Rectal Bleeding

Question 1

What is rectal bleeding usually caused by?

Answer 1

Bleeding from the lower GI but can occur in upper GI as well.

They can be from anything between benign to ife threatening

Question 2

Common causes

Answer 2

Diverticular disease

Ischaemic or infective colitis

Haemorrhoids

Malignancy

Angiodysplasia

Crohn’s

UC

Radiation proctitis

Question 3

What is the most common cause of lower GI bleed?

Answer 3

Diverticulosis

Question 4

Clinical features that are important to ascertain

Answer 4

Stable vs unstable

Nature of bleed with duration, freq, colour of bleed and relation to stool and defecation

Associated symptoms like pain, haematemesis, PR mucus or previous episodes

FH of bowel cancer or IBD

Question 5

What can be used to help stratify patients presenting with a lower GI bleed to determine if outpatient management is feasible?

Answer 5

Oakland score

Question 6

Factors in Oakland score

Answer 6

Age

Sex

Previous admissions for lower GI lbeeds

PR findings

HR

SBP

Hb concentration

Question 7

Lab tests

Answer 7

Routine bloods with FBC, U&Es, LFTs and clotting

G6S

Stool cultures to exclude infective cause

Question 8

What investigations should be done in haemodynamically unstable patients?

Answer 8

They need to be stabilised first then sent for urgent CT angiogram.

This is to identify source of bleed, + therapeutic intervention and embolisation.

Question 9

Further investigations

Answer 9

Stable bleeds -> Flexible sigmoidoscopy or colonoscopy

If there is no abnