Rectal Bleed and Altered Bowel Habit Flashcards
common causes of rectal bleeding?
benign anorectal disease (haemorrhoids, anal fissure, anal fistula)
diverticular disease
IBD (UC bleeds more commonly than crohns)
colonic polyps
colorectal carcinoma
less common causes of rectal bleeding?
infectious gastroenteritis (esp shigella) coagulopathy angiodysplasia/AV malformation radiation proctitis (result of radiotherapy to prostate as bowel is very proximal to prostate) ischaemic colitis solitary rectal ulcer mickels diverticulum rectal varices
what can cause a rectal ulcer?
nicorandil
what is mickels diverticulum?
congenital defect in small bowel caused by the incomplete regression of the vitelline duct
causes an outpouching/bulge in small intestine (diverticulum) and rectal bleeding
usually presents in young children
what things often cause occult bleeding (not visible in stool)?
carcinoma of caecum
angiodysplasia
ischaemic colitis
how can occult bleeding be detected?
faecal occult blood (FOB) testing
what is a change in bowel habit defined as?
change in
- frequency
- consistency
- associated symptoms (urgency, incomplete emptying etc)
common causes of altered bowel habit?
IBS iatrogenic malnutrition (diarrhoea as not absorbing anything) dehydration (constipation) bowel obstruction diverticulitis UC
classic diverticulitis history?
spasmodic pain in abdo
urgent desire to move bowels
diarrhoea
pain then resolves
important causes of altered bowel habit?
colorectal cancer
faecal impaction (can cause overflow diarrhoea)
GI infection
how does colorectal cancer alter bowel habit?
commonly causes diarrhoea
causes constipation in later stages when obstruction occurs
rare causes of altered bowel habit?
anal cancer (tenesmus and irritation in lower cancer) rectal cancer
important things to ask about in rectal bleeding?
amount colour frequency duration associated abdo or anal pain medication history symptoms of anaemia
red flags in rectal bleeding?
change in bowel habit (diarrhoea is more concerning)
weight loss
anorexia
family history of bowel cancer (1st degree relative at young age = high risk)
investigations in rectal bleeding?
bloods tumour markers (CEA = colorectal cancer) stool tests (FOB/QFIT) CXR/AXR imaging
what blood tests should be done in rectal bleeding?
FBC (Hb very important) coagulation screen LFTs RFTs albumin (marker of nutritional status)
imaging in rectal bleeding?
proctoscopy sigmoidoscopy (shows up to splenic flexure, can be flexible or rigid) colonoscopy CT scan/CT colonography MRI pelvis/small bowel
what is CT colonography?
CT with air blown into the colon to distend the colon
often used if patient cant tolerate a colonoscopy
when might MRI be used in rectal bleeding?
important for staging rectal cancer (MRI pelvis)
small bowel MRI is important for crohns disease
what is an anal fissure?
longitudinal ulcer in anal canal
usually posterior and associated with a skin tag
causes of anal fissure?
usually due to straining
types of anal fissure?
acute (more painful)
chronic
symptoms of anal fissure?
anal pain
rectal bleeding
investigations in anal fissure?
PR exam
examination under anaesthetic
treatment of anal fissure?
lifestyle modifications (diet change, drink more water)
sometimes give laxatives
topical ointments
botox injection is last resort
what topical ointments are used in anal fissure?
6-8 week trial of GTN cream
diltiazem = 2nd line if GTN not working after 6-8 weeks (can cause headaches)
what are haemorrhoids?
varicosities of veins in anal canal
grades of haemorrhoids?
1 = inside and invisible 2 = come out when moving bowels but go back in by themselves 3 = come out and need to be pushed back in manually 4 = out and stay out all the time, cant be pushed back in
types of haemorrhoids?
internal external (depends on whether they are above or below the dentate line)
what is the dentate line?
AKA pectinate line
divides upper 2/3 and lower 1/3 of anal canal
symptoms of haemorrhoids?
rectal bleeding (usually after stool, covers toilet pan) painless
investigations in haemorrhoids?
rectal exam
proctoscopy
flexible/rigid sigmoidoscopy (flexible in older people to look further into colon)
management of haemorrhoids?
topical
banding (gun fires band around haemorrhoids)
THD (surgical trans-anal haemorrhoidal de-arterisation, ligates the vessles feeding the haemorrhoids)
haemorrhoidectomy (surgical removal)
what can cause diverticular disease?
associated with increased intraluminal pressure
symptoms of diverticular disease?
can be asymptomatic
PR bleed
abdo pain
can have change in bowel habit
investigations in diverticular disease?
CT (if diverticular disease not already known, should be done to exclude cancer)
colonoscopy
CT colonography
barium enema
management of diverticular disease?
diet (keep bowel regular, constipation makes it worse)
antibiotics if needed
PC drainage if abscess present
surgical (hartmanns procedure, depends on hinchey classification)
pathology in crohns?
chronic inflammation affecting any part of the GI tract
full thickness inflammation (trans-mural)
symptoms of crohns?
abdo pain mucus obstructive symptoms diarrhoea rectal bleeding weight loss fever
investigations in crohns?
colonoscopy in new diagnosis AXR endoscopy CT MRI small bowel
management of crohns?
usually medical treatment (steroids, immunosuppressants etc)
surgery is last resort (only if fistula or stricture etc present)
pathology in UC?
chronic inflammation affecting colon (starting in rectum)
inflammation confined to mucosa
symptoms of UC?
abdo pain
bloody diarrhoea
fever
weight loss
symptoms in crohns vs UC?
only really get obstructive symptoms in crohns
bloody diarrhoea more in UC
symptoms in colorectal cancer?
weight loss anaemia altered bowel habit PR bleeding tenesmus in rectal cancer
diagnosis of colorectal cancer?
CEA levels (tumour marker) AXR (shows obstruction) CT (chest and abdo for staging) MRI colonoscopy (gold standard) CT colonography (if colonoscopy not tolerated)
management in colorectal cancer?
EMR (endoscopic mucosal resection)
surgery
neo-adjuvant/adjuvant treatment
palliative (RT/chemo/defunctioning/stenting)
in PR bleeding referral pathway, who needs referral within 2 weeks?
abdo or rectal mass on examination
unexplained iron deficiency anaemia
abnormal findings consistent with bowel cancer on imaging
(at any age)
who gets urgent referral?
age >50 with 6 week history of either PR bleeding without change in bowel habit or change in bowel habit without PR bleeding
age >40 and week history of PR bleeding and change in bowel habit
who gets routine referral?
age <40 and 6 week history of change in bowel habit and either PR bleeding or altered blood mixed in stools
who gets referral for direct access sigmoidoscopy?
age <50 and 6 weeks history of fresh red PR bleeding and no change in bowel habit
how does adenoma progress to carcinoma?
normal epithelium > hyperproliferation > early adenoma > intermediate adenoma > late adenoma > cancer
