Diagnostic Tests for Rectal bleeding
Rectal bleeding Tests: Book Excerpts
Home Diagnostic Testing
These home medical tests may be relevant to Rectal bleeding:
- Colon & Rectal Cancer: Home Testing
- Fatigue: Related Home Tests:
- Home Anemia Diagnostic Tests
- Food Allergies & Intolerances: Home Testing:
- Digestive-Related Home Testing:
Rectal bleeding Diagnosis: Book Excerpts
Diagnosis of Rectal bleeding: medical news summaries:
The following medical news items
are relevant to diagnosis of Rectal bleeding:
Diagnostic Tests for Rectal bleeding: Online Medical Books
16 MEDICAL BOOKS ONLINE!
Review excerpts from medical books online, free, without registration,
for more information about the diagnostic tests for Rectal bleeding.
MELENA:
DIAGNOSTIC WORKUP
(Algorithmic Diagnosis of Symptoms and Signs)
Routine laboratory tests include a CBC, sedimentation rate, urinalysis, chemistry panel, coagulation panel, VDRL test, and stool for occult blood. A stool for ovum and parasites may also need to be done. If these tests are inconclusive, an upper GI series and esophagogram would be the next step. Perhaps a small bowel series should be added to the above studies.
If all of these tests are negative or still inconclusive, referral to a gastroenterologist should be made. The gastroenterologist will probably perform panendoscopy and resolve the diagnostic dilemma. Occasionally, a fluorescein string test may be useful. A radioactive scan following intravenous chromium or technetium-99 may show the site of bleeding in obscure cases. When bleeding continues despite therapy, mesenteric angiography or splenic venography may assist in the diagnosis. Exploratory laparotomy may be necessary in some cases. Needless to say, a gastroenterologist should be consulted before undertaking this.
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Source: Algorithmic Diagnosis of Symptoms and Signs, 2003
RECTAL PAIN:
DIAGNOSTIC WORKUP
(Algorithmic Diagnosis of Symptoms and Signs)
Routine diagnostic studies include a CBC, sedimentation rate, urinalysis, chemistry panel, VDRL test, anoscopy, sigmoidoscopy, and barium enema. In females, a pregnancy test and vaginal smear and culture should be done. Ultimately, culdocentesis, pelvic ultrasound, and laparoscopy may be necessary, but a gynecologist should be consulted before considering these tests. In males, prostatic massage may yield a urethral discharge for smear and culture. An intravenous pyelogram or cystoscopy with retrograde pyelography may also be helpful.
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Source: Algorithmic Diagnosis of Symptoms and Signs, 2003
RECTAL BLEEDING:
DIAGNOSTIC WORKUP
(Algorithmic Diagnosis of Symptoms and Signs)
Most cases can be diagnosed by anoscopy, sigmoidoscopy, and a barium enema. A stool culture and examination for ovum and parasites should also be done. If the diagnosis is uncertain after these studies, referral to a gastroenterologist should be done for colonoscopy and other diagnostic studies. The gastroenterologist may order angiography or small intestinal enteroscopy as well as radioisotope studies.
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Source: Algorithmic Diagnosis of Symptoms and Signs, 2003
Melena:
History and physical examination
(Handbook of Signs & Symptoms (Third Edition))
If the patient’s condition permits, ask when he discovered his stools were black and tarry. Ask about the frequency and quantity of bowel movements. Has he had melena before? Ask about other signs and symptoms, notably hematemesis or hematochezia, and about use of anti-inflammatories, alcohol, or other GI irritants. Also, find out if he has a history of GI lesions. Ask if the patient takes iron supplements, which may also cause black stools. Obtain a drug history, noting the use of warfarin or other anticoagulants.
Next, inspect the patient’s mouth and nasopharynx for evidence of bleeding. Perform an abdominal examination that includes auscultation, palpation, and percussion.
» READ BOOK EXCERPT ONLINE »
Source: Handbook of Signs & Symptoms (Third Edition), 2006
Rectal pain:
History and physical examination
(Handbook of Signs & Symptoms (Third Edition))
If the patient reports rectal pain, inspect the area for bleeding; abnormal drainage, such as pus; or protrusions, such as skin tags or thrombosed hemorrhoids. Also, check for inflammation and other lesions. A rectal examination may be necessary.
