One of the interesting things working in Australia is the English we use – even today after nearly 20 years here, I am still learning the language.
Just the other day, my theatre nurse was saying “this whipper snapper is having a double banger this arvo”. I could see that my registrar(who is an international medical graduate) had no idea what she was talking about. I sort of had to guess what a whipper snapper is…
Anyway, a double banger(also called a top & tail or top & bottom) is a gastroscopy and colonoscopy.
Whipper snapper – I am told that this is a term we refer to someone who is younger. But in this case, we were referring to a “young” elderly man!
To all the medical students and doctors taking the AMC exams who may be reading this, don’t worry – this will should not come out in your exams! Imagine getting a question like this in “layman’s terms” – “Please discuss with this whipper snapper who has family history of bowel cancer the pros and cons of doing a double banger”
Oh.. and by the way, “arvo” means afternoon – learnt that years ago, when my colleague told me he was taking the “arvo” off and handing over the pager to me.
Not uncommonly, an abdominal CT scan report may say there is thickening of the bowel wall in particular the rectum. The differentials here include:
1. normal bowel wall – perhaps the muscles the wall were contracted at the time of the scan
2. Rectal cancer in particular a circumferential tumour – therefore the next investigation from this is usually a colonoscopy
3. Inflammatory bowel disease, diverticular disease – but one would also see the diverticula etc
An elderly patient was referred with rectal bleeding thought to be from haemorrhoids(The patient has just had colonoscopy <2 years ago by a gastroenterologist which showed only haemorrhoids and was otherwise reported as normal) The patient’s bleeding had not really settled at all since the previous colonoscopy and the patient’s bleeding was attributed to the haemorrhoids reported in the colonoscopy. The patient was referred recently for the haemorrhoidal bleeding and a colonoscopy was performed. A low rectal cancer measuring about 5cm was found(the cancer was arising from a tubulovillous adenoma, located just above the anal canal, the tumour can be felt on rectal examination – mobile, T2 on MRI). Fortunately, this could be treated with a transanal excision of the rectal cancer and the patient recovered quickly from the surgery.
The points to learn from here is that :
1. One should not always assume any rectal bleeding is due to haemorrhoids- especially if this persist despite treatment of the haemorrhoids. (If haemorrhoids have been bleeding up to the colonoscopy, it would be a good idea to band them at the end of the colonoscopy) If symptoms persist, reinvestigate or refer on.
2. A rectal examination is still useful even in the 21st century- As Norman Browse’s book on Symptoms and Signs of Surgical Diseases says “”Every patient with a rectal complaint should have a rectal examination”". This still holds true today. Be thankful that there are gloves these days – I have heard in the past in places where gloves were not easily available, doctors used to put soap into their fingernails before doing the rectal examination. ( A good tip is to double glove the hand doing the rectal examination – that way you can throw away the top glove after the rectal exam before doing anything else)
3. On colonoscopy, care must be taken to look carefully at the anal canal and what is just above. Sometimes faeculent fluid can obscure the view – this should be sucked out. A J manouvre at the end in the rectum is also useful. In fact during my training, I remembered one of my mentors telling me how he heard about a case of a low rectal cancer being missed during a colonoscopydue to too rapid an insertion.