Kocher’s test for stridor in a goiter

by Tan Yan Wei, year 3, Jeffrey Cheah School of Medicine and Health Sciences, Monash University Malaysia

26 March 2016

Introduction

A large thyroid gland presses on the trachea. This pressure may decalcify the tracheal cartilage (tracheomalacia), and produce some degree of narrowing [Dandekar et al, 2016]. This can cause difficulties during intubation for surgery, as well as after surgery [Agarwal et al, 2007]. Although pre-operative compression testing does not appear to reliably predict tracheomalacia [Agarwal et al, 2007], it can be a useful guide to increased awareness.

Kocher’s test is done during examination of the thyroid to rule out trachea narrowing (scabbard trachea). [Bhat, 2013] A “scabbard” trachea is a deformity of the trachea caused by flattening and approximation of the lateral wall, producing stenosis. It is called scabbard trachea because the trachea looks, radiologically, like a scabbard: the sheath of a sword.

Method

The test is started by asking the patient to extend the neck, followed by asking the patient to take heavy deep breaths through the mouth continuously. After that, the examining physician compresses the swelling from the sides. The test is positive if there is the presence of stridor when the lateral lobes are pushed posteromedially with fingers [Bhat, 2013]. An 11-12 minute procedure of the examination can be viewed at .

Significance/ Implication

The positive Kocher’s test is normally seen in scabbard trachea, which may occur in a large multinodular goiter or carcinoma of the thyroid.

When there is a long standing thyroid enlargement, the constant pressure of the thyroid gland on the trachea causes weakened tracheal rings. When the thyroid is being compressed during this test, the weakened trachea narrows, and this presents as stridor during compression of the thyroid (positive Kocher’s test). Due to the weakened tracheal ring, the patency of the trachea is mainly maintain by thyroid. This is important because after thyroidectomy, there is no support to trachea and so it may collapse, causing respiratory embarrassment. For this condition, temporary tracheostomy need to be done for 2-3 weeks. After 2-3 weeks, the trachea will regain its strength.

Tracheomalacia causing stridor is a rare complication after thyroid surgery [Lacoste et al, 1993; Findlay et al, 2011]. Nevertheless, it does occur, and may be commoner in countries where large endemic goiters are common [Agarwal et al, 2007; Abdel Rahim et al, 1999]. It may take the treating team by surprise and cause life-threatening respiratory distress [Tripathi and Kumari, 2008; Lee et al, 2011]. Surgeons should, therefore, be aware of the possibility of tracheomalacia when operating on large goiters. As regards the Kocher test, studies ([Agarwal et al, 2007, and others]) indicate that this test is only moderately reliable. A more reliable indicator of the need for tracheostomy may be the assessment of the tracheal cartilage at the time of surgery. The test is, of course, uncomfortable for the patient, and it can be debated whether it should be performed at all.

There are three interesting asides. One: Kocher’s sign (also known as Ramsay’s sign) is different fro the Kocher’s test described here. The sign refers to a retraction of the upper eyelid in Graves’ disease. Two: There is also a “Kocher’s testicular sign”! Three: Finally, did Kocher really describe the Kocher test? Plenty of books call it the Kocher test, but no book is able to provide an authentic reference.

    References:

