- • Localization/point of origin: peritoneal cavity (ascites, bowel dilation), abdominal wall (hernia, obesity).
- • Associated symptoms: nausea, vomiting, abdominal pain and cramping, altered bowel function, bleeding?
- • Symptom evolution: acute/progressive, intermittent, recurrent, chronic.
- • Appearance: diffuse, focal area.
- • Grading: mild, severe.
- • Underlying systemic disease: congenital malformation, malignancy, cardiovascular disease, IBD, history of previous surgeries.
- • Probability of being sign of serious disease (liability issue): high.
- 1. Malformation
- – acquired: obesity, organomegaly (liver, spleen)
- – cystic fibrosis (mucoviscidosis) with fecal impaction in the small bowel
- – megacolon (Hirschsprung disease)
- – colonic malrotation
- – intestinal atresia
- – acquired: obesity, organomegaly (liver, spleen)
- 2. Vascular
- – ischemia-related bowel obstruction (ischemic stricture)
- 3. Inflammatory
- – inflammatory process with bowel obstruction (diverticulitis, Crohn disease)
- – toxic megacolon
- – inflammatory process with bowel obstruction (diverticulitis, Crohn disease)
- 4. Tumor
- – tumor-related bowel obstruction (neoplasm, endometriosis)
- – carcinomatosis
- – pseudomyxoma peritonei
- – tumor-related bowel obstruction (neoplasm, endometriosis)
- 5. Degenerative/functional
- – adhesion-related bowel obstruction
- – Ogilvie syndrome
- – hernia
- – pseudohernia from denervation of abdominal wall musculature
- – fecal impaction
- – ascites (eg, liver cirrhosis)
- – adhesion-related bowel obstruction
- 6. Traumatic/posttraumatic
- – hematoma
- 1. Constitutional: obesity.
- 2. Bowel obstruction (SBO, LBO).
- 3. Hernia.
- 4. Megacolon/pseudoobstruction.
- 5. Ascites.
- • Patient’s surgical/medical history: habitus, symptom progression, previous abdominal surgeries, tumor, etc.
- • Clinical examination: patient’s general condition and habitus, presence/absence of (tympanitic) bowel sounds, focal/diffuse tenderness to palpation, organomegaly, peritoneal signs, stool in rectal vault.
- • Imaging:
- – Abdominal x-ray series, chest x-ray: evidence of bowel obstruction (SBO vs LBO), free air, distended loops of bowel, air/fluid levels, gastric dilation, transition point, presence of air in distal colon, calcifications, pneumobilia.
- – CT scan (if possible with oral and IV contrast): ascites, hernia, small or large bowel dilation, transition point, extensive mucosal thickening, intestinal pneumatosis, pneumobilia, portal vein gas, suspicion of closed loop, intraabdominal/retroperitoneal mass, extent and location of tumor burden, etc.
- – Ultrasound: ascites, tumor.
- – Abdominal x-ray series, chest x-ray: evidence of bowel obstruction (SBO vs LBO), free air, distended loops of bowel, air/fluid levels, gastric dilation, transition point, presence of air in distal colon, calcifications, pneumobilia.
- • Localization/point of origin: upper GI, mid-GI, lower GI, anorectal.
- • Associated symptoms: pain, pruritus, prolapse, altered bowel habits, constipation, diarrhea, dizziness, weakness, weight loss?
- • Time factor: onset, constant, certain times, certain activity, link to menstrual cycle?
- • Symptom evolution: continuous, intermittent, worsening, one-time, self-limited.
- • Appearance: BRBPR, dark blood, melena, invisible/occult bleeding, false positive (nonhematogenous red color).
- • Severity: acute/massive, acute/moderate, sporadic, occult, anemia.
- • Underlying systemic disease: hematologic, liver disease, medications (ASA, warfarin).
- • Probability of being sign of serious disease (liability issue): high.
