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Figure 17-38 Relationship of the size of the prostate gland to the examining finger.

Clinicopathologic Correlations

There is evidence that detecting and removing polyps reduces the incidence of colorectal cancer and that detecting early cancers lowers the mortality rate from colorectal cancer. The American Cancer Society has suggested the following guidelines for the early detection of colorectal cancer in individuals without increased risk. Beginning at age 50 years, men and women should follow one of the following examination schedules:

1. FOBT every year

2. Flexible sigmoidoscopy every 5 years

3. Annual FOBT and flexible sigmoidoscopy every 5 years

SigmoidoscopyBen Kevin Gay Yaoi Porn Gif
Figure 17-40 The obturator test.

4. Double-contrast barium enema testing every 5 years

5. Colonoscopy every 10 years

The colorectal cancer mortality rate can be reduced 15% to 33% by FOBT and diagnostic evaluation and treatment for positive test results. Annual FOBT screening leads to a greater reduction in the colorectal cancer mortality rate than does biennial screening. Flexible sig-moidoscopy identifies nearly all cancers and polyps greater than 0.4 inch (1 cm) in diameter and 75% to 80% of small polyps that are located in the portion of the bowel examined. Screening with flexible sigmoidoscopy has been shown to result in a 60% to 80% reduction in risk of death from colorectal cancer in the part of the colon examined. There is indirect evidence supporting the use of double-contrast barium enema testing in screening for colorec-tal cancer. This test can image the entire colon and detect cancers and large polyps. Screening colonoscopy offers the potential both to identify and remove cancers and premalignant lesions throughout the colon and rectum. However, no studies that show a reduction in the mortality rate associated with screening colonoscopy have been completed to date.

Anal cancer is increasing in both men and women worldwide. Men who have sex with men, HIV-positive individuals, transplant recipients, and women with cervical neoplasia have a higher risk for anal cancer than the general population. Men who have sex with men have a 44% greater risk for anal cancer than the general population (Chin-Hong, 2008). Anal cancer, like cervical cancer, is potentially preventalbe. Anal cytology has been studied and found to be a useful screening test to detect anal cancer. It has been shown that a high proportion of men who have sex with men were infected with anal human papillomavirus (HPV) (66%).

Table 17-2 lists the classic locations of pain referred from abdominal structures. Table 17-3 summarizes the maneuvers for ameliorating abdominal pain. Table 17-4 summarizes the sensitivities and specificities of the various maneuvers used to detect ascites. Table 17-5 is a comparison of the clinical manifestations of ulcerative colitis and Crohn's disease. Table 17-6 lists the clinical features of cancer of the stomach, pancreas, and colon. Table 17-7 lists the variation of symptoms in right-sided and left-sided colon cancer and in rectal cancer. Table 17-8

Table 17-5. Clinical Comparison of Ulcerative Colitis and Crohn's Disease Feature Ulcerative Colitis Crohn's Disease

Diarrhea

Present

Present

Hematochezia

Common

Rare

Extraintestinal manifestations Common

Common

Perirectal disease

Fissures

Fistulas Abscesses

Rectal disease

Present

Absent

Anal disease

Absent

Present

Table 17-6. Clinical Comparison of Cancer of the Stomach, Pancreas, and Colon

Cancer of Stomach Cancer of Pancreas Cancer of Colon

Upper abdominal pain

Occult bleeding

Weight loss

Vomiting

Anorexia

Dysphagia

Risk Factors

Upper abdominal pain Back pain Weight loss Jaundice

Change in bowel habits Gastrointestinal bleeding Lower abdominal pain

Adenomatous polyps

Smoking

Adenomatous polyps

Pernicious anemia

Alcoholism (?)

Ulcerative colitis

Family history

Familial polyposis

Immigrants from Japan

Gardner's syndrome

Villous adenomas

compares the symptoms and signs of cirrhosis, which are numerous, as they relate to hepatocellular failure and portal hypertension.

Prostate cancer is the leading cancer diagnosed among men in the United States, accounting for 33% of all cancers in men. However, racial/ethnic variations in the Surveillance, Epidemiology, and End Results (SEER) study data are striking: The incidence rate among African-American men (180.6 per 100,000) is more than seven times that among Koreans (24.2 per 100,000). Indeed, African Americans in the United States have the highest rates of this cancer in the world. Although the incidence among white persons is quite high, it is distinctly lower than that among African Americans. Asian and Native American men have the lowest rates. The very low rate in Korean men possibly reflects the fact that most of the Koreans in the SEER areas were recent immigrants from Asia, where rates are lower than in the United States.