  • Abdel Rahim AA, Ahmed ME, Hassan MA. Respiratory complications after thyroidectomy and the need for tracheostomy in patients with a large goitre. Br J Surg 1999; 86: 88-90.
  • Agarwal A, Mishra AK, Gupta SK, Arshad F, Agarwal A, Tripathi M, Singh PK. High Incidence of Tracheomalacia in Longstanding Goiters: Experience from an Endemic Goiter Region. World J Surg 2007;31:832-7
  • Bhat MS, Chapter 6 Thyroid, Jaypee Brothers Medical Publisher (P) Ltd, India, 2013, pg 526
  • Dandekar M, Kannan S, D’Cruz A. The thyroid and parathyroids. In: Lumley JSP, D’Cruz AK, Hoballah JJ, Scott-Connor CEH (editors) In: Hamilton Bailey’s Demonstrations of Physical Signs in Clinical Surgery, 19th edition. CRC Press, Boca Raton, 2016, p410.
  • Findlay JM, Sadler GP, Bridge H, Mihai R. Post-thyroidectomy tracheomalacia: minimal risk despite significant tracheal compression.Br J Anaesth. 2011;106(6):903-6. doi: 10.1093/bja/aer062.
  • Lacoste L, Gineste D, Karayan J, et al. Airway complications in thyroid surgery. Ann Otol Rhinol Laryngol 1993; 102: 441-6.
  • Lee C, Cooper RM, Goldstein D. Management of a patient with tracheomalacia and supraglottic obstruction after thyroid surgery. Canadian Journal of Anesthesia 2011, 58:1029.
  • Tripathi D, Kumari I. Tracheomalacia: A Rare Complication After Thyroi dectomy. Indian J Anaesth [serial online] 2008 [cited 2016 Mar 28];52:328-30. Available from: http://www.ijaweb.org/text.asp?2008/52/3/328/60644.
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The thyroid gland: history and examination

By Vinod Ramachandran

Year 3, Monash University Malaysia

23 Mar 2016

Introduction

This article is titled “History and examination of the thyroid gland”. It has a definite focus towards a patient with a thyromegaly, but it can also be considered a guide to the history and presentation of a patient with a swelling in the neck.

    History

    Demographic details

  1. Age
  2. Simple goiter; girls approaching puberty and pregnancy; multinodular, solitary nodular goiters and colloidal goiters; women in their 20s and 30s; Papillary carcinoma; young girls; follicular carcinoma; middle aged women; Anaplastic carcinoma; old age; Hashimoto’s disease; middle aged women

  3. Sex
  4. Majority of thyroid disorders are seen in women. Thyrotoxicosis is much commoner in females than in males; Thyroid carcinomas occur three times more often in females

  5. Occupation
  6. Thyrotoxicosis may appear in individuals working under stress & strain

  7. Residence
  8. Endemic goiter due to iodine deficiency. Certain areas known to have low iodine content in the water and food

    Swelling

  9. Swelling
  10. How to take a history of swelling is described in the presentation titled “Mass, history and examination”. The same questions should be asked, including onset, duration, rate of growth, and appearance of symptoms such as pain. Does it cause symptoms that relate to pressure effects on nearby structures? A swelling that appears after trauma may be a hematoma, not a thyroid swelling. Benign swellings grow slowly; malignant swellings (like an anaplastic cancer of the thyroid) usually grow faster. Note that papillary cancers of the thyroid usually grow slowly. Goitres are painless, unless the patient has thyroiditis. Anaplastic carcinomas infiltrate surrounding structures and often cause pain.

    Special features of neck swellings

  11. Adjacent structures: trachea, esophagus, recurrent laryngeal nerves
  12. Ask about the effect of the swelling on the

    a. trachea, causing breathing difficulty and stridor.

    b. esophagus, causing dysphagia.

    c. recurrent laryngeal nerve, causing hoarseness.

    The thyroid may also press on the carotid, but that will be evaluated during examination.

  13. Hyperthyroidism and hypothyroidism
  14. In a patient with a neck swelling that may be the thyroid gland, look for symptoms of hyperthyroidism and hypothyroidism

    Hyperthyroidism: Heat intolerance, raised appetite, weight loss, sweating, palpitations, tiredness, agitation/nervousness, dyspnea; also diarrhea, menstrual changes (commonly amenorrhea), insomnia

    Hypothyroidism: Weight gain, loss of appetite, constipation, cold intolerance, hoarseness of voice, decreased hearing, hair loss, dry skin, hand pain (carpal tunnel syndrome), angina pectoris, intellectual/ motor slowing (excessive sleeping), muscle cramps, (commonly menorrhagia)

    Past, treatment, family, and dietary history

  15. Medications
  16. Ask about treatment the patient has taken, and its effects on the swelling. Drugs (some may be goitrogenic)

  17. Family history
  18. Some thyroid disorders have a familial predilection.

  19. Dietary history
  20. Dietary habits are important as vegetables of the brassica family (cabbage, kale, rape) are goitrogens. If there is insufficient iodine in the diet, an iodine-deficiency goiter may develop.

