1	Chapter 5 Problem-Based Learning Competency-Based Testing Recognizing Normals and Variations of Normal By Wm. MacMillan Rodney, MD Revised October 2003 E.R. Gillett, MD
2	Performance Based Learning Advanced Family Medicine Remember to read the syllabus with particular attention to the chapters describing equipment cleaning, equipment disinfection, equipment maintenance, and practice management issues.
3	Clinical Reminder Before every flexible sigmoidoscopy or colonoscopy, remember to do an abdominal exam, a rectal exam, and a visual inspection of the perianal region. Look for tags, fissures, fistulae, and/or sinus tracts. Make sure you have reviewed the patient’s medical records and updated the database.
4	Problem-Based Learning Wherever appropriate,the physician performing the endoscopy should have a consistent system for the description of visual findings D², S³ (i.e., depth, distribution, size, shape, and surface characteristics).
5	Advanced Family Medicine Normal or Abnormal ? Observe, Biopsy or Refer ?
6	Remember the Golden Rules of Family Practice 1. Know your patients. 2. Update your history and physical. Have an organized medical record.
7	Variations of Normal Rectosigmoid area. Semilunar valve. Normal vascular pattern. Mucous/light reflections.
8	Rectal Canal/Recto Sigmoid Semilunar valve (Image LUQ). Prominent vascular pattern. Veins visible. Light reflections (Image LLQ).
9	Problem-Based Learning This view reveals: A. A semilunar valve. B. Normal vascular pattern. C. Mucous stand in left-lower corner. D. Light reflections. E.* All of the above
10	Problem-Based Learning This view best represents: A. Two semilunar valves B. Normal vascular pattern C. Probable rectosigmoid area. D.* All of the above E. None of the above
11	Problem-Based Learning When the flexible sigmoidoscope/colonoscope is first placed into the patient, this view is commonly encountered. Appropriate descriptions include: A. * Mucosa against the scope lens. B. * A “red out.” C. Acute bleeding. D. Probable cancer
12	Problem-Based Learning A 23-year-old G1PO, LMP- EGA 13 weeks. Flexible sigmoidscopy of rectal bleeding. Depth--20cm. Appropriate comments include: A. Normal vascular pattern. B. Enlarged veins commonly seen in pregnancy. C. Semilunar valve. D. Rectosigmoid area. E.* All of the above.
13	Problem-Based Learning 46-year-old white female with family history of colorectal cancer. Depth: 20 cm. Appropriate comments include: A. Less prominent vascular pattern. B. Normal mucosa. C. Spiral configuration. D. Consistent with sigmoid area. E.* All of the above.
14	Problem-Based Learning 50-year-old black male for screening flexible sigmoidoscopy. Depth: 52cm. Appropriate interpretation would include: A. Mucosa normal. B. Concentric haustrae. C. Vascular pattern non prominent. D. Characteristic of descending colon. E.* All of the above
15	Problem-Based Learning This 57-year old white female for screening flexible sigmoidoscopy. Depth: 60cm. Appropriate interpretations of this view would include: A. Probable splenic flexure. B. Transmucosal effect of nearby spleen. Likely anatomical location is the junction of the descending and transverse colon. D. * All of the above.
16	Problem-Based Learning Technique tip: This schematic drawing is a useful physician and patient education aid demonstrating the major areas of lower intestine. A.* Rectal canal. B.* Sigmoid. C.* Descending colon D.* Transverse colon. E.* Ascending colon. F.* Cecum.
17	Problem-Based Learning 65-year-old black female with vague abdominal pains over past two months. Otherwise, healthy. Insertion depth: 62cm. The most likely location of this view is: A.* Splenic flexure. B. Rectosigmoid. C. Sigmoid. D. None of the above.
18	Problem-Based Learning “Much to their amazement, some early flexible sigmoidoscopists believed that they were going past the splenic flexure and into the transverse colon. They confirmed this location by auscultating air insufflation, and palpating the tip of the scope in the area of the epigastrum. This view with triangular haustrae is characteristic of the transverse colon, and documents insertion to this area.” True* or False
19	Problem-Based Learning 47-year old white male whose father died of colorectal cancer at age 54. Flexible sigmoidoscope has been inserted to a depth of 65-cm. This view suggests: A. Normal mucosa. B. Transverse colon. C. Non prominent vascular pattern. D. Lens washing will improve clarity. E.* All of the above.
20	Problem-Based Learning This is a 53 year old black male with one of six FOBT positive. The insertion depth is 120-cm. This view represents. A. Fiberoptic photography, pre- videoendoscopy B. The rounded triangular arches of haustrae in the ascending colon. C. Normal mucosa. D. The golden/amber hue characteristic of the ascending colon and the ileocecal area. E.* All of the above.
