Colorectal - General PR Bleed Flashcards
What is Lower GIT Bleeding?
LBGIT is defined as bleeding that originates from a source distal to the Ligament of Treitz
What is hematochezia?
Hematochezia is defined as gross, fresh blood seen either on toilet paper after defecation or mixed with stools.
What is Massive BGIT?
Massive LBGIT is defined as bleeding that requires ≥ 3 units of blood over 24 hours or in patients with hemodynamic instability
For a patient with BGIT, when would you recommend colonoscopy?
For all patients with PR bleed above 50 years old
What are the aspects of history to take for LBGIT?
- First Episode or Recurrent
- If Recurrent: does it ‘come and go’ (benign cause - hemorrhoidal bleed or anal fissure) or ‘persistent and progress’ (malignant cause) - How was the PR bleed observed?
- wiping (a/w anal fissures, look for pain to confirm)
- having blood drip into the toilet bowl (hemorroidal)
- frank blood on defecation coating stools (distal bleed)
- frank blood on defecation mixed in with stools (proximal bleed) - Colour of Bleed
- Frank red bleeding: suggestive of blood originating from left colon
- Maroon colored bleeding: suggestive of blood originating from right colon (may be mixed with stools)
- Melena: suggestive of UBGIT or occasionally from right sided colonic bleed
—Ask if stools are foul-smelling, sticky, and as black as hair. - Number of Episodes, Presence of Clots
- Associated Symptoms
- Pain on defecation: suggestive of anal fissure, rectal tumours (i.e. tenesmus– incomplete defecation, recurrent
inclination to defecate, frequently painful), ischemic colitis
- Bloody Diarrhoea: suggestive of infective causes, inflammatory bowel disease (diarrhoea mixed with blood & mucus), colitis
- Abdominal pain with PR bleed: suggestive of colitis (inflammatory, ischemic, infective)
- Passing of mucus
- Hematemesis: suggestive of massive UBGIT - Systems Review
- Change in bowel habits such as alternating constipation and diarrhoea
- Any spurious diarrhoea
- Change in stool calibre such as pencil thin stools
- Presence of tenesmus, which can be due to rectal tumours, infective colitis, inflammatory colitis and radiation proctitis
- Any constitutional symptoms such as loss of weight and appetite
- Other risk factors: smoking, diet (i.e. red meat), obesity
- Additional UGIT History - Age - Young patients: suggestive for benign perianal causes such as hemorrhoids, anal fissures, can also be due to
inflammatory bowel disease though uncommon in our local setting (Asians); Older patients: suggestive for diverticular disease, colorectal malignancy, ischemic colitis - PMH
- Prev Colonoscopy? When? Findings?
- Colorectal Polyps?
- Previous admissions for PR Bleed? Findings? Procedures? Imaging?
- Radiation History?
- Cardiac Risk Factors (Arrythmias, AMI) - Family History
- Any family history of IBD, GI malignancies, cancers - Social History
- smoking, alcohol intake, obesity, diet (i.e. red meat), these are known risk factors for CRC
- recent travel history / positive contact history (infective colitis such as traveller’s diarrhoea, usually a/w fever) - Medication
- Any recent intake of NSAIDs or Steroids (NSAIDs induced colitis)
- Any anti-platelets, anticoagulants, novel oral anticoagulants (NOACs) → bleeding diathesis
- Any antihypertensive medications
- Any iron supplementation → dark green stools mimicking melena - symptomatic anemia (i.e. SOB on exertion, postural dizziness, syncope, chest pain, palpitation, lethargy/fatigue)
Physical Examination for a patient with PR Bleed?
- Hemodynamic Assessment
▪ Is the patient hemodynamically stable or unstable?
▪ Assess hemodynamic stability – BP (MAP), HR, SpO2, Temperature
▪ Urine output (keep >0.5ml/hr) - Abdominal Examination
▪ Abdominal Examination – any abdominal tenderness, abdominal masses
▪ DRE: examine perianal externally, look for any anal fissures, prolapsed hemorrhoids, thereafter confirm presence of
hematochezia or melena or brown stools, any masses (if paitent has an anal fissure, he will be too tender to allow for
PR examination.
▪ Proctoscopy: can assess if bleeding is due to ano-rectal causes (i.e. low rectal ulcers, hemorrhoidal bleeding) or
bleeding distal to the proctoscope, can assess if bleeding is active (i.e. free flowing +/- clots) or if bleeding has stopped.
▪ +/- NGT insertion – if suspect Upper BGIT, can consider insertion where positive aspirate will indicate UBGIT and need
for OGD. However, absence of blood does not rule out Upper BGIT. (rarely performed) - Any systemic manifestation of inflammatory bowel disease (joint, liver, eye and skin manifestations)
- Assess for complications
▪ Signs of Anaemia
▪ Face – (i) conjunctival pallor (ii) pallor of mucous membrane
▪ Cardiac Auscultation – short systolic flow murmur at aortic area
▪ Pulse – (i) tachycardia (ii) bounding (iii) collapsing pulse
▪ Hands – pallor of palmar creases
What are the differential diagnoses for PR Bleed?
