6. A patient with rectal bleed and abdominal pain Flashcards
A 40-year-old man sees his GP complaining of a two month history of increased bowel
frequency, which is associated with loose motions and rectal bleeding. He describes
the bleeding as fresh red, mixed with his motions and occasionally with mucus. He is
otherwise fit and well and had no past surgical history. He does not smoke nor drink
alcohol. He has two siblings aged 40 and 45 who have been diagnosed with polyps
and his father developed colorectal cancer at the age of 67.
Q1. What are the possible diagnoses based on history as above?
IBD
IBS unlikely as blood present
Diverticular disease
Haemorrhoids
How can you structure different pathologies causing bleeding? [3]
Whole bowel:
- Crohns
- Coeliac
More common to large bowel:
- UC
- Diverticulitis
- Colorectal cancer
- Ulcerations around rectum
Anal pathologies:
- Haemorrhoids
- Fissures
- Fistulas
- Trauma
What is the bleeding like in haemorrhoids? [3]
- Fresh / bright red blood
- Blood on surface of stool
- Blood when they wipe / toilet pan
Q2. What investigations should the GP request?
Blood:
- FBC
- Hb
- MCV - microcytic / macrocytic?
- Anaemia
- ESR / CRP for inflammation
- Ferritin / Transferrin
- Clotting screen: check for blood disorder
U&Es
Stool:
- Faecal calprotectin: IBD
- MC & S: organic causes
- anti tTGA
- FIT test
PR exam:
- Blood
- Lumps
- Fissures
- Internal / external haemorrhoids
- If there is stool - colour and mucus
Colonoscopy
What are causes of B12 and folate deficiency? [2]
Coeliac disease
Pernicious anaemia
What is this? [1]
Anal fissure
Which stool test would you use to investigate bowel malignancy? [1]
FiT Test
A few days after seeing his GP, he presents to the Emergency Department with three
days of central abdominal pain and vomiting. On examination he is pale. Examination
of the abdomen is normal, there are no palpable groin herniae and examination of the
rectum is normal. Sigmoidoscopy examination is normal.
Q4. What is the differential diagnosis based on the clinical presentation in
ED? [5]
Bowel obstruction
Gastroenteritits
Appendicitis
Pancreatitis
Toxic megacolon
Ruptured AA
DKA
Describe the symptoms of a ruptured AA [5]
classical triad of:
- pain in the flank or back, hypotension and a pulsatile abdominal mass; however, only about half have the full triad. The patient will complain of the pain and may feel cold, sweaty and faint on standing
Explain these:
* Haemoglobin 9.1 g/dL (13 - 18)
* MCV 76 fL (80 - 99)
IDA microcytic anaemia
Explain these results
* Sodium 149 mmol/L (135 - 145)
* Potassium 3.2 mmol/L (3.5 - 5)
Vomiting [1]
Explain these results [1]
Creatinine 149 µmol/L (70 - 120) [1]
Pre-renal AKI from vomiting
Explain these results:
ALT 338 u/L (3 - 35)
AST 102 u/L (3 - 35)
ALP 21 u/L (30 - 35)
Derenged LFTs
ALP low:
What is a good marker for pancreatitis? [1]
Amylase
Which is the next most appropriate investigation for this man while in ED?
Why? [3]
Erect CXR:
- Bowel obstruction / burst causing pneumoperitoneum
Abdominal XR:
- Bowel dilation
- Obstruction
CT Abdo Pelvis: shows more detailed scan, but takes longer to occur
Q7. What does the XR abdomen show?
Small bowel:
- More central
- Valvulae conniventes
Is this large or small bowel obstruction? [1]
The white lines passing across the full width of the bowel are ‘valvulae conniventes’ - these are only found in the small bowel.
Q11. What are the causes of small and large bowel obstruction?
