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Diagnostic Dilemma

Diagnostic Dilemma

A 75-year-old attorney presents with intermittent rectal bleeding. He had
refused routine sigmoidoscopy in the past. His primary care physician was his
friend, and he had convinced him to at least send in stool specimens for occult
blood testing. Three years ago, his primary care physician informed him that
"several" of the tests were positive and that he required evaluation.
The patient refused and his doctor retired.

The patient was seen by a new physician who insisted that he undergo
colonoscopy. The patient described intermittent bright red blood per rectum.
His past history was positive for hypertension controlled with medications.
There was no family history of colorectal carcinoma. Physical examination was
normal, and fecal occult blood testing was negative. The patient consented to
colonoscopy (see Figure at right).

1. The photograph demonstrates:

a. Parasites
b.
A foreign body
c.
A mass
d.
Hemorrhoids
e.
Colitis

2. Appropriate next steps include:

a. Biopsy
b.
Attempt at endoscopic treatment
c.
Surgical consultation
d.
CT scan


The correct answer to quest 1 is c. The endoscopic photograph demonstrates a large
mass in the sigmoid colon. There are no findings to suggest parasites, foreign
body, hemorrhoids, or colitis. The mass is exophytic, friable, and appears
malignant.

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