Diagnosis of Rectal cancer
Rectal cancer Diagnosis: Book Excerpts
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RECTAL PAIN:
Ask the Following Questions:
(Algorithmic Diagnosis of Symptoms and Signs)
- Is there bleeding? The presence of bleeding with pain suggests an anal fissure, hemorrhoids, carcinoma, rectal prolapse, and intussusception.
- Is there a mass? The presence of rectal pain along with a mass would suggest internal and external hemorrhoids, rectal carcinoma, and perirectal or ischiorectal abscesses. However, in females, masses in the cul-de-sac, such as an acute salpingitis, ectopic pregnancy, or endometriosis, will cause rectal pain. In males, prostatic abscess, foreign bodies, and seminal vesiculitis may cause rectal pain.
- Is there a purulent discharge? Fistula in ano, perirectal abscess, ischiorectal abscess, and submucous abscess may cause a purulent discharge.
DIAGNOSTIC WORKUP
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.
» READ BOOK EXCERPT ONLINE »
Source: Algorithmic Diagnosis of Symptoms and Signs, 2003
RECTAL DISCHARGE:
Ask the Following Questions:
(Algorithmic Diagnosis of Symptoms and Signs)
- Is it mucopurulent or feculent? A mucopurulent discharge suggests an anal fistula, perirectal abscess, proctitis, anal ulcer, or rectal prolapse. A feculent discharge suggests anal incontinence, internal hemorrhoids, chronic anal fissure, or ulcer.
- Is it painful? Painful discharge suggests a perirectal abscess, proctitis, anal ulcer, or rectal prolapse.
- Is there an abnormal neurologic examination? An abnormal neurologic examination suggests that there is anal incontinence from an upper or lower motor neuron lesion. This may be due to spinal cord trauma, multiple sclerosis, spinal cord tumor, transverse myelitis, and many other disorders.
DIAGNOSTIC WORKUP
Routine laboratory tests include a CBC, sedimentation rate, urinalysis, chemistry panel, and smear and culture of the discharge. A Frei test may be necessary to rule out lymphogranuloma venereum. Sigmoidoscopy, colonoscopy, and a barium enema may be needed in selected cases. A proctologist or gastroenterologist should be consulted in difficult diagnostic problems. If there are abnormalities on the neurologic examination, a neurologist should be consulted.
» READ BOOK EXCERPT ONLINE »
Source: Algorithmic Diagnosis of Symptoms and Signs, 2003
RECTAL MASS:
Ask the Following Questions:
(Algorithmic Diagnosis of Symptoms and Signs)
- Is it painful? A painful rectal mass should suggest perirectal abscess, thrombosed hemorrhoid, anal ulcer, ruptured ectopic pregnancy, tubo-ovarian abscess, and pelvic appendix.
- Is it soft or cystic? The presence of a soft or cystic mass would suggest internal hemorrhoids, polyps, intussusception, villous tumor, granular proctitis, ovarian cyst, and blood or pus in the cul-de-sac.
- Is it hard? The presence of a hard lesion would suggest a fecal impaction, foreign body, retroverted uterus, enlarged prostate, malignant deposits in the pouch of Douglas, stricture, and carcinoma.
- Is there associated bleeding? The presence of bleeding should make one suspect carcinoma above all else, but it may be due to internal hemorrhoids, polyps, intussusception, villous tumors, or granular proctitis.
DIAGNOSTIC WORKUP
Routine laboratory tests include a CBC, sedimentation rate, and urinalysis. A smear and culture should be made of any rectal or vaginal discharge. Most cases will be diagnosed by anoscopy and proctoscopy. A pelvic ultrasound and CT scan of the abdomen and pelvis may be useful in evaluating ectopic pregnancy and other gynecologic disorders. Ultrasound of the prostate may also be done to evaluate a prostatic mass. A gynecologist, proctologist, or urologist should be consulted in difficult cases.
