RECTAL BLEEDING

Question 1

What are the alarm symptoms of someone presenting with rectal bleeding?

Answer 1

Active blood loss
Persistent and heavy bleeding
Postural hypotension
Low blood pressure ( 100)
Pallor with cold sweaty peripheries

Question 2

What questions might be helpful when taking a history from patients with rectal bleeding?

Answer 2

Change in stool consistency
Change in bowel habit

Family history of:
colonic polyps
colon or rectal cancer
IBD

Rectal or abdominal pain
Treatment with anticoagulants or antipatelets agents
Is blood bright red and mainly on toilet paper or darker red mainly mixed with the stool

Question 3

With regard to someone who presented with rectal bleeding, what might fresh blood on the toilet paper suggest about the location of the bleeding?

Answer 3

Outlet bleeding from rectum or anus (typical presentation of haemorrhoids)

Question 4

With regard to someone who presented with rectal bleeding, what might blood mixed in with the stool suggest about the location of the bleeding?

Answer 4

Bleeding is probably more proximal than the rectum or anus

Question 5

What signs might you look for when examining a patient who presents with rectal bleeding?

Answer 5

Pallor
Abdominal masses
Abdominal tenderness
PR signs

Question 6

When performing a PR exam on someone who presents with rectal bleeding, what might you look for when inspecting the anal verge?

Answer 6

Tags
Eczema
Herpetic lesions
Fissure

Question 7

Can haemorrhoids be diagnosed on PR examination?

Answer 7

No, requires visual inspection with proctoscopy

Question 8

What imaging techniques should be used initially with a patient who presents with rectal bleeding?

Answer 8

Proctoscopy

Sigmoidoscopy

Question 9

What might a proctoscopy in someone with rectal bleeding be able to diagnose without the need of further testing?

Answer 9

Local perianal disorders
Obvious haemorrhoids
Rectal mass
Proctitis

Question 10

What might a sigmoidoscopy in someone with rectal bleeding be able to diagnose without the need of further testing?

Answer 10

Haemorrhoids
Sessile or pedunculated polyps
Obvious rectal or colon cancer
IBD (Proctitis, Crohn’s, UC, radiation proctitis)

Question 11

When would you suspect that diverticulosis was the cause of bleeding in someone who presents with blood in their stools?

Answer 11

When full colonic imaging revealed no other abnormalities or when diverticulum are actively seen to be bleeding

Question 12

If a flexible sigmoidoscopy reveals no abnormalities in a patient who presented with rectal bleeding, what criteria would need to be met in order to justify sending them home at this point?

Answer 12

Under 40
No family history of polyps or colon cancer
Rectal bleed had only occured once or twice
No alarm or risk factors
Normal Hb

Question 13

What might colonoscopy reveal that flexible sigmoidoscopy did not in a patient who presents with rectal bleeding?

Answer 13

Polyps
Cancer
Angiodysplasia
Segmental Crohn's disease
Diverticulosis (if no other abnormality explains bleeding)

Question 14

What is angiodysplasia?

Answer 14

Angiodysplasia is a small vascular malformation of the gut. It is a degenerative lesion, acquired, probably resulting from chronic and intermittent contraction of the colon that is obstructing the venous drainage of the mucosa. As time goes by the veins become more and more tortuous, while the capillaries of the mucosa are gradually dilate and precapillary sphincter becomes incompetent. Thus is formed an arteriovenous malformation characterized by a small tuft of dilated vessels.

Question 15

Where is the gut is angiodysplasia most frequently found?

Answer 15

In the caecum and ascending colon, although they can be present anywhere.

Question 16

Apart from colonoscopy, what other imaging techniques might be used to locate the source of bleeding in a patient with uncomplicated (rather than acute) rectal bleeding?

Answer 16

Barium enema
CT colography
Red cell radioisotope-labelled scanning
Selective angiography

Question 17

Why are Barium enemas and CT colographies not as good as colonoscopy?

Answer 17

They are accurate for cancer, but less sensitive for polyps and completely insensitive for vascular lesions

Question 18

What bloods tests must you always do in a patient who presents with bouts of rectal bleeding?

Answer 18

FBC - constantly looking for iron defiency anaemia

Question 19

Does small intestinal bleeding present as rectal bleeding?

Answer 19

Not normally. This would be occult bleeding. It is however an important cause of iron deficiency.

Question 20

In the acutely unwell patient with rectal bleeding, what are the possible causes of severe lower GI bleeding?

Answer 20

Diverticular bleeding is most common cause
Bleeding from carcinoma or polyp
Active colitis (including ischaemic colitis)
Brisk bleeding from angiodysplasia
Haemorrhage following polypectomy

Question 21

How do you treat someone diagnosed with angiodysplasia?

Answer 21

Inject area with 1:10,000 adrenaline
Cauterise lesion down endoscope using either argon plasma photocoagulation or other forms of thermal cautery
Possibly embolisation but threat of complications
Larger lesions will need resection

Question 22

How do you treat someone diagnosed with post-polypectomy bleeding?

Answer 22

Possible to apply endoscopic clips or ligatures
Cauterise if not possible
Inject area with 1:10,000 adrenaline

Question 23

Would a colonoscopy be done on patients who continue to bleed from their rectum in hospital?

Answer 23

No as bleeding source is unlikely to be visualised if there is a lot of blood in colon. Blood coats the lens and obscures the image.

Question 24

In someone who is continuously to bleed from their rectum in hospital, what imaging techniques might be used to try and identify the source of the bleeding?

Answer 24

Angiography

Red cell scanning

Question 25

How do you treat someone diagnosed with diverticular bleeding?

Answer 25

Inject area with 1:10,000 adrenaline

Cauterise if vessel is visible

Question 26

If acute rectal bleeding continues despite cauterisation or endo-clips and the patient is unfit for surgery, what option might you consider?

Answer 26

Angiography followed by embolisation, high risk of complications though (bowel infarction)

Question 27

For angiography to be useful in the case of a patient who is acutely bleeding from their rectum, what must the minimum flow rate be?

Answer 27

> 0.5 - 1 ml/minute

Question 28

In a patient suffering from acute rectal bleeding where the bleeding rate is less than 0.5 ml/minute and therefore angiography is no use, what imaging modality might be used to help the surgeon identify the location of the bleed?

Answer 28

Technetium labelled red cell scan - not very precise tool, provides a rough idea of the segment from which bleeding is occurring.