Diagnostic Tests for Fecal incontinence
Fecal incontinence: Diagnostic Tests
The list of diagnostic tests
mentioned in various sources as
used in the diagnosis of Fecal incontinence
includes:
Fecal incontinence Tests: Book Excerpts
Home Diagnostic Testing
These home medical tests may be relevant to Fecal incontinence:
- Bladder & Urinary Health: Home Testing:
- Food Allergies & Intolerances: Home Testing:
- Kidney Health: Home Testing:
- Digestive-Related Home Testing:
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 of 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 the diagnostic tests for Fecal incontinence.
CONSTIPATION:
DIAGNOSTIC WORKUP
(Algorithmic Diagnosis of Symptoms and Signs)
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.
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Source: Algorithmic Diagnosis of Symptoms and Signs, 2003
INCONTINENCE OF FECES:
DIAGNOSTIC WORKUP
(Algorithmic Diagnosis of Symptoms and Signs)
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.
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Source: Algorithmic Diagnosis of Symptoms and Signs, 2003
INCONTINENCE OF URINE:
DIAGNOSTIC WORKUP
(Algorithmic Diagnosis of Symptoms and Signs)
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.
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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
.
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Source: Algorithmic Diagnosis of Symptoms and Signs, 2003
DIARRHEA, ACUTE:
DIAGNOSTIC WORKUP
(Algorithmic Diagnosis of Symptoms and Signs)
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.
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Source: Algorithmic Diagnosis of Symptoms and Signs, 2003
DIARRHEA, CHRONIC:
DIAGNOSTIC WORKUP
(Algorithmic Diagnosis of Symptoms and Signs)
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.
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Source: Algorithmic Diagnosis of Symptoms and Signs, 2003
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.
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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.
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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.
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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:
Physical examination
(The 10-Minute Diagnosis Manual: Symptoms and Signs in the Time-Limited Encounter)
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:
Physical examination
(The 10-Minute Diagnosis Manual: Symptoms and Signs in the Time-Limited Encounter)
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.
Testing (5)
A. Acute diarrhea. Laboratory testing should be reserved for those patients with severe symptoms (e.g., fever, bloody diarrhea, abdominal pain, and dehydration, or symptoms not improving after 5 days) or a comorbid condition. Examination of the stool sample is the most important laboratory test. A single specimen should be submitted for a Wright’s stain for leukocytes, occult blood, Sudan stain for fat, and selected bacterial cultures (Salmonella, Shigella, Campylobacter, and Yersinia organisms). Large numbers of white cells are consistent with inflammatory causes, whereas isolated occult or gross blood may suggest amebiasis, neoplastic disease, vascular disease, or intestinal ischemia. If excess fat is present, malabsorption should be considered (e.g., celiac sprue). Clostridium difficile toxin should be obtained in the elderly and in those with a recent antibiotic history. Tests for ova and parasites on three consecutive specimens should be done in patients with diarrhea that persists for more than 7 to 10 days. In patients where ova and parasite testing is negative and clinical suspicion is high, an enzyme-linked immunosorbent assay test for the Giardia antigen should be considered as well as a wet mount examination of the stool for amebiasis. Sigmoidoscopy is warranted acutely in patients with symptoms of severe proctitis and in patients with suspected C. difficile colitis who appear ill. Rectal swabs for Chlamydia, herpes simplex virus, and gonorrhea may additionally be warranted in sexually active patients with severe proctitis.
B. Chronic diarrhea. Additional tests to be considered include complete blood count, serum electrolytes, liver function tests, calcium, phosphate, albumin, B12, folate, and iron studies to rule out significant abnormalities secondary to the diarrhea, nutritional abnormalities, or hepatobiliary disease. Thyroid studies, serum gastrin, and vasoactive intestinal peptide should be ordered if clinically indicated. Sigmoidoscopy, which allows direct visualization for biopsy and culture, may be helpful in detecting inflammatory bowel disease. Barium studies of the small and large bowel can identify Crohn’s disease, blind loops, celiac sprue, fistulae, and tumors. The stool specimen can be alkalinized for phenolphthalein, consistent with laxative abuse. The presence of steatorrhea warrants a 72-hour collection of stool fat (Chapter 9.12). A gastroenterologist can pursue additional specialized testing, including upper endoscopy with biopsy, breath testing for malabsorption, and pancreatic function testing.
Diagnostic assessment
A careful history helps to classify the diarrhea, provides clinical clues for selected diagnostic testing, and aids in risk stratifying the patient. Comorbid diseases and associated symptoms increase the urgency for diagnostic workup and management (e.g., fever, symptoms > 5 days, bloody diarrhea, known exposures, weight loss). Abnormal vital signs or bloody diarrhea identify patients at higher risk who require early therapeutic intervention. Although most diarrhea is benign and self-limited, a thorough history, focused physical examination, and directed laboratory testing will identify those cases requiring early diagnostic evaluation, aggressive management, or referral.
References
1. Kroser JA, Metz DC. Evaluation of the adult patient with diarrhea. Primary Care 1996;23(3):629–647.
2. Blacklow NR, Greenberg HB. Viral gastroenteritis. N Engl J Med 1991;325(4):
252–264.
3. Donowitz M, Kokke FT, Saidi R. Evaluation of patients with chronic diarrhea. N Engl J Med 1995;332(11):725–729.
4. Norris TE. Lower gastrointestinal problems. Monograph, edition No. 198. Home Study Self-Assessment program. Kansas City, Mo: American Academy of Family Physicians, November 1995.