21	Problem-Based Learning 58-year old white female with intermittent constipation times 18 months and an unintentional 10 lb. weight loss. Insertion depth: 140-cm. This view is characteristic of: A. Rounded arch haustrae of the ascending colon. B. Golden amber hue of ascending colon. C. Normal mucosa. D.* All of the above.
22	Problem-Based Learning By the mid-1980’s, Welch- Allyn had created a hybrid instrument which combined fiberoptic endoscopy, television, freeze-frame camera, and a computerized word processor. Note the ability to instantly document time, place, patient, physician, and findings.
23	Problem-Based Learning 65-year-old white male with FOBT positive times one. Insertion depth: 100-cm. Performed in the office. The view suggests: A.* Ascending colon. B. Transverse colon C. Rectosigmoid. D. Sigmoid
24	Problem-Based Learning In the office, colonoscopy of previous 65-year-old male. Insertion depth 130-cm. This view represents: A. An area near the cecum. B. A vertical strut suggestive of taenia coli convergence. C. Normal mucosa. D.* All of the above.
25	Problem-Based Learning 54-year-old white female who has reported intermittent diarrhea over the past five months. 8 years ago she had a partial colonic resection for Crohn’s disease. Old medical records are not available. She recently lost her medical insurance. This view at 55cm of insertion reveals: (continued on next slide)
26	Problem-Based Learning A. Convergence of the taenia creating a structure something like a “crow’s foot.” B. A surgical staple. C. Mucosa without inflammation. D. Golden globules suggesting malabsorption. E.* All of the above.
27	Problem-Based Learning Same 54-year-old female. Note unabsorbed fat droplets floating on top of intestinal fluids. Cecal area reached in relatively short distance because of previous intestinal surgery. True* or False
28	Problem-Based Learning 65-year-old black male fecal occult blood test positive in one of six specimens. This slide depicts: A.* Convergence of the taenia coli. B.* The cecal area. C.* Light reflections. D.* Normal mucosa. E.* Normal vascular pattern
29	50-year-old black female for screening. Patient had 2 Fleets enemas. This 48-year-old black male reports intermittent rectal bleeding over the past 10 years. View at 20-cm. Although the prep is less than ideal, colonoscopy can produce useful clinical information. True* or False
30	68-y-o Hispanic female for screening. Prep was 4 Dulcolax tablets the evening before and 2 Fleets enemas this morning. In other areas, the mucosa is clear. In this area, one should conclude that: A.* Visual interpretation of the mucosa is not possible. B. The exam is useless C.* Notation should be made in the medical record regarding prep related limitations. D. None of the above.
31	Although much of the mucosa is seen, 20% is obscured by fecal debris as depicted in this view. Although this view is normal, biopsy would be contraindicated because of the increased risk for biopsy-related bacteremia. True or *False
32	48-year-old white male with previous diagnosis of “irritable bowel syndrome.” View at 60-cm. The physician should conclude at the prep, although not ideal, is sufficient to produce high sensitivity exam. True* or False
33	43-year-old Hispanic female who does not speak English. Compliance with bowel prep difficult to ascertain. This view at 40-cm after lengthy periods of washing, suction, and air insufflation. No matter how the scope is turned, the view remains constant. The physician should conclude that: A.* Fecal debris is stuck to the lens. B.* There is a high probability that the procedure will be terminated. C.* This is also known as a “brown out.” D.* At the very least, removal of the scope will probably be necessary to clean the lens.
34	All the advantages of flexible sigmoidoscopy and colonoscopy can disappear if the colon isn’t properly cleansed
35	Problem-Based Learning Abrasions and suction artifacts are occasionally seen. This would be one example of an abrasion secondary to slide-by. True* or False
36	50-year-old white female for screening. View at 30cm. No other abnormalities have been noted. The physician might conclude that: A.* This is probably a slide-by abrasion. B.* Although biopsy would not be harmful, it probably would not produce any useful information. C. Biopsy is mandatory.
37	Problem-Based Learning Abrasion effect True* or False
38	Problem-Based Learning Abrasion effect True* or False
39	Problem-Based Learning In addition to fecal debris, occasionally clear fluids, mucous, and foamy material is encountered. This was a 53-year-old white male who suffered from psoriasis. Screening flexible sigmoidoscopy revealed this view at 44-cm. Intestinal psoriasis can present like this. True or False*
40	Problem-Based Learning Investigation by biopsy forceps can be useful for: A.* Flat lesions. B.* Nodular lesions. C.* Foamy, white mucosal areas such as this one. D. Large vascular structures.