- Upper GIT (proximal to ligament of Treitz)
- Upper GI bleeding – esophageal, gastric, duodenum - Small Intestine (2-9%)
- Angiodysplasia (50-60%) – more common in elderly
- Meckel’s diverticulum – more common in children
- Small bowel neoplasms (i.e. gastro-intestinal stromal tumours)
- Crohn’s Disease
- Enteritis (inflammatory / infective / radiation / ischemic)
- Aortoduodenal fistula (patients with synthetic vascular graft), - Large Intestine
- Colonic (60-80%)
– Diverticular Disease (bleeding diverticulosis) – 20-50%
– Colitis
—Infective (i.e. Bacterial / Viral / Parasitic)
—Inflammatory (i.e. UC, CD, Indeterminate IBD)
—Chemical (i.e. NSAIDs use, anti-angina drug (nicorandil))
—Ischaemic: at water-shed area (splenic flexure – 3-9%, recto-sigmoid junction) o Radiation (i.e. radiation proctitis)
— Colonic Carcinoma / Post-polypectomy bleeding
— Angiodysplasia* (capillary, cavernous haemangioma) ~ 3-10%
— Dieulafoy’s Lesion (most common in stomach – 75%, duodenum – 14%, colon 5%)
— Others: Colonic varices, Aorto-colonic fistula, Vasculitis - Rectal
- Rectal Cancer
- Anorectal varices
- Rectal ulcer / Stercoral ulcer
- Solitary Rectal Ulcer Syndrome (SRUS)
- Perianal (4-10%)
– Haemorrhoids, anal fissure, anal cancers - Others
- Bleeding after endoscopy procedure (i.e. post-polypectomy bleeding, post-RBL bleeding)
- Bleeding after operation (i.e. staple line bleeding)
What is angiodysplasia?
Angiodysplasia: small AVM composed of clusters of dilated vessels in the mucosa and submucosa. Bleeding more commonly affects the right colon and cecum (80%), small intestine (15%), stomach
What is bleeding diverticular disease?
Bleeding Diverticular disease: It is the most common cause of massive acute LGIT, painless hematochezia (maroon or bright red). The perforating artery adjacent to the colonic diverticulum becomes attenuated and eventually erodes. This leads to arterial bleeding. Majority of the time, the bleeding stops spontaneously. (risk of re-bleeding ~15%)
What are the causes of infective colitis?
Causes of infective colitis includes: E coli, Salmonella, Shigella, Campylobacter jejuni, Entamoeba histolytica, Histopla sma, Cytomegalovirus
What is a stercoral ulcer?
Stercoral Ulcer: a/w hard stools impacted in rectum or rectosigmoid leading to ischemia, necrosis, ulceration and eventua l perforation
Tell me about Solitary Rectal Ulcer Syndrome?
Condition is a sequela of both internal rectal prolapse & outlet obstruction constipation.
The lesion is not always solitary (it may be multiple),
it is not ulcerative (it may be polypoid / nodular or affecting the erythematous mucosa only) and is not restricted to the rectum (it may involve the sigmoid colon).
Patients present with rectal bleeding, straining during defecation and a sense of incomplete defecation (tenesmus), and passage of mucus.
Histology is crucial for diagnosis, findings of fibromuscular obliteration of the lamina propria helps to differentiate this condition from IBD / malignancy.
What investigations will you do for a patient with PR Bleed?
Biochemical:
1. FBC
2. Kidney Function Tests
3. PT/PTT
4. GXM
5. Cardiac Enzymes
6. ABG/Lactate
Colonoscopy (in the setting of a hemodynamically stable patient who is able to tolerate adequate bowel preparation)
Imaging (if hemodynamically unstable)
1. CTMA
2. Selective Mesenteric Angiography / Angioembolization
3. Radionuclide imaging with technetium 99 m (99mTc-RBC)
What is diagnostic for LBGIT on CTMA?
active blush is detected with IV contrast entering the bowel lumen
What is the management of a patient with PR Bleed?
- Resuscitation & Hemodynamic Stabilization
- Keep patient NBM
- ABC: Fast infusion of crystalloids +/- colloids while waiting for whole blood
- Continuous hourly vital signs monitoring
- Input / Output Charting, Stool Charting
- Catheterisation for strict urine output monitoring– 0.5ml/kg/h
- KIV for NGT insertion if suspicion for Upper BGIT is high
- Decide on patient’s disposition, can he be managed in general ward or require high dependency or ICU care
- KIV insertion of arterial line / central venous line, depending on patient’s hemodynamic status
- Stop all anti-hypertensive medications
- Stop all antiplatelets, anticoagulants and novel oral anticoagulants (NOACs), KIV anticoagulation reversal
- Take bloods for investigation (as above) - Identify site of bleeding
- The first dichotomy is to differentiate if this is an Upper BGIT or Lower BGIT
- For Lower BGIT, clinical examination (DRE / Protoscope) can help reveal if bleeding is from the ano-rectal junction and if
bleeding is active
- For patients who are hemodynamically unstable, a CTMA is the preferred investigation of choice. If an active blush is present,
the patient can proceed to either a selective mesenteric angiography or colonoscopy (depending on the location of the
bleed).
- For patients who are hemodynamically stable and with persistent PR bleeding, a colonoscopy can be performed after
mechanical bowel preparation
- Rarely, surgical intervention is required if the source of bleeding cannot be identified and the patient has persistent lower
BGIT . - Treat accordingly
- Refer to specific sections on the treatment required
- Surgical Intervention can be considered in the following settings:
▪ Continued or recurrent haemorrhage despite non-operative attempts at localization,
▪ On-going hemodynamic instability,
▪ Transfusion requirement > 6-10 units,
▪ Pathological findings requiring surgical intervention
- Aim to have pre-surgical localization of bleed, improve mortality and morbidity
- If bleeding appears to be from colon but cannot be localized – emergency total abdominal collection (TAC) – high mortality
rate (10-30%), re-bleeding rate of < 1%, segmental colectomy have mortality rate 10% with re-bleeding rate of 35-75%