After the examination, proceed with your evaluation by taking the patient’s history. Ask him to describe the pain. Is it sharp or dull, burning or knifelike? How often does it occur? Ask if the pain is worse during or immediately after defecation. Does the patient avoid having bowel movements because of anticipated pain? Find out what alleviates the pain.
Make sure to ask appropriate questions about the development of associated signs and symptoms. For example, does the patient experience bleeding along with rectal pain? If so, find out how frequently this occurs and whether the blood appears on the toilet tissue, on the surface of the stool, or in the toilet bowl. Is the blood bright or dark red? Also, ask whether the patient has noticed other drainage, such as mucus or pus, and whether he’s experiencing constipation or diarrhea. Ask when he last had a bowel movement. Obtain a dietary history.
» READ BOOK EXCERPT ONLINE »
Source: Handbook of Signs & Symptoms (Third Edition), 2006
Melena:
History and physical examination
(Professional Guide to Signs & Symptoms (Fifth Edition))
If the patient’s condition permits, ask when he discovered his stools were black and tarry. Ask about the frequency and quantity of bowel movements. Has he had melena before? Ask about other signs and symptoms, notably hematemesis or hematochezia, and about use of anti-inflammatories, alcohol, or other GI irritants. Also, find out if he has a history of GI lesions. Ask if the patient takes iron supplements, which may also cause black stools. Obtain a drug history, noting the use of warfarin or other anticoagulants.
Next, inspect the patient’s mouth and nasopharynx for evidence of bleeding. Perform an abdominal examination that includes auscultation, palpation, and percussion.
» READ BOOK EXCERPT ONLINE »
Source: Professional Guide to Signs & Symptoms (Fifth Edition), 2006
Rectal pain:
History and physical examination
(Professional Guide to Signs & Symptoms (Fifth Edition))
If your patient reports rectal pain, inspect the area for bleeding; abnormal drainage such as pus; or protrusions, such as skin tags or thrombosed hemorrhoids. Check for inflammation and other lesions. A rectal examination may be necessary.
After examination, proceed with your evaluation by taking the patient’s history. Ask the patient to describe the pain. Is it sharp or dull, burning or knifelike? How often does it occur? Ask if the pain is worse during or immediately after defecation. Does the patient avoid having bowel movements because of anticipated pain? Find out what alleviates the pain.
Be sure to ask appropriate questions about the development of any associated signs and symptoms. For example, does the patient experience bleeding along with rectal pain? If so, find out how frequently this occurs and whether the blood appears on the toilet tissue, on the surface of the stool, or in the toilet bowl. Is the blood bright or dark red? Ask whether the patient has noticed other drainage, such as mucus or pus, and whether he’s experiencing constipation or diarrhea. Ask when he last had a bowel movement. Obtain a dietary history.
» READ BOOK EXCERPT ONLINE »
Source: Professional Guide to Signs & Symptoms (Fifth Edition), 2006
Hematochezia [Rectal bleeding]:
History and physical examination
(Professional Guide to Signs & Symptoms (Fifth Edition))
If the hematochezia isn’t immediately life-threatening, ask the patient to fully describe the amount, color, and consistency of his bloody stools. (If possible, also inspect and characterize the stools yourself.) How long have the stools been bloody? Do they always look the same, or does the amount of blood seem to vary? Ask about associated signs and symptoms.
Next, explore the patient’s medical history, focusing on GI and coagulation disorders. Ask about the use of GI irritants, such as alcohol, aspirin, and other nonsteroidal anti-inflammatory drugs.
Begin the physical examination by checking for orthostatic hypotension, an early sign of shock. Take the patient’s blood pressure and pulse while he’s lying down, sitting, and standing. If systolic pressure decreases by 10 mm Hg or more, or pulse rate increases by 10 beats/minute or more when he changes position, suspect volume depletion and impending shock.
Examine the skin for petechiae or spider angiomas. Palpate the abdomen for tenderness, pain, or masses. Also, note lymphadenopathy. Finally, a digital rectal examination must be done to rule out rectal masses or hemorrhoids.