- 1. Malformation
- – AV malformations, angiodysplasia, Osler disease
- – Meckel diverticulum
- – congenital aneurysms
- – AV malformations, angiodysplasia, Osler disease
- 2. Vascular
- – ischemic colitis
- – mesenteric ischemia
- – vasculitis
- – Osler disease
- – rectal varices
- – hemorrhoids
- – anorectal Dieulafoy lesion
- – acquired (pseudo-)aneurysms
- – radiation injury
- – esophageal varices
- – ischemic colitis
- 3. Inflammatory
- – colitis (infectious, idiopathic, postradiation)
- – SRUS
- – fissure
- – perianal dermatitis
- – peptic ulcer disease, Mallory-Weiss syndrome
- – colitis (infectious, idiopathic, postradiation)
- 4. Tumor
- – epithelial: cancer, adenomatous polyps
- – mesenchymal: lymphoma, leiomyoma, GIST, etc
- – neurogenic: melanoma
- – endometriosis
- – epithelial: cancer, adenomatous polyps
- 5. Degenerative/functional
- – diverticulosis
- – stercoral ulcers
- – prolapse
- – intussusception
- – Mallory-Weiss syndrome
- – diverticulosis
- 6. Traumatic/posttraumatic
- – blunt/penetrating trauma
- – anal intercourse, autoeroticism, foreign body
- – iatrogenic
- – paraplegia with need for manual stimulation
- – blunt/penetrating trauma
- 1. Fissure.
- 2. Hemorrhoids.
- 3. Neoplasm.
- 4. Prolapse.
- 5. Trauma.
- 1. Diverticulosis (distal > proximal).
- 2. Tumor.
- 3. Colonic AV malformation (proximal > distal).
- 4. IBD.
- 5. Ischemia.
- 6. Bleeding proximal to ileocecal valve (Meckel, Crohn, varices, Mallory-Weiss, peptic ulcer, etc).
Children:
- 1. Anal fissure
- 2. Intussusception
- 3. Meckel diverticulum
- 4. Polyps
- • Clinical examination: general condition, abdominal exam, rectal exam, anoscopy/rigid sigmoidoscopy.
- • Blood work: CBC, PT, PTT → rule out coagulopathy.
- • Colonoscopy: limited by poor visibility (unprepped colon, strong light absorption of blood that results in darkness); distribution of blood in the colon has only limited value in localization of bleeding source.
- • Tagged red blood cell scan: > 0.5 mL bleeding, particularly the first 15–30 min are meaningful for localization.
- • Angiography: > 1 mL/min bleeding.
- • Bleeding proximal to ileocecal valve: NGT insertion, EGD, capsule endoscopy.
- • Definition: visible inflammatory changes in colon or rectum (edema, ulcerations, friability).
- • Localization/point of origin: begin at the dentate line? Most distal segment disease-free or with limited disease (caveat: distal begin of disease potentially masked by previous local therapy!).
- • Associated symptoms: altered bowel habits, diarrhea, bleeding, mucous discharge, urgency, tenesmus, weight loss, pelvic or abdominal pain, abdominal distention, fever, toxic signs, urinary tract infections? Extraintestinal manifestations?
- • Time factor: sudden onset, gradual onset, relapsing, one-time, continuous.
- • Symptom evolution: gradual worsening, on/off relapsing.
- • Appearance: diffuse involvement of affected segment, patchy/discontinuous involvement, very localized.
- • Severity: extent of involvement, chronic/acute/fulminant/toxic.
- • Underlying systemic disease: known IBD, status postcancer treatment (radiation, chemotherapy, bone marrow transplantation, etc).
- • Probability of being sign of serious disease (liability issue): high.
- 1. Malformation
- – cavernous hemangioma (→ no true inflammation)
- 2. Vascular
- – ischemic colitis (peripheral vascular disease, embolic disease, vasculitis)
- – radiation injury
- – ischemic colitis (peripheral vascular disease, embolic disease, vasculitis)
- 3. Inflammatory
- – IBD: ulcerative colitis, Crohn disease
- – C difficile colitis, diverticulitis
- – infectious colitis (amebic, shigella, enterohemorrhagic E coli, tuberculosis, cytomegalovirus, etc)
- – STD proctitis: lymphogranuloma venereum, gonorrhea, etc
- – side effect: bowel cleansing (aphthoid ulcers or diffuse), NSAIDs, etc
- – eosinophilic colitis
- – IBD: ulcerative colitis, Crohn disease
- 4. Tumor
- – colorectal cancer (eg, signet cell cancer results in diffuse infiltration with lack of mass effect)
- – extraintestinal cancer
- – lymphoma, Kaposi sarcoma
- – endometriosis
- – colorectal cancer (eg, signet cell cancer results in diffuse infiltration with lack of mass effect)
- 5. Degenerative/functional>
- – SRUS
- – stercoral ulcerations (fecal impaction)
- – SRUS
- 6. Traumatic/posttraumatic
- – anal intercourse, autoeroticism, foreign body
- – iatrogenic
- – anal intercourse, autoeroticism, foreign body
- 1. IBD.