    Examination

    General physical examination

  21. Body habit
  22. Patients with thyrotoxicosis are usually thin and underweight. Patients with hypothyroidism are usually obese and overweight. In case of carcinoma of thyroid; signs of anaemia and cachexia may be present, especially with anaplastic cancers. Patients with early papillary cancer are usually well-preserved.

  23. Alertness and motor activity
  24. Patients with thyrotoxicosis may show hyperkinetic movements. Voice changes may occur with hypothyroidism, and with thyroid cancers.

  25. Hands
  26. Patients who are hyperthyroid may show features such as fine tremors, onycholysis, palmar erythema, warm and sweaty palms, and clubbing. Xanthomas, cool and dry palms, and cyanosis suggest hypothyroidism.

  27. Vital signs
  28. Pulse and blood pressure: Tachycardia and other arrhythmias occur in hyperthyroidism, while bradycardia and hypotension indicate hypothyroidism.

  29. Eyes
  30. The eye signs of hyperthyroidism include exophthalmos, chemosis, conjunctival injection, corneal ulceration, opthalmoplegia, lid-lag, lid retraction, and others. The eye signs of hypothyroidism include periorbital edema, loss of outer third of eyebrows, and xanthelasmas near the eyes.

  31. Face
  32. Patients with hypothyroidism may have dry skin and hair, and yellow discoloration of the face and palms due to hypercarotenemia that results from slowing down of hepatic metabolism of carotene.

    Neck

    Inspection

  33. Mass
  34. Inspect the swelling as for a mass. Note the location, size, shape, surface, edges, margins, overlying skin, pulsatility, and adjacent structures (particularly the trachea). Dilated veins may indicate compression of the superior vena cava.

  35. Four special features of neck swellings
  36. Inspect the swelling for:

    a. Look for movement with swallowing. You may need to ask the patient to swallow some water.

    b. Thyroglossal cysts (but usually not the thyroid glands) move with protrusion of the tongue.

    c. Look at the adjacent structures, especially the trachea.

    d. Look for pressure on the thoracic inlet (Pemberton’s test).

    Palpation

    Palpate from behind.

  37. Mass
  38. Palpate the swelling as for a mass. Note the tenderness, temperature, location, size, shape, surface, margins, edges, fixity, consistency, and thrill. Consider fluctuation and transillumination. Tenderness indicates thyrotoxicosis. A raised temperature indicates inflammation: thyrotoxicosis, or an abscess. Thrills occur in thyrotoxicosis. Be sure to check if you can get below the gland.

    The “Lahey’s test” is a palpation of the thyroid from the front. Its objective is to feel the posterior part of the gland.

  39. Three special features of neck swellings
  40. Inspect the swelling for:

    a. Examine the trachea.

    b. Perform Kocher’s test.

    c. Feel the carotid (Berry’s sign).

    Percussion

  41. Percuss the swelling for one special feature of a neck swelling
  42. Although most swellings do not need percussion, there are some exceptions (e.g. a suspected kidney mass). In neck swellings, one should percuss the upper sternum for a possible retrosternal extension of the goiter.

