by nocturnal leakage.
Overflow incontinence: Due to impaired detrusor contractility and/or bladder outlet obstruction. There is frequent leakage of small amounts of urine, hesitancy, decreased flow, and incomplete emptying. The post-void residual is increased, and the bladder is palpable. Common mechanisms include bladder outlet obstruction caused by benign prostatic hypertrophy or urethral stricture; decreased detrusor tone due to a herniated disc; or peripheral neuropathy caused by diabetes, pernicious anemia, tabes, or cauda equina.
» READ BOOK EXCERPT ONLINE »
Source: Field Guide to Bedside Diagnosis, 2007
Acute Diarrhea:
Differential Overview
(Field Guide to Bedside Diagnosis)
❑ Viral gastroenteritis
❑ Staphylococcal enterotoxin
❑ E. coli
❑ Salmonella
❑ Campylobacter
❑ Drugs
❑ C. difficile colitis
❑ Giardia
❑ Shigella
❑ Yersinia
❑ Entamoeba histolytica
❑ Typhoid fever
❑ Vibrio parahaemolyticus
❑ Cryptosporidia
❑ Cholera
❑ Strongyloides
Diagnostic Approach
Most cases of acute diarrhea are self-limited. Red flags to prompt further evaluation include: profuse watery diarrhea with dehydration; passage of blood or mucous; temperature .38.5˚C, duration .48 hours; severe abdominal pain in a patient over 50; or an immunocompromised patient.
Symptoms that begin within 6 hours of eating suspect food suggest a preformed toxin of Staph aureus or Bacillus cereus, at 8 to 14 hours Clostridium perfringens, and over 14 hours from viral agents or bacterial contamination of food with E. coli.
Secretory diarrhea is characterized by the absence of fever and prominent nausea/vomiting with watery stools that persist when fasting. It is caused by a toxin (Staph, E. coli, Vibrio cholera), gastrin (pancreatic cancer), calcitonin (medullary carcinoma of the thyroid), or vasoactive intestinal peptide
(VIP). Invasive infection with exudative diarrhea is associated with systemic
symptoms, fever, chills, and blood, pus, and proteinaceous material in
the stools. It is most commonly found with infections such as Salmonella, Shigella, Campylobacter, or enterohemorrhagic E. coli. Bloody diarrhea usually indicates invasive infection, but the differential also includes superior mesenteric artery thrombosis, inflammatory bowel disease, and drug-induced or ischemic colitis.
Small bowel diarrhea is characterized by passage of large loose stools, and with periumbilical pain. Large bowel diarrhea has frequent passage of small stools, with tenesmus.
Common pathogens in HIV-associated diarrhea are cytomegalovirus, Cryptosporidia, Isospora, Salmonella, and Giardia.
» READ BOOK EXCERPT ONLINE »
Source: Field Guide to Bedside Diagnosis, 2007
Chronic Diarrhea:
Differential Overview
(Field Guide to Bedside Diagnosis)
Altered Intestinal Motility
❑ Irritable bowel syndrome
❑ Diabetic enteropathy
Inflammatory
❑ Inflammatory bowel disease
❑ Giardiasis
❑ Cryptosporidiosis
Osmotic
❑ Lactase deficiency
❑ Drugs
❑ Pancreatic insufficiency
❑ Post-gastrectomy
❑ Celiac sprue
❑ Small bowel lymphoma
Secretory
❑ Villous adenoma
❑ Pancreatic cholera
❑ Carcinoid
❑ Zollinger-Ellison syndrome
❑ Medullary carcinoma of the thyroid
Diagnostic Approach
Symptoms of inflammatory diarrhea are fever, abdominal tenderness, blood in the stool, or extraintestinal manifestations such as arthritis, erythema nodosum, pyoderma gangrenosum, or iritis. Osmotic diarrhea is suggested by steatorrhea or carbohydrate malabsorption. It improves with fasting. Secretory diarrhea is evidenced by large volume and watery stools, which persist at night and with fasting. Voluminous watery diarrhea is more likely with small bowel disorders, while small-volume frequent diarrhea occurs with colon disorders.
Fat malabsorption is characterized by increased stool bulk with foul-smelling stools. Stools are difficult to flush and leave oil in the bowl. Weight loss occurs despite adequate appetite and intake. Increased flatulence occurs with carbohydrate malabsorption. Protein-losing enteropathy is associated with peripheral edema and ascites. Malabsorption of fat-soluble vitamins may cause specific deficiencies, such as vitamin A (night blindness and dry eyes), vitamin D (paresthesias and cramps), or vitamin K (easy bruising) deficiencies.
» READ BOOK EXCERPT ONLINE »
Source: Field Guide to Bedside Diagnosis, 2007
Chronic constipation:
Diagnosis
(Handbook of Diseases)
A patient history of dry, hard stool and infrequent bowel movements suggests chronic constipation due to an inactive colon. A digital rectal examination reveals stool in the lower portion of the rectum and a palpable colon. Analoscopy may show an unusually small colon lumen, prominent veins, and an abnormal amount of mucus. Diagnostic tests to rule out other causes include an upper GI series, barium enema, and examination of stool for occult blood from neoplasms.
Colonoscopy may be performed for inactive colon. Manometric studies may be done to exclude Hirschsprung’s disease, and internal and external sphincters may be evaluated.
» READ BOOK EXCERPT ONLINE »
Source: Handbook of Diseases, 2003
Diarrhea:
History
(Alarming Signs and Symptoms: Lippincott Manual of Nursing Practice Series)
Obtain the patient’s history. Does he have abdominal pain and cramps? Difficulty breathing? Is he weak or fatigued? Ask about his drug history. Has he had GI surgery or radiation therapy recently? Ask the patient to briefly describe his diet. Does he have any known food allergies? Lastly, find out if he’s under unusual stress.
