Rectal Bleed and Altered Bowel Habit Flashcards by Joanne McEwan

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

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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

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what can cause a rectal ulcer?

nicorandil

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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

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

carcinoma of caecum
angiodysplasia
ischaemic colitis

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how can occult bleeding be detected?

faecal occult blood (FOB) testing

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what is a change in bowel habit defined as?

change in

frequency
consistency
associated symptoms (urgency, incomplete emptying etc)

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common causes of altered bowel habit?

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

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classic diverticulitis history?

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

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important causes of altered bowel habit?

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

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how does colorectal cancer alter bowel habit?

commonly causes diarrhoea

causes constipation in later stages when obstruction occurs

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rare causes of altered bowel habit?

anal cancer (tenesmus and irritation in lower cancer)
rectal cancer

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important things to ask about in rectal bleeding?

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

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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)

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investigations in rectal bleeding?

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

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what blood tests should be done in rectal bleeding?

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

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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

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what is CT colonography?

CT with air blown into the colon to distend the colon

often used if patient cant tolerate a colonoscopy

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when might MRI be used in rectal bleeding?

important for staging rectal cancer (MRI pelvis)

small bowel MRI is important for crohns disease

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what is an anal fissure?

longitudinal ulcer in anal canal

usually posterior and associated with a skin tag

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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