    Auscultation

  43. Auscult the swelling, as any other mass. Look for a bruit. Toxic thyroids may produce bruits. Carotid body tumors of the neck (which are, of course, not related to thyroids) also produce bruits.
  44. Nodes

  45. Cervical lymph nodes
  46. Always examine the cervical nodes.

    Examination for thyroid function

  47. Hyperthyroidism
  48. Evaluate the patient for hyperthyroidism. The commonest features of hormonal dysfunction are in the eyes, which have already been examined during general physical examination. Other general features of hyperthyroidism include pretibial myxedema.

  49. Hypothyroidism
  50. Evaluate the patient for hypothyroidism .

    Examination of other systems

  51. Neurological examination
  52. Patients with hyperthyroidism may have neurological changes such as anxiety, proximal muscle weakness, and increased tendon reflexes. Patients with hypothyroidism may have changes such as mental dullness (even coma), hearing loss, and decreased tendon reflexes.

  53. Examination of the rest of the body
  54. The other systems: cardiovascular, respiratory, and others should be examined for completeness.

References

  • Talley NJ, O’Connor S. The thyroid. In: Clinical Examintion, a Systematic Guide to Physical Diagnosis. 7th edition, Australia: Elsevier; 2014, p355-61.
  • Das S. A Manual on Clinical Surgery. 10 ed. Kolkata: Somen Das; 2013.
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Striae distensae (stretch marks)

Jery Park, Year 3, Jeffrey Cheah School of Medicine and Health Sciences, Monash University Malaysia

6 Mar 2016

Striae distensae are a common scarring on the skin. They can be erythematous, violaceous or hyperpigmented linear striations.

There are 2 main types:

  1. Striae rubra
  2. Striae alba

Striae rubra presents in striae distensae before progressing to striae alba in the course of 6 to 10 months.

Common causes are: pregnancy, rapid weight gain or loss, rapid growth, bodybuilding exercise and medications(particularly topical and systemic corticosteroids).

Striae distensae are commonly found on abdomen, breasts, medial upper arms, hips, lower back and thighs.

What to look for in a patient with striae

Characteristic Variants Clinical implications
Color Red (erythematous) or violet (violaceous): “striae rubra” During pregnancy, rapid weight gain or loss, rapid growth, bodybuilding exercise and medications (particularly topical and systemic corticosteroids)
White: “striae alba” Past pregnancy
Location Lateral borders of hips, and over the back at the upper sacral region only Puberty striae in boys
Over the hips posteriorly and laterally, extending to the posterolateral thighs Puberty striae in girls
Chest, and back in the area between the scapulae and the sacral bones Bodybuilders, striae related to lifting or stretching
Breasts, entire anterolateral abdomen mostly below the umbilicus Pregnancy
Intertriginous areas* Striae distensae secondary to topical corticosteroid use
Particularly prominent and widely distributed Cushing’s syndrome

*Intertriginous: where two skin areas may touch or rub together,eg axilla

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Dilated abdominal veins, examination of

Gerald Tan, Year three, Jeffrey Cheah School of Medicine and Health Sciences, Monash University Malaysia

Last updated 26 Feb 2016

What to look for in a patient who has dilated abdominal veins

Characteristic Sign Differential diagnosis
Location Periumbilical Caput medusae
Over costal margin Congenital (no clinical revelance)
Flow (below umbilicus, obstruct from 2 points to determine) Towards legs Caput medusae due to portal hypertension
Towards head Obstructed inferior vena cava

Comments

Caput medusae: There exist anastomoses from the superficial epigastric veins to the portal vein via the paraumbilical veins. These veins carry oxygenated blood from the mother to the foetus and usually close after birth. In portal hypertension, the veins re-canalise and cause a caput medusae. The flow goes down because the blood is trying to go to the great saphenous vein from the superficial epigastric veins .

Dilated veins in IVC obstruction:  Deoxygenated blood cannot be returned normally to the heart. The abdominal veins stagnate and build pressure, overcoming the normal valves. Blood from the great saphenous vein can backflow into the superficial epigastric veins which anastomose with the lateral thoracic vein, which is a tributary of the axillary vein. The flow goes up because the blood is trying to go to the SVC due to IVC obstruction [Snell].