- 2. Specific proctitis/colitis (C difficile, infectious, STD).
- 3. Ischemic colitis (caveat: ischemic proctitis unlikely!).
- 4. Radiation proctitis/colitis.
- • History: narration with specific details, identification of risk factors (family, travel, radiation, cardiovascular surgery, anoreceptive intercourse, etc).
- • Clinical examination: anoscopy/rigid sigmoidoscopy or partial/full colonoscopy, endoscopic picture, and biopsies.
- • Histology: type of inflammation, granulomatous disease.
- • Stool analysis: cultures, C difficile toxin, ova and parasites, possible fecal WBCs.
- • Serum analysis: possible serum titers for viral/amebic pathogens.
- • Possible imaging studies, eg, small bowel follow-through or CT enterography: small bowel involvement?
- • Appearance: decreased frequency of bowel movements, increased consistency of the stools, change in shape (pencil-/pellet-like bowel movements), need for straining or manual support, incomplete evacuation; multiple/ repetitive small bowel movements.
- • Localization/point of origin: intestinal transport, evacuation.
- • Associated symptoms: bleeding, weight loss, fever, dehydration (primary/ secondary), vaginal bulging, etc.
- • Time factor: acute vs chronic.
- • Symptom evolution: one-time, gradually worsening, lifelong.
- • Underlying systemic disease: tumor, cardiopulmonary disease, diabetes, renal disease, etc.
- • Probability of being sign of serious disease (liability issue): age-dependent.
- 1. Malformation
- – atresia
- – Hirschsprung disease
- – atresia
- 2. Vascular
- – ischemic stricture
- 3. Inflammatory
- – Crohn diseaes with stricture
- – chronic diverticulitis with stricture
- – anastomotic stricture
- – Crohn diseaes with stricture
- 4. Tumor
- – tumor-related obstruction
- 5. Degenerative/functional
- – dietary
- – social (poor habits)
- – drug-induced
- – immobility
- – endocrine/metabolic: hypothyroidism, diabetes, hyperparathyroidism
- – psychiatric/neurologic (Parkinson disease, multiple sclerosis, etc)
- – constipation-predominant IBS
- – slow transit constipation (colonic inertia)
- – pelvic floor dysfunction: functional outlet obstruction, intussusception, prolapse, rectocele
- – Chagas disease
- – pregnancy (pelvic/abdominal lack of space, endocrine-induced decrease of motility, insufficient fluid intake)
- – dietary
- 6. Traumatic/posttraumatic
- – spinal injury, paraplegia
- – retroperitoneal/spinal pathology (hematoma, fracture, etc)
- – spinal injury, paraplegia
- 1. Habits.
- 2. Drug-induced.
- 3. Functional (IBS, slow transit constipation).
- 4. Morphologic obstruction (tumor, stricture etc).
- 5. Pelvic floor dysfunction.
- • Patient’s surgical/medical history: habits, daily routine (diary), alarm symptoms, previous abdominal surgeries, tumor, systemic disease, etc. Previous colonic evaluations?
- • Clinical examination: patient’s general condition, abdominal distention, palpable mass, tenderness to palpation? Digital rectal exam: perineal descent, stool in rectal vault, stool quality, rectocele, sphincter and puborectalis muscle tone, etc?
- • Based on evidence from H&P, the likelihood of a morphologic problem has to be determined in order to decide on further tests:
- – Colonic evaluation.
- – Colonic function tests: colonic transit time, defecation proctogram.
- – CT scan.
- – Contrast studies.
- – Colonic evaluation.
- • Localization/point of origin: intestinal, colonic, systemic.
- • Associated symptoms: nausea, vomiting, abdominal pain and cramping, abdominal distention, high ileostomy output of watery (tealike) quality, bleeding, altered bowel habits, diarrhea, urinary tract infections?
- • Time factor: acute vs chronic.
- • Symptom evolution: single episode (self-limited).
- • Appearance: increased frequency, decreased consistency (loose, watery, etc), added components (blood, mucus), etc.
- • Severity: decompensated → dehydration; compensated → preserved hydration and organ function.