» READ BOOK EXCERPT ONLINE »
Source: Algorithmic Diagnosis of Symptoms and Signs, 2003
Rectal Pain:
Differential Diagnosis
(In a Page: Signs and Symptoms)
- Anal fissure
–Acute fissure presents with pain and bleeding (noticed on toilet paper) immediately following defecation
–Chronic fissure presents with long-standing itching and mild pain, with or without bleeding
-
Perianal abscess (with or without associated fistula formation
-
Thrombosed hemorrhoid
-
Levator ani syndrome
-
Proctalgia fugax (rectal muscle spasm)
-
Coccyodynia/coccygodynia
-
Fecal impaction
-
Neoplasm (rectal, pelvic, or cauda equina)
-
Idiopathic
-
Inflammatory bowel disease (ulcerative proctitis, Crohn's disease)
-
Solitary rectal ulcer syndrome
–Misnomer: May be multiple, not restricted to rectum, and lesion may be polypoid
–Neoplasm is a concern
-
Pruritus ani
-
Trauma
-
Anal sex
-
Constipation
-
Diarrhea
-
Less common causes (“zebras”) include familial rectal pain, endometriosis, pelvic inflammatory disease, prostatitis, myopathies, foreign bodies, and compression or inflammation of sacral nerves
Workup and Diagnosis
- A careful history and physical exam are crucial and often diagnostic for many conditions
–Acute anal fissure presents as an anal tear (typically posterior) with a tender perineum; no further workup is necessary if the classic history and exam are found
–Chronic anal fissure presents as an open ulcer with drainage and sentinel pile
–Levator ani symptoms can be elicited by digital rectal
examination
–Proctalgia fugax symptoms cannot be elicited by exam
–Coccyodynia: Palpation of coccyx reproduces symptoms
-
In cases of perianal abscess, must rule out the presence of an anal fistula and inflammatory bowel disease
-
Anoscopy may be indicated to rule out inflammatory bowel disease
-
If an underlying disease process is suspected, consider stool cultures, viral titers, serologies, and/or biopsy
» READ BOOK EXCERPT ONLINE »
Source: In a Page: Signs and Symptoms, 2004
Rectal Masses:
Differential Diagnosis
(In a Page: Signs and Symptoms)
-
Hemorrhoids
-
Rectal prolapse
-
Rectal cancer
-
Rectal polyp
-
Prostate cancer
-
Prostatitis
-
Endometriosis
-
Presacral neurogenic tumor
-
Rectal intussusception
- Anal cancer (2% of colorectal cancers)
–Anal canal tumors (above the anal verge) include adenocarcinoma, melanoma, and epidermoid tumors
–Anal margin tumors (below the anal verge) include squamous cell carcinoma, verrucous (from condyloma acuminatum), basal cell carcinoma, Bowen's disease, and Paget's disease of the anus
-
Foreign body
-
Less common diagnoses (“zebras”) include rectal carcinoid, lymphoid hyperplasia, malignant lymphoma, lipoma, dermoid cyst, teratoma, rectal duplication, and leiomyosarcoma
Workup and Diagnosis
- History should include changes in bowel habits or consistency of stool, and family history of colorectal cancer
–Bleeding is the most common symptom associated with benign and malignant lesions; melena suggests upper GI bleeding, blood on toilet paper suggests anal fissure or hemorrhoids, bright red separate from stool suggests hemorrhoids, clots in stool suggests colonic source
–Pain is usually associated with benign pathology
-
Fecal occult blood testing may be used for screening
-
Digital rectal exam and anoscopy are used initially to distinguish many anorectal lesions
-
Endoscopy (sigmoidoscopy and/or full colonoscopy) with biopsy of all polyps and suspicious lesions
-
Barium enema is indicated if colonoscopy unavailable
-
Endorectal ultrasound is necessary to evaluate for potential rectal cancer, to appropriately stage tumor invasion and lymph node status, and to direct appropriate treatment
-
Manometry may be indicated in incontinent patients
» READ BOOK EXCERPT ONLINE »
Source: In a Page: Signs and Symptoms, 2004
RECTAL PAIN:
Approach to the Diagnosis
(Differential Diagnosis in Primary Care)
The cause of rectal pain is usually obvious on examination with an anoscope or proctoscope. Careful palpation may be necessary to discover a perirectal abscess, coccydynia, or an ectopic pregnancy. Anal fissures may be missed unless all quadrants of the anus are examined with the slitanoscope.
» READ BOOK EXCERPT ONLINE »
Source: Differential Diagnosis in Primary Care, 2007
RECTAL DISCHARGE:
Approach to the Diagnosis
(Differential Diagnosis in Primary Care)
Smear and culture of the discharge are axiomatic. Visualization of the lesion with the anoscope or sigmoidoscope is usually necessary. A Frei test should be done if lymphogranuloma venereum is suspected.
