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)
DDx of rectal bleeding that is painful with blood separate from stool
Colitis
DDx of rectal bleeding that is not painful with blood on toilet paper
Haemorrhoids
DDx of rectal bleeding that is painful with blood on toilet paper
Anal fissure
What questions should you ask in the PMHx of someone presenting with rectal bleeding? (8)
Previous rectal bleeding?
Ulcerative colitis? Increases likelihood of malignancy or a flare up of UC
Recent bowel trauma?
Aortic surgery?
Radiotherapy to the rectum?
Bleeding tendency?
PMHx that predisposes to upper GI bleeds, e.g. peptic ulcer disease, chronic liver disease etc
Which group of patients can be on anticoagulants or anti platelets for life?
Prosthetic heart patients
CVD patients
What drugs can cause any existing angiodysplasia to bleed?
Long term anti-coags such as in prosthetic heart patients
What drugs are known do increase the likelihood of bleeds from diverticular disease?
NSAIDs
What drugs predispose to peptic ulceration? (3)
NSAIDs, steroids and bisphosphonates
Which drugs can predispose to colitis, and colitis of which organism?
ABx use to C Diff colitis, as well as PPI
How can beta-blockers play a role in rectal bleeding?
They can stop patients from mounting the usual tachycardic response to hypovolaemia
Which drugs can contribute towards rectal bleeding? (8)
Anticoagulants Antiplatelets NSAIDs Steroids Bisphosphonates ABx PPI Beta-blockers
What do you need to check in the general examination of someone who has had rectal bleeding?
Haemodynamical stability
Signs of chronic blood loss (pallor, koilonychia…) or malignancy (cachexia, lymphadenopathy…)
What are you looking for in the abdominal examination of someone presenting with rectal bleeding? (5)
Focal tenderness or masses
Signs of GI malignancy (supraclavicular lymphadenopathy, palpable lesions of the colon, hepatomegaly, ascites etc)
What first line Ix do you order in someone with rectal bleeding?
FBC for anaemia
Clotting screen to see if they have a bleeding tendency
Group and save
Urea (a rise in urea is consistent with a recent upper GI bleed)
Proctoscopy +/- rigid sigmoidoscopy (can be performed at the bedside in A&E)
What are the four further main investigations in someone presenting with rectal bleeding that a proctoscopy +/- rigid sigmoidoscopy has been unable to locate? And in what order? Which are therapeutic?
Colonoscopy (therapeutic
Mesenteric angiography (therapeutic)
CT angiography
Technetium 99m labelled RBC scintigraphy (if available)
What are the 3 other non-main Ix in someone presenting with rectal bleeding after proctoscopy +/- rigid sigmoidoscopy?
Upper GI endoscopy
Gastric lavage
Small bowel visualisation by enteroscopy or video capsule endoscopy
What are two causes of intermittent rectal bleeding that can be very hard to visualise?
Angiodysplasia and Dieulafoy lesions
What is angiodysplasia?
Colonic angiodysplasia is a submucosal arteriovenous malformation that is believed to be acquired. The cause of these lesions is unknown, but the predomi- nance of lesions in the right colon raises the possibility that high wall tension may be a contributory factor. Typically, lesions are less than 1 cm in diameter, but they can bleed out of proportion to their size. In contrast to haemorrhage from colonic diverticular disease (which is arterial, from the vasa recta), angiodysplasia results in venous blood loss. Angiodysplasia produces a characteristic ‘cherry red spot’ appearance at endoscopy (although blood will frequently obscure the field of view during acute haemorrhage). The diagnosis has become more common since the advent of mesenteric angiography. It may present with frank rectal bleeding or may result in occult blood loss and subsequent anaemic symptoms. Treatment options include embolization, surgical resection, or endoscopic laser electrocoagulation.
Best way to detect angiodysplasia?
Mesenteric angiography
What is mesenteric angiography really good at detecting?
Angiodysplasia
Where is angiodysplasia most common?
Right colon
Difference in the blood loss between angiodysplasia and diverticular lesions
Angiodysplasia is venous blood
Mx options of internal haemorrhoids (conservative (3), medical (2), surgical (6)
Lifestyle modification
• Increased dietary fibre, which may soften faeces and minimize straining at stool (although study evidence is somewhat lacking)
• Keep well hydrated
• Avoid straining at stool
Medical management
• Local anaesthetic creams can be used to relieve soreness and itching
• Steroidal creams/suppositories can be used to reduce local inflammation
• Evidence of efficacy for both is limited
Surgical management There are numerous surgical options, the suitability of which may differ according to patient and the haemorrhoid characteristics: • Rubber band ligation • Injection sclerotherapy • Infrared coagulation/photocoagulation • Haemorrhoidectomy • Stapled haemorrhoidopexy • Doppler-guided haemorrhoidal artery ligation and recto-anal repair (DG-HAL-RAR)
What is a relatively large, non-painful, bright red rectal bleed with no other associated symptoms most suggestive of?