» READ BOOK EXCERPT ONLINE »
Source: Professional Guide to Signs & Symptoms (Fifth Edition), 2006
Gastrointestinal Bleeding:
Physical examination
(The 10-Minute Diagnosis Manual: Symptoms and Signs in the Time-Limited Encounter)
A. Vital signs. The single most important aspect of the initial physical examination is determining the patient’s hemodynamic stability. Unstable patients should be managed as trauma patients. Placement of a nasogastric (NG) tube is considered the “fifth vital sign” in patients with acute GI bleeding (2).
B. Focused physical examination. After ensuring hemodynamic stability, the initial physical examination should eliminate a nasal or oropharyngeal source of bleeding. Examine the skin and abdomen carefully for clues to an underlying cause. A rectal examination is mandatory.
1. Skin examination. Ecchymoses, petechiae, and varices should be noted. Conjunctival pallor is a sign of chronic anemia. Numerous mucosal telangiectasias can point to an underlying vascular abnormality.
2. Abdominal examination. Look for stigmata of chronic liver disease (hepatosplenomegaly, spider angiomata, ascites, palmar erythema, caput medusae, gynecomastia, and testicular atrophy) (Chapter 9.9).
3. Rectal examination. Rectal varices, hemorrhoids, and fissures should be noted.
Laboratory evaluation
A. Basic laboratory studies should include a complete blood count with particular attention to the hematocrit, coagulation studies [prothrombin time (PT) and partial thromboplastin time (PTT)], liver function tests (LFTs), serum chemistries (blood urea nitrogen is elevated disproportionately to creatinine in patients with GI blood loss), electrocardiogram (ECG), and NG aspirate analysis. Acutely, the hematocrit is a poor indicator of blood loss; however, serial hematocrits can be useful in assessing ongoing blood loss. A prolonged PT or PTT suggests an underlying coagulopathy. Elevated LFTs suggest underlying liver disease. An ECG is important, especially in elderly patients, to search for evidence of cardiac ischemia. Finally, the NG aspirate is essential. If the aspirate is bright red, or “coffee grounds” in appearance, an upper GI source is likely.
B. Endoscopy plays a central role in the diagnosis and management of GI bleeding. Fiberoptic endoscopy is 90% accurate in pinpointing the source of upper GI bleeding. In addition, the endoscope can also be used to deliver therapy directly.
C. Anoscopy can be used to identify the source of lower GI bleeding; however, the yield is poor (5). Often the site of bleeding cannot be directly visualized or the volume of bleeding is sufficiently heavy to obscure clear visualization.
D. Nuclear medicine studies are useful in grossly localizing bleeding sources to the small intestine, right colon, or left colon. Nuclear scanning is also useful in detecting Meckel’s diverticulae. These images can detect ongoing GI bleeding with a sensitivity of blood loss at 0.05 to 0.1 ml/minute.
E. Angiography can also identify the source of lower GI bleeding. It is not as sensitive as nuclear scanning, requiring a blood loss of more than 0.5 ml/minute.
Diagnostic assessment
The key to the successful approach to GI bleeding is ensuring the hemodynamic stability of the patient. Once done, a systematic search for the source of the bleeding should be undertaken. Although often unreliable, a careful patient history can provide valuable clues to factors that may predispose the patient to hemorrhage from a particular site within the GI tract. Physical examination (including placement of a NG tube) can further delineate whether an upper source or a lower source is most likely. The key diagnostic modality in GI bleeding is fiberoptic endoscopy. Following the clues provided by a careful history and physical examination, targeted endoscopy is then used to definitively identify the source of bleeding. In the rare cases where endoscopy is unable to adequately identify the source of GI bleeding, specialized nuclear medicine and angiographic studies can be used.
References
1. Zimmerman HM, Curfman K. Acute gastrointestinal bleeding. AACN Clin Issues 1997;8(3):449–458.
2. Laine L. Acute and chronic gastrointestinal bleeding. In: Feldman M, Sleisinger MH, Scharschmidt BF, eds: Gastrointestinal and liver disease: pathophysiology, diagnosis, and management. Philadelphia: WB Saunders, 1998:198–218.
