Rectal bleeding Flashcards
Differential diagnoses of Rectal bleeding
- Hemorrhoids*
Probability diagnosis Haemorrhoids/perianal haematoma Anal fissure Colorectal polyp Diverticulitis Excoriated skin (anal pruritus)
Serious disorders not to be missed Vascular: •ischaemic colitis •angiodysplasia (vascular ectasia) •anticoagulant therapy
Infection:
•enteritis (e.g. Campylobacter, Salmonella)
Cancer/tumours:
•colorectal, caecum
•lymphoma
•villous adenoma
Other:
•inflammatory bowel disease (colitis/proctitis)
•intussusception
Pitfalls (often missed)
Rectal prolapse
Anal trauma (accidental/non-accidental)
Villous adenoma
Rarities:
•Meckel diverticulum
•solitary ulcer of rectum
Rectal Bleeding - Key History
Key history
Nature of the bleed, including fresh versus altered blood, mixed with faeces and/or mucus, in toilet bowl or on underwear.
Quantity of bleeding: slight, moderate or torrential.
Associated symptoms (e.g. weight loss, constipation, diarrhoea, pain, weakness, presence of lumps, urgency, unsatisfied defecation, recent change of bowel habit).
Rectal Bleeding - Key PE
Key examination
- General inspection (evidence of anaemia) and vital signs
- Abnormal examination, anal inspection, digital rectal examination, proctosigmoidoscopy
Rectal Bleeding - Key Investigations
Key investigations
- FBE and ESR
- Stool M&C
- Faecal occult blood
- Colonoscopy
- Consider abdominal X-ray, CT colonography, angiography, small bowel enema (depending on clinical findings)
Rectal Bleeding - Diagnostic tips
Diagnostic tips
- Black, tarry (melaena) stool indicates bleeding from upper GIT: rare distal to lower ileum.
- Frequent passage of blood and mucus indicates a rectal tumour or proctitis.
- If substantial haemorrhage, consider diverticular disease, angiodysplasia or more proximal lesions (e.g. Meckel diverticulum, duodenal ulcers).
- New bleeding age >55 years demands colonic investigation.
- 80% of rectal tumours are within fingertip range.
- In young adults, diagnosis is likely to be haemorrhoids or a fissure.