Nearly 9 per 10 prostate cancers (86%) are diagnosed at a localized stage, when the 5-year survival rate is 100%. The incidence rates for prostate cancer, however, continue to increase, in part because of increased numbers of screening tests. Prostate cancer can often be found early by a DRE and by testing the amount of prostate-specific antigen (PSA) in a sample of blood. If a man has routine yearly examinations and either one of these test results becomes abnormal, any cancer that he may have has probably been found at an early, more treatable stage. Since the use of these early detection tests for prostate cancer became relatively common around 1990, the death rate from prostate cancer has dropped.

PSA is a substance made by the normal prostate gland. Although PSA is found mostly in semen, a small amount is also present in the blood. Most men have levels under 4 ng/mL of blood. When prostate cancer develops, the PSA level usually goes above 4 ng/mL. If the level is above 4 ng/mL but less than 10 ng/mL, the man has about a 25% chance of having prostate cancer. If it goes above 10 ng/mL, the chance of having prostate cancer is more than 67% and increases as the PSA level increases.

PSA occurs in two major forms in the blood. One is bound (attached) to blood proteins and the other circulates free (unattached). The percent-free PSA test indicates how much PSA circulates free in comparison with the total PSA level. The percentage of free PSA is lower in men

Table 17-7.

Variation of Symptoms of Cancer of the Right Colon, Left Colon, and Rectum

Symptom

Cancer of Right Colon

Cancer of Left Colon

Cancer of Rectum

Pain

Ill defined

Colicky*

Steady, gnawing

Obstruction

Infrequent

Common

Infrequent

Bleeding

Brick-red

Red mixed with stool

Bright red coating stool

Weakness1"

Common

Infrequent

Infrequent

*Worse with ingestion of foods. {Secondary to anemia.

Table 17-6. Clinical Comparison of Cancer of the Stomach, Pancreas, and Colon

Cancer of Stomach Cancer of Pancreas Cancer of Colon

Table 17-8. Signs and Symptoms of Cirrhosis

Hepatocellular Failure

Portal Hypertension

Spider angiomata

Ascites

Gynecomastia

Varices: esophageal

Palmar erythema

Hemorrhoids

Ascites

Caput medusae

Jaundice

Splenomegaly

Testicular atrophy

Erectile dysfunction

Bleeding problems

Changes in mental function

who have prostate cancer than in men who do not. If the PSA results are in the borderline range (4 to 10 ng/mL), a low percent-free PSA (< 10%) means that the likelihood of having prostate cancer is about 50%, and a biopsy should be performed.

The PSA level can be affected by many factors. It is increased with noncancerous enlargement of the prostate (i.e., benign prostatic hypertrophy), and with prostatitis. PSA levels also normally rise slowly with aging. Ejaculation can cause a temporary increase in blood PSA levels, so it is often recommended that men abstain from ejaculation for 2 days before testing.

The American Cancer Society believes that health-care professionals should offer the PSA blood test and DRE yearly, beginning at age 50 years, to men who have at least a 10-year life expectancy. Men at high risk, such as African Americans and men who have a first-degree relative (father, brother, son) in whom prostate cancer was diagnosed at an early age should begin testing at age 45 years. Men at even higher risk (because they have several first-degree relatives who had prostate cancer at an early age) could begin testing at age 40 years. Depending on the results of this initial test, further testing might not be needed until age 45 years.

Useful Vocabulary

Listed here are the specific roots that are important for understanding the terminology related to abdominal disease.

Root

Pertaining to

Example

Definition

aer(o)-

air; gas

aerophagia

Air swallowing

celi(o)-

abdomen

celiac

Pertaining to the abdomen

chol(e)-

bile

cholelith

Gallstone

cyst-

sac containing liquid

cholecystitis

Inflammation of the gallbladder

enter(o)-

intestines

enteritis

Inflammation of the small intestines

gastr(o)-

stomach

gastrectomy

Surgical removal of the stomach

lapar(o)-

loin; flank

laparotomy

Surgical incision through the flank; generally, any abdominal incision

-phago-

eating

phagocyte

Any cell that ingests other cells or microorganisms

-tripsy

shock waves

lithotripsy

Noninvasive technique for breaking up stones by the use of shock waves

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