3. McGuirk TD, Coyle WJ. Upper gastrointestinal tract bleeding. Emer Med Clin N Am 1996;14(3):523–545.
4. Zuccaro G. Management of the adult patient with acute lower gastrointestinal bleeding. Am J Gastroenterol 1998;93(8):1202–1208.
5. Bono MJ. Lower gastrointestinal bleeding. Emer Med Clin N Am 1996;14(3):547–556.
» READ BOOK EXCERPT ONLINE »
Source: The 10-Minute Diagnosis Manual: Symptoms and Signs in the Time-Limited Encounter, 2000
Rectal Bleeding:
Physical examination
(The 10-Minute Diagnosis Manual: Symptoms and Signs in the Time-Limited Encounter)
Assess the patient’s weight, general condition, and vital signs. Orthostatic blood pressure changes with a drop of 10 mm Hg or an increase in heart rate of 10 beats/minute indicates a blood loss of at least 1,000 ml (20% of circulating blood volume) (5). It is important to perform an external anal inspection, (checking for external hemorrhoids, fissures), digital rectal examination (checking for a rectal mass, polyp or anal pain), abdominal examination (checking for tenderness or mass), and nasopharyngeal examination (checking for a bleeding source).
Testing
A. Anoscopy. The anoscope allows inspection for fissures, fistulas, bleeding and nonbleeding hemorrhoids, and rectal friability.
B. Rigid proctosigmoidoscopy has given way to flexible sigmoidoscopy; it visualizes well the distal 25 cm of the proctosigmoid area for neoplasia, friability, polyps, ulcers, or hemorrhoids. Rigid sigmoidoscopy has a sensitivity of 69% and specificity of 95% in determining the presence or absence of disease (1).
C. Flexible sigmoidoscopy is much better tolerated by the patient than rigid proctosigmoidoscopy. It visualizes the distal 60 to 70 cm of the colon and detects similar findings as rigid proctosigmoidoscopy with similar sensitivity and specificity.
D. Air contrast barium enema demonstrates polyps, masses, mucosal irregularities, diverticulae and inflammatory bowel disease with a sensitivity of 52% and a specificity of 98% (1). When used in combination with sigmoidoscopy, it has a sensitivity of 96% and specificity of 76% with a positive predictive value of 55% (1).
E. Stool guaiac testing. As a test for occult bleeding in determining serious pathology, the guaiac card has a sensitivity of 44% to 75% and a specificity of 85%. As a screening tool, it has received mixed blessings, being promoted by the American Cancer Society and National Cancer Institute, but with insufficient evidence to recommend for or against by the US Preventive Services Task Force.
F. Colonoscopy. The diagnostic procedure of choice to visualize the entire colon. It allows only one bowel preparation and has identification rates of 74% to 82% of lower GI bleeding sources (5). The sensitivity of this examination approaches 98%.
G. Nuclear scintigraphy. 99mTechnetium-labeled red blood cells detects occult bleeding sources when the above-mentioned methods fail. Sensitivity ranges from 80% to 98% in the colon with specificity of 41% to 97% (5).
H. Mesenteric angiography uses a transfemoral placement to selectively evaluate the superior mesenteric, inferior mesenteric, and celiac axis. The sensitivity is 40% to 86% with a complication rate of 2% (5). Treatment interventions include arterial infusion of vasopressin and embolization with coil springs or gel foam.
I. Enteroscopy. Small bowel enteroscopy uses a special enteroscope or pediatric colonoscope. This scope is passed orally and has a diagnostic yield of 25% (5).
