Rectal Bleeding Flashcards
What clinical features suggest haemodynamic instability? (5)
Hypotension, tachycardia, cool peripheries, tachypnoea, or decreased consciousness
Where are the different areas rectal bleeding can arise from? (4)
Anorectal
Colonic
Ileo-jejunal
Upper GI
Anorectal causes of rectal bleeding (8)
Haemorrhoids Rectal tumour (benign or malignant) Anal tumour (benign or malignant) Anal fissure Anal fistula Solitary rectal ulcer Radiation proctitis Rectal varices
Colonic causes of rectal bleeding (9)
- Diverticular disease
- Angiodysplasia
- Colitis (inflammatory, ischaemic, infective)
- Colonic tumour (benign or malignant)
- Iatrogenic (endoscopic biopsy, anastomotic leakage)
- Vasculitis
Ileo-jejunal causes of rectal bleeding (7)
• Peptic ulceration (including Meckel’s diverticulum) • Angiodysplasia • Arteriovenous malformation • Crohn’s disease • Coeliac disease • Aorto-enteric fistula • Small bowel tumours
Upper GI causes of rectal bleeding (8)
- Peptic ulcer
- Gastritis/duodenitis
- Varices
- Tumour
- Mallory–Weiss tear
- Osler–Weber-Rendu syndrome
- Aorto–enteric fistula
- Dieulafoy lesion
Can upper GI blood be passed as red blood?
Large volumes of blood in the GI tract can act as a cathartic (stimulant of peristalsis) and the resultant rapid transit through the intestine leads to the passage of red blood per rectum.
What questions should be asked specifically about the history of the presenting complaint in rectal bleeding? (9)
How much blood has been passed?
What is the duration and frequency of the symptoms?
What did the blood look like?
What is the relationship of blood with the stool?
Is there any pain or prolapse when opening the bowel?
Is there any tenesmus?
Has there been any change of bowel habit?
Has the patient lost weight?
Are there symptoms of anaemia?
Use of anticoagulant drugs?
What should you be aware of when asking about how much blood has been passed in rectal bleeding?
That it is very easy to overestimate volumes of blood loss if, for example, blood has mixed with water in the toilet bowl. You should additionally enquire about symptoms of hypovolaemia – any postural hypotension, light-headedness, or collapse?
What can the colour of the blood tell you in rectal bleeding?
Substantial bleeding from lesions proximal in the GI tract can present with melaena but large volumes can be cathartic and lead to frank blood
What should you do if someone suggests they’ve lost a fair bit of blood in rectal bleeding? (3)
Check for symptoms of hypovolaemia - postural hypotension, light-headedness, collapse…
What are the 4 different scenarios of the relationship of blood and stool in rectal bleeding?
Blood is mixed with stool
Blood is streaked on stool
Blood is separate from the stool
Blood is only seen on the toilet paper
What does blood mixed with stool suggest?
That the lesion is proximal to
the sigmoid colon. Stool in the proximal colon is soft (thus facilitating mix-
ing with blood) and there is sufficient transit time to enable mixing
What does blood streaked on stool suggest?
a sigmoid or anorectal source of bleeding.
What does blood separate from stool suggest? (both immediately after (1) and separate (5))
Immediately after stool suggests an anal condition such as haemorrhoids
However is blood is passed on its own this suggests diverticular disease, angiodysplasia, IBD or sometimes a rapidly bleeding cancer (or upper GI haemorrhage rarely)
What does blood only seen on the toilet paper imply (2)
relatively minor bleeding from the anal canal, most likely due to haemorrhoids or an anal fissure
Does anal bleeding usually cause pain? Are there any exceptions?
No it doesn’t
Exceptions are anal fissure, a haemorrhoid that has thrombosed (and anal tumour or colitis but they can also present with no pain)
What does tenesmus with anal bleeding suggest?
Rectal cancer or a symptom of colitis
What is the passage of blood per rectum alongside diarrhoea suggestive of?
Colitis
What is the passage of blood per rectum alongside mucus suggestive of? (5)
Colitis, proctitis, rectal cancer, villous adenomas of the rectum and extensive haemorrhoids
What can weight loss with rectal bleeding suggest?
Cancer
Why should we ask about symptoms of anaemia in overt rectal bleeding?
May represent occult bleeding that has been unmasked
DDx of rectal bleeding that is painful with blood mixed with stool
Colitis
DDx of rectal bleeding that is not painful with blood mixed with stool
Colonic tumour
Colitis
DDx of rectal bleeding that is not painful with blood streaked on stool
Rectal tumour
DDx of rectal bleeding that is painful with blood streaked on stool
Anal tumour
DDx of rectal bleeding that is not painful with blood separate from stool (5)
Haemorrhoids
Diverticular disease Angiodysplasia
Rapidly bleeding colonic or rectal tumour
Colitis (+ mucus)