Rectal Bleeding Flashcards
How can the differential diagnosis of rectal bleeding be categorised?
They can be categorised based on the source of the bleed Anorectal Colonic Ileojejunal Upper GI
List some differentials for rectal bleeding. Anorectal Colonic Ileojejunal Upper GI
- Anorectal Haemorrhoids Anal fissure Rectal tumour Anal tumour Anal fistula - Colonic Diverticular disease Angiodysplasia Colitis (inflammatory, ischaemic, infective) Colonic tumour (benign or malignant) Iatrogenic - Ileojejunal Coeliac disease Aorto-enteric fistula Small bowel tumours Peptic ulceration (Meckel’s diverticulum) Angiodysplasia - Upper GI Peptic ulcer Oesophageal varices Mallory-Weiss tear Aorto-enteric fistula Osler-Weber-Rendu syndrome Dieulafoy lesion
List some important questions to ask about the history of presenting complaint.
How much blood has passed?
How long have you had rectal bleeding and how often do you experience it?
What does the blood look like?
Describe the relationship between the blood and the stools.
Is there any pain or prolapse when opening your bowels?
Has there been a feeling of incomplete emptying of your bowels after you’ve gone to the toilet (tenesmus)?
Has there been a change in bowel habit?
Have you lose weight?
Ask about signs of anaemia (e.g. lethargy, breathlessness)
Describe the different appearances of blood in stools.
Frank blood = haematochezia
Black, tarry stools = melaena
Other than melaena, what else can cause black tarry stools?
Iron supplements
Explain how the relationship between the blood and the stool can give clues about the source of the bleed.
Blood mixed with stool – lesion is proximal to the sigmoid colon, so it can mix with loose stools
Blood streaked on stool – sigmoid or anorectal source
Blood separate from stool – haemorrhoids can cause bleeding after defecation. Some bleeding may be sufficient to trigger defecation (e.g. diverticular bleeds, angiodysplasia, IBD)
Blood is only on toilet paper – suggest minor bleeding from anal canal (e.g. haemorrhoids, anal fissure)
Most causes of rectal bleeding are painless. Which cause of rectal bleeding is known for causing intense pain?
Anal fissures cause an intense tearing pain on defecation
What does tenesmus suggest?
It suggests that there is a space-occupying lesion in the rectum
What can cause bloody diarrhoea?
Ischaemic colitis
Ulcerative colitis
What can cause bloody, mucoid diarrhoea?
Proctitis
Rectal cancer
Villous adenomas
Chronic GI blood loss can lead to anaemia. Which symptoms of anaemia should you ask the patient about?
Breathlessness
Fatigue
List some key features of the past medical history that you should ask about.
Previous rectal bleeding
Ulcerative colitis
Recent bowel trauma (e.g. surgery, colonoscopy)
Aortic surgery
Radiotherapy to the rectum
Bleeding tendency
PMH of risk factors for upper GI bleeds (e.g. peptic ulcer disease, chronic liver disease)
Which types of drugs are particularly important to take note of in a patient with rectal bleeding?
Increased bleeding tendency (e.g. anticoagulants, antiplatelets)
Increased risk of peptic ulcers (e.g. NSAIDs, steroids, bisphosphonates)
Increased risk of C. difficile colitis (e.g. antibiotics, PPIs)
Drugs that attenuate the cardiac response to hypovolaemia (e.g. beta-blockers)
Why is it important to check for Virchow’s lymphadenopathy in a patient presenting with rectal bleeding?
It is a sign of GI malignancy
Before performing a DRE, what do you inspect the anus for?
Skin tags
Anal fissures
Haemorrhoids
Anal fistulae
Under what conditions will haemorrhoids be palpable on DRE?
If the haemorrhoid is prolapsed or thrombosed
List some important blood tests to conduct in a patient with rectal bleeding. Explain why these tests are important.
FBC – chronic GI bleeding can lead to anaemia
Clotting screen – check if the patient has a bleeding tendency
Urea – high urea is consistent with upper GI bleeds (due to digestion of red blood cells)
Which methods of visualising the anus, rectum and sigmoid colon can be performed at the bedside of a patient with rectal bleeding?
Proctoscopy
Rigid sigmoidoscopy
List some imaging methods used to identify the source of the bleeding.
Colonoscopy
Mesenteric angiography
CT angiography
Technetium-99 m-labelled red blood cell scintigraphy
Upper GI endoscopy
Small bowel visualization by enteroscopy or video capsule endoscopy
Which cause of rectal bleeding is mesenteric angiography particularly useful for diagnosing and treating?
Angiodysplasia
List two causes of upper GI bleeding that are difficult to visualise.
Angiodysplasia
Dieulafoy lesion
Define angiodysplasia.
An abnormal collection of small blood vessels usually in the lining of the GI tract, which can bleed
They are common in the large and small intestine but can also be found in the lining of the stomach and mouth
List the treatment options for angiodysplasia.
Embolisation
Surgical resection
Endoscopic laser electrocoagulation
List the treatment options for haemorrhoids:
- Conservative Increase dietary fibre Improve hydration Avoid straining at the stool - Medical Local anaesthetics Steroidal creams Laxatives - Surgical Rubber band ligation Injection sclerotherapy Haemorrhoidectomy Stapled haemorrhoidopexy
Which class of drugs increases the risk of diverticular bleeds?
NSAIDs
Which scoring system is used to predict the risk of future diverticular bleeds?
HAS-BLED
Describe two surgical procedures that are used for patients with diverticular disease.
Hartmann’s procedure – proctosigmoidectomy with an end colostomy and a rectal stump
Primary anastomosis – resection of the affected portion of bowel with anastomosis of the loose ends – a loop ileostomy may be used to allow the primary anastomosis to heal
Most anal fissures heal spontaneously. Why do deep fissures heal more slowly?
Anal sphincter spasm restricts the anal blood supply, which is required for healing
What are the main aims of treatment of anal fissures?
Reduce anal sphincter spasm
Reduce tearing of the anal mucosa
Promote healing
Describe the medical treatment options for anal fissures.
High-fibre diet with laxatives
Avoid constipating analgesics (e.g. opioids)
Topical anaesthetics (e.g. lidocaine)
Topical GTN (relaxes the anal sphincter and promotes healing)
Topical diltiazem
Botox injections
Describe the surgical treatment options for anal fissures.
Lateral internal sphincterectomy (this comes with a risk of faecal incontinence)
Anal advancement flap