Diagnostic assessment
The answers provided in the patient’s history and physical examination are important to risk stratify this common problem. If a workup is believed necessary to deal with diagnostic uncertainty, then the entire colon should be visualized. This approach should consist of a digital rectal examination, anoscopy, rigid or flexible sigmoidoscopy, and the use of air contrast barium enema as deemed necessary. Alternatively, exploration by colonoscopy can be used, based on the provider’s discretion. The latter makes most sense as two bowel preparations can be reduced to one with enhanced patient comfort. Further workup, including nuclear scintigraphy, mesenteric angiography, enteroscopy, and referral to a surgeon or a gastroenterologist, depends on the clinical situation and seriousness of the bleed encountered. Serious pathology occurs in approximately 25% of rectal bleeding patients with 6.5% to 10% having cancer, 13% to 25% having polyps, and 4% to 11% having inflammatory bowel disease (1,2). Ten year follow-up of patients with benign anorectal disease or no evident cause of bleeding found no difference in the incidence of cancer compared with similarly aged cohort in the general population (1).
References
1. Helfant M, Marton KI, Zimmer-Gembeck MJ, Sax HC. History of visible rectal bleeding in a primary care population: initial assessment and 10-year follow-up. JAMA 1997;277(1):44–48.
2. Talley NJ, Jones M. Self reported rectal bleeding in a United States community: prevalence, risk factors, and health care seeking. Am J Gastroenterol 1998;93:
2179–2183.
3. Thompson M, Prytherah D. Rectal bleeding: when is it right to refer. Practitioner 1996;240:198–200.
4. Colletti RB, Compton CC. Weekly clinicopathological exercises: case 7-1997. A 14-year-old girl with recurrent painless rectal bleeding. N Engl J Med 1997;336(9):
641–648.
5. Vernava AM, Moore BA, Longo WE, Johnson FE. Lower gastrointestinal bleeding. Dis Colon Rectum 1997;40:846–858.
» READ BOOK EXCERPT ONLINE »
Source: The 10-Minute Diagnosis Manual: Symptoms and Signs in the Time-Limited Encounter, 2000
Gastrointestinal Bleeding:
DIagnostic Approach
(Field Guide to Bedside Diagnosis)
With overt bleeding, determining whether a source is proximal or distal to the ligament of Treitz is key to the further diagnostic evaluation. Hematemesis confirms an upper GI source, and suggests loss of more than a quarter of blood volume. Melena (black, tarry stool) also comes from an upper source unless the bleeding is brisk or large volume and transit is rapid. Melena without hematemesis usually results from a lesion distal to the pylorus (e.g., duodenal ulcer) or to slow bleeding. Tarry stools may be produced by as little as 100 mL of blood. Lower sources produce hematochezia (maroon or clots from the right colon and bright red from the left colon). A small amount of blood only on the toilet tissue nearly always comes from a bleeding hemorrhoid or fissure. Silver stool is said to arise from acholic stools combined with luminal bleeding in an ampullary cancer.
Determine the hemodynamic significance of the bleeding by looking for postural lightheadedness or changes in pulse or blood pressure. Early symptoms of thirst and lightheadedness occur with loss of more than 15% of intravascular volume. An orthostatic blood pressure drop of 10 mm Hg indicates a loss greater than or equal to 20% of volume. Shock with hypotension and pallor develops with 25% to 40% volume loss.
Stools may be falsely colored by ingestants such as bismuth subsalicylate, iron, licorice or charcoal, which turn it black, or beets, which turn it red. These stools are not sticky. A negative stool test for occult blood will usually resolve this.
Hemoccult screening detects blood loss down to 1 to 10 ml/day. Evaluation of a heme positive stool will reveal colon cancer in 5% to 14% of patients, and large adenomatous polyps in another 15% to 35%. Any single positive stool should be evaluated. Hemoccult screening reduces colon cancer mortality by 15% to 33%. An asymptomatic patient with a negative Hemoccult has only a 0.2% chance of having colon cancer (compared with 1.4% prevalence in this population). Using Hemoccult alone as a screening strategy will miss 50% to 60% of colon cancers.
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Source: Field Guide to Bedside Diagnosis, 2007
Rectal Pain:
Diagnostic Approach
(Field Guide to Bedside Diagnosis)
Tenesmus is a painful urge to defecate with little result.
» READ BOOK EXCERPT ONLINE »
Source: Field Guide to Bedside Diagnosis, 2007
Melena:
Physical assessment
(Signs & Symptoms: A 2-in-1 Reference for Nurses)
Inspect the patient’s mouth and nasopharynx for evidence of bleeding. Perform an abdominal assessment that includes auscultation, palpation, and percussion. Perform a cardiovascular assessment to detect signs and symptoms of shock.
