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  #1  
Old 06-24-2011
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GIT Chronic Progessive Constipation

A 56-year-old obese white man sees his physician regarding the management of chronic, progressive constipation he has had for the past 2 months. A routine colonoscopy 3 years ago was within normal limits. His medical history is significant for hypertension, which is being treated with hydrochlorothiazide 25 mg daily. Physical examination and laboratory examination is unremarkable. The stool is negative for occult blood. Which of the following is the next course of action?

Answer Choices
A. Order abdominal computed tomography
B. Order colonoscopy
C. Replace the diuretic with a different antihypertensive agent
D. Start oral sorbitol
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Old 06-25-2011
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Default B. Colonoscopy

Would go ahead with repeat colonoscopy!

Switching diuretics is also a good option in real practice.
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Old 06-25-2011
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i would go with C replace diuretic because this constipation from hypercalcemia and no need for colonoscopy again

colonoscopy every 10 year , also in question negative occult blood
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Old 06-25-2011
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I agree with Kemoo.. You have to change the diuretic
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Old 06-25-2011
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Thiazide = hypercalcemia , since we did the colonoscopy as well as stool occult then the best thing would be to switch his antihypertensive to something else
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Old 06-25-2011
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Option B (Order colonoscopy) is correct. Although a colonoscopy was negative 3 years ago, a repeat endoscopy is necessary to rule out a new malignancy or any other pathology.

Option A (Order abdominal computed tomography) is incorrect. Abdominal computed tomography may detect extracolonic causes and peritoneal masses resulting in constipation, but it is not the screening test for colonic cancer.

Option C (Replace the diuretic with a different antihypertensive agent) is incorrect. Although taking a different antihypertensive agent is not unreasonable advice, a repeat endoscopy is necessary to rule out a new malignancy or any other pathology.

Option D (Start oral sorbitol) is incorrect. This is only symptomatic therapy and hence is not considered most appropriate.

High-yield Hit 1
Hyperplastic polyps: no follow-up (unless polyp is > 2 cm or > 20 polyps are found throughout the colon).
1-2 adenomatous polyps < 1 cm, negative family history: 5 years.
2 adenomatous polyps or adenomatous polyp > 1 cm: 3 years.
Villous histology or high-grade dysplasia: 3 years.
Polyps in a patient with a positive family history: 3 years.
Large, sessile, or numerous adenomatous polyps: although 1-2 years is usual, follow-up is based on clinical judgment and should be individualized for each patient.
Dirty prep: clinical judgment.
Piecemeal resection of > 2 cm sessile adenoma: look at site within 3-6 months and biopsy to exclude dysplasia of the flat mucosa. Follow-up then based on clinical judgment.
Once follow-up is negative for new polyps: every 5 years.
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