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Misleading position in sigmoidoscopy
AMisleading Position IRVING ROSENEERG,
OR the past two years
M.D.,Philadelphia, Pennsylvania
I have been using the Ritter proctologic table and have found it to be of great aid in sigmoidoscoping patients who otherwise might not be cooperative or comfortable. Recently. I had an experience with this table in whrch its practical use almost worked against its own advantage. On January 29, 1954, J. I., a sixty-four year old man, presented himself with rectal bleeding of two days’ duration. DigitaI examination was essentiahy negative. Proctoscopic examination revealed large prolapsing internal hemorrhoids which were obviousIy the source of his bleeding. As was my custom, I sigmoidoscoped the patient purely as a precautionary measure. The patient was placed on the tabIe which was tilted to its fuII turn; this placed the patient at approximateIy a 60 degree angle. An I I by 36 inch sigmoidoscope was passed with ease for its full distance. As the sigmoidoscope reached for a fleeting second a spot of red “bottom,” was seen. I could not be sure that I had not imagined this or that I had not seen a reflex of light, but I was disturbed. Removing the I again passed it for the fulI sigmoidoscope, distance. At this time I saw nothing whatsoever. The sigmoidoscope was removed and I tried again with a IO by 71 inch sigmoidoscope, believing that if one could dilate the bowel a bit it could foreshorten the bowel. Again nothing was found. I shouId probabIy add that it is not my custom to use air inflation during sigmoidoscopy. The tabIe was straightened; the patient descended and was made to jump up and down several times. He was placed back on the table, which was tilted 4 degrees and raised to its greatest height, and the sigmoidoscope was a passed once more. Under these conditions
F so-called
in Sigmoidoscopy tremendous polypoid mass was picked up at approximately the 6 inch level. It completely hIled the mouth of the sigmoidoscope. I carried it the full length of the instrument, still carrying the tumor, and was able to push it out of sight with the aid of a cotton wiper. I had just proved to myseIf that I had a polyp on a Iong pedicIe whrch was attached a distance above the II inch marker from the anus. Had the table not been tilted 3 degrees and had the patient not hopped up and down, the polyp wouId have been easily missed. The patient entered the hospital where a barium enema was given and a second polyp was found above the first. On February 15, 1954, simpIe colotomy was performed and both polyps were removed. The Iowermost polyp, which was the one in which I was most interested, surprisingly enough had a pedicle of only 3 inches. Th eoreticahy, this polyp shouId have been at Ieast 6 to 7 inches long since it was picked up at the 6 inch level and carried to the I I inch level. This makes 5 inches of sight and at least I inch beyond, or more. We can explain this phenomenon by the fact that in the second position the patient was intussuscepting one side of the bowe1 which in itself acted Iike a pedicle. CONCLUSIONS
The compIeteIy “ upside down position,” which is usuahy employed in examining patients on a Ritter table or a tabIe of the same type, is a great aid in examination. At the same time, if a polyp has a high attachment and great mobiIity, it may be ahowed by gravity to fall out of sight and the diagnosis wilI thus be missed.
489
OR the past two years
M.D.,Philadelphia, Pennsylvania
I have been using the Ritter proctologic table and have found it to be of great aid in sigmoidoscoping patients who otherwise might not be cooperative or comfortable. Recently. I had an experience with this table in whrch its practical use almost worked against its own advantage. On January 29, 1954, J. I., a sixty-four year old man, presented himself with rectal bleeding of two days’ duration. DigitaI examination was essentiahy negative. Proctoscopic examination revealed large prolapsing internal hemorrhoids which were obviousIy the source of his bleeding. As was my custom, I sigmoidoscoped the patient purely as a precautionary measure. The patient was placed on the tabIe which was tilted to its fuII turn; this placed the patient at approximateIy a 60 degree angle. An I I by 36 inch sigmoidoscope was passed with ease for its full distance. As the sigmoidoscope reached for a fleeting second a spot of red “bottom,” was seen. I could not be sure that I had not imagined this or that I had not seen a reflex of light, but I was disturbed. Removing the I again passed it for the fulI sigmoidoscope, distance. At this time I saw nothing whatsoever. The sigmoidoscope was removed and I tried again with a IO by 71 inch sigmoidoscope, believing that if one could dilate the bowel a bit it could foreshorten the bowel. Again nothing was found. I shouId probabIy add that it is not my custom to use air inflation during sigmoidoscopy. The tabIe was straightened; the patient descended and was made to jump up and down several times. He was placed back on the table, which was tilted 4 degrees and raised to its greatest height, and the sigmoidoscope was a passed once more. Under these conditions
F so-called
in Sigmoidoscopy tremendous polypoid mass was picked up at approximately the 6 inch level. It completely hIled the mouth of the sigmoidoscope. I carried it the full length of the instrument, still carrying the tumor, and was able to push it out of sight with the aid of a cotton wiper. I had just proved to myseIf that I had a polyp on a Iong pedicIe whrch was attached a distance above the II inch marker from the anus. Had the table not been tilted 3 degrees and had the patient not hopped up and down, the polyp wouId have been easily missed. The patient entered the hospital where a barium enema was given and a second polyp was found above the first. On February 15, 1954, simpIe colotomy was performed and both polyps were removed. The Iowermost polyp, which was the one in which I was most interested, surprisingly enough had a pedicle of only 3 inches. Th eoreticahy, this polyp shouId have been at Ieast 6 to 7 inches long since it was picked up at the 6 inch level and carried to the I I inch level. This makes 5 inches of sight and at least I inch beyond, or more. We can explain this phenomenon by the fact that in the second position the patient was intussuscepting one side of the bowe1 which in itself acted Iike a pedicle. CONCLUSIONS
The compIeteIy “ upside down position,” which is usuahy employed in examining patients on a Ritter table or a tabIe of the same type, is a great aid in examination. At the same time, if a polyp has a high attachment and great mobiIity, it may be ahowed by gravity to fall out of sight and the diagnosis wilI thus be missed.
489