» READ BOOK EXCERPT ONLINE »
Source: Signs & Symptoms: A 2-in-1 Reference for Nurses, 2007
Rectal pain:
Physical assessment
(Signs & Symptoms: A 2-in-1 Reference for Nurses)
Inspect the rectal area for bleeding; abnormal drainage such as pus; or protrusions, such as skin tags or thrombosed hemorrhoids. Also, check for inflammation and other lesions. A rectal examination may be necessary.
» READ BOOK EXCERPT ONLINE »
Source: Signs & Symptoms: A 2-in-1 Reference for Nurses, 2007
Gastrointestinal Bleeding:
Diagnostic Approach
(The Diagnostic Approach to Symptoms and Signs in Pediatrics)
Determination of Gastrointestinal Bleeding
Determinewhether reddish color of vomitus or stool is blood (e.g., raspberries,beets, and food colorings can give reddish color).Gastroccult (Smith Kline Diagnostics,San Jose, CA) test may be used to detect presence of blood in vomitusor gastric aspirate. Hemoccult test can be used to confirm presenceof blood in stool. Severity of Bleeding
If GI bleedingis obvious, most important task is to determine severity.Important to quantitate amount of bleeding:1–2 drops, 1 teaspoonful, 1 cupful, or massive bleedingwith clot formation. Passage of clots via rectum or vomiting of >1cupful of bright red blood is indicative of significant bleeding.In such cases, first note vital signsand perform any necessary resuscitation.Immediate fluid replacement is requiredto stabilize BP. Site of the Bleeding
Determinethe site of bleeding—whether it is from the upper or lowertract or both. Blood from nose or mouth can be swallowed and subsequentlyvomited or passed in stool. Retching from vomiting also can producesome blood-stained vomitus but is rarely severe.Except in these instances, NG tubeshould be placed to document level and rate of bleeding.Gastric aspirate that is positive forblood is highly specific for upper tract bleeding. Negative aspiratesuggests lower tract bleeding but does not totally preclude uppertract bleeding, especially from duodenum. Specific Diagnosis
Importantfactors to consider in diagnosis areAgeClinical findings (e.g., vomiting,diarrhea, fever, constipation, abdominal pain, hepatomegaly, splenomegaly,abdominal distension, weight loss, and jaundice)History of aspirin, NSAID, or alcoholingestionPresence of known diseases (e.g., IBDor liver disease) Diagnostic studies that may identifysource of acute bleeding include endoscopy, radionuclide scanning,and selective angiography.If upper tract bleeding has stoppedor is intermittent, upper endoscopy can be performed to diagnoseesophagitis, gastritis, gastric or duodenal ulcer, Mallory-Weisstear, and esophageal varices.If endoscopic exam is impossible to performbecause of continuous bleeding, radionuclide scan or selective angiographycan be performed. Technetium sulfur colloid scan can detect slow ongoingbleeding, whereas technetium red cell scan can detect slow intermittentbleeding. These techniques help localize site of bleeding, so thatother diagnostic studies can be performed.Sulfur colloid scan can detect bleedingat rate as low as 0.1 mL/min, but only if bleeding is occurringat time of injection because half-life of tracer is <2.5mins. Labeled red cells remain in blood for 24 hrs, so technetiumred cell scan can detect intermittent bleeding.If these scans fail to disclose siteof bleeding or bleeding is brisk, selective angiography should beperformed—angiography of celiac axis and superior mesentericartery for suspected upper tract bleeding, and superior mesentericand inferior mesenteric artery angiography for suspected lower tract bleeding.Another advantage of angiography isthat therapeutic measures (e.g., vasopressin infusion and embolization)can be used if necessary.If the bleeding is massive or uncontrolled,immediate surgery should be considered. In stable child with lower tract bleeding,anus should be examined for anal fissure and rectum for polyp.With bloodydiarrhea, bacterial stool culture should be performed, and examof stool for ova and parasites should be considered.Technetium 99m–pertechnetatescan to identify ectopic gastric mucosa in Meckel diverticulum orintestinal duplication also should be considered. If diagnosis remainsuncertain, proctosigmoidoscopy should be performed. This may befollowed by colonoscopy or contrast studies.Colonoscopy with biopsy may diagnosepolyps, colitis, IBD, hemangiomas, and malignant lesions. Air-contrastenema may diagnose intussusception. With persistent undefined bleeding,upper tract endoscopy may be useful to identify ulcer, esophagealor gastric varices, or vascular lesion.Upper GI radiographic series with smallbowel follow-through may diagnose lesions of esophagus, stomach,and duodenum as well as lesions of small bowel, including CrohndiseaseSelective angiography may not revealsite of bleeding if bleeding is too slow, but it may suggest angiodysplasticlesion or tumor by revealing abnormal vascular pattern. >