DSCN0473

In the picture above, note the dilated veins over the chest and abdomen. This patient had a superior mediastinal tumor occluding the superior vena cava (see the CT scan below).

DSCN0482

This CT scan slice is taken just before the tracheal bifurcation. You can see the trachea (on the patient’s right), and the esophagus (to the left of the trachea). Above the trachea is the arch of the aorta, opacified by contrast. The superior vena cava is not visible, since it has been flattened by the tumor.

    References

  • Browse NL, Black J, Burnand KG, Thomas WEG. The abdominal wall, herniae and the umbilicus. In: Browse’s Introduction to the Symptoms and Signs of Surgical Disease, 4th Edition, Taylor & Francis Group, UK, 2005. Page: 385.
  • Snell RS. The Abdomen. In: Clinical Anatomy by Regions, 9th edition, Lippincott Williams & Wilkins, Maryland. Pages: 96, 98, 126, 195.
  • Talley NJ, O’Connor S. The gastrointestinal examination. In: Clinical Examination, 7th Edition, Elsevier Australia, New South Wales, 2014. Pages: 196, 197.
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Umbilicus, examination of

Ng Wei Yao, Chong Yee Ting, Year 3, Jeffrey Cheah School of Medicine and Health Sciences, Monash University Malaysia

Last updated 28 Feb 2016

This table lists some abnormalities of the umbilicus. If, on abdominal examination, the umbilicus looks abnormal, this table provides a useful guide for examining it.

Location Normal Umbilicus is usually located almost in the middle of the line joining the tip of xiphoid process and the top of the pubic symphysis. [1]

 

Displaced upwards (a) Due to swelling arise from pelvis/ pelvis mass.

(b) Enlargement of uterus during pregnancy [2]

Displaced downwards Ascites – Tanyol sign

 

Shape [1] Inverted Normal
Everted Ascites
Tucked-in Obesity

 

Bulging mass Presence *Umbilical hernia

– Expansile impulse on coughing. [3]

 

*Sister Mary Joseph Nodule

– hard, palpable nodule

– suggestive of intra-abdominal carcinoma, especially gastric malignancy. [1]

 

* Umbilical adenoma

– raspberry-like tumour with a tendency to bleed

– due to prolapse of the mucosa of the unobliterated distal end of vitello-intestinal duct. [4]

Absence Normal
Discoloration

(periumbilical area)

Presence of bluish decolorisation Cullen sign [5]

Indicates hemoperitoneum. One cause is severe, hemorrhagic pancreatitis which has bled into the peritoneal cavity.

Absence of bluish discoloration Normal

 

Discharge Urine Patent urachus [4]
Faecal + mucous Patent vitello-intestinal duct [4]
Seropurulent discharge with characteristics foul-smelling odor Omphalitis [5]
Blood (during menstruation) Endometrioma [5]
Veins Dilated veins around the umbilicus (“caput medusa”) Cirrhosis
    References

  • Browse N. The abdominal wall, hernias and the umbilicus, In: Burnand KG, Black J, Corbett SA, Thomas WEG (editors) Browse’s Introduction to The Symptoms & Signs of Surgical Disease, 5th edition, CRC Press, 2015, pages: 478-479.
  • Das S. Examination of an abdominal lump. In: A Manual on Clinical Surgery, 10th edition, Dr S Das, Kolkata, 2013, pages: 531
  • Das S. Examination of chronic abdominal conditions. In: A manual on Clinical Surgery, 10th edition, Dr S Das, Kolkata, 2013, page 486.
  • Das S. Examination of chronic abdominal conditions. In: A Manual on Clinical Surgery, 10th edition, Dr S Das, Kolkata, 2013, page 516.
  • Talley NJ, O’Connor S. The Gastrointestinal Examination. In: Clinical Examination, 7th edition, Elsevier Australia, New South Wales, 2014, pages: 195-196.
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Hematemesis

