rectal bleeding

Question 1

define rectal bleeding

Answer 1

Rectal bleeding indicates that the patient complains of the presence of blood passed per rectum. The patient is not simply faecal occult blood positive.

This is a common presentation and may indicate serious underlying disease. It must not be attributed to haemorrhoids without proper investigation.

aka haematochezia

Question 2

aetiology

Answer 2

fresh red rectal bleeding = typically from lesion in rectum/colon

COMMON possible causes include:

• haemorrhoids
  
  • engorged vascular cushions in anal canal
  • can present as mass/ with pruritus/fresh rectal bleeding
• diverticular disease - from inflamed areas
  
  • classically painless
  • clinically indistinguishable from angiodysplasia [small avms in colonic wall]
• large bowel polyps or carcinoma
  
  • wt loss, other gi symptoms, fhx
  • anyone with rectal bleeding in abscence of pruritus must exlude cancer with FLEXI SIG/ COLONOSCOPY
• angiodysplasia - a common cause in the elderly

other poss causes:

• anal fissures
• ibd
• ischemic colitis
• aorto-enteric fistula

Question 3

s/s

Answer 3

In the clinical history it is useful to try and localise the anatomical source of the blood.:

• Bright red blood is usually of rectal anal canal origin, whilst dark red blood is more suggestive of a proximally sited bleeding source.
• Blood which has entered the GI tract from a gastro-duodenal source will typically resemble malaena due to the effects of the digestive enzymes on the blood itself.

The patient with lower GI bleeding may complain of abdominal pain, fresh blood passed with the stool -

• haematochezia,
• shortness of breath,
• fainting episodes or fatigue

ask also about:

• • haematemesis
• • mucus
• • previous episodes

On examination, there may be

• conspicuous bleeding from the rectum,
• peritonism,
• shock,
• orthostatic hypotension and
• abdominal distention.
• pr exam = essential- assess for rectal masses/ anal fissures

Question 4

ix:

Answer 4

PR EXAM

routine bloods

• fbc
• u+e
• LFT
• coag studies
• group and save [as a minimum]

stool cultures- to exclude infective causes

pts who are hemodynamically stable

• • FLEXI SIG to exclude L colonic malignancy
• if flexi sig = inconclusive, do a full colonoscopy [if symptoms suggest proximal disease] or CT angiogram [allows you to identify culprit for bleeding + permits therapeutic intervention if needed]

pts who are hemodynamically unstable:

• emergency OGD +/- CT angiogram with emobolization & suitable resus

~~~~~~~

O/E:

All patients presenting with rectal bleeding require PR EXAM and procto-sigmoidoscopy as a minimal baseline.

nb::::: haemorrhoids = typically impalpable and to attribute bleeding to these in the absence of accurate internal inspection is unsatisfactory.

In young patients with external stigmata of fissure and a compatible history it is acceptable to treat medically and defer internal examination until the fissure is healed. If the fissure fails to heal then internal examination becomes necessary along the lines suggested above to exclude internal disease.

Question 5

mx

Answer 5

3 options of mx

1. acute large rectal bleed needs careful resus

• ABCDE approach
• 2 large bore cannulaw
• iv fluid
• blood products if needed

2. 95% of cases rsolve spontaneously

> if pts are stable + otherwise fit

> where bleeding has stopped

> Hb is normal

• can be discharged
• be ix’d as outpatient
• older pts may need admission for observation

3. minority of pts have ongoing bleeding + become unstable

• resuscitate
• urgent endoscopy
• CT angiogram
• v v v rarely is ‘blind laparotomy’ needed..

MANAGEMENT OF SPECIFIC PATHOLOGY:

Fissure in ano

1. GTN ointment 0.2% or diltiazem cream applied topically is the usual first line treatment.
2. Botulinum toxin for those who fail to respond.
3. Internal sphincterotomy for those who fail with botox, can be considered at the botox stage in males.

Haemorroids

1. Lifestyle advice,
2. for small internal haemorrhoids can consider injection sclerotherapy or rubber band ligation.
3. For external haemorrhoids consider haemorrhoidectomy. Modern options include HALO procedure and stapled haemorrhoidectomy.

Inflammatory bowel disease

1. Medical management- although surgery may be needed for fistulating Crohns (setons).

Rectal cancer

• Anterior resection or abdomino-perineal excision of the colon and rectum.
• Total mesorectal excision is now standard of care.
• Most resections below the peritoneal reflection will require defunctioning ileostomy.
• Most patients will require preoperative radiotherapy.