Physical examination
If the patient isn’t in shock, proceed with a brief physical examination. Evaluate hydration, check skin turgor and mucous membranes, and take blood pressure with the patient lying, sitting, and standing. Inspect the abdomen for distention, and palpate for tenderness. Auscultate bowel sounds. Check for tympany over the abdomen. Take the patient’s temperature, and note any chills. Also, look for a rash. Conduct a rectal examination and a pelvic examination if indicated.
» READ BOOK EXCERPT ONLINE »
Source: Alarming Signs and Symptoms: Lippincott Manual of Nursing Practice Series, 2007
Constipation:
History
(Signs & Symptoms: A 2-in-1 Reference for Nurses)
Ask the patient to describe the frequency of his bowel movements and the size and consistency of his stools. How long has he been constipated? Acute constipation usually has an organic cause, such as an anal or rectal disorder. In a patient over age 45, a recent onset of constipation may be an early sign of colorectal cancer. Conversely, chronic constipation typically has a functional cause and may be related to stress.
Does the patient have pain related to constipation? If so, when did he first notice the pain, and where is it located? Cramping abdominal pain and distention suggest obstipation — extreme, persistent constipation due to intestinal tract obstruction. Ask the patient if defecation worsens or helps relieve the pain. Defecation usually worsens pain, but with disorders such as irritable bowel syndrome, it may relieve it.
Ask the patient to describe a typical day’s menu; estimate his daily fiber and fluid intake. Ask him, too, about any changes in eating habits, medication or alcohol use, or physical activity. Has he experienced recent emotional distress? Has constipation affected his family life or social contacts? Also, ask about his job. A sedentary or stressful job can contribute to constipation.
Find out whether the patient has a history of GI, rectoanal, neurologic, or metabolic disorders; abdominal surgery; or radiation therapy. Then ask about the medications he’s taking, including over-the-counter preparations, such as laxatives, mineral oil, stool softeners, and enemas.
» READ BOOK EXCERPT ONLINE »
Source: Signs & Symptoms: A 2-in-1 Reference for Nurses, 2007
Diarrhea:
History
(Signs & Symptoms: A 2-in-1 Reference for Nurses)
Explore signs and symptoms associated with diarrhea. Does the patient have abdominal pain and cramps? Difficulty breathing? Is he weak or fatigued? Find out his drug history. Has he had GI surgery or radiation therapy recently? Ask the patient to briefly describe his diet. Does he have any known food allergies? Lastly, find out if he’s under unusual stress.
» READ BOOK EXCERPT ONLINE »
Source: Signs & Symptoms: A 2-in-1 Reference for Nurses, 2007
Urinary incontinence:
History
(Signs & Symptoms: A 2-in-1 Reference for Nurses)
Ask the patient when he first noticed the incontinence and whether it began suddenly or gradually. Have him describe his typical urinary pattern: Does incontinence usually occur during the day or at night? Does he have any urinary control, or is he totally incontinent? If he is occasionally able to control urination, ask him the usual times and amounts voided. Determine his normal fluid intake. Ask about other urinary problems, such as hesitancy, frequency, urgency, nocturia, and decreased force or interruption of the urine stream. Also ask if he has ever sought treatment for incontinence or found a way to deal with it himself.
Obtain a medical history, especially noting urinary tract infection (UTI), prostate conditions, spinal injury or tumor, stroke, or surgery involving the bladder, prostate, or pelvic floor. Ask a woman how many pregnancies she has had and how many childbirths.
» READ BOOK EXCERPT ONLINE »
Source: Signs & Symptoms: A 2-in-1 Reference for Nurses, 2007
Constipation:
Clinical Features and Diagnosis
(The Diagnostic Approach to Symptoms and Signs in Pediatrics)
Constitutional
Some children seem to have predispositionto passage of hard, infrequent bowel movements. Others have colonicinertia with delayed transit time and increased absorption of fluidin colon.
Dietary Factors
Inadequate fluid intake or high-protein dietwithout enough fiber are common factors predisposing to constipation.Undernutrition also may produce constipation.
Developmental, Situational, and Psychologic Disturbances
Often intertwineddevelopmental, situational, and psychologic factors may result in developmentof constipation. In such cases, stool pattern usually is normaluntil toilet training begins at 2–3 yrs. Excessive parentalconcern and forced attempts at defecation often cause conflict thatresults in fecal retention. Common response to negative toilet-trainingexperience or unresolved conflict between child and parent is withholdingof bowel movement.Purposefully avoiding bowel movementduring travel or while at school is another common cause.Stress that produces anxiety or depressionalso may produce constipation because of inability to attend toneed for defecation. Gastrointestinal Disorders
Anal Fissure
Tear in anal mucosa may contribute to constipationbecause children withhold stool rather than experience pain duringbowel movement. Fissures are readily seen on exam of anus.
