Rectal bleeding Flashcards
What conditions cause ‘mixed’ blood in stool?
Colon cancer
Inflammatory bowel disease
Diverticulitis
Bacillary dysentery
Clinically differentiate colon cancer from IBD
IBD more associated with increased frequency
Mass may be felt in CRC
CRC tends to present in >60s rather than 20-40s
Who gets screened via FIT testing in Scotland? how often
All men and women
50-74 years old
Every 2 years
If a FIT test is abnormal, what investigation should be performed? What happens if this doesn’t work?
Colonoscopy
CT colonography alternative
Who gets a 2 week referral for suspected colorectal cancer?
40 yrs…
Abdo pain + weight loss
50 yrs
unexpected rectal bleeding
>60 yrs
change in bowel habit/microcytic anaemia
Consider if mass or other red flag symptoms
Name the resection and anastamosis
caecal –> proximal transverse
Right hemicolectomy
Ileo-colic
Name the resection and anastamosis
Distal transverse –> descending colon
Left hemicolectomy
Colo-colon
Name the resection and anastamosis
Sigmoid
High anterior
Colorectal
Name the resection and anastamosis:
Upper rectum
Anterior resection
Colorectal
Name the resection and anastamosis
Lower rectum
Anterior resection +/- defunctioning stoma bag
Name the resection and anastamosis
Anal verge
Abdomino-perineal rectal excision
None
What complication of surgery increases the risk of anastomosis? If this occurs what is the safest treatment option?
Bowel perforation
End colostomy
Differentiate ileostomy and colostomy based on location, appearance and output
Ileostomy // Colostomy
RIF // Varies but likely left
Spouted // Flushed
Liquid // Solid
Classify bowel cancer according to Duke’s Criteria
A: Limited to muscularis
B: Extends beyond muscularis
C: Regional Lymph Node Involvement
D: Distant metastases
How do you monitor treatment response in colorectal cancer?
Blood CEA
What criteria can help with diagnosing Lynch Syndrome
>=3 cases colorectal (or endometrial, small bowel, ureter or pelvis)
>=2 generations affected
>=1 of affected is first degree relative and/or <50yrs at diagnosis
FAP should be excluded
How does HNPCC and FAP differ in terms of
Incidence
Implicated genes
Cancer site
HNPCC // FAP
More vs less common
MSH2/MLH1 vs APC
Proximal colon vs throughout
FAP features + retinal pigmentation/head osteomas/thyroid caricinomas/epidermoid cysts a indicates what
Gardner’s syndrome
Variant of FAP
Why are you worried about a teen with darkly pigmented mouth and GI polyps
Peutz-Jeugher’s syndrome
Small chance of malignant conversion to CRC so surveillance needed.
24 year old male presents with mixed rectal bleeding, abdominal pain and increased frequency of stool passage. Likely diagnosis?
Inflammatory Bowel Disease
How can the pain differ in IBD?
CD: Right as affects whole tract
UC: LIF as colon affected
What IBD is associated with gallstones?
Crohn’s
What IBD is more associated with primary sclerosing cholangitis?
UC
What feature is this and which IBD is it more common in?
Thumbprinting
UC due to thickening of colon
What is the imaging below and which IBD do you see it in?
Drainpipe/lead pipe colon
Seen in AXR for UC
Chronic inflammation causes muscularis hypertrophy, resulting in haustral loss
‘Deep skip lesions’
‘Widespread, continuous ulceration’
Match the IBD to the above endscopy report
Deep skip lesions (‘Cobblestoning’) —> Crohn’s
Widespread contiuous disease –> UC
What happens to goblet cells in the IBDs?
Crohn’s: Increased goblet cells
Ulcerative Colitis: Reduced goblet cells
Crypt abcesses
Granulomas
Match the features to their IBDs
Crypt abscesses –> UC
Granulomas –> CD
What induction agents are used for Crohn’s?
- Glucocorticoids/budenoside
- 5-ASA (mesalazine)
+ Azathioprine/mercaptopurine
If induction agents don’t work in Crohn’s what can you give?
>5 days without improvement
Consider infliximab/adalimumab
What induction agents are used for UC?
Mild-mod (4-6 stools)
1st: topical 5-ASA (-salazine) +/- oral 5-ASA or corticosteroid if proctitis
Severe (>6 stools)
IV steroids + ciclosporin if no improvement
What maintenance agent is used in Crohn’s?
STOP SMOKING
Azathioprine/mercaptopurine
What maintenance agents are used in UC?
Mild-mod: Top/oral/both AS
Severe (systemic unwell)/>2 relapses: Azathioprine/mercaptopurine
Since they both have rectal bleeding and LIF pain, clinically differentiate diverticulitis and UC
RIF pain more likely if Asian
Patients tend to be over 40
N+V, low fever present
How do you investigate for suspected diverticulitis? Whst should be avoided?
1st line: AXR shows dilated bowel, obstruction, abscesses
GS: CT
DON’T DO COLONOSCOPY DUE TO PERFORATION RISK
How is suspected diverticulitis managed?
mild: oral Co-amoxiclav and non-NSAID analgesia
Severe/>72 hours: Admit for IV antibiotics
What cause of rectal bleeding is most associated with AKI?
Bacillary dysentery
How do you investigate and treat bacillary dysentery?
Stool culture to confirm
Supportive; Abx if unwell/vulnerable
What 4Cs increase C diff?
Cephalosporins
Co-amoxiclav
Clindamycin
Ciprofloxacin
What causes painful fresh rectal bleeding?
Fissure in ano
Thrombosed Haemorrhoids
Where are anal fissures found vs haemorrhoids?
Fissures: 6 and 12 O clock
Haemorrhoids: 3, 7 and 11 O clock
Apart from stool softeners, how do you treat haemorrhoids?
Rubber band ligation > sclerotherapy
Surgery if large or <72 hour thrombosis history
Faecal incontinence, perianal pain and bleeding are seen in which cancer?
Rectal cancer
