ABC of colorectal diseases. Investigation of colorectal disorders.
Authors: D. J. Jones, M. H. Irving
Journal: BMJ (1992)

Symptoms of colorectal disordersWhen investigating a patient for colorectal disorders a detailed history is important and will provide clues to the diagnosis.Symptoms arising from General-Malaise; weight loss;vomiting the large bowel tend to be non-specific and are often difficult to interpret.Abdominal-Pain (constant or colic);There is a wide variation in bowel habit, so alterations from a patient's distension; borborygmi normal bowel pattern, changes in longstanding symptoms, and the passage Bowel habit-Altered frequency; of blood and mucus are of most importance.constipation; diarrhoea; taking laxative and olood dimucus are ofiot ip tance.antidiarrhoeal drugs; stool consistency; Colorectal disorders are associated with several systemic manfestations bleeding (bright red, mixed in motion, dark, which may hint at the underlying diagnosis.Anaemia is associated with altered); slime (mucus) neoplasia and inflammatory bowel disease; dermatoid cysts with Gardner's Analand perineal-Pruritus; pain and its syndrome; acanthosis nigricans and dermatomyositis with neoplasia; and relation to defecation; prolapse; continence pyoderma gangrenosum, arthropathy, uveitis, and finger clubbing all with and incontinence; discharge; tenesmus; inflammatory bowel disease.swelling (painful or painless) Abdominal examination Differential diagnosis of lower abdominal mass Left iliac fossa Ideally the patient should be comfortable, relaxed, and supine for * Carcinoma of the sigmoid colon abdominal examination.The abdomen should be inspected for distension * Diverticular disease and visible peristalsis.Gentle palpation will often reveal a palpable sigmoid Right iliac fossa colon, which can be considered a normal finding in constipated patients.* Carcinoma of the caecum Diverticular disease and colonic cancer may manifest as palpable masses.* Crohn's disease Palpation of the liver may disclose secondary spread in patients with * Abscess of the appendix colorectal cancer.* Ileocaecal tuberculosis clrca acr * Actinomycosis The characteristic rebound tenderness associated with peritonitis should * Intussusception be elicited by gentle percussion and not by the sudden release of a deeply Either palpating hand, which is less sensitive and causes extreme discomfort in * Ovarian mass patients with peritonitis.* Ectopic kidney * Transplanted kidney Anorectal examination Findings on anal inspection * Pruritus aniThe rectum and anus are readily accessible, so their clinical examination * Perianal warts is often the mainstay of diagnosis.Few patients relish this examination, * Perianal abscess which should be indicated and not performed "routinely."Patients feel * Perianap haematoma embarrassed and exposed, and anxiety provokes spasm of the anal * Prolapsing haemorrhoids * Thrombosed haemorrhoids sphincters and buttocks.This is exacerbated by a rough technique, which * Skin tags results in an unpleasant examination with little yield.Fears are allayed by * Fistula-in-ano prior explanation.Patients should be placed in the left lateral position with a * Fissure-in-ano pillow under the hip and covered with a blanket.They are warned that * Rectocele although they may feel they are losing control of their continence during the * Rectal prolapse examination, an "accident" is unlikely.