- • Underlying systemic disease: IBD, celiac disease, history of previous abdominal surgeries, antibiotic use, etc.
- • Probability of being sign of serious disease (liability issue): moderate.
- 1. Malformation
- – short bowel syndrome (postresection)
- – internal fistula (eg, gastrocolic, enterocolonic, enteroenteric fistula)
- – short bowel syndrome (postresection)
- 2. Vascular
- – acute mesenteric ischemia (first stage)
- – chronic intestinal ischemia
- – massive GI bleeding
- – acute mesenteric ischemia (first stage)
- 3. Inflammatory
- – infectious enteritis/enterocolitis (viral, bacterial, parasites, fungal, STDs, etc)
- – toxic colitis (eg, C difficile colitis, chemotherapy)
- – collagenous colitis (abortive form of ulcerative colitis?)
- – microscopic colitis (abortive form of ulcerative colitis?)
- – IBD (ulcerative colitis, Crohn disease)
- – pouchitis
- – radiation enteritis
- – celiac disease
- – infectious enteritis/enterocolitis (viral, bacterial, parasites, fungal, STDs, etc)
- 4. Tumor
- – neuroendocrine tumor (eg, VIPoma)
- 5. Degenerative/functional
- – contrast-induced
- – IBS (diarrhea predominant)
- – dietary (eg, artificial sweeteners, enteral tube feeding)
- – drug-induced (eg, laxatives, bowel cleansing, HAART, chemotherapy, etc)
- – bile acid–induced (eg, postileal resection, Crohn disease)
- – malabsorption
- – pancreatic insufficiency
- – stress-induced
- – paradoxical diarrhea (in fecal impaction)
- – contrast-induced
- 6. Traumatic/posttraumatic
- – loss of bowel
- 1. Infectious enterocolitis (including traveler’s diarrhea).
- 2. Iatrogenic (contrast-induced, drugs, cleansing).
- 3. Antibiotic-associated diarrhea.
- 4. IBD.
- 1. IBS.
- 2. IBD.
- 3. Malabsorption.
- 4. Collagenous/microscopic colitis.
- • Patient’s surgical/medical history: exposure (travel, foods, oral–anal intercourse, etc)? Other family members affected? Previous endoscopies? Previous abdominal surgeries, tumor, antibiotic treatment, immunosuppression (HIV, drug-induced), current medications, etc.
- • Clinical examination: patient’s general condition (hydration, hemodynamic status), abdominal distention, hyperactive bowel sounds, focal/diffuse tenderness to palpation, peritoneal signs, stool in rectal vault (fecal impaction?), etc.
- • Further testing (typically not needed for acute self-limited diarrhea):
- – Stool analysis: cultures, toxins, O&P, 24-hour fat content.
- – Blood/urine tests: celiac disease, 5-HIAA, etc.
- – Endoscopy:
- – Stool analysis: cultures, toxins, O&P, 24-hour fat content.
- • Colonoscopy with biopsies (even if macroscopically normal → assess for collagenous or microscopic colitis).
- • EGD → consider small bowel biopsy to rule out celiac disease?
- • Capsule endoscopy?
- – Imaging:
- • Contrast studies: small bowel follow-through, CT enterography.
- • Response to empirical treatment (antidiarrheals, cholestyramine, etc).
- • Localization/point of origin: per rectum, perianal, per vagina?
- • Associated symptoms: perianal/perineal moisture (→ skin irritation), odor, bleeding, pain, itching, tenesmus, urgency, prolapse, altered bowel habits, diarrhea, weight loss, pulmonary symptoms?
- • Time factor: onset, constant, cyclic, certain time, certain activity?
- • Symptom evolution: continuous, intermittent, worsening, one-time, self-limited.
- • Appearance: aqueous; clear, colorless mucus; brownish; feculent; purulent.
- • Underlying systemic disease: fistula-in-ano, fecal incontinence/soiling, rectovaginal fistula, IBD (ulcerative colitis, Crohn disease), HIV, STDs, tuberculosis.
- • Probability of being sign of serious disease (liability issue): moderate.