Melody Shu Ling Tsen, Harkamal, Joshua, Zi Ning

Year 3, Jeffrey Cheah School of Medicine and Health Sciences, Monash University Malaysia

22 Feb 2016

What to ask in a patient who complains of vomiting of blood

The following is a guide to the questions one should ask a patient who complains of vomiting of blood:

Symptoms: Hematemesis
Examples/Indications:
1.       Volume of blood: Less than 20mL in 24 hours Slowly bleeding peptic ulcer
More than 250mL in 24 hours Eg. Carcinoma, cystic fibrosis, bronchiectasis and tuberculosis

 

2.       Color of blood: Bright red Indicates upper gastrointestinal bleeding is more acute or more severe, or originates more proximally than the stomach

Eg. Mallory-Weiss Tear

Dark brown/ Coffee ground Classic sign of upper gastrointestinal bleeding.

Eg. Peptic Ulcer, damage to the mucosa due to NSAIDs or SSRIs

 

3.       Associated Symptoms: Retching & Vomiting episodes
(before Hematemesis)
Eg. Mallory-Weiss Tear
Weight Loss + Appetite Loss Eg. Malignancy (Stomach Cancer/ Oesophageal Cancer)
4.       Medications NSAIDs (inhibits the gastric prostaglandins, gastric mucosa is unprotected) / Anticoagulant Ibuprofen/ Aspirin
5.       Liver Alcohol ·         How much?

·         Duration

·         Standard drink

Hepatitis ·         Immunisation

·         Travel history

Intravenous injection Leads to Hepatitis
Diet Leads to fatty liver,  scarring of the liver, cirrhosis, portal hypertension, esophageal varices and hematemesis

 

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Blood in the stools (hematochezia)

Ng Jay Shen, Gerald Tan Chen Jie, Kang Hui Wen, Year three, Monash University Malaysia

Updated 22 Feb 2016

Hematochezia is blood in the stools (Greek, hemato- (from haima, blood); chezo, to go to stool). Different dictionaries define it as “bleeding per rectum”, “bright red blood in the stools”, and maroon or red blood in the stools”. Perhaps the best use of hematochezia is simply to differentiate it from melena.

How to take a history from a patient who complains of bleeding per rectum

The following is a brief account of what to ask while taking a history of a patient who complains of blood in the stools.

  1. Onset
    • Sudden, quick onset suggests anal fissure or dysentery
    • Long time, gradual onset suggests Inflammatory bowel disease, colon cancer, polyps, haemorrhoids
  2. Colour
    • Bright red: this indicates a very distal source of bleeding, especially anorectal disorders such as haemorrhoids, fissure, and rectal cancer. Often, bleeding from a colonic cancer, diverticulosis, or ulcerative colitis is bright red as well.
    • Maroon or dark red, but not black colored bleeding occurs from ileal or colonic disorders. Bleeding Meckel’s diverticulum, angiodysplasias of the right colon, ulcerative colitis, diverticulosis causing bleeding: in these cases the blood is maroon or dark red, and sometimes bright red (see the note “Color” below). The further the source is from the anus, the darker is the color of the blood.
    • Dark, tarry stools imply Melena, not hematochezia. This occurs in upper gastrointestinal lesions such as erosive gastritis, peptic ulcer disease, Mallory- Weiss tears, esophageal varices, esophagitis, and duodenitis.
  3. Location [Penner and Majumdar, 2015; emedicine Health, 2016]
    • On the toilet paper: blood seen only on the toilet paper after defecation typically occurs in haemorrhoids and fissures.
    • Mixed with stools: bleeding that originates above the surgical anal canal is usually mixed with stools. Examples include polyps and cancer.
    • On top of stools: bleeding that oritinates from lesions distal to the anorectal junction often presents as a drop or two of blood on the surface of the stools. It occurs in anal fissures and haemorrhoids
  4. Volume
    • Massive bleeding is usually caused by diverticular disease, ulcerative colitis, angiodysplasia, colonic varices, small bowel arteriovenous malformations, and bleeding Meckel’s diverticulum.
    • Small bleeds are typical of hemorrhoids, fissure, and colon cancer. Bleeding from colon cancer may be occult, and picked up only on testing the feces for blood.
  5. Clots
  6. Clots indicate large bleeds, and suggest conditions such as angiodysplasia and diverticulosis.