41	Problem-Based Learning Additionally, the biopsy jaws can be opened to “size” various lesions. When the jaws are open, most biopsy forceps measure 6-8 mm from tip to tip True* or False
42	Spasm occurs infrequently among patients receiving IV sedation/analgesia. Flexible sigmoidoscopy patients demonstrate some spasm in less than 20% of cases. Note the puckered/wrinkled appearance in the upper left-hand quadrant of this view. In these cases, the physician should immediately inject 2mm of Glucagon IM. True or False*
43	Problem-Based Learning Some elderly patients have “floppy” intestinal tissue which can give the pseudo appearance of spasm. In these cases, it is reasonable to insufflate air for 5 to 15 seconds to determine whether or not air insufflation will have a beneficial effect. True* or False
44	For historical purposes, this view was obtained by photographing down the 25-cm metal tube of a rigid scope. This was considered a “good view.” With a tip of the hat to David Markham, M.D. This view also demonstrates pseudospasm because the open shaft of rigid scope could not effectively insufflate air once the window had been opened to take a photograph.
45	Problem-Based Learning Retroflexing the scope is an absolute “standard of care” issue for every flexible sigmoidoscope examination. True* or False
46	Problem-Based Learning The retroflexion, also know as a J-maneuver, depicts: A. The squamo- columnar junction. B. The pectinate line. C. The dentate line. D. Normal mucosa. E.* All of the above.
47	Problem-Based Learning This retroflexion, as known as a turn-around maneuver, depicts: A. The squamocolumnar junction. B. The dentate/pectinate line. C. A white film of squamous metaplasia. D. Internal hemorrhoids. E.* All of the above.
48	Problem-Based Learning This retroflexion reveals: A. Prominent, but normal mucosa pattern. B. Healed scar tissue from previous internal hemorrhoids C. At least one hypertrophied anal papilla. D.* All of the above.
49	Problem-Based Learning This turnaround maneuver reveals: A.* The scope shaft in the lower-right hand corner B.* Internal Hemorrhoids. C. Inadequate prep. D. Neoplastic lesions E. All of the above.
50	Remember all flexible sigmoidoscopy exams begin with knowing the patient, reviewing the record, updating the record, and performing an examination. At a minimum, there should be an abdominal examination with palpation and auscultation. The perianal area should be inspected for fistulae, fissures, tags, and sinus tracks. This view demonstrates an anal fissure. True* or False
51	Problem-Based Learning A rectal examination at the time of flexible sigmoidoscopy/ colonoscopy is at the current “standard of care.” Following the rectal examination, this view is seen. It is consistent with internal hemorrhoids. True* or False
52	"This Slide demonstrates the ability..." This Slide demonstrates the ability of the rectal ampulla to accommodate various household objects (in this case, a lightbulb)
53	Problem-Based Learning Remember to read the syllabus chapters describing equipment, cleaning, disinfection, and practice management issues related to flexible sigmoidoscopy/colonoscopy.
54	Problem-Based Learning This slide represents: A. Normal mucosa. B. Normal vascular pattern. C. Interesting but non- pathologic mucous. D.* All of the above.
55	Problem-Based Learning This view in the rectal canal represents: A.* Normal mucosa. B.* Several light reflections. C. An excellent opportunity to biopsy the large tortuous blue structure.
56	Problem-Based Learning This slide represents: A. Normal mucosa. B. Normal vascular pattern. C. Some light reflection artifacts. D.*All of the above.
57	Problem-Based Learning From this view, the physician can conclude that: A. The child probably has a normal temperature. B.* The parents are stressed. C.* The mucosa is normal D.* Grasping this object may require anal relaxation, special tools and/or consultation/referral
58	Mystery Lesion
59	Mystery Lesion Normal or Abnormal? Advanced Family Medicine Observe, Biopsy, or Refer
60	DIAGNOSTIC SKILLS- PATHOLOGY RECOGNITION The physician performing GI endoscopy should have a consistent system for the description of visual findings (D2,S3) Depth, Distribution Size, Shape, and Surface characteristics
61	Clinical Reminder Before every flexible sigmoidoscopy or colonoscopy, remember to do an abdominal exam, a rectal exam, and a visual inspection of the perianal region. Look for tags, fissures, fistulae, and/or sinus tracts. Make sure you have reviewed the patient’s medical records and updated the database.
62	Problem-Based Learning In summary, this series has given you some experience with normals, nearly normals, normal variations, and non-pathologic artifacts. As the physician moves on, consider developing a descriptive system such as the D2S3 system.