Preoperative Examination

Preoperative interviews and examinations should include the following: a review of stool color (by interview or rectal examination); body weight (to determine the sedatives' doses);

3. Indications, Contraindications, and Preoperative Examination medical history, such as past history (previous abdominal surgery, trauma, accident); the presence or absence of previous anesthesia and its related complications; previous drug allergies; the presence or absence of contraindications to anticholinergic agents, such as ischemic heart disease, glaucoma, prostatic hypertrophy; review of oral medications [use of anticoagulants or nonsteroidal antiinflammatory drugs (NSAIDs)]; blood coagulation tests; thoracic and abdominal radiography; and electrocardiography.

It is particularly important to interview patients regarding their use of NSAIDs. Many of the patients taking NSAIDs are older individuals who are unaware of the name and action of medications. These drugs have often been prescribed at multiple medical institutions, and some patients take their medications without knowing that they are "painkillers." Their medications should therefore be reviewed by contacting the medical institutions at which the patients have undergone outpatient treatment. In patients with current or previous use of NSAIDs, NSAID-induced enterocolitis should be taken into consideration at the examination. Etodolac, meloxicam, and other agents with high selectivity for cyclooxygenase-2 are preferentially prescribed for orthopedic disorders, and their unlimited use may lead to iron deficiency anemia or hypoproteinemia "unknown cause". Recently developed capsule endoscopy has shown that patients taking NSAIDs are more likely to have lesions in the small intestine compared with a control group; and it is preferable that endoscopists and gastroenterologists enlighten other physicians on possible NSAID-induced small-intestinal disorders. Patients with intestinal stenosis should be interviewed about previous abdominal contusions associated with traffic accidents or falls, which may have caused mesenteric injury and subsequent ischemic stenosis. The type of abdominal surgery and the procedure should be reviewed, particularly when the surgery involves the intestine. Blind loop syndrome should be taken into consideration in patients with previous intestinal surgery. Thus, the medical interview often helps identify lesions in the small intestine.

Conventional modalities that are potentially useful for diagnosis should also be considered, depending on the case. Such modalities include upper gastrointestinal endoscopy, colonoscopy, contrast-enhanced studies of the gastrointestinal tract (double-contrast examination of the small intestine), abdominal computed tomography (plain and contrast-enhanced), abdominal magnetic resonance imaging (MRI), «¡-antitrypsin test of feces, nuclear medicine examinations (including gastrointestinal bleeding scintigraphy, albumin scintigraphy, Meckel's scintigraphy, gallium scintigraphy, positron emission tomography), and abdominal angiography.

Review of previous films is also important. Particularly, a diagnosis using double-contrast examination of the small intestine is difficult, and abnormalities may be overlooked. To prevent an oversight, the diagnosis is preferably made by multiple physicians.

To identify a source of bleeding, 99mTc-labeled red blood cell scintigraphy can reveal persistent bleeding of as little as 0.1 ml/min, and abdominal angiography can detect as little as 0.5 ml/min. Although double-balloon endoscopy is relatively minimally invasive, a thorough examination of the entire small intestine requires considerable effort, and thus information on a rough estimation about the location of the abnormality helps improve the accuracy of the examination. Therefore, in a patient with gastrointestinal bleeding, scintigraphy, capsule endoscopy, or other procedures should be considered before double-balloon endoscopy is undertaken.

Effective examinations can be performed by narrowing the choice of possible locations of lesions and by determining the approach route based on the results of these examinations. When no factors are available to determine whether the oral or anal approach is better, the anal approach should be selected because the patient is less likely to experience discomfort. An enteroscope is inserted through the anus, and tattooing is performed at the deepest site reached; the subsequent examination may be done through the mouth.

1. The Japan Gastroenterological Endoscopy Society (2002) Guidelines for gastroenterological endoscopy, 2nd edn. Igaku-Shoin, Tokyo il?

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