» READ BOOK EXCERPT ONLINE »
Source: Differential Diagnosis in Primary Care, 2007
RECTAL MASS:
Approach to the Diagnosis
(Differential Diagnosis in Primary Care)
Anoscopy, sigmoidoscopy, and a barium enema are the most significant tools in the proctologist’s armamentarium. Biopsy or excision of polyps is routine. When one polyp is found, a barium enema or colonoscopy is always done to look for others.
» READ BOOK EXCERPT ONLINE »
Source: Differential Diagnosis in Primary Care, 2007
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
Colorectal cancer:
Diagnosis
(Professional Guide to Diseases (Eighth Edition))
Only a tumor biopsy can verify colorectal cancer, but other tests help detect it:
❑Digital rectal examination can detect almost 15% of colorectal cancers.
❑Fecal occult blood test can detect blood in stools. However, it's commonly negative in patients with colon cancer.
❑ Proctoscopy or sigmoidoscopy can detect up to 66% of colorectal cancers.
❑ Colonoscopy permits visual inspection (and photographs) of the colon up to the ileocecal valve, and gives access for poly-pectomies and biopsies of suspected lesions.
❑ Computed tomography scan helps to detect areas affected by metastasis.
❑ Barium X-ray, using a dual contrast with air, can locate lesions that are undetectable manually or visually. Barium examination should follow endoscopy or excretory urography because the barium sulfate interferes with these tests.
❑Carcinoembryonic antigen, though not specific or sensitive enough for early diagnosis, is helpful in monitoring patients before and after treatment to detect metastasis or recurrence.
» READ BOOK EXCERPT ONLINE »
Source: Professional Guide to Diseases (Eighth Edition), 2005
Introduction: Malignant Neoplasms:
Diagnostic methods
(Professional Guide to Diseases (Eighth Edition))
A thorough medical history and physical examination should precede sophisticated diagnostic procedures. Useful tests for the early detection and staging of tumors include X-ray, endoscopy, isotope scan, computed tomography scan, and magnetic resonance imaging, but the single most important diagnostic tool is a biopsy for direct histologic study of tumor tissue. Biopsy tissue samples can be taken by curettage, fluid aspiration (pleural effusion), fine-needle aspiration biopsy (breast), dermal punch (skin or mouth), endoscopy (rectal polyps), and surgical excision (visceral tumors and nodes).
An important tumor marker, carcinoembryonic antigen (CEA), although not diagnostic by itself, can signal malignancies of the large bowel, stomach, pancreas, lungs, and breasts. CEA titers range from normal (less than 5 ng) to suspicious (5 to 10 ng) to suspect (over 10 ng). CEA serves many valuable purposes:
❑as a baseline during chemotherapy to evaluate the extent of tumor spread
❑to regulate drug dosage
❑to prognosticate after surgery or radiation
❑to detect tumor recurrence.
Although no more specific than CEA, alpha-fetoprotein — a fetal antigen uncommon in adults — can suggest testicular, ovarian, gastric, and hepatocellular cancers. Beta human chorionic gonadotropin may point to testicular cancer or choriocarcinoma. Other commonly used tumor markers include prostate-specific antigen to detect and monitor prostatic cancer, and CA-125, useful for monitoring ovarian, colorectal, and gastric cancers.
» READ BOOK EXCERPT ONLINE »
Source: Professional Guide to Diseases (Eighth Edition), 2005
Malignant spinal neoplasms:
Diagnosis
(Professional Guide to Diseases (Eighth Edition))
❑Spinal and lumbosacral magnetic resonance imaging confirm spinal tumor.
❑ X-rays show distortions of the intervertebral foramina; changes in the vertebrae or collapsed areas in the vertebral body; and localized enlargement of the spinal canal, indicating an adjacent block.
❑ Myelography identifies the level of the lesion by outlining it if the tumor is causing partial obstruction; it shows anatomic relationship to the cord and the dura. If obstruction is complete, the injected dye can't flow past the tumor. (This study is dangerous if cord compression is nearly complete because withdrawal or escape of cerebrospinal fluid (CSF) will allow the tumor to exert greater pressure against the cord.)
❑ Radioisotope bone scan demonstrates metastatic invasion of the vertebrae by showing a characteristic increase in osteoblastic activity.
❑ Computed tomography scan shows cord compression and tumor location.
