常见肛肠疾病的误诊

根据一项回顾性研究，初级保健医生常常误诊如肛裂和疣等肛肠疾病。

该研究显示初级保健医生误诊了70%的肛裂、50%的疣和49%的肛瘘。这些疾病通常被作为“痔”转诊给专科医生。而他们对脓肿和痔的诊断成功率较高，对脓肿和痔的误诊率分别为15%和22%。

本研究由芝加哥Rush Presbyterian St.Lukes医疗中心肛肠外科的Marc Brand医生和Theodore J.Saclarides医生领导。Marc Brand在2000年美国结肠和直肠外科医师年会上发表了他的研究小组的发现，他认为：“这些结果表明，在初级保健医生中应该更加强调普通肛肠疾病的培训。”

Brand和他的同事们注意到，非常多的由初级保健医生转诊到他们中心肛肠外科医生的病人诊断不准确。他们复习了该中心两名肛肠外科医生从1996年7月到1999年7月的门诊病历，选取最后诊断为痔、肛裂、肛瘘、脓肿和疣的病例。研究组定义，转诊诊断与最后诊断相同者为正确诊断，正确诊断率为所转诊患者正确诊断的百分比；误诊率为所转诊患者诊断不正确的百分比。563名最后诊断为痔，肛裂，肛瘘，脓肿和疣的病人。其中91%的转诊诊断来自内科医生、5%来自家庭开业医生、4%来自妇产科医生。

尽管初级保健医生能可靠的诊断脓肿，但鉴于他们对其它疾病的高误诊率，研究者们建议肛肠科专科医生对初级保健医生的转诊诊断应持有怀疑态度。Brand博士在《内科医学世界报道》中说：“初级保健医生的误诊可导致延误或错误的治疗，使患者接受不适宜的治疗，并提高医疗费用。因此，应该建议患者定期去就诊于专科医生。”

多伦多Rudd结肠和直肠病医院主任Warren Rudd医生同意Brand的观点，他也认为对初级保健医生的培训中应更加强调普通肛肠疾病。

Brand说：“家庭开业医生，以及其他专科的医生由于他们既没学过又没有此专科的经验，而且他们没有正确检查所需的工具，所以不能作出正确的初始诊断。因此，肛肠区的许多问题都被认为是痔。本研究未涉及肛管炎，它是最常见的肛肠疾病，也是最常被漏诊的，它比痔更常引起出血。由于肛管炎是一种较难定义的疾病，因此研究起来比较容易混淆。”

[英文对照] BOSTON-Primary care physicians (PCPs) commonly misdiagnose anorectal conditions, such as anal fissures and warts, according to a retrospective study.

In fact, the study revealed that PCPs misdiagnose 70% of anal fissures, 50% of warts, and 40% of fistulas. These problems usually are referred to specialists as "hemorrhoids."

Their success rate is better with abscesses and hemorrhoids, however. In the study, PCPs misdiagnosed these problems 15% and 22% of the time, respectively.

"These results indicate that more emphasis should be placed on common anorectal conditions in the training of primary care physicians," said Marc Brand, MD, who co-authored the study with Theodore J. Saclarides, MD, both colorectal surgeons at Rush-Presbyterian-St.Luke's Medical Center in Chicago. Dr. Brand presented his research team's findings here at the 2000 Annual Meeting of the American Society of Colon and Rectal Surgeons.

He and his colleagues had noted that a large number of patients referred by PCPs to the colorectal surgeons at their center had been inaccurately diagnosed.

The researchers reviewed the outpatient records of two colorectal surgeons at the center from July 1996 to July 1999. They selected charts with a final diagnosis (fDx) of hemorrhoids, fissures, fistulas, abscesses, and warts. The team defined a correct diagnosis as agreement between the referring diagnosis (rDx) and the fDx, and defined a correct diagnosis rate as the percentage of accurately referred patients. The researchers defined a misdiagnosis (MisDx) rate as the percentage of treated conditions given an incorrect rDx.

The patient population consisted of 563 patients with a fDx of hemorrhoids, fissures, fistulas, abscesses and warts.

Internists accounted for 91% of the rDx, whereas family practitioners accounted for 5% and obstetricians/gynecologists, 4%.

Although PCPs can recognize abscesses reliably, the high MisDX rate for the other conditions led the researchers to suggest that colorectal specialists view PCPs' referring diagnoses with skepticism. "Misdiagnosis by the PCPs may result in delayed or erroneous treatment contributing to suboptimal patient care and rising health care costs," Dr. Brand told Internal Medicine World Report. "Therefore, patients should be referred to the specialists in a timely manner."

Warren Rudd, MD, director of the Rudd Clinic for Diseases of the Colon and Rectum in Toronto, agreed with Dr. Brand that more emphasis should be placed on common anorectal conditions in the training of PCPs.

"The family physician or even other specialists often do not make the correct initial diagnosis, as they are neither taught nor experienced in this specialty and they do not have the instruments for a proper examination. Therefore, many problems in the anorectal area are labeled as hemorrhoids," Dr. Rudd said. "This study however did not mention anusitis, which is the most frequent anal problem and the most frequently missed; it causes bleeding more often than hemorrhoids."

"Anusitis is a difficult condition to define and therefore confusing to study," Dr. Brand replied.

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