History + Exam Flashcards
Rectal bleeding first things?
Start with ABDE,
with GI haemorrhage check haemodynamic status (hypotension, tachycardia, cool peripheries, tachypnoea or decreased consciousness).
Rectal bleeding diagnoses?
Angiodysplasia?
small vascular malformation of the gut. It is a common cause of otherwise unexplained gastrointestinal bleeding and anemia. Lesions are often multiple, and frequently involve the cecum or ascending colon, although they can occur at other places.
How can an upper GI bleed cause frank blood?
Upper GI causes can result in rectal bleeding without haematemesis, as large volumes of blood act be cathartic (stimulant of peristalsis) resulting in rapid transit through the intestine.
How much blood?
to check if haemodynamically stable, also enquire about hypovolaemia – lightheaded, collapse, chest pain, breathless.
What did the blood look like?
fresher blood is more distal, substantial bleeding from proximal can be malaena or may be frank blood = haematochezia if transit is rapid enough.
Relationship between blood and stool?
- blood is mixed with stool (lesion is proximal to sigmoid colon),
- blood streaked on stool (sigmoid or anorectal source)
- blood is separate from stool (if blood is passed immediately after stool, its anorectal condition like haemorrhoids, if blood alone implies lots of bleeding, so diverticular disease, angiodysplasia, inflammatory bowel disease or rapidly bleeding cancer),
- blood is only seen on the toilet paper (minor bleeding from anal canal).
Is there any pain or prolapse when opening the bowels?
most are not painful except anal fissure (tearing pain during and an itch),
colitis is associated with abdo cramping and lower anal cancers can be painful.
Is there tenesmus?
most specific for rectal cancer but also a symptom of colitis.
Change in bowel habit?
fs associated with dairrhoea then colitis,
if with mucus then colits, proctitis, rectal cancer, and villous adenomas of the rectum.
Has the patient lost weight?
in older patients think cancer.
diagnoses by blood type and pain?
PMH UC?
increased likelihood of colonic malignancy, or a flare up of their UC.
PMH recent bowel trauma?
bowel surgery, colonoscopy or other anorectal procedure may result in rectal bleeding.
PMH aortic surgery?
suspect aortoenteric fistula
PMH radiotherapy to the rectum?
can induce proctitis
PMH bleeding tendency?
warfarin, haemophilia, platelet dysfunction.
Degree of blood loss may be disproportionate.
PMH that disposes to upper GI bleeds?
peptic ulcer disease, chronic liver disease
Drug history increased risk of bleeding?
anticoagulant and antiplatelet meds can make previously occult bleeds overt. Long term anticoagulants make any existing angiodysplagia more likely to bleed. NSAIDs increase diverticular disease bleeds.
Drug history increased risk of peptic ulcers?
NSAIDs, steroids, bisphosphonates predispose to peptic ulceration
Drug history increased risk of infectious colitis?
antibiotic use may predispose to C.difficile colitis.
Drug history attenuated response to hypovolaemia?
beta-blockers can stop usual tachycardic response
Exam how to check if haemodynamically stable?
pulse and BP.
Exam features of chronic blood loss?
extreme pallor or koilonychias
Exam signs of malignancy?
cachexia or obvious lymphadenopathy.
Abdo exam?
focal tenderness or masses; look for signs of GI malignancy
Rectal exam?
inspection (anal fissure, skin tag, sentinel pile, haemorrhoid, fistula),
then DRE (palpable masses, inspect for blood on glove)
