Tuesday, 26 June 2007

Rectal, Rectal, Rectal !!!!!

Dear Bloggers

This case has been anonymised for patient confidentiality.

An elderly female patient with a two month history of watery diarrhoea was admitted to another hospital. The diarrhoea had started gradually and built up to a peak which had plateaued at 15x per day!! The diarrhoea was described as painful and in the lower abdomen. There was no blood and no mucus in the stool.

The patient described loss of appetite, weight loss of 7 kg and night sweats for the preceding 1 month prior to admission.

On further questioning, the stool was described as looking like 'paper' as it was thin when she produced it, just like paper.

However, the patient had been seen at another hospital where she was told that the problem was irritable bowel syndrome.

Having asked the patient if any doctor had in the last 2 months performed a rectal examination, the answer was NO.

The patient presented to hospital because of the development of urinary frequency, stool-coloured urine and production of gas per urethra at the end of micturition (pneumaturia). The patient also had a feeling of always needing to go to do stool which is known as Tenesmus which is usually an ominous symptom of cancer.

There was no previous medical history and the patient was taking no medications.

There was no relevant family history whatsoever.

Review of systems: No joint pain, no eye discomfort, no myalgias, no bone pain, no chest complaints.

Physical examination revealed a fever of 37.9 degrees C, normal vitals otherwise.

Cardiovascular and Respiratory examinations were unremarkable.

Abdominal examination revealed tenderness in the suprapubic and both iliac fossae. There was no costovertebral angle tenderness. There was no rebound tenderness and no guarding. An indiscrete mass could be palpated.

Bloods revealed a neutrophil leucocytosis, raised CRP and LDH. All other bloods were normal.

CXR was normal.

Differential Diagnosis

From the history of weight loss, appetite loss, night sweats, increasing diarrhoea without blood/mucus and new onset symptoms of UTI are consistent with an advanced colonic tumour NOT irritable bowel syndrome.

Other differential diagnoses should include inflammatory bowel disease but this is somewhat unusual in the absence of bloody diarrhoea. Also, patients will sometimes develop extraintestinal manifestations affecting the eyes (iritis), joints (arthritis), skin (erythema nodosum) etc, which this patient did not have.

Diverticulitis should also be considered, as post-inflammatory masses can occur which cause stricture and can invade the bladder.

CT scan of this patient revealed a colonic mass attaching to the bladder and with air seen inside the bladder which was unsurprising.

Two mistakes were made in the management of this patient.

Firstly, no Rectal Examination was ever done. 45% of all colonic malignancies present in the rectum and are therefore detectable with the tip of the finger! If performed two months ago, this could have perhaps been picked up at a stage when it could have been more amenable to surgical therapy.

Secondly, this patient had a fever and urinary signs of infection including faeces in the urine, white cells >100/hpf , 2+ bacteria and blood. However, the fatal mistake was to rely on urine culture which was negative. Hence, no antibiotic therapy was given on admission. This was clearly wrong as the patient has symptoms and signs of a UTI. Moreover, only 50% of urine cultures prove positive despite a UTI being present. Therefore, giving antibiotics such as a fluoroquinolone antibiotic would be advisable e.g. levofloxacin, as the patient was not being sick, the fluoroquinolones are rapidly absorbed and are effective against gram negative bacteria.

However, the diagnosis could have soon been established by performing a rigid sigmoidoscopy o admission to hospital as again another 25% of colonic cancers can be picked up where they occur in the sigmoid area. [please note 5% occur in the descending colon, 10% in the transverse colon and 15% in the ascending colon].

Thus, 70% of colonic tumour can be potentially picked up with the aid of a finger tip and a rigid signmoidoscope. Simple but rapid and effective in establishing a cause.

The Lessons to be Learnt here include:

  • In patient with any lower GI symptoms ALWAYS DO A RECTAL EXAMINATION. It is negligent to avoid doing one, and relying on CT to make a diagnosis in this circumstance is incorrect. CT is a guide only.

  • The patient had symptoms of OVERFLOW DIARRHOEA. This occurs when there is a blockage in the colon either by a internal occlusion [for example constipation, tumour] or external compression [e.g. invading non-colonic tumour]. Hard stool is unable to pass through the small hole produced by the compression. The liquid stool within the right colon migrates over the obstructed harder stool and through the stenosis of the colon to produce tape-like stool or diarrhoea, just as in the case of this patient. Thus, taking a decent history about the consistency of the stool should have set of warning alarms to do a rectal examination and rigid sigmoidoscopy at the bedside.

  • The patient clearly had developed a fistula from bowel to bladder with subsequent infection. Relying on culture alone is not correct. Look at the history, physical, vital signs [such as fever] and other laboratory data and they ALL point to a UTI. Hence, patient should have been treated on suspicion of infection which might otherwise progress to a complicated UTI.
Please consider..............

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