Anal Stenosis
Less commonanatomic cause. Entire canal or any portion may be involved. Mayoccur in normal child or follow surgical repair of anal atresiaor other anorectal problems.Digital exam or endoscopy confirmsdiagnosis. Anterior Location of Anus
In thisunusual cause, anal opening is closer to vagina or scrotum thannormal.Diagnosis is made by visual inspection. Proctitis
Pain associatedwith proctitis may cause a child to withhold stool, so that constipation develops.Rectal trauma (foreign body) and sexualabuse are common causes of proctitis.History, physical exam, and proctoscopyare diagnostic. Congenital Aganglionic Megacolon (Hirschsprung Disease)
Absenceof ganglion cells in affected segment of intestine is responsiblefor this disorder. Delayed passage of meconium at birth is characteristic.Common manifestation is infrequentpassage of small, hard stools. Slow weight gain, abdominal distension,and empty ampulla on rectal exam are frequent findings.Suction rectal biopsy with acetylcholinesterasestaining can establish diagnosis. Otherwise, full-thickness rectalbiopsy sample that shows absence of ganglion cells is diagnostic.Manometric studies may help in somecases. Cystic Fibrosis
Childrenbeyond neonatal period may develop inspissation of intestinal contentsin terminal ileum, cecum, and proximal colon. Formerly called meconiumileus equivalent, this condition is now known as distal intestinalobstruction syndrome.Usual findings are vomiting, abdominalpain, and failure to pass bowel movements. Intestinal obstructionrequiring surgery may occur in some cases.See Chap.10, Cough, and Chap.14, Diarrhea. Celiac Disease
Althoughdiarrhea is usually the presenting symptom of celiac disease andoccurs in most cases, a few children may have constipation and markedabdominal distension.See Chap.14, Diarrhea. Chronic Intestinal Pseudoobstruction
Rare groupof familial and nonfamilial disorders of gastrointestinal smoothmuscle and enteric nervous system associated with ineffective intestinalmotility.Besides constipation, vomiting, crampyabdominal pain, and abdominal distension also may occur.See Chap.55, Regurgitation and Vomiting. Abdominal, Pelvic, and Sacral Masses
Large abdominal,pelvic, or sacral mass may compress colon and rectum and cause constipation.Besides abdominal exam, abdominal radiography,abdominal U/S, CT, and MRI are useful in locating and definingextent of mass.See Chap.1, Abdominal Masses. Neurologic Disorders
Neurologicallyimpaired children may have constipation because of difficulty in learningproper bowel control. Common example is mental retardation.Constipation also may be associatedwith spinal dysraphism, spinal cord injury, or spinal tumor becauseof damage to sensory and motor nerves in T12–S3 distribution.History and physical exam with absence of cremasteric reflex andanal wink along with poor rectal tone should suggest diagnosis.CT and MRI locate and define extent of lesions.Neuromuscular disorders (e.g., spinalmuscular atrophy, myasthenia gravis, muscular dystrophies, and infantbotulism) also may result in constipation.See Chap.33, Hypotonia and Weakness. Metabolic Disorders
Constipationmay occur with hypothyroidism and diabetes insipidus.See Chap.23, Growth Deficiency: Weight and Height, and Chap. 47, Polyuria and Polydipsia. Drugs
Some commonly used drugs that may produceconstipation include opioids, diuretics, anticholinergics, antacids(aluminum), phenytoin, and calcium channel blockers.
Diagnostic Approach
Diagnosisof many causes of constipation can be made by history and physicalexam.Age is a key factor. Although neonatesare more likely to have anatomic cause, most common causes in infantsand children are inadequate fluid and fiber in diet and combinationof developmental, situational, and psychologic factors.Physical exam is usually normal withmild constipation, whereas with severe constipation, stool is oftenpalpable in lower left quadrant and rectum is filled with hard feces.Abdominal radiograph shows presenceof stool, its extent, and whether lower spine is normal.If constipation fails to improve withusual therapy of adequate fluid intake, high-fiber diet, and laxatives,other disorders (e.g., congenital aganglionic megacolon) shouldbe suspected.
» READ BOOK EXCERPT ONLINE »
Source: The Diagnostic Approach to Symptoms and Signs in Pediatrics, 2006
Diarrhea:
Clinical Features and Diagnosis: Acute Diarrhea
(The Diagnostic Approach to Symptoms and Signs in Pediatrics)
Infection
Gastroenteritis
Viral
Rotavirus
Most commoncause of viral gastroenteritis in North America.Usually occurs between 3 mos and 3yrs of age.Although most common during wintermonths, it may occur year round.Diarrhea may be accompanied by feverand vomiting. Blood is not usually found in stools. Usually lastsfor few days and up to 1 wk.Detection of rotavirus antigen in stoolby enzyme immunoassay is diagnostic. Other Viruses
Adenovirusesmay be associated with acute gastroenteritis, especially in children <2 yrsof age.Illnessusually occurs during summer.Stool viral culture is diagnostic. Caliciviruses, which include Norwalkand Norwalk-like viruses, usually cause epidemics in school-agedchildren or adults.Infection usually comes from contaminated wateror food.Cramping abdominal pain, vomiting,and low-grade fever may be associated with diarrhea. Illness usuallylasts several days.Diagnostic tests include enzyme immunoassayfor detection of viral antigen in stool or antibody in serum, reverse-transcriptasepolymerase chain reaction for detection of viral RNA in stool, and electronmicroscopy for detection of viral antigen in stool. Astrovirus infection usually occursduring winter.Vomitingand fever are variable findings.Stool viral culture is diagnostic. Role of enteroviruses in GI diseaseis still unsettled.Although diarrhea may occur, incidence is probablyvery low.Stool viral culture is diagnostic. Bacterial
Most commoncauses of bacterial diarrhea include Salmonella species, Shigellaspecies, C. jejuni, and E. coli. Less common are Y. enterocolitica,A. hydrophila, C. difficile, V. parahaemolyticus, non-O1 Vibrioserogroups, S. aureus, and C. perfringens.Positive bacterial stool culture isdiagnostic. Salmonella
