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)
What is the management for haemorrhoids
Lifestyle modification: increase fibre, minimise straining, keep hydrated
Medical: local anaesthetic, steroidal creams, laxative therapy for constipation
Surgical: Rubber band ligation, injection sclerotherapy, infrared coagulation/photocoagulation
Haemorrhoidectomy
What is the typical presentation for diverticular disease and angiodysplasia
Large, non-painful, bright red rectal bleed with no associated symptoms
What are the surgical options for diverticular disease
Hartmann’s (end colostomy) + rectal stump
Hartmann’s (end colostomy) + mucous fistula
Primary anastamosis
What is the medical management for anal fissures
High fibre diet + laxatives/non-constipating analgesics topical anaesthetics e.g. lidocaine gel Topical GTN (increased local blood flow and relax the internal anal sphincter) Topical diltiazem (CCB) if GTN intolerable due to headache Botox injection to the anal sphincter to relieve spasm
What is the surgical management for persistent deep anal fissures
Lateral internal sphincterotomy
Anal advancement flap
What is the anatomical definition of lower GI haemorrhage
Bleeding that arises distal to the ligament of Treitz at the duodenojejunal junction
How are internal haemorrhoids classified
Grade I: no prolapse
Grade II: prolapses on straining and reduces spontaneously on cessation
Grade III: prolapses and requires manual reduction
Grade IV: permanent prolapse, irreducible
What are the differentials for a patient with known haemorrhoids who has acute anal pain
Thrombosed external haemorrhoid Anal fissure Proctalgia fugax Anal abscess Lower anal cancer
What are the risk factors for colorectal carcinoma
Age
Males (Rectal only)
Central obesity
Colorectal disease: IBD, previous history, polyps, irradiation
Familial: FAP, HNPCC, Peutz-Jeghers, juvenile polyposis, Cowden’s, MYH-related polyposis
Sedentary lifestyle
