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