Most commoncause of bacterial diarrhea in children.Presentation is variable.Uncomplicatedacute gastroenteritis is associated with diarrhea, vomiting, cramping abdominalpain, and fever, with resolution usually within 1 wk. Blood in stoolis variable finding.Salmonella food poisoning occurs 12–24hrs after ingestion of contaminated food or milk products. Vomiting,diarrhea, and abdominal cramping pain usually occur for 2–3days. History and positive culture of stool or contaminated foodproduct are diagnostic.Enteric or typhoid fever causes abdominalpain and diarrhea. During second week of illness, fine pink macularor papular rash with typical rose spots occurs, and S. typhi maybe isolated from stool and blood. Shigella
Usual clinicalpresentation of intestinal shigellosis is watery diarrhea and fever. Bloodin stool is variable finding. Occasionally, seizure occurs.Another presentation is dysentery,which is characterized by severe diarrhea, tenesmus, and fever.Stools contain mixture of blood, mucus, and pus. Campylobacter jejuni
Peak incidenceof illness due to C. jejuni is between 1 and 5 yrs of age.Clinical findings include fever, vomiting,abdominal pain, and watery, foul-smelling diarrhea. Stools may containblood and mucus. Escherichia coli
5 groupsof pathogenic E. coli are recognized: enteropathogenic, enterotoxigenic,enteroinvasive, enteroaggregative, and enterohemorrhagic. In theU.S., disease caused by first 4 groups is uncommon, whereas enterohemorrhagicform is often associated with diarrheal illness seen with hemolytic-uremicsyndrome (HUS).Although stool culture can identifyE. coli, serotyping must be performed to identify specific strains.Enteropathogenic strains cause diarrheaand low-grade fever, primarily in infants.Enterotoxigenic strains produce toxinsthat cause watery diarrhea, vomiting, abdominal cramping pain, andlow-grade fever. Major cause of traveler's diarrhea, butdefinitive diagnosis requires enterotoxin identification, whichis not widely available.Enteroinvasive strains produce illnesscharacterized by watery diarrhea, abdominal cramps, and high feverwith or without blood in stool. Outbreaks usually occur secondaryto food contamination.Enteroaggregative strains usually producemild chronic diarrhea.Enterohemorrhagic strains produce toxinsthat cause watery diarrhea mixed with streaks of blood, hemorrhagiccolitis, or HUS. Serotype 0157:H7 is most common strain associatedwith HUS. Other Bacterial Pathogens
Infectionwith Y. enterocolitica is most common in children <5 yrsof age.Clinical findings include fever, vomiting,diarrhea with occasional blood in stool, and right lower quadrantabdominal pain, which may mimic pain of acute appendicitis. Associatedreactive arthritis also may occur. Diarrhea usually lasts 1–2wks.Usual presentation of A. hydrophilainfection is self-limited, watery diarrhea that usually occurs inchildren <3 yrs of age. Vomiting, fever, and occasionalblood in stools also may occur.Transmission of V. cholerae, rare infectionin the U.S., occurs by contaminated food or water. Ingested bacteriarelease toxin in intestinal lumen that causes explosive diarrheawith rice water–like stools and massive fluid losses. Parasitic
Giardia lamblia
G. lamblia,flagellate protozoan, is most common intestinal parasite in the U.S.Can cause acute self-limited illnesswith diarrhea and crampy abdominal pain or chronic diarrhea withmalabsorption and poor weight gain. Fever is unusual, and bloodin stool is rare. Eosinophilia occurs in minority of cases.Presence of either trophozoites orcysts in stool or detection of G. lamblia antigens in stool by enzymeimmunoassay is diagnostic. Entamoeba histolytica
Althoughmany species of amebae exist, only E. histolytica is clearly pathogenic.Transmission occurs by fecal contaminationof food or water.Infection is endemic throughout theworld, especially where poor sanitation exists.Clinical manifestations include diarrheaand abdominal pain or acute colitis with abdominal cramps, tenesmus,and diarrhea containing blood and mucus.Diagnosis is usually made by identificationof cysts or trophozoites in stool. Serology also may be helpful,particularly with diagnosis of extraintestinal amebiasis and liverinvolvement. Cryptosporidium parvum
Infectionhas been described in normal persons, individuals with drug-inducedimmunosuppression, and those with HIV.Normal individuals usually have self-limitedillness, which consists of crampy epigastric pain, nausea, vomiting,and watery, nonbloody diarrhea.Chronic diarrhea may occur with HIVinfection.Identification of oocysts in stoolis diagnostic. Strongyloides stercoralis
This roundworm,2.5 mm in length, is endemic in southern U.S. and common in tropicsand Asia.Skin becomes red and pruritic afterpenetration by larvae, which usually occurs on feet. Diarrhea, vomiting,and abdominal pain may follow. Migration of larvae through lungscan cause cough and pneumonia. Peripheral eosinophilia also mayoccur.Identification of larvae in stool isdiagnostic. Ascaris lumbricoides
Infectioncan be asymptomatic or cause mild diarrhea, intermittent epigastricpain, anorexia, and vomiting.Identifying whitish-brown Ascaris worm,20–40 cm in length, or finding Ascaris eggs on microscopicexam of stool is diagnostic. Hookworm Infection
Adult hookwormsN. americanus and A. duodenale can cause red, pruritic lesions on feetor between toes where larvae penetrate. Other manifestations includediarrhea, vomiting, abdominal pain, anemia from GI blood loss, andperipheral eosinophilia.Detecting hookworm eggs on stool smearis diagnostic. Trichuris trichiura
T. trichiura,4-cm long whipworm, occurs most commonly in tropical areas but isalso found in subtropical areas (e.g., southern U.S.).Most individuals are asymptomatic,but diarrhea, tenesmus, weight loss, anemia, and peripheral eosinophiliamay occur.Seeing eggs on microscopic stool examis diagnostic. Fungal
Candida Species
C. albicansis most common cause of Candida enteritis, which is characterizedby watery diarrhea and abdominal pain.Predisposing factors include prolongedantibiotic or immunosuppressive therapy.Because yeast forms are ubiquitousand occur in fecal flora of normal persons, their presence aloneis not diagnostic. Definitive diagnosis requires demonstration ofintestinal mucosal invasion by Candida on biopsy or isolation ofCandida from ulcerative lesions. Other Infections
Diarrhea also may be associated with otitismedia, urinary tract infection, meningitis, and septicemia (seefurther discussion of these disorders in other chapters).