- 1. Malformation
- – ectropion (eg, post–Whitehead hemorrhoidectomy)
- 2. Vascular
- – prolapsing internal hemorrhoids
- – radiation proctitis
- – prolapsing internal hemorrhoids
- 3. Inflammatory
- – proctitis/colitis (infectious, idiopathic, postradiation)
- – SRUS
- – abscess
- – fistula-in-ano
- – anastomotic leak
- – dermatitis (eczema, contact allergy, etc)
- – proctitis/colitis (infectious, idiopathic, postradiation)
- 4. Tumor
- – large adenoma (particularly villous adenoma)
- – anorectal tumors (cancer, Paget disease, Bowen disease)
- – large adenoma (particularly villous adenoma)
- 5. Degenerative/functional
- – IBS
- – rectal prolapse/intussusception
- – fecal incontinence
- – transpiration
- – inadequate local hygiene
- – IBS
- 6. Traumatic/posttraumatic
- – anal intercourse, autoeroticism, foreign body
- – rectourinary fistula
- – anal intercourse, autoeroticism, foreign body
- 1. Abscess/fistula.
- 2. Incontinence/transpiration.
- 3. Prolapse (rectal, hemorrhoidal).
- 4. Villous adenoma.
- 5. IBS.
- 6. Neoplasm.
- 7. Proctitis.
- 8. Trauma.
- • Patient history: precipitating/risk factors, characterization of symptoms.
- • Clinical examination: careful anorectal exam including inspection, palpation, anoscopy/rigid sigmoidoscopy.
- • Colonoscopy: (a) for diagnostic purposes if diagnosis not clear from local exam; (b) colonic evaluation per guidelines.
- • Functional studies: anophysiology testing, defecating proctogram, etc.
- • Radiologic finding: conventional x-ray, CT scan.
- • Associated abdominal symptoms: nausea, vomiting, abdominal pain and cramping, distention, GI dysfunction, tissue crepitans?
- • Evolution: primary progression/regression, temporary resolution (eg, postoperative) with secondary recurrence?
- • Location: peritoneal, retroperitoneal, mediastinal, abdominal wall/soft tissue.
- • Probability of being sign of serious disease (liability issue): high.
- 1. Malformation
- – Chilaiditi syndrome, situs inversus: pseudo–free air
- 2. Vascular
- – portal vein gas: sign of ischemic bowel necrosis
- 3. Inflammatory
- – perforated viscus (colon, peptic ulcer, appendicitis, etc): → confined or free perforation
- – anastomotic leak → confined or free perforation
- – abscess → small pocket of extraluminal air
- – appendicitis: rarely leading to pneumoperitoneum
- – emphysematous cholecystitis
- – necrotizing soft tissue infection
- – perforated viscus (colon, peptic ulcer, appendicitis, etc): → confined or free perforation
- 4. Tumor
- – perforated tumor → confined or free perforation
- 5. Degenerative/functional
- – spontaneous pneumoperitoneum without peritonitis: aspiration of air, eg, through vagina and tubes
- – peritoneal dialysis
- – spontaneous pneumoperitoneum without peritonitis: aspiration of air, eg, through vagina and tubes
- 6. Traumatic/postsurgical
- – postoperative pneumoperitoneum: normal resolution expected within 7 days, sporadically taking up to 2½–3 weeks (however, worsening not compatible with delayed absorption → new pathology has to be suspected)
- – postoperative while nonvacuum drains still in place
- – postcolonoscopy: small amounts of gas possible even without perforation
- – colonoscopic/endoscopic perforation → generally massive pneumoperitoneum and/or retroperitoneal air (due to insufflation of pressured gas)
- – post–transanal endoscopic microsurgery (TEM): extensive retroperitoneal gas expected.
- – postcardiopulmonary resuscitation: air leak from pressured ventilation → pneumomediastinum/pneumothorax with abdominal extension; rib fractures → sharp injury to lung/diaphragm
- – pneumobilia: status post-ERCP/sphincterotomy, status post-hepaticojejunostomy
- – postoperative pneumoperitoneum: normal resolution expected within 7 days, sporadically taking up to 2½–3 weeks (however, worsening not compatible with delayed absorption → new pathology has to be suspected)
- • Patient’s immediate surgical/medical history: type and time frame of previous abdominal surgeries or procedures, prodromal symptoms (eg, epigastric or LLQ pain, etc).
- • Clinical examination: patient’s general condition, vital signs, abdominal distention, tenderness to percussion/palpation, peritoneal signs (involuntary guarding, rebound tenderness), bowel sounds, drains, etc.
- • Context synthesis: combination of radiologic data with information from H&P.
- • Additional imaging: eg, water-soluble contrast study.
