Rectal Bleeding Flashcards
What is the first priority when assessing patients with rectal bleeding
ABCDE
Specifically C
hypotension, tachycardia, cool peripheries, tachypnoea, decreased consciousness - must resuscitate
What are the anorectal differentials for Rectal bleeding
Haemorrhoids Rectal/anal tumour Anal fissure Anal fistula Solitary rectal ulcer Radiation proctitis Rectal varices Trauma
What are the colonic differentials for rectal bleeding
Diverticular disease Angiodysplasia Inflammatory/ischaemic/infective colitis Colonic tumour Iatrogenic Vasculitis
What are the ileo-jejunal differentials for rectal bleeding
Coeliac Aorto-enteric Small-bowel tumours Crohn's AV malformation Angiodysplasia Peptic ulcers
What are the upper-GI differentials for rectal bleeding
Mallory-Weiss tear Peptic ulcers Aorto-enteric fistula Dieulafoy lesions Osler-Weber-Rendu sundrome Gastritis/duodenitis Tumour Varices
What questions should be asked about rectal bleeding itself
How much blood has been passed + hypovolaemia symptoms
What is the duration and frequency of symptoms
What does the blood look like
What is the relationship of blood with stool
Is there any pain or prolapse
Is there any tenesmus
Has there been a change in bowel habit
Any weight loss
Any anaemia symptoms?
What does the relationship of blood with stool suggest
Blood mixed with stool: lesion proximal to the sigmoid
Blood streaked on stool: sigmoid or anorectal source
Blood separate from stool immediately after: haemorrhoids
Blood separate from stool completely: diverticular disease, angiodysplasia, IBD, rapidly bleeding cancer
Blood only seen on toilet paper: haemorrhoids, fissure
What does pain/no pain or prolapse suggest with rectal bleeding
Pain - excruciating pain: anal fissure/anal herpes
Abdominal cramping: colitis
Most conditions causing bleeding are painless e.g. haemorrhoids
What is mucous passage associated with (with rectal bleeding)
Colitis
Proctitis
Rectal cancer
Villous adenomas of the rectum
What are the most common causes of rectal bleeding
Diverticular disease Angiodysplasia Haemorrhoids Colitis Anal fissures Lower GI tumours
What should be asked about past medical history for rectal bleeding
Previous rectal bleeding Ulcerative colitis Recent bowel trauma Aortic surgery Radiotherapy to the rectum Bleeding tendency (warfarin, blood thinners, haemophilia, platelet disorders etc.)
What drugs should be asked about for rectal bleeding
Anticoagulants or antiplatelets
NSAIDs (peptic ulcer or diverticular disease)
Bisphosphonates, aspirin, steroids (peptic ulcers)
Antibiotic or PPI use (C. diff -> infectious colitis)
Beta blockers (attenuate cardia response to hypovolaemia)
What should be looked for on exam for rectal bleeding
Is the patient haemodynamically stable?
Chronic blood loss signs - koilonychia (IDA), pallor
Malignancy signs - lymphadenopathy, cachexia
Focal tenderness or masses - check for malignancy
DRE - fissures, skin tags, sentinel pile haemorrhoids, fistula
Feel for palpable mass, observe for blood on gloved finger
Investigations for rectal bleeding?
FBC - ?anaemia ?platelets
Clotting - ?bleeding tendency
Group + save - if haemodynamically unstable
Urea - Raised - recent upper GI bleed (from breakdown of RBCs)
Endoscopy ± rigid sigmoidoscopy
Pathway of imaging: colonoscopy -> mesenteric or CT angiography -> radionuclide imaging
What is angiodysplasia
Submucosal arteriovenous malformation (acquired)
Predominance in the right colon
Lesions typically <1cm , but may bleed out of proportion to size
Results in venous blood loss
Produces a characteristic “cherry red spot” appearance on endoscopy (but blood will frequently obscure the field of view in acute haem)
