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Z Year3 Clinical Presentations > Rectal bleeding 2 > Flashcards

Rectal bleeding 2 Flashcards

1
Q

What do you look for on general examination of rectal bleeding?

A
  1. Haemodynamically stable?
  2. Signs of chronic blood loss?
  3. Signs of malignancy?
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2
Q

How do you check if patient is haemodynamically stable?

A

pulse and BP for signs of continuing or new bleeding

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3
Q

What would signs of chronic blood loss be?

A

signs of anaemia e.g. extreme pallor or koilonychia

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4
Q

What would signs of malignancy be?

A

cachexia or obvious lympahdeopathy

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5
Q

What do you look for on abdominal exam in rectal bleeding?

A

focal tenderness or masses: signs of GI malignancy e.g.

  1. left supraclavicular lympahedopathy
  2. palpable lesions of colon
  3. hepatomegaly
  4. ascites
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6
Q

What do you do during a rectal exam?

A
  1. Inspect anus

2. DRE

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7
Q

What do you inspect for on the anus?

A
  1. anal fissure
  2. skin tag
  3. setinel pile
  4. heamorroid
  5. fistula
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8
Q

When do you not do a DRE?

A

presence of painful anal fissure or abscess

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9
Q

Why do you carry out a DRE?

A

feel for palpable masses and inspect blood on withdrawn gloved finger

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10
Q

When can you feel haemorrhoids on a DRE?

A

if prolapsed or thrombosed

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11
Q

What bloods do you carry out for rectal bleeding?

A
  1. FBC
  2. Clotting
  3. Group and Save
  4. Urea
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12
Q

Why do you look at FBC in rectal bleeding?

A

check for anaemia and low platelets (from chronic blood loss)

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13
Q

Why do you measure clotting in rectal bleeding?

A

check if patient has a bleeding tendency

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14
Q

Why do you do a group and save in rectal bleeding?

A

if patient need blood replacement or may need to go to theatre - or a cross match if urgent

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15
Q

Why do you check urea in rectal bleeding?

A

raise in urea in recent upper GI bleed (urea is a breakdown product of digested rbc)

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16
Q

What endoscopy do you always perform?

A

protoscopy ± rigid sigmoidscopy

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17
Q

When would you not peform a protoscopy ± rigid sigmoidscopy?

A

painful anal lesion

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18
Q

What are the downsides of protscopy ± flexible sigmoidscopy?

A

if too much blood visualistion of rectum may be poor

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19
Q

What are the advantages of protscopy ± flexible sigmoidscopy?

A
  1. enable identifcation of bleeding haemorrhoids or a rectal cancer
  2. can be done at bedside
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20
Q

What are some further main investigations for acute lower GI haemorrhage (frank blood per rectum) that can be considered in stable patients?

A
  1. Colonscopy
  2. Mesenteric angiography
  3. CT angiography
  4. Technetium-99 m-labelled RBC scintigraphy (if available)
21
Q

What are advantages of colonscopy?

A
  1. Diagnostic

2. Can be therapeutic

22
Q

How can a colonscopy be therapeutic?

A
  1. control local haemorrhage by adrenaline injection
  2. argon plasma coagulation
  3. diathermy
  4. clipping
23
Q

What are the disadvanatges of rectal bleeding?

A
  1. Need to prepare bowel

2. Invasive

24
Q

How can you improve visualisation for colonoscopy?

A

colon can be irrigated via caecal catheter

25
Q

When is mesenteric angiography used?

A

if haemorrhage obscures view for colonscopy or colonscopy not possible - used in patients that blled, then stop, then bleed

26
Q

What is mesenteric angiography useful to visualise?

A

angiodysplasia

27
Q

Is mesenteric angiogrpahy widely avilable?

A

no

28
Q

How can mesenteric angiography be therapeutic?

A

embolization of bleeding vessel can be peformed during procedure

29
Q

Why is CT angiography useful?

A

multislice CT can detect even minor bleeds

30
Q

Why is CT angiography better than mesenteric angiography?

A
  1. Venous access not like arterial in mesenteric so fewer complications
  2. Provides rapid imaging and enables other abdominal pathology (related or incidental) to be seen
31
Q

What are the disadvantages of CT angiography?

A
  1. no therapeutic opportunity so may need mesenteric or laparotomy
  2. involves contract so contradindicated in patients with significant renal impairment
32
Q

When is Technetium-99 m-labelled RBC scintigraphy useful?

A

for patients where source of bleeding haven’t been able to be identified - short lived intermittent bleeds e.g. from Meckel’s diverticulum

33
Q

Is Technetium-99 m-labelled RBC scintigraphy widely available?

A

no

34
Q

What are the disadvantages of Technetium-99 m-labelled RBC scintigraphy?

A
  1. lacks specificity of colonoscopy and mesenteric angiography
  2. no therapeutic potential
35
Q

What are the advantages of Technetium-99 m-labelled RBC scintigraphy?

A
  1. non-invasive
  2. can detect bleeding lesions up to 24hr after tracer administration
  3. no bowel prep needed
36
Q

What is the imaging algorithm for stable patient with rectal bleeding?

A
  1. Protoscopy +/- rigid sigmoidscopy
  2. colonscopy
  3. Mesenteric angiography / CT angiography
  4. Radionuclide imaging
37
Q

When would you do an upper GI endoscopy?

A

if history and exam suggests 80% of acute GI haemorrhage is upper

38
Q

Why is small bowel visualisation by enteroscopy or video capsule endoscopy not used very often?

A

limited usage in acute lower GI haemorrhage

39
Q

Which conditions have classic causes of intermittent bleeding can be difficult to visualise?

A

Angiodysplasia and Dieulafoy lesion

40
Q

What is colonic angiodysplasia?

A

submucosal ateriovenous malformation

41
Q

What the cause of angiodysplasia?

A

unknown but predominance in right colon suggests that high wall tension may be factor

42
Q

How big are the lesions in angiodysplasia?

A

usally less than 1cm in diameter but can bleed out of proportion to size

43
Q

What sort of blood loss is in angiodysplasia?

A

venous blood loss

44
Q

How does angiodysplasia look on endoscopy?

A

charactersitic ‘cherry red spot’ (sometimes too much blood tho)

45
Q

How can angiodysplasia present?

A

with frank rectal bleeding or occult blood loss and subsequent anaemic symptoms

46
Q

What is the best imaging for angiodysplasia?

A

mesenteric angiography

47
Q

What is the treatment of angiodysplasia?

A
  1. embolization
  2. surgical resection
  3. endoscopic laser electrocoagulation
48
Q

What sort of blood loss is in haemorrhage from colonic diverticular disease?

A

arterial from vasa recta

Z Year3 Clinical Presentations (37 decks)

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