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Source: The Diagnostic Approach to Symptoms and Signs in Pediatrics, 2006
Melena:
History and physical examination
(Nursing: Interpreting Signs and Symptoms)
If the patient's condition permits, ask when he discovered that his stools were black and tarry. Ask about the frequency and quantity of bowel movements. Has he had melena before? Ask about other signs and symptoms, notably hematemesis or hematochezia, and about use of anti-inflammatories, alcohol, or other GI irritants. Also, find out if he has a history of GI lesions. Ask if the patient takes iron supplements, which may also cause black stools. Obtain a drug history, noting the use of warfarin or other anticoagulants.
Next, inspect the patient's mouth and nasopharynx for evidence of bleeding. Perform an abdominal examination that includes inspection, auscultation, palpation, and percussion. Then perform a rectal examination.
» READ BOOK EXCERPT ONLINE »
Source: Nursing: Interpreting Signs and Symptoms, 2007
Rectal pain:
History and physical examination
(Nursing: Interpreting Signs and Symptoms)
Begin by taking the patient's history. Ask him to describe the pain. Is it sharp or dull, burning or knifelike? How often does it occur? Ask if the pain is worse during or immediately after defecation. Does the patient avoid having bowel movements because of anticipated pain? Find out what alleviates the pain.
Be sure to ask appropriate questions about the development of associated signs and symptoms. For example, does the patient experience bleeding along with rectal pain? If so, find out how frequently this occurs and whether the blood appears on the toilet tissue, on the surface of the stools, or in the toilet bowl. Is the blood bright or dark red? Also, ask whether the patient has noticed other drainage, such as mucus or pus, and whether he's experiencing constipation or diarrhea. Ask when he last had a bowel movement. Obtain a dietary and drug history.
Then inspect the rectal area for bleeding; abnormal drainage, such as pus; or protrusions, such as skin tags or thrombosed hemorrhoids. Also, check for inflammation and other lesions. A rectal examination may be necessary.
» READ BOOK EXCERPT ONLINE »
Source: Nursing: Interpreting Signs and Symptoms, 2007
Hematochezia [Rectal bleeding]:
History and physical examination
(Nursing: Interpreting Signs and Symptoms)
If hematochezia isn't immediately life-threatening, ask the patient to fully describe the amount, color, and consistency of his bloody stools. (If possible, also inspect and characterize the stools yourself.) How long have the stools been bloody? Do they always look the same, or does the amount of blood seem to vary? Ask about associated signs and symptoms.
Next, explore the patient's medical history, focusing on GI and coagulation disorders. Ask about the use of GI irritants, such as alcohol, aspirin, and other nonsteroidal anti-inflammatory drugs (NSAIDs).
Begin the physical examination by checking for orthostatic hypotension, an early sign of shock. Take the patient's blood pressure and pulse while he's lying down, sitting, and standing. If systolic pressure decreases by 10 mm Hg or more or if the pulse rate increases by 10 beats/minute or more when he changes position, suspect volume depletion and impending shock.
Examine the skin for petechiae or spider angiomas. Palpate the abdomen for tenderness, pain, or masses. Also note lymphadenopathy. Finally, a digital rectal examination must be done to rule out rectal masses or hemorrhoids.
» READ BOOK EXCERPT ONLINE »
Source: Nursing: Interpreting Signs and Symptoms, 2007
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