Either angiodysplasia or diverticular disease
What is the traditional surgical management of diverticular disease?
Hartmann’s (both types available)
What are the options for surgical management of diverticular disease
Hartmann’s + rectal stump
Hartmann’s + mucous fistula
Primary anastomosis
Why do deep anal fissures have poor healing
Because sphincter spasm impairs the anal blood supply
What is the anatomical definition of ‘lower’ GI haemorrhage
‘Lower’ GI haemorrhage refers to bleeding that arises distal to the ligament of Treitz at the duodeno-jejunal junction.
Mx of anal fissure (8)
High fibre diet
Laxative
Non-constipating analgesics (e.g. avoid opiates)
Topical anaesthetics (e.g. lidocaine gel)
GTN may increase blood flow and relax the internal anal sphincter (but can also cause headaches)
Topical diltiazem (CCB) if GTN in ineffective
Also botox injections
Lateral internal sphincterotomy
What must you check before performing a lateral internal sphincterotomy and why
The integrity of the external anal sphincter must be checked with an ultrasound scan before surgery because cutting the internal sphincter in the presence of a dam- aged external sphincter (e.g. due to childbirth) would cause disastrous faecal incontinence.
How do you classify internal haemorrhoids?
The most commonly used grading system for internal haemorrhoids reflects the degree of prolapse and reducibility, but does not necessarily reflect symptom severity:
• First degree: bleed but do not prolapse
• Second degree: prolapse but reduce spontaneously
• Third degree: prolapse and do not reduce spontaneously, but can be manually reduced
• Fourth degree: prolapse and are irreducible
What is the anatomical significance of the dentate line?
The dentate or pectinate line represents an anatomical watershed that separates zones of different epi- thelial cell types, arterial supply, venous drainage, lymphatic drainage, and nervous supply (see Fig. 21.3 and Table 21.3):
Above the dentate line what is the: Epithelium cell type Arterial supply Venous drainage Lymphatic drainage Innervation type
Columnar (mucosa)
Branches of inferior mesenteric, e.g. superior rectal artery
Portal circulation via inferior mesenteric veins
Mesenteric nodes
Autonomic (stretch only)
Below the dentate line what is the: Epithelium cell type Arterial supply Venous drainage Lymphatic drainage Innervation type
Stratified squamous (skin)
Branches of internal iliac e.g. inferior rectal artery
Systemic circulation via internal iliac veins
Inguinal nodes
Somatic (normal skin sensation)
What is the difference between diverticulosis, diverticular disease, and diverticulitis?
- Diverticulosis refers to the presence of diverticula (out-pouchings of the mucosa) in the intestine
- Symptomatic diverticulosis (e.g. bleeding, producing pain) is referred to as diverticular disease
- Diverticulitis refers to diverticular inflammation
A patient presents to you with a known diagnosis of haemorrhoids. He is now suffering acute anal pain. What is your differential diagnosis? (5)
Uncomplicated haemorrhoids are not normally painful, thus acute pain in the anal region suggests either a complication of haemorrhoids or an additional pathology. The differential diagnosis includes:
• Thrombosed external haemorrhoid
• Anal fissure
• Proctalgia fugax (a poorly understood stabbing/cramp-like sensation in the anus, that may last up to 30 minutes, and is more common at night)
• Anal abscess
• Lower anal cance
What are the known risk factors for colorectal carcinoma? (14)
• Increasing age • Male sex (only for rectal carcinoma) • Central obesity • Colorectal disease: − Inflammatory bowel disease (especially ulcerative colitis, but also Crohn’s) − Previous history of colorectal cancer − Colorectal polyps − Colorectal irradiation • Familial conditions including: − Familial adenomatous polyposis (FAP) − Hereditary non-polyposis colorectal cancer (HNPCC) − Peutz–Jeghers − Juvenile polyposis − Cowden’s disease − MYH-related polyposis • Sedantary lifestyle (lack of regular exercise) Dietary factors such as red meat, high fat, and low fibre may also be risk factors, but the evidence base for these is weaker
Ferritin, TIBC and CRP in anaemia of chronic disease
Ferritin high
TIBC low
CRP normal or high
Ferritin, TIBC and CRP in iron deficiency anaemia
Ferritin Low
TIBC High
CRP Normal
Ferritin, TIBC and CRP in iron deficiency anaemia and inflammation/infection
Ferritin High
TIBC High
CRP High
What can elevate ferritin (4)
infection, inflammation, or malignancy, and is also increased by excess alcohol consumption