Food Poisoning
Occurs becauseof food contaminated with bacterial toxins. Most common bacteria areS. aureus, C. perfringens, and V. parahaemolyticus.Children usually have acute onset ofcrampy abdominal pain, vomiting, and profuse watery diarrhea.Resolution usually occurs in 2–3days.Positive stool culture or culture ofsuspected contaminated food is confirmatory. Antibiotic-Associated Diarrhea
Oral antibiotictherapy may produce mild, self-limited diarrhea, nausea, vomiting, andabdominal pain.Frequently implicated antibiotics includeamoxicillin, erythromycin, and tetracycline. Discontinuing drugleads to resolution of diarrhea.C. difficile–associated diseasepresumably occurs because of antibiotic alteration of colonic floraallowing spores to form vegetative forms that produce toxins. Almostany antibiotic can be implicated, but most frequent ones are amoxicillin,ampicillin, cephalosporins, and clindamycin. Spectrum of illnessvaries from self-limited diarrhea to severe colitis.Confirm diagnosis with assay specificfor C. difficile toxin because nontoxigenic strains can be isolatedfrom anaerobic cultures. Sigmoidoscopy with biopsy can show typicalmultiple plaquelike lesions (pseudomembranes) in colon. Allergic Disorders
Developmentof diarrhea after formula feeding may indicate cow milk proteinor soy protein sensitivity.Clinical picture is variable, rangingfrom acute enterocolitis to chronic diarrhea with or without bloodin stools. Cow Milk Protein Sensitivity
Although >25known proteins in cow milk are immunogenic, casein and beta-lactoglobulinare of most clinical importance.Besides diarrhea, other manifestationsof cow milk protein sensitivity are urticaria and anaphylaxis.Positive skin tests are useful butmay be negative in children <3 yrs. There also may be false-positiveresults with radioallergosorbent test to cow milk protein.Elimination of cow milk with subsequentchallenge can confirm diagnosis, but if symptoms have been severe,most physicians would not rechallenge. Soy Protein Sensitivity
Many infantswith cow milk protein sensitivity also have soy protein sensitivity.Most common presentation is persistentdiarrhea.History of soy protein formula intakefollowed by clearance of symptoms on hypoallergenic formula [Alimentum(Abbott Laboratories, Abbott Park, IL), Nutramigen (Mead JohnsonNutritionals, Evansville, IN), Neocate (SHS North America, Gaithersburg,MD)], and if necessary, rechallenge with soy formula confirmsdiagnosis. Other Food Allergy
Common causesbesides milk and soy include eggs, chocolate, shellfish, citrusfruits, and nuts.Clinical manifestations include diarrhea,urticaria, rhinitis, wheezing, eczema, and anaphylaxis.History is often diagnostic. Double-blindfood challenges are also diagnostic but can be dangerous if severeallergic reactions have previously occurred. Congenital Aganglionic Megacolon (Hirschsprung Disease)
Characterizedby absence of enteric ganglia along variable length of intestine.May present in many ways, including delayed passage of meconium;constipation; intestinal obstruction with vomiting and abdominaldistension; or enterocolitis with explosive diarrhea, abdominaldistension, vomiting, and fever.Suction rectal biopsy with acetylcholinesterasestaining is usually diagnostic. Hemolytic-Uremic Syndrome
E. coli0157:H7 is most common pathogen associated with HUS.Onset often begins with fever, vomiting,abdominal pain, and diarrhea, which may contain blood, followedin 5–10 days by hemolytic anemia, hematuria, thrombocytopenia,and often oliguria or anuria. Intussusception
Most commonage of presentation is 6–12 mos. Usual clinical manifestationsare crampy abdominal pain, vomiting, and blood in stool. Abdominalmass may be palpable, and diarrhea may occasionally occur.Abdominal radiographs that show leadingedge of intussusceptum outlined by air are diagnostic. Otherwise,radiographs may be normal or show evidence of bowel obstruction.If intussusception is suspected, air-contrastenema should be performed. If bowel obstruction is suspected, surgicalconsultation should be obtained before proceeding with air-contrastenema. Diagnostic Approach: Acute Diarrhea
Most commoncause of acute diarrhea is infection with rotavirus. Common bacterial pathogensinclude Salmonella species, Shigella species, and C. jejuni.Presence of fever and blood or pusin stool suggests bacterial infection, and bacterial stool cultureshould be performed.Stool toxin assay for C. difficileshould be considered whenever diarrhea persists during or followingantibiotic therapy.Cow milk or soy protein sensitivityis likely when diarrhea occurs after ingestion of these productsand no evidence of infection or antibiotic usage exists.Intussusception and HUS also shouldbe considered in children with bloody diarrhea. '>'>>>
» READ BOOK EXCERPT ONLINE »
Source: The Diagnostic Approach to Symptoms and Signs in Pediatrics, 2006
Fecal Incontinence:
Clinical Features and Diagnosis
(The Diagnostic Approach to Symptoms and Signs in Pediatrics)
Maturational Delay or Developmental Conflict
Some childrenexperience maturational delay in developing bowel control. Others havenever been toilet trained.Sometimes developmental conflicts resultin fecal incontinence.History and normal physical exam arediagnostic. Stress-Related Factors
Stress iscommon cause of secondary fecal incontinence. Stress-related factorsinclude illness, separation, birth of sibling, attending new school,death of family member, parental divorce, or any other personalor family upset.History and normal physical exam arediagnostic. Constipation
Chronicconstipation from functional fecal retention is thought to be majorcause of encopresis, which is defined as fecal incontinence notresulting from illness or organic disorder.Most cases of encopresis occur in school-agedchildren, who soil their underclothes.See Chap.9, Constipation. Neurologic Disorders
Childrenwith mild mental retardation may have delay in achieving bowel control, whilesome with severe retardation never achieve control.Spinal dysraphism, spinal cord injury,or spinal cord tumor can be associated with fecal incontinence.History andphysical exam, including rectal and neurologic exams, screen forthese disorders. Often there is history of lower extremity weakness,impaired sensation, and lack of bladder or bowel control. Strength,tone, sensation, and reflexes of lower extremities; back; anal sphinctertone; perianal sensation; and gait should be particularly examined.Spine radiography, CT, and MRI locateand define extent of lesion. Primary Psychologic Disturbance
Childrenwith severe behavioral disorders or psychosis may develop fecalincontinence.History (including psychosocial historyof child and family), physical exam, clinical observation of child,and psychologic testing are diagnostic. Diagnostic Approach
In childwith normal physical exam, most common causes of fecal incontinenceare maturational delay, developmental conflict, stress-related factors,and constipation. If primary psychologic disturbance exists, furtherevaluation should be performed by clinical psychologist or psychiatrist.History and physical exam can screenfor a neurologic disorder. Relaxed anal sphincter tone, decreasedperianal sensation, lower extremity weakness, and urinary incontinencesuggest spinal cord lesion. Combination of spine radiography, CT,and MRI is usually diagnostic.