5. Kearney DJ, McQuaid KR. Approach to the patient with gastrointestinal disorders. In: Grendell JH, ed. Current diagnosis and treatment in gastroenterology. Norwalk, CT: Appleton & Lange, 1996.
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Source: The 10-Minute Diagnosis Manual: Symptoms and Signs in the Time-Limited Encounter, 2000
Urinary Incontinence:
Physical examination
(The 10-Minute Diagnosis Manual: Symptoms and Signs in the Time-Limited Encounter)
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.
Testing
A. Voiding journal. A voiding journal is a good way to get additional information about the patient’s problem. Have the patient record the time and approximate amount of each voiding, and whether they were wet or dry.
B. Urinalysis. Be cautious when interpreting the urine analysis: in the absence of other symptoms, bacteriuria is seldom the primary cause of UI. Treat cystitis or urethritis when the rest of the clinical picture confirms them. Unexplained, persistent microhematuria requires investigation (Chapter 10.2).
C. Postvoiding urine volume. The patient should be catheterized immediately after voiding. In general, the postvoid urine volume should be less than 50 ml. Volumes in the range of 100 to 200 ml may suggest impaired bladder contractility or obstruction. Volumes greater than 200 ml strongly suggest obstruction.
D. Blood urea nitrogen, creatinine, and glucose are simple blood tests that help rule out underlying renal disease and diabetes.
E. Special tests are available via urologic consultation to further delineate the cause of UI. These include cystoscopy, cystometry, and other voiding studies. Up to two-thirds of patients can be successfully treated without urologic referral.
Diagnostic assessment
The clinical history is the most important factor leading to the correct diagnosis and successful treatment of urinary incontinence. However, it is an imperfect tool at best. In one review, clinical history had a sensitivity and specificity for stress incontinence of 0.90 and 0.50, respectively. For detrusor instability, the figures were 0.74 and 0.55 (2).
The task becomes even more problematic when considering the reluctance of patients to talk about their symptoms and the tendency for UI to be of a mixed type. Response to therapy (or lack thereof) often drives the practical management of this condition. Lack of response to multiple trials of therapy is a good indication for consulting a urologist. Remember, that your initial assessment will often be incorrect, so keep an open mind and consider all possible diagnoses. Finally, recall that UI frequently involves more than one causal factor. For example, many elderly people have a functional component (can’t get to the toilet quickly) in addition to one of the other types.
References
1. Urinary incontinence in adults: acute and chronic management. AHCPR Clinical Practice Guideline, No. 2 (1996 Update) Accessed August 1999; http://text.nlm.nih.gov/
ftrs/gateway/
2. Jensen JK, Nielsen FR, Ostergard DR. The role of patient history in the diagnosis of urinary incontinence. Obstet Gynecol 1994;83(5):904–910.
3. Finding out about incontinence. AAFP Patient Information Handout (1998) Accessed August 1999; http://www.aafp.org/patientinfo/incont.html
4. Goode PS, Burgio KL. Pharmacologic treatment of lower urinary tract dysfunction in geriatric patients. Am J Med Sci 1997;314(4):262–267.
5. Weiss BD. Diagnostic evaluation of urinary incontinence in geriatric patients. Am Fam Physician 1998;57(11):2665–2687. Accessed August 1999; http://www.aafp.org/afp/
980600ap/weiss.html
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Source: The 10-Minute Diagnosis Manual: Symptoms and Signs in the Time-Limited Encounter, 2000
Constipation:
Diagnostic Approach
(Field Guide to Bedside Diagnosis)
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.
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Source: Field Guide to Bedside Diagnosis, 2007
Urinary Incontinence:
Diagnostic Approach
(Field Guide to Bedside Diagnosis)
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.
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Source: Field Guide to Bedside Diagnosis, 2007
Acute Diarrhea:
Diagnostic Approach
(Field Guide to Bedside Diagnosis)
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.
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Source: Field Guide to Bedside Diagnosis, 2007
Chronic Diarrhea:
Diagnostic Approach
(Field Guide to Bedside Diagnosis)
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.
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Source: Field Guide to Bedside Diagnosis, 2007
Constipation:
Physical assessment
(Signs & Symptoms: A 2-in-1 Reference for Nurses)
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.
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Source: Signs & Symptoms: A 2-in-1 Reference for Nurses, 2007
Diarrhea:
Physical assessment
(Signs & Symptoms: A 2-in-1 Reference for Nurses)
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.
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Source: Signs & Symptoms: A 2-in-1 Reference for Nurses, 2007
Urinary incontinence:
Physical assessment
(Signs & Symptoms: A 2-in-1 Reference for Nurses)
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.
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Source: Signs & Symptoms: A 2-in-1 Reference for Nurses, 2007
Constipation:
Diagnostic Approach
(The Diagnostic Approach to Symptoms and Signs in Pediatrics)
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.
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Source: The Diagnostic Approach to Symptoms and Signs in Pediatrics, 2006
Diarrhea:
Diagnostic Approach: Acute Diarrhea
(The Diagnostic Approach to Symptoms and Signs in Pediatrics)
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.
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Source: The Diagnostic Approach to Symptoms and Signs in Pediatrics, 2006
Fecal Incontinence:
Diagnostic Approach
(The Diagnostic Approach to Symptoms and Signs in Pediatrics)
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.
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Source: The Diagnostic Approach to Symptoms and Signs in Pediatrics, 2006
Urinary Incontinence:
Diagnostic Approach
(The Diagnostic Approach to Symptoms and Signs in Pediatrics)
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.
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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.
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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.
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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.
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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.
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Source: Nursing: Interpreting Signs and Symptoms, 2007
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