  7. Mucus
  8. Patients with inflammatory bowel disease (ulcerative colitis, Crohn’s), acute dysentery, irritable bowel syndrome, and hemorrhoids often also complain of a discharge of mucous.

  9. Smell
  10. Melena produces a particularly offensive smell. Black stools due to drugs, such as charcoal, are not as foul-smelling.

  11. Pain
  12. Pain at the anus during, or immediately after defecation, occurs in patients with anal fissure

Note that hematochezia and melena are different. Hematochezia is a term used for red blood in the stools. It indicates lower gastrointestinal bleeding. Melena is a term used for black stools. It indicates upper gastrointestinal bleeding.

The color of the blood darkens as the source of the bleeding moves away from the anus. This is because in the gut, hydrochloric acid from the stomach oxidizes the heme iron from ferrous to ferric. The heme becomes “hematin”, which cannot carry oxygen [Vasudevan, 2013].
Blood color may be described as bright red, maroon (darker), burgundy, rosewood (very dark red), and, finally, black [Greensleeves Hubs, 2015.
Fine and coworkers [1999] showed that bleeding from anorectal sources, such as an anal fissure or hemorrhoids, was almost always bright red. Bleeding from colonic conditions like diverticulosis or inflammatory bowel disease was bright red in about 50% of cases, and maroon in the rest. Bleeding from lesions of the cecum or small bowel was bright red in 20% of cases, and maroon or burgundy-rosewood in most patients. Obviously, any lesion can cause bright red bleeding, but the most distal lesions rarely cause dark colored blood in the stools.

References

  • Centre for Digestive Diseases, (2009). Rectal Bleeding. [online] Available at: http://www.cdd.com.au/pages/disease_info/rectal_bleeding.html [Accessed 20 Feb. 2016].
  • Fine KD, Nelson AC, Ellington T, Mossburg A. Comparison of the Color of Fecal Blood With the Anatomical Location of Gastrointestinal Bleeding Lesions: Potential Misdiagnosis Using Only Flexible Sigmoidoscopy for Bright Red Blood per Rectum. Am J Gastroenterol 1999;94:3202-10.
  • emedicine Health. Hemorrhoids. http://www.emedicinehealth.com/hemorrhoids-health/page3_em.htm. accessed 19 April 2016.
  • Greensleeves Hubs. Shades and tones of red. http://hubpages.com/art/Shades-Red-Greensleeves, uldated 22 October 2015, accessed 19 April 2016.
  • Longmore JM, Wilkinson IB. Gastroenterology. In: Oxford Handbook Of Clinical Medicine, 9th edition, Oxford: Oxford University Press, 2014, pages: 246,252.
  • Penner RM, Majumdar SR. Patient information: Blood in the stool (rectal bleeding) in adults (Beyond the Basics). UpToDate, http://www.uptodate.com/contents/blood-in-the-stool-rectal-bleeding-in-adults-beyond-the-basics, updated 3 September 2015, accessed 19 April 2016.
  • Talley NJ, O’Connor S. The gastrointestinal history. In: Clinical Examination, 7th edition, Elsevier Australia, N.S.W., 2014, pages: 178-179.
  • Vasudevan DM, Sreekumari S, Vaidyanathan K. Textbook of Biochemistry for Medical Students. Jaypee Brothers Medical Publishers, New Delhi, 2013, p273.
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