» READ BOOK EXCERPT ONLINE »
Source: The Diagnostic Approach to Symptoms and Signs in Pediatrics, 2006
Urinary Incontinence:
Clinical Features and Diagnosis
(The Diagnostic Approach to Symptoms and Signs in Pediatrics)
Maturational Delay
Most commoncause of primary urinary incontinence is lag in maturation of normal inhibitingmechanism of urine control. There is often family history of incontinence.Many children may achieve daytime controlbut still experience incontinence during sleep.This is a diagnosis of exclusion inan otherwise normal child who has no evidence of organic disease,no history of stress-related or psychologic disturbance, and normalUA and urine culture.At 5–10 yrs of age, spontaneouscure rate of nocturnal enuresis is about 15%/yr. Stress-Related Causes
Stress is frequent cause of secondary incontinence.Examples of stress-related factors are illness, separation, birthof sibling, attending new school, death of family member, divorcein family, and other personal and family problems. Once problemis recognized, proper support and counseling usually help with itsresolution.
Urinary Tract Disorders
Urinary Tract Infection
May causenighttime and daytime incontinence.Other common findings include fever,dysuria, urinary frequency, abdominal or flank pain, and vomiting.Positive urine culture confirms diagnosis(see Chap. 15, Dysuria). Dysfunctional Voiding Disorders
Voidingdysfunction occurs in many children who do not have known organiccause (e.g., neurologic disorder, injury, or malformation).Although some children have small-capacitybladder and experience urgency and often incontinence, others havehyperreflexic bladder with uninhibited detrusor contractions duringfilling. Still others have large hypotonic bladder that does notempty completely with voiding.Failure to empty bladder results inchronically distended bladder that is prone to urinary tract infectionand overflow incontinence.Urinary urodynamic testing is helpfulin determining abnormality in each case. Lower Urinary Tract Obstruction
Can producebladder distension and overflow incontinence. Poor urinary streamwith dribbling and excessive straining with urination are prominentfeatures.Specific causes include posterior urethralvalves, urethral duplication, or urethral cyst.Combination of tests including renalU/S, intravenous urography, and voiding cystourethrographyusually can confirm diagnosis. Retrograde urethrography is generallyrequired for adequate evaluation of urethral duplication. Ectopic Ureter in Girls
Ectopicureter may empty into bladder neck, urethra, vagina, or, rarely,uterus with continuous leakage of small amount of urine. Child hasnormal voiding habits but is frequently wet.Because of frequent occurrence of completeureteral duplication and associated renal parenchymal dysplasiain segment drained by ectopic ureter, renal U/S, intravenousurography, and voiding cystourethrography are useful in evaluation.If diagnosis remains uncertain afterthese studies, but ectopic ureter is still suspected, magnetic resonanceurography may be diagnostic. Cystoscopy can help identify ureteralorifice if it is in urethra, whereas vaginoscopy may be needed ifureter empties into vagina. Neurologic Disorders
Mental Retardation
Although children with mild mental retardationmay have voluntary control of urination, they may have incontinencefor behavioral reasons, while those with severe retardation usuallylack voluntary control of urination.
Neurogenic Bladder
Lower extremityweakness, gait disturbance, fecal incontinence, decreased or absent perianalsensation, and lack of normal anal sphincter tone are common findingsin children with neurogenic bladder.Bladder size can be small, normal,or large, but usually it is small with thick wall.Evaluation of urinary tract may includerenal U/S, voiding cystourethrography, and urodynamic testing.Spinal dysraphism, a common cause ofneurogenic bladder in children, includes myelomeningocele, congenitaldermal sinus, diastematomyelia, and tethered cord syndrome.Myelomeningoceleand dermal sinus tract are visible on physical exam.Diastematomyelia is the splitting ofspinal cord at 1 or more vertebral levels, usually by bony or fibrousspur in spinal canal. The bone spicule may be detectable on spineradiography, but MRI is definitive imaging procedure.Tethering of spinal cord maintainsabnormally low position of cord and prevents its normal ascent.Lipoma, dermoid cyst, or dermal sinus tract are associated lesions,and MRI is diagnostic. Other causes of neurogenic bladderare sacral agenesis, spinal cord injury, and spinal cord tumors.Failure to palpate sacrum and coccyxsuggest sacral agenesis. Radiography of lumbosacral spine showsabsence of sacral segments.History of trauma exists with spinalcord injury.Tumors affecting spinal cord are discussedin Chap. 5, Back Pain. Abdominal or Pelvic Mass
Abdominal or pelvic mass (fecal impaction,mesenteric cyst, presacral teratoma) that impinges on bladder cancause urinary incontinence during running, laughing, coughing, orlifting. Abdominal or pelvic U/S is most useful screeningtest.
