Bright Red blood Per Rectum

Question 1

What are the DDX for lower GI bleeding

Answer 1

1. Diverticulosis
2. Neoplasia(Colorectal adenocarcinoma)
3. Colitis (infectious, inflammatory, ischemic)
4. Anorectal( Hemorrhoids, Anal fissure, Rectal varices, Rectal ulcer)
5. Angiodysplasia
6. Iatrogenic(post polypectomy or biopsy)

Question 2

What is the mnemonic for LGIB

Answer 2

H-DRAIN
Hemorrhoid
Diverticulosis 
Rectal(ulcer, varices)
Anal(fissure), Angiodysplasia 
Infection, ischemic, inflammatory colitis
Neoplasia, polyp

Question 3

How is age an important factor in LGIB

Answer 3

In Older patients the causes are Diverticulosis, Angiodysplasia or malignancy
In younger patients the causes are IBD, infection, haemorrhoids or anal fissures

Question 4

What is significant about the onset and duration of bleeding

Answer 4

Acute and large amount of bleeding is usually associated with Diverticulosis(arterial bleeding)
Angiodysplasia and malignancy are more chronic and present with anemia or dark stoles

Question 5

What does the color and amount of blood tell us about the source of LGIB?

Answer 5

1. Upper GI,Small bowel and right colon- dark maroon mixed with stools
2. Right colon, Rectum, Anus, Massive Upper GI bleed with rapid transit– copious bight red blood(hematochezia)
3. Rectum, Anus – spots on toilet paper, dripping post defecation
4. Angiodysplasia– Scant, dark red

5- polyp, colorectal ca– occult

Question 6

What is the fate of right diverticula as compared to the left?

Answer 6

The right is more likely to bleed and the left is more likely to get infected

Question 7

What is an occult blood?

Answer 7

Bleeding detected by faecal occult blood testing or by finding IDA(iron def anemia) and not seen by patient

Question 8

What may be the cause of occult blood?

Answer 8

In older pts. Suspect malignancy (esp. Colorectal)

In younger pts. IBD or Familial cancer syndromes (FAP, HnpCRca)

Question 9

What are the associated symptoms with LGIB that help us in ruling out diagnoses

Answer 9

Systemic symptoms- fever and bloody diarrhoea
Recurrent symptoms
Weight loss with bowel habits and/or anemia
Bleeding timing - following straining, painless,
Anal pain, tenesmus
Abdominal pain

Question 10

Why is past history or colonoscopy important

Answer 10

Recent history (<5 yrs) of normal screening makes colon ca unlikely

Question 11

Why is history of liver cirrhosis symptoms important

Answer 11

Liver disease can lead to coagulopathy and portal HTN..portal HTN may cause varices in rectal veins

Question 12

What is the significance of family history

Answer 12

Colorectal Ca and IBD can be hereditary

Question 13

What drugs(medications) exacerbate GI bleeding

Answer 13

Anticoagulant(warfarin, aspirin, clopidogrel) and NSAIDs

Question 14

What does abdominal tenderness suggest in the setting of LGIB

Answer 14

Colitis(IBD, ischemic, infectious)

Question 15

What is the significance of finding IDA in association with LGIB

Answer 15

In man or a post menopausal woman raises suspicion for malignancy (colorectal).

Question 16

What are the initial steps in management of LGIB

Answer 16

If patient demonstrates significant blood loss - two large bore needle placement and fluid resuscitation (NS or RL) followed by packed RBC (as needed)
Send lab tests for
Type and cross
CBC
Chemistry 
INR/PTT

Question 17

What results do we expect in CBC

Answer 17

Microcytic anemia (IDA due to occult blood loss by Colorectal Ca. Or chronic bleed from Angiodysplasia)

Leukocytosis - infection or inflammation

Question 18

After fluid resuscitation and sending blood for lab test what is the next step

Answer 18

NG tube placement

Question 19

Why is NG tube placement recommended for all patients presenting with large volume hematochezia?

Answer 19

10% of pt presenting with hematochezia are due to massive upper GI bleed…aspirated gastric content by NG tube helps to rule out upper GI bleed…if blood or coffee grounds are aspirated the patient has UGIB

Question 20

How does the hemodynamic stability of the patient affect subsequent management and diagnostic workup?

Answer 20

If unstable- admission in ICU with expeditious workup to localize source of bleeding

Question 21

What is the first diagnostic test of choice in an unstable pt.?

Answer 21

Colonoscopy– if urgent- no bowel prep, may fail to visualise source site but can generally determine if it is from colon or small bowel

Question 22

What other diagnostic tests can we perform if colonoscopy fails to localize active bleeding site?

Answer 22

Arteriography

Nuclear scintigraphy - tagged RBC scan with technetium 999

Question 23

What if all tests fail to identify the exact source? What is the next step

Answer 23

Depends on whether the bleeding has stopped and pt is stable or bleeding is still there and patient is unstable

Question 24

Bleeding has stopped and patient is stable, what’s the next step?

Answer 24

If source is thought to be small bowel(blood above illeocecal valve on colonoscopy), small bowel studies are performed such as

Meckel’s nuclear scan
Capsure endoscopy
Enteroscopy

If source is not clear but somewhere in colon
Repeat colonoscopy
Nuclear scan and/or arteriography

Question 25

Bleeding has not stopped and patient is unstable. what is the next step

Answer 25

Emergent laparatomy with total colectomy leaving rectum and end ileostomy…provided that bleeding is at least from colon