Lower GI Bleed

Question 1

What are other differential diagnosis for lower GI bleed?

Answer 1

Crohn’s disease

Ulcerative Colitis

Question 2

What are the symptoms of diverticular disease?

Answer 2

typically over 65 years of age; may be a history of recurrent left lower abdominal pain, bloating, constipation, diarrhoea; mild or severe painless haematochezia (bright red rectal bleeding), stops spontaneously in most, recurrent bleeding in 10% to 40% of patients

Question 3

What are the signs of diverticular disease?

Answer 3

vital signs may indicate severe bleeding (e.g., systolic BP <115 mmHg, heart rate >100 bpm); abdominal examination is usually normal; rectal examination may reveal bright red blood or blood clots, may be indistinguishable from colonic angiodysplasia but bleeding is usually more profuse and more likely to cause haemodynamic instability

Question 4

What first line investigations would you do in diverticular disease?

Answer 4

FBC: haemoglobin normal or low
platelets: normal or rarely thrombocytopenia in severe bleeding
clotting studies: usually normal
colonoscopy: active bleeding or fresh blood may be seen along with diverticulae

Question 5

What other investigations would you consider in diverticular disease?

Answer 5

radionuclide imaging: tagged red blood cell scintigraphy demonstrates extravasation and identifies the site of bleeding
mesenteric angiography: localises the site of bleeding, if the bleeding rate is >0.5 mL/minute

Question 6

What are the symptoms of colonic angiodysplasia?

Answer 6

typically over 65 years of age; intermittent, mild, or severe episodes of painless haematochezia (bright red rectal bleeding), may be history of end-stage renal disease, von Willebrand’s disease, aortic stenosis, or anticoagulant therapy

Question 7

What are the signs of colonic angiodysplasia?

Answer 7

vital signs may indicate severe bleeding (e.g., systolic BP <115 mmHg, heart rate >100 bpm); signs and symptoms of anaemia may be present; abdominal examination is usually unremarkable, rectal bleeding may be indistinguishable from diverticular disease but bleeding usually less severe and less likely to cause haemodynamic instability

Question 8

What first line investigations would you consider for colonic angiodysplasia?

Answer 8

FBC: haemoglobin normal or low
platelets: normal or rarely thrombocytopenia in severe bleeding
clotting studies: usually normal
colonoscopy: angiomas may be visualised: 5 to 10 mm cherry red, ectatic blood vessels radiating from a central vessel

Question 9

What other investigations would you consider for colonic angiodysplasia?

Answer 9

radionuclide imaging: may localise bleeding site

mesenteric angiography: the site of active bleeding may be seen

Question 10

What are the symptoms of ischaemic colitis?

Answer 10

age typically over 60 years, sudden-onset lower abdominal cramping, diarrhoea, and self-limited haematochezia (bright red rectal bleeding); may be history of haemodialysis, hypertension, hypo-albuminaemia, diabetes mellitus, constipation-inducing drugs

Question 11

What are the signs of ischaemic colitis?

Answer 11

lower abdominal tenderness; presence of peritoneal signs/absence of bowel sounds may suggest trans-mural infarction or perforation

Question 12

What first line investigations would you do for ischaemic colitis?

Answer 12

FBC: haemoglobin normal or low; WBC count may be elevated
platelets: normal
clotting studies: normal
CT scan of abdomen: segmental circumferential wall thickening

Question 13

What other investigations would you consider in ischaemic colitis?

Answer 13

colonoscopy: petechial haemorrhages, oedema, ulceration of colonic mucosa

Question 14

What are the symptoms of infectious colitis?

Answer 14

acute diarrhoea, abdominal pain, may be a history of travel to regions with higher risk of infectious diarrhoea

Question 15

What are the signs of infectious colitis?

Answer 15

abdominal tenderness may be present, fever

Question 16

What first line investigations would you do in infectious colitis?

Answer 16

stool studies: stool culture: may reveal the specific pathogen; stool white blood cell count: may be elevated; tests for ova and parasites may be positive

Question 17

What are the symptoms of colorectal cancer?

Answer 17

typically age is over 40 years; rectal bleeding; weight loss; change in bowel movements; tenesmus, abdominal pain

Question 18

What are the signs of colorectal cancer?

Answer 18

palpable mass may be present in the abdomen; rectal mass may be felt on digital rectal examination

Question 19

What first line investigation would you consider in colorectal cancer?

Answer 19

colonoscopy: friable mass in the colon may be seen and biopsy is diagnostic.

Question 20

What are the symptoms of internal haemorrhoids?

Answer 20

self-limited, intermittent, painless bright red rectal bleeding that may be chronic or intermittent; constipation may also be present; blood may be covering the stool

Question 21

What are the signs of internal haemorrhoids?

Answer 21

general examination is usually normal

Question 22

What first line investigation would you do in internal haemorrhoids?

Answer 22

anoscopy: internal haemorrhoids visualised

Question 23

What are the symptoms of anal fissure

Answer 23

rectal bleeding (usually seen on wiping) and severe peri-anal pain on defecation

Question 24

What are the signs of anal fissure?

Answer 24

fissure may be visible when parting buttocks, most commonly in the posterior midline

Question 25

What first line investigations would you consider in anal fissure

Answer 25

none: usually a clinical diagnosis in younger people

examination under anaesthetic: fissure present

Question 26

What are the symptoms of colonic polyps?

Answer 26

typically age is over 40 years; may be a family history of colonic polyps, colon cancer, or familial adenomatous polyposis or Gardner’s syndrome; rectal bleeding, may be otherwise asymptomatic, change in bowel movements, abdominal pain

Question 27

What are the signs of colonic polyps?

Answer 27

normal abdominal examination

Question 28

What investigation would you consider in colonic polyps?

Answer 28

colonoscopy: polyps visible