Diagnosing Colorectal Cancer

(Great Britain—The Practitioner, April 1999, p. 298.) More than one half of all persons with colorectal cancer die of the disease, even though 80 percent of cases in which cancer is localized within the bowel are potentially curable. Adults with a strong family history of colon cancer or associated conditions such as familial adenomatous polyposis should be screened by colonoscopy. Other persons at increased risk include those with chronic inflammatory bowel disease, colonic adenoma or ureterosigmoid diversion. Colorectal cancer has no pathognomic features, and the diagnosis is often delayed because of the insidious or vague onset of symptoms. Altered bowel habit (either constipation or diarrhea), rectal bleeding, abdominal pain and tenesmus are the most common presenting complaints, but all may be caused by other conditions. Unexplained iron-deficiency anemia and abnormality discovered on rectal examination are other presenting features. Approximately 20 percent of cases present only when distant metastases are present. A high index of suspicion and follow-up of symptoms initially attributed to benign causes are necessary.

Hyperandrogenism in Women

(Australia—Australian Family Physician, May 1999, p. 447.) The most common presenting symptoms of hyperandrogenism in women are hirsutism, acne and alopecia. In more serious cases, changes in the voice and enlargement of the genitalia may occur. Hyperandrogenism is often the result of idiopathic hirsutism, or polycystic ovary syndrome followed by late-onset congenital adrenal hyperplasia, hyperprolactinemia, Cushing's syndrome and androgen-secreting tumors. Androgen excess may also occur as part of hypothyroidism, porphyria and anorexia nervosa. The diagnostic investigation of each woman should be based on the most probable etiology determined from the history and a complete physical examination. In addition to identifying and treating the primary pathology (if possible), patients should be assisted with weight control, managing excess hair growth and dealing with the psychologic and social issues of hyperandrogenism. Acne, hirsutism and alopecia may respond to spironolactone or antiandrogens such as cyproterone acetate. Other therapies include oral contraceptive pills to suppress androgen production by the ovaries and metformin to increase the insulin sensitivity that is common in polycystic ovary syndrome.

Neck Pain

(Great Britain—The Practitioner, April 1999, p. 334.) Neck pain is common in adults and may result from multiple conditions. A careful history and detailed physical examination (including neurologic assessment) with follow-up are essential to distinguish between simple musculoskeletal conditions and more sinister causes of neck pain. Musculoskeletal pain is distinguished by features such as intermittent initial symptoms, increase in pain and stiffness during the work day, location in the cervical spine and proximal shoulder, improvement with heat and exacerbation with cold, later radiation to arms and hands, and poor response to long-term use of nonsteroidal anti-inflammatory drugs (NSAIDs). Further investigations are of limited value in most cases. Patient education stressing the remitting pattern of neck pain, avoidance of precipitants and exacerbating situations, and self-management, is essential. Pain control should be individualized. Use of NSAIDs for more than six weeks is not recommended and is usually ineffective. Local heat, physical therapy, transcutaneous nerve stimulation (TENS) and use of alternative therapies such as acupuncture and chiropractic manipulation have been suggested.

Morphea

(China—Hong Kong Practitioner, March 1999, p. 132.) Morphea is a localized form of scleroderma characterized by indurated plaques with violaceous borders. The condition is three times more common in women than in men. Multiple or single lesions may be present, progressing slowly over months or years. The condition may be simulated by lichen sclerosus et atrophicus, which usually presents as ivory-white, shiny atrophic papules or plaques with follicular plugging. Treatment of morphea is often unsatisfactory; however, injection of triamcinolone into the advancing edge may slow progression. Lesions usually regress after years but leave hyperpigmentation. Morphea may occur in linear form, especially on the head (en coup de sabre—“sword slash”) or on the lower abdomen and buttocks. Spina bifida may be associated with morphea occurring on the legs and lower trunk.