Polyuria
Childrenwith diabetes mellitus may have incontinence, especially at night,if they have persistent hyperglycemia that is difficult to control.Other causes of polyuria are diabetes insipidus and psychogenicpolydipsia.Diabetes insipidus is associated withdefect in urine-concentrating ability. Random sample of urine withspecific gravity of >1.028 rules out concentration defect.Even specific gravity of >1.020 on random or early-morningurine sample is evidence of good concentrating ability and againstconcentrating defect.Children with persistent polyuria mayhave structural and functional changes in bladder, which contributeto voiding dysfunction.See Chap.47, Polyuria and Polydipsia. Primary Psychologic Disturbance
Urine incontinence occurs in some childrenwith primary psychologic problems (e.g., depression, a severe personalityor behavioral disorder, or psychosis). History, physical exam, clinicalobservation, and psychologic testing are diagnostic.
Diagnostic Approach
Thoughtfullistening to parents and child usually reveals maturational, stress-related, orother psychologic factors that contribute to urinary incontinence.History, physical exam, UA (includingmeasurement of specific gravity), and urine culture screen for organicdisorders and are helpful in pinpointing the cause of urinary incontinence.Physical exam should include observation of any gait disturbance,exam of sacrum, and testing of perianal sensation, anal sphinctertone, and lower extremity strength, sensation, and reflexes.Abdominal U/S is useful forsuspected lower urinary tract obstruction, ectopic ureter, and abdominalor pelvic mass. Urinary urodynamic testing helps distinguish varioustypes of dysfunctional voiding disorders. CT and MRI are usefulin diagnosis of lesions that cause neurogenic bladder.
» READ BOOK EXCERPT ONLINE »
Source: The Diagnostic Approach to Symptoms and Signs in Pediatrics, 2006
Constipation:
History and physical examination
(Nursing: Interpreting Signs and Symptoms)
Ask the patient to describe the frequency of his bowel movements and the size and consistency of his stools. How long has he had constipation? Acute constipation usually has a physiological cause such as an anal or rectal disorder. In a patient older than age 45, a recent onset of constipation may be an early sign of colorectal cancer. Conversely, chronic constipation typically has a functional cause and may be related to stress.
Does the patient have pain related to constipation? If so, when did he first notice the pain, and where is it located? Cramping abdominal pain and distention suggest obstipation—extreme, persistent constipation due to intestinal tract obstruction. Ask the patient if defecation worsens or helps relieve the pain. Defecation usually worsens pain, but with such disorders as irritable bowel syndrome, it may relieve it.
Ask the patient to describe a typical day's diet; estimate his daily fiber and fluid intake. Ask him about recent changes in eating habits, medication or alcohol use, or physical activity. Has he experienced recent emotional distress? Has constipation affected his family life or social contacts? Also ask about his job and exercise pattern. A sedentary or stressful job can contribute to constipation.
Find out whether the patient has a history of GI, rectoanal, neurologic, or metabolic disorders; abdominal surgery; or radiation therapy. Then ask about the medications he's taking, including opioids and over-the-counter preparations, such as laxatives, mineral oil, stool softeners, and enemas.
Inspect the abdomen for distention or scars from previous surgery. Then auscultate for bowel sounds, and characterize their motility. Percuss all four quadrants, and gently palpate for abdominal tenderness, a palpable mass, and hepatomegaly. Next, examine the patient's rectum. Spread his buttocks to expose the anus, and inspect for inflammation, lesions, scars, fissures, and external hemorrhoids. Use a disposable glove and lubricant to palpate the anal sphincter for laxity or stricture. Also palpate for rectal masses and fecal impaction. Finally, obtain a stool sample and test it for occult blood.
As you assess the patient, remember that constipation can result from several life-threatening disorders, such as an acute intestinal obstruction and mesenteric artery ischemia, but it doesn't herald these conditions.
» READ BOOK EXCERPT ONLINE »
Source: Nursing: Interpreting Signs and Symptoms, 2007
Diarrhea:
History and physical examination
(Nursing: Interpreting Signs and Symptoms)
If the patient isn't in shock, proceed with a physical examination. Evaluate hydration, check skin turgor and mucous membranes, and take blood pressure with the patient lying, sitting, and standing. Inspect the abdomen for distention, and palpate for tenderness. Auscultate bowel sounds. Check for tympany over the abdomen. Take the patient's temperature, and note any chills. Also, look for a rash. Conduct a rectal examination and a pelvic examination if indicated.
Explore signs and symptoms associated with diarrhea. Does the patient have abdominal pain and cramps? Difficulty breathing? Is he weak or fatigued? Find out his drug history. Has he had GI surgery or radiation therapy recently? Ask the patient to briefly describe his diet. Does he have any known food allergies? Last, find out if he's under unusual stress.
» READ BOOK EXCERPT ONLINE »
Source: Nursing: Interpreting Signs and Symptoms, 2007
Fecal incontinence:
History and physical examination
(Nursing: Interpreting Signs and Symptoms)
Ask the patient with fecal incontinence about its onset, duration, and severity and about any discernible pattern—for example, does it occur at night or only with episodes of diarrhea? Note the frequency, consistency, and volume of stools passed within the past 24 hours and obtain a stool specimen. Focus your history taking on GI, neurologic, and psychological disorders.