❑ Frozen section biopsy at surgery identifies the tissue type.
❑ Lumbar puncture may be normal, abnormal, or nonspecific. It may show clear yellow CSF as a result of increased protein levels if the flow is completely blocked. If the flow is partially blocked, protein levels rise, but the fluid is only slightly yellow in proportion to the CSF protein level. Cytology of the CSF may show malignant cells of metastatic carcinoma.
» READ BOOK EXCERPT ONLINE »
Source: Professional Guide to Diseases (Eighth Edition), 2005
Rectal polyps:
Diagnosis
(Professional Guide to Diseases (Eighth Edition))
Confirming diagnosis Firm diagnosis of rectal polyps requires identification of the polyps through proctosigmoidoscopy or colonoscopy and rectal biopsy.
Barium enema can help identify polyps that are located high in the colon. Supportive laboratory findings include occult blood in the stools, low hemoglobin level and hematocrit (with anemia) and, possibly, serum electrolyte imbalances in patients with villous adenomas.
» READ BOOK EXCERPT ONLINE »
Source: Professional Guide to Diseases (Eighth Edition), 2005
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
Rectal Pain:
Differential Overview
(Field Guide to Bedside Diagnosis)
❑ Hemorrhoid
❑ Rectal fissure
❑ Prostatitis
❑ Anal fistula
❑ Pruritus ani
❑ Fecal impaction
❑ Coccydynia
❑ Perirectal abscess
❑ Infected pilonidal cyst
❑ Ulcerative proctitis
❑ Infective proctitis
❑ Proctalgia fugax
❑ Anal carcinoma
Diagnostic Approach
Tenesmus is a painful urge to defecate with little result.
» READ BOOK EXCERPT ONLINE »
Source: Field Guide to Bedside Diagnosis, 2007
Colorectal cancer:
Diagnosis
(Handbook of Diseases)
Only a tumor biopsy can verify colorectal cancer, but the following tests help detect it:
❑ Digital examination can help detect almost 15% of colorectal cancers.
❑ Hemoccult test (guaiac) may show blood in the stool.
❑ Proctoscopy or sigmoidoscopy can help detect up to 66% of colorectal cancers.
❑ Colonoscopy permits visual inspection (and photographs) of the colon up to the ileocecal valve and gives access for polypectomies and biopsies of suspected lesions.
❑ Computed tomography scan helps detect areas affected by metastasis.
❑ Barium X-ray, using a dual contrast with air, can locate lesions that are undetectable manually or visually. Barium examination should follow endoscopy or excretory urography because the barium sulfate interferes with these tests.
❑ Carcinoembryonic antigen, although not specific or sensitive enough for an early diagnosis, is helpful in monitoring patients before and after treatment to detect metastasis or recurrence.
» READ BOOK EXCERPT ONLINE »
Source: Handbook of Diseases, 2003
Rectal pain:
History
(Signs & Symptoms: A 2-in-1 Reference for Nurses)
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? 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: Signs & Symptoms: A 2-in-1 Reference for Nurses, 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
RECTAL PAIN:
Approach to the Diagnosis
(Differential Diagnosis in Primary Care)
The cause of rectal pain is usually obvious on examination with an
anoscope or proctoscope. Careful palpation may be necessary to discover a
perirectal abscess, coccydynia, or an ectopic pregnancy. Anal fissures may
be missed unless all quadrants of the anus are examined with the slit
anoscope.
» READ BOOK EXCERPT ONLINE »
Source: Differential Diagnosis in Primary Care, 2007
RECTAL DISCHARGE:
Approach to the Diagnosis
(Differential Diagnosis in Primary Care)
Smear and culture of the discharge are axiomatic. Visualization of the
lesion with the anoscope or sigmoidoscope is usually necessary. A Frei test
should be done if lymphogranuloma venereum is suspected.
» READ BOOK EXCERPT ONLINE »
Source: Differential Diagnosis in Primary Care, 2007
RECTAL MASS:
Approach to the Diagnosis
(Differential Diagnosis in Primary Care)
Anoscopy, sigmoidoscopy, and a barium enema are the most significant
tools in the proctologist’s armamentarium. Biopsy or excision of polyps is
routine. When one polyp is found, a barium enema or colonoscopy is always
done to look for others.
» READ BOOK EXCERPT ONLINE »
Source: Differential Diagnosis in Primary Care, 2007
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