Rectal Bleeding

Question 1

Causes of fresh rectal bleeding - lower GI

Answer 1

Diverticular disease
Ischaemic or infective colitis
Haemorrhoids
Malignancy
Angiodysplasia
IBD
Peri-anal disease

Question 2

Causes of fresh rectal bleeding - upper GI

Answer 2

Oesophageal varices
Gastric/ duodenal ulceration
Oesophagitis
Gastritis
Gastric malignancy
Meckel’s diverticulum
Vascular malformations (e.g. dieulafoy lesion)

Question 3

Large, fresh rectal bleeding + haemodynamic instability = … bleed until proven otherwise

Answer 3

Large, fresh rectal bleeding + haemodynamic instability = UGI bleed until proven otherwise

Question 4

Meleana =

Answer 4

Thick black stool - beware iron supplements + Guinness

Question 5

Raised urea (without creatinine rise) - … meal

Answer 5

Raised urea (without creatinine rise) - protein meal

Question 6

Risk factors for UGIB

Answer 6

Dyspepsia or liver disease

Question 7

Oesophageal varices - what are we worried about

Answer 7

Bleeding is an emergency

Liver disease - coagulopathy

Question 8

Clinical features in bleeding:

Answer 8

Stable or unstable?
Nature of bleeding - duration, frequency, relation to stool and defection), haematemesis, PR mucus or previous episodes
Family history: bowel cancer or IBD
Abdominal examination: tenderness, palpable masses
PR examination: rectal masses, blood
Oakland score

Question 9

What is an Oakland score ?

Answer 9

For safe discharge after a lower GI bleed

Question 10

Investigations in GI bleeding

Answer 10

Routine bloods + INR + G&S
Consider stool cultures/calprotectin
Unstable? Stabilise before imaging
Urgent CT angiogram
Further - flexible sigmoidoscopy/colonoscopy

Question 11

Management in GI bleeds

Answer 11

Stable? Conservative
Unstable - A-E assessment and urgent resuscitation
- Transfuse
Endoscopic haemostasis methods:
- Injection (diluted adrenaline)
- Contact and non-contact thermal devices (bipolar electrocoagulation or argon plasma coagulation)
- Arterial embolisation: bleeding point “blush” of sufficient size on angiogram
- Surgical intervention - repair/resection

Question 12

Diverticular disease/bleed

Answer 12

Most common cause of lower GI bleeding
Outpouching of the bowel wall
Most commonly in the sigmoid colon
Diverticulosis, Diverticular disease, diverticulitis, diverticular bleed
Lab tests, CTAP, endoscopy
Conservation management - fluids, analgesia, Abx
Embolisation
Surgical resection: resection and anastomosis

Question 13

Acute mesenteric ischaemia/ischaemic colitis:
Sudden decrease in the blood supply to the bowel, resulting bowel ischaemia
Features?

Answer 13

• Generalised abdominal pain, out of proportion to clinical findings
• Associated nausea and vomiting in 75% of cases
• Abdomen soft with no guarding/rebound tenderness —> abdominal distension with guarding, rebound tenderness and absent bowel sounds
• Bloody diarrhoea once bowel has infarcted (late finding)

Question 14

Acute mesenteric ischaemia/ischaemic colitis:
Sudden decrease in the blood supply to the bowel, resulting bowel ischaemia
Causes?

Answer 14

Acute mesenteric arterial thrombosis (AMAT)
Acute mesenteric arterial embolisation (AMAE)
Non-occlusive mesenteric ischaemia (NOMI)
Mesenteric venous occlusion and congestion (MVT)

Question 15

Acute mesenteric ischaemia: causes

Answer 15

Question 16

Acute mesenteric ischaemia: investigations + management

Answer 16

Lab: ABG/VBG - lactate, routine tests
Imaging: CT scan with contrast: oedematous bowel, loss of bowel wall enhancement, pneumatosis - may identify embolus/thrombus
Surgical emergency: early senior involvement/early ITU input, resuscitate! Broad spectrum Abx, options:
- excision of necrotic/non-viable bowel or revascularisation of the bowel
Mortality 50-80%

Question 17

Mortality of acute mesenteric ischaemia

Answer 17

50-80%

Question 18

Angiodysplasia: what is this?

Answer 18

Most common vascular abnormality of the GIT
6% of lower GI bleeds, 8% of upper GI bleeds
Formation of AV malformations
Commonly caecum and ascending colon
Acquired or congenital
Clinical features: rectal bleeding and anaemia - asymptomatic, painless occult PR bleeding (majority), acute haemorrhage
Symptom degree depends on location