Rectal Bleeding

Question 1

Rectal bleeding

Answer 1

Blood- fresh, altered, melaena
On tissue or mixed in stool
When does it occur

Question 2

Stool

Answer 2

Any mucus

How much, how. Often, consistency

Question 3

Systems review

Answer 3

FWAR

GI- dysphagia, n and v, indigestion, abdominal pain, bowel habit change, mucus in stool

ALARMS

Question 4

Anal fissure

Answer 4

Bleeding on defecation
Bright red on tissue paper
Intense anal pain
Constipation history

Question 5

Haemorrhoids

Answer 5

Bleeding on defecation
Bright red on toilet paper
Constipation history
Anal pruritus

Question 6

Diverticulitis haemorrhage

Answer 6

Sudden painless rectal bleeding
Left iliac fossa pain
Elderly
Diverticulitis- fever nausea and vomiting and bloody diarrhoea

Question 7

Distal malignancy

Answer 7

Alternating bowel habit 
Fresh blood
Weight loss
Urgency or tenesmus 
Anal discomfort

Question 8

IBD

Answer 8

Blood mixed with stool 
Mucus 
Diarrhoea
Abdominal pain 
Weight loss and night time pain

More common in UC than Crohns

Question 9

Haemorrhagic infective gastroenteritis

Answer 9

Acute diarrhoea and vomiting

History of high risk food intake and travel

Question 10

Angiodyplasia

Answer 10

Elderly
Painless
Subtle bleeding

Question 11

Proximal malignancy

Answer 11

Weight loss
Malaena
Anaemia Sx

Question 12

PUD

Answer 12

Gastritis symptoms
Haematemesis
Risk f actors
Melaena

Question 13

Oesophageal varices

Answer 13

History of liver disease, alcoholism
Encephalopathy or alcohol withdrawal
Haematemesis

Question 14

Sequence of events

Answer 14

Open question

Timeline

Question 15

Symptom analysis

Answer 15

Site- back passage and definitely not from the front
Onset
Character/colour- dark, fresh, on paper or mixed in stool etc.
Radiation to paper/pain- on toilet bowl or in paper
Associated features
Timing- happened before/how frequently
Exacerbating factors- trauma, constipation
Smell- foul smelling, dark or tarry

Question 16

Systems review

Answer 16

GI- pain, stool, mucus, how often, is that normal, itching, n and v, vomited any blood, mouth ulcers, fever, painful red eye, joint or back pain

Travel- been abroad

Constitutional- FWARJNLCT

Question 17

Patients perspective

Answer 17

Feelings and impact on life

ICE

Question 18

Background

Answer 18

PMH (PUD, recent GI surgery, haemorrhoids, IBD and diverticulitis, malignancy)
DH
FH (CRC and ovarian carcinoma)
SH

Question 19

Gastroenteritis

Answer 19

History of eating uncooked food/foreign travel
Diarrhoea (watery, bloody, loose, vomiting)
Household contacts may be unwell with similar symptoms

Question 20

Upper GI bleed

Answer 20

Large volume bleed, unwell patient may be haemodynamically unstable
Melaena
Haematemesis and other red flag symptoms
Previous dyspepsia, peptic ulcers, chronic liver disease, long term anti inflammatory use

Question 21

Investigations for rectal bleeding

Answer 21

Full abdominal examination including PR exam, stool culture and sensitivities if diarrhoea, and faecal cal protection
Bloods- FBC, UE, LFT, clotting, CRP, group and save or cross match if severe
Imaging- sigmoidoscopy, colonoscopy, staging CT abdomen, pelvis (if malignancy suspected on endoscopy)