Let the history guide your physical examination. If you suspect a brain or spinal cord lesion, perform a complete neurologic examination. (See Neurologic control of defecation.) If a GI disturbance seems likely, inspect the abdomen for distention, auscultate for bowel sounds, and percuss and palpate for a mass. Inspect the anal area for signs of excoriation or infection. If not contraindicated, check for fecal impaction, which may be associated with incontinence.
» READ BOOK EXCERPT ONLINE »
Source: Nursing: Interpreting Signs and Symptoms, 2007
Urinary incontinence:
History and physical examination
(Nursing: Interpreting Signs and Symptoms)
Ask the patient when he first noticed the incontinence and whether it began suddenly or gradually. Have him describe his typical urinary pattern: Does incontinence usually occur during the day or at night? Does he have any urinary control, or is he totally incontinent? If he can occasionally control urination, ask him the usual times and amounts voided. Determine his normal fluid intake. Ask about other urinary problems, such as hesitancy, frequency, urgency, nocturia, and decreased force or interruption of the urine stream. Also ask if he has ever sought treatment for incontinence or found a way to deal with it himself.
Obtain a medical history, especially noting urinary tract infection (UTI), prostate conditions, spinal injury or tumor, stroke, or surgery involving the bladder, prostate, or pelvic floor. Ask a woman how many pregnancies she has had and how many childbirths. A diary of voiding habits for a 24- to 48-hour period may provide useful information. Obtain a complete drug history.
After completing the history, have the patient empty his bladder. Inspect the urethral meatus for obvious inflammation or anatomic defect. Have female patients bear down; note any urine leakage. Gently palpate the abdomen for bladder distention, which signals urine retention. Perform a complete neurologic assessment, noting motor and sensory function and obvious muscle atrophy.
» READ BOOK EXCERPT ONLINE »
Source: Nursing: Interpreting Signs and Symptoms, 2007
CONSTIPATION:
Approach to the Diagnosis
(Differential Diagnosis in Primary Care)
Rectal examination for a fecal impaction and subsequent enemas are the
first steps if no contraindication exists. This may disclose a fissure,
inflamed hemorrhoid, or abscess. Pelvic examination must be done in all
female patients. If nothing is found here a proctoscopic examination and
barium enema would be indicated, provided the neurologic examination and a
flat plate of the abdomen are normal. Careful inquiry about diet, drugs, and
emotional stress should be made.
» READ BOOK EXCERPT ONLINE »
Source: Differential Diagnosis in Primary Care, 2007
INCONTINENCE, URINARY:
Approach to the Diagnosis
(Differential Diagnosis in Primary Care)
First, exclude stress incontinence with a pad test. Perineal pads are
weighed before and after walking and stress for 30 minutes. An increase in
weight identifies urine loss. Catheterization and examination, smear, and
culture of the urine are essential at the outset. Cystoscopy and cystometric
studies are often needed. Surgical repair of a cystocele or a
parasympathomimetic drug in cases of a flaccid neurogenic bladder and
propantheline bromide (ProBanthine), a parasympatholytic drug, for spastic
neurogenic bladders may be all that is necessary. A neurologist and
urologist often need to cooperate in the diagnosis and treatment of these
unfortunate individuals.
» READ BOOK EXCERPT ONLINE »
Source: Differential Diagnosis in Primary Care, 2007
INCONTINENCE, FECAL:
Approach to the Diagnosis
(Differential Diagnosis in Primary Care)
Before beginning an expensive diagnostic workup, pay attention to the
history and physical examination. Is there a small volume of stool? Look for
an anal fissure, hemorrhoids, or other causes of sphincter incompetence. If
the incontinence is sporadic, look for organic brain syndrome, epilepsy, or
functional psychosis. If the neurologic examination reveals pathologic or
hyperactive reflexes in the lower extremities, consider a spinal cord or
brainstem lesion. If there are hypoactive reflexes in the lower extremities,
consider the possibility of cauda equina tumor or tabes dorsalis. Careful
digital examination will often reveal a local cause. If the sphincter is
tight, consider a spinal cord lesion. If it is flaccid, consider a lesion of
the cauda equina or nerve roots.
Patients with signs of mental deterioration need a CT scan or MRI of the
brain. Normal pressure hydrocephalus can be excluded by radioactive
cisternography. Patients with hyperactive reflexes in the lower extremities
need a CT scan or MRI of the suspected level of spinal cord involvement,
whereas patients with hypoactive reflexes require an MRI of the lumbar spine
or myelography. Anorectal manometry and defecography will assist in the
diagnosis of anal and rectal sphincter dysfunction. A neurologist or
gastroenterologist may need to be consulted.
» READ BOOK EXCERPT ONLINE »
Source: Differential Diagnosis in Primary Care, 2007
It's no secret that our bodies change as we age, and some adjustments are unavoidable. But urinary incontinence is one problem older people...
Diagnosing irritable bowel syndrome today is often simpler than it has been in the past. Doctors used to focus on ruling out other diseases and...
Some people with vague digestive symptoms needlessly suffer in silence believing there is no treatment. Abdominal discomfort, bloating, and either...
Pain and bowel irregularities caused by irritable bowel syndrome (IBS) can make a marked impact on day-to-day living. Abdominal discomfort, bloating,...
See full list of 38 related videos
» Next page: Signs of Fecal incontinence
Rate This Website
What do you think about the features of this website?
Take our user survey and have your say:
Website User Survey
Medical Tools & Articles:
Next articles:
Tools & Services:
Medical Articles:
Forums & Message Boards
- Ask or answer a question at the Boards:
