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Year 4 > Rectal Bleed and Altered Bowel Habit > Flashcards

Rectal Bleed and Altered Bowel Habit Flashcards

1
Q

common causes of rectal bleeding?

A

benign anorectal disease (haemorrhoids, anal fissure, anal fistula)
diverticular disease
IBD (UC bleeds more commonly than crohns)
colonic polyps
colorectal carcinoma

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2
Q

less common causes of rectal bleeding?

A 
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
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3
Q

what can cause a rectal ulcer?

A

nicorandil

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4
Q

what is mickels diverticulum?

A

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

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5
Q

what things often cause occult bleeding (not visible in stool)?

A

carcinoma of caecum
angiodysplasia
ischaemic colitis

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6
Q

how can occult bleeding be detected?

A

faecal occult blood (FOB) testing

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7
Q

what is a change in bowel habit defined as?

A

change in

  • frequency
  • consistency
  • associated symptoms (urgency, incomplete emptying etc)
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8
Q

common causes of altered bowel habit?

A 
IBS
iatrogenic
malnutrition (diarrhoea as not absorbing anything)
dehydration (constipation)
bowel obstruction
diverticulitis 
UC
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9
Q

classic diverticulitis history?

A

spasmodic pain in abdo
urgent desire to move bowels
diarrhoea
pain then resolves

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10
Q

important causes of altered bowel habit?

A

colorectal cancer
faecal impaction (can cause overflow diarrhoea)
GI infection

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11
Q

how does colorectal cancer alter bowel habit?

A

commonly causes diarrhoea

causes constipation in later stages when obstruction occurs

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12
Q

rare causes of altered bowel habit?

A 
anal cancer (tenesmus and irritation in lower cancer)
rectal cancer
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13
Q

important things to ask about in rectal bleeding?

A 
amount
colour
frequency
duration
associated abdo or anal pain
medication history
symptoms of anaemia
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14
Q

red flags in rectal bleeding?

A

change in bowel habit (diarrhoea is more concerning)
weight loss
anorexia
family history of bowel cancer (1st degree relative at young age = high risk)

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15
Q

investigations in rectal bleeding?

A 
bloods
tumour markers (CEA = colorectal cancer)
stool tests (FOB/QFIT)
CXR/AXR
imaging
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16
Q

what blood tests should be done in rectal bleeding?

A 
FBC (Hb very important)
coagulation screen
LFTs
RFTs
albumin (marker of nutritional status)
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17
Q

imaging in rectal bleeding?

A 
proctoscopy 
sigmoidoscopy (shows up to splenic flexure, can be flexible or rigid)
colonoscopy 
CT scan/CT colonography 
MRI pelvis/small bowel
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18
Q

what is CT colonography?

A

CT with air blown into the colon to distend the colon

often used if patient cant tolerate a colonoscopy

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19
Q

when might MRI be used in rectal bleeding?

A

important for staging rectal cancer (MRI pelvis)

small bowel MRI is important for crohns disease

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20
Q

what is an anal fissure?

A

longitudinal ulcer in anal canal

usually posterior and associated with a skin tag

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21
Q

causes of anal fissure?

A

usually due to straining

22
Q

types of anal fissure?

A

acute (more painful)

chronic

23
Q

symptoms of anal fissure?

A

anal pain

rectal bleeding

24
Q

investigations in anal fissure?

A

PR exam

examination under anaesthetic

25
Q

treatment of anal fissure?

A

lifestyle modifications (diet change, drink more water)
sometimes give laxatives
topical ointments
botox injection is last resort

26
Q

what topical ointments are used in anal fissure?

A

6-8 week trial of GTN cream

diltiazem = 2nd line if GTN not working after 6-8 weeks (can cause headaches)

27
Q

what are haemorrhoids?

A

varicosities of veins in anal canal

28
Q

grades of haemorrhoids?

A 
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
29
Q

types of haemorrhoids?

A 
internal
external
(depends on whether they are above or below the dentate line)
30
Q

what is the dentate line?

A

AKA pectinate line

divides upper 2/3 and lower 1/3 of anal canal

31
Q

symptoms of haemorrhoids?

A 
rectal bleeding (usually after stool, covers toilet pan)
painless
32
Q

investigations in haemorrhoids?

A

rectal exam
proctoscopy
flexible/rigid sigmoidoscopy (flexible in older people to look further into colon)

33
Q

management of haemorrhoids?

A

topical
banding (gun fires band around haemorrhoids)
THD (surgical trans-anal haemorrhoidal de-arterisation, ligates the vessles feeding the haemorrhoids)
haemorrhoidectomy (surgical removal)

34
Q

what can cause diverticular disease?

A

associated with increased intraluminal pressure

35
Q

symptoms of diverticular disease?

A

can be asymptomatic
PR bleed
abdo pain
can have change in bowel habit

36
Q

investigations in diverticular disease?

A

CT (if diverticular disease not already known, should be done to exclude cancer)
colonoscopy
CT colonography
barium enema

37
Q

management of diverticular disease?

A

diet (keep bowel regular, constipation makes it worse)
antibiotics if needed
PC drainage if abscess present
surgical (hartmanns procedure, depends on hinchey classification)

38
Q

pathology in crohns?

A

chronic inflammation affecting any part of the GI tract

full thickness inflammation (trans-mural)

39
Q

symptoms of crohns?

A 
abdo pain
mucus
obstructive symptoms 
diarrhoea 
rectal bleeding
weight loss
fever
40
Q

investigations in crohns?

A 
colonoscopy in new diagnosis
AXR
endoscopy 
CT
MRI small bowel
41
Q

management of crohns?

A

usually medical treatment (steroids, immunosuppressants etc)

surgery is last resort (only if fistula or stricture etc present)

42
Q

pathology in UC?

A

chronic inflammation affecting colon (starting in rectum)

inflammation confined to mucosa

43
Q

symptoms of UC?

A

abdo pain
bloody diarrhoea
fever
weight loss

44
Q

symptoms in crohns vs UC?

A

only really get obstructive symptoms in crohns

bloody diarrhoea more in UC

45
Q

symptoms in colorectal cancer?

A 
weight loss
anaemia
altered bowel habit
PR bleeding
tenesmus in rectal cancer
46
Q

diagnosis of colorectal cancer?

A 
CEA levels (tumour marker)
AXR (shows obstruction)
CT (chest and abdo for staging)
MRI
colonoscopy (gold standard)
CT colonography (if colonoscopy not tolerated)
47
Q

management in colorectal cancer?

A

EMR (endoscopic mucosal resection)
surgery
neo-adjuvant/adjuvant treatment
palliative (RT/chemo/defunctioning/stenting)

48
Q

in PR bleeding referral pathway, who needs referral within 2 weeks?

A

abdo or rectal mass on examination
unexplained iron deficiency anaemia
abnormal findings consistent with bowel cancer on imaging
(at any age)

49
Q

who gets urgent referral?

A

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

50
Q

who gets routine referral?

A

age <40 and 6 week history of change in bowel habit and either PR bleeding or altered blood mixed in stools

51
Q

who gets referral for direct access sigmoidoscopy?

A

age <50 and 6 weeks history of fresh red PR bleeding and no change in bowel habit

52
Q

how does adenoma progress to carcinoma?

A

normal epithelium > hyperproliferation > early adenoma > intermediate adenoma > late adenoma > cancer

Year 4 (83 decks)

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