Rectal bleeding

Question 1

What are the ddx for rectal bleeding

Answer 1

1. Anorectal: haemorrhoids, rectal tumour, anal tumour, anal fissure, solitary rectal ulcer, radiation proctitis, rectal varices, trauma
2. Colonic: diverticular disease, angiodysplasia, colitis, colonic tumour, iatrogenic, vasculitis
3. Ileo-jejunal: peptic ulceration, angiodysplasia, arterio-venous malformation, Crohns/coeliacs, Aorto-Enteric fistula, small-bowel tumour
4. Upper GI: peptic ulcer, gastritis/duodenitis, varices, tumour, Mallory-Weiss tear, aorto-enteric fistula

Question 2

Why does the relationship of the blood with the stool matter

Answer 2

1. Blood mixed with stool: lesion proximal to sigmoid colon - colitis/colonic tumour(painless)
2. Blood streaked on stool: sigmoid or anorectal source of bleeding - anal tumour (painful) / rectal tumour (painless)
3. Blood is separate from stool: haemorrhoids or diverticular disease/angiodysplasia/IBD/rapidly bleeding cancer
4. Blood on toilet paper: minor bleeding from anal canal.- anal fissure (painful) / haemorrhoids (painless)

Question 3

An intense, tearing pain during defecation indicates what?

Answer 3

Anal fissure

Question 4

Abdominal cramping may suggest?

Answer 4

Colitis

Question 5

Tenesmus (feeling of incomplete evacuation) indicates?

Answer 5

Rectal cancer?

May suggest colitis secondarily

Question 6

Hx of Aortic surgery should make you suspicious of what cause of rectal bleeding?

Answer 6

Aortoenteric fistula until otherwise proven

Question 7

Radiotherapy to the rectum can induce what?

Answer 7

Proctitis

Question 8

NSAIDS increase risk of bleeding from diverticular disease. Long term anticoagulation may make existing ____ more likely to bleed

Answer 8

Angiodysplasia

Question 9

NSAIDS, bisphosphonates and steroids predispose to?

Answer 9

Peptic ulceration

Question 10

What bloods would you do in someone with rectal bleeding?

Answer 10

FBC
Clotting
Group and save if blood replacement needed
Urea - raised urea consistent with upper GI bleed

Question 11

Which endoscopic measures should be done to investigate rectal bleeding?

Answer 11

1. Proctoscopy +/- rigid sigmoidoscopy
   Colonoscopy, mesenteric angiography (if available) - ?angiodysplasia, CT angiography, Technetium-99 red blood scintigraphy

Question 12

Which is more common; upper GI haemorrhage or lower GI haemorrhage?

Answer 12

Upper GI (80% of acute GI haemorrhages)

Question 13

Cherry red spots on endoscopy indicate angiodysplasia. How may it present and how is it treated

Answer 13

May present with frank rectal bleeding +/- occult bleeding and anaemic symptoms.

Treatment may involve embolisation, surgical resection, endoscopic laser electrocoagulation

Question 14

A large, non-painful, bright red rectal bleed with no other associated symptoms suggests which 2 pathologies

Answer 14

Diverticular disease (NB DIVERTICULITIS has LIF pain and is not associated) or angiodysplasia

Question 15

Persistent tearing pain following defecation, fresh red blood on wiping and a posterior midline crack point to which diagnosis?

Answer 15

Anal fissure

They typically spontaneously heal within a few weeks

If topical anaesthetics/topical GTN/botox injection doesn’t work, consider lateral internal sphincterotomy

Question 16

How can you use ferritin and Total Iron Binding Capacity (TIBC) to differentiate iron deficiency anaemia and anaemia of chronic disease

Answer 16

Ferritin = acute phase reactant (elevated in infection/inflammation/malignancy)

In iron deficiency anaemia, low ferritin and high TIBC
In anaemia of chronic disease, high ferritin and low TIBC