NMS. Casos Clínicos

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Part II ♦ Specific Disorders

Case Variation 8.19.3. Bright red blood on the glove after rectal examination

◆ ◆ Anoscopy or sigmoidoscopy is necessary to determine the cause of anorectal bleeding, which may be due to internal hemorrhoids, a fissure, a bleeding rectal or anal carcinoma, or a polyp. If the lesion is not visualized in the anus or rectum, colonoscopy is required to ensure that a polyp or cancer is not causing the bleeding. Case Variation 8.19.4. A 5-cm perianal fungating mass ◆ ◆ It is important to obtain a biopsy of this mass because it most likely represents an anal carci- noma. Transanal ultrasound may also be necessary to determine the depth of invasion and help guide your treatment strategy (Fig. 8-22).

Case 8.20 Heme-Positive Stool in Patient with Polyp

A 60-year-old reports bright red blood on the stool. On examination, no other abnor- malities are apparent. A colonoscopy finds a polyp in her colon .

Q: What is the appropriate management of a colonic polyp? A: Polyps can either be pedunculated, on a stalk, or be sessile, flush with the mucosa (Fig. 8-23). It is necessary to remove them because of the risk of adenocarcinoma development. The supposed histologic progression from formation of polyps to invasive carcinoma may take up to 10 years. Q: What is the management, prognosis, and recommended surveillance after treatment for each of the following findings? Case Variation 8.20.1. A 1-cm pedunculated polyp ◆ ◆ A polypectomy is appropriate, which involves placing a snare around the polyp and advancing it down the stalk. The snare is then closed as the polyp is lifted up, with the application of electrocautery to the stalk as the polyp is ensnared. The pathology of the lesion determines whether further resection is necessary (e.g., in the case of invasive carcinoma). Case Variation 8.20.2. A 5-cm pedunculated polyp ◆ ◆ A large pedunculated polyp may require removal in a piecemeal fashion or may necessitate more than one endoscopic session for removal. These patients are at increased risk for developing colorectal cancers and should also have surveillance colonoscopy. Case Variation 8.20.3. A 4-cm flat, sessile lesion ◆ ◆ Whether sessile polyps warrant biopsy or attempted ensnaring is controversial. One tech- nique involves the injection of saline under the polyp and attempting to ensnare it in its entirety. Usually, sessile polyps less than 2 cm are possible to remove successfully, but those greater than 2 cm may require formal surgical resection . SAMPLE