Rectal Bleeding Flashcards
What is the intial assement of someone with rectal bleeding?
ABCDE
And if acute bleeding - check circulation
What are clinical features to suggest haemodynamic instability?
- hypotension
- tachycardia
- cool peripheries
- tachypnoea
- or decreased conciseness
What are the anorectal differential diagnosis for rectal bleeding?
- Haemorrhoids
- Rectal tumour
- Anal tumour
- Anal fissure
- Anal fistula
- Solitary rectal ulcer
- Radiation proctitis
- Rectal Varices
- Trauma
What are the colonic differentials for rectal bleeding?
- Diverticular disease
- Angiodysplasia
- Colitis (inflammatory, ischaemic, infective)
- Colonic tumour (benign or malignant
- Latrogenic (endoscopic biopsy, anastomotic leakage)
- Vasculitis
What are the ileo-jejunal differential diagnosis for rectal bleeding?
- Peptic ulceration (including Meckel’s diverticulum
- Angiodysplasia
- Arterio-venous malformation
- Crohn’s disease
- Coeliac disease
- Aortic-enteric fistula
- Small bowel tumours
What are the Upper GI differential diagnosis for rectal bleeding?
- Peptic ulcer
- Gastritis/duodenitis
- Varcies
- Tumour
- Mallory-Weiss tear
- Olser-Weber-Rendu syndrome
- Aorto-enteric fistuala
- Dieufoy lesion
How can a GI haemorrhage show up?
overt or occult bleeding
How do upper GI sources of haemorrhage present?
- rectal bleeding alone
- also upper GI sources may present with haematemsis but large volumes of blood in GI tract can cause stimulation of peristlaisis and resultant rapid trasnit through intestine leads to passage of red blood per rectum
What questions should you ask about history of presenting complaint for rectal bleeding?
- How much blood has been passed
- Duration and frequency of symptoms
- What did blood look like
- Relationship of blood with stool
- Any pain or prolapse when opening bowels
- Is there tenesemus
- Any change in bowel habit
- Patient lost wieght
- Symptoms of anaemia
How do you find out from the patient how much blood has passed? What else do you ask about
- quantify with teaspoon
- may over estimate
- ask about symptoms of hypovolemia, light headiness, collapse, chest pain or breathlessness
What does fresh blood mean?
more distal the bleed
How would substantial bleed from lesions in GI tract show up?
- meleana
2. haematochezia if transit times are very rapid
Why might a non pathological reason patient may have black stool?
iron supplements
What are the 4 possible relationships of blood with stool?
- Blood mixed in with stool
- Blood streak stool
- Blood seperate from stool
- Blood seen on toilet paper
What does blood mixed in with stool suggest?
lesion proximal to sigmoid colon
What is tool in proximal colon like?
soft (facilitating mixing with blood) and sufficient transit time to mix in
What does it mean if blood is passed immediately after stool?
anorectal condition e.g. haemorrhoids
What does it mean if blood is passed on its own?
sufficient bleeding to dilate the rectum and produce a defecation stimulation e.g.
- diverticular disease
- angiodysplasia
- IBD
- sometimes a rapidly bleeding cancer
What would blood seen on toilet paper suggest?
minor bleeding from anal canal e.g. haemorrhoids or anal fissure
What would intense/tearing pain during defecation with pain after maybe and itching suggest?
anal fissure or anal herpes
What would abdmoinal pain/cramping with rectal bleeding suggest?
colitis
What would pain with rectal bleeding suggest?
lower anal cancers
When are haemorrhoids painful?
thrombosed
What is tensemus specific for?
rectal cancer
What other condition can you get tensemus in sometimes?
colitis
What would blood and diarrhoea suggest?
colitis
What would blood and mucus suggest?
- colitis
- procitis
- rectal cancer
- villous adenomas of rectum
What can extensive haemorrhoids do to the bowel?
mucus per rectum
What would a patient loosing weight with rectal bleeding suggest?
malignancy, esp older people, rectal cancer can have big loss of weight without metastasis
Why do you ask about symptoms of anaemia with rectal bleeding?
current overt bleed may represent an occult bleed that has been masked e.g. by anticoagulant drugs so ask about symptoms of anaemia e.g. lethargy and SOB
What would blood mixed with stool and pain suggest?
colitis
What would blood mixed with stool and no pain suggest?
- colonic tumour
2. colitis
What would blood streaked on stool with pain suggest?
anal tumour
What would blood streaked on stool with no pain suggest?
rectal tumour
What would blood seperate from stool with pain suggest?
colitis
What would blood seperate from stool with no pain suggest?
- Haemorrhoids
- diverticular disease
- angiodysplasia
- rapidly bleeding colonic or rectal tumour
- colitis (+mucus)
What would blood on toilet paper with pain suggest?
anal fissure
What would blood on toilet paper with no pain suggest?
haemorrhoids
What PMHx and PSHx must you ask about with rectal bleeding?
- Previous rectal bleeding
- UC
- Recent bowel trauma
- Aortic surgery
- Radiotherapy of rectum
- Bleeding tendency
- PMHx that redisposes to upper GI bleed
What do you ask about previous rectal bleeding?
were these episodes investigated + outcome?
Why do you ask about UC with rectal bleeding?
increases likelihood of colonic malignancy or flare up of UC
What would recent bowel trauma e.g. bowel surgery, colonscopy, anorectal procedure with rectal bleeding suggest?
can all result in recent rectal bleeding
What would aortic surgery with rectal bleeding suggest?
aortoenteric fistula until proven otherwise
What would radiotherapy of rectum and rectal bleeding suggest?
proctitis
What would bleeding tendency with rectal bleeding suggest?
e.g. warfarin, haemophilia, platelet dysfunction: degree of blood loss may be disproportionate to that normally expected from a particular lesion
What conditions may predispose to upper GI bleeds?
E.g. peptic ulcer disease, chronic liver disease can present as with rectal bleeding if bleeding is profuse enough
How can drugs contribute to rectal bleeding?
- Increase risk of bleeding
- Increase risk of peptic ucler
- Increase risk of infectious colitis
- Attenuated cardiac response to hypovolaemia
What drugs can cause an increased risk of bleeding?
- anticoagulant and antiplatelet medications accenuate bleeding from established lesions (previously occult can become overt)
- LT anticoagulant e.g. for AF make existing angiodysplasia more likely to bleed
- NSAIDs increase bleeds from diverticular disease
What drugs can cause an increased risk in peptic ulcer disease?
- NSAIDs
- steroids
- bisphosphonates
What drugs increase risk of infectious colitis?
- PPIs
- Antibiotics
What drug cause an attenuated cardiac response to hypovoleamia?
beta blockers can stop patients mounting the usual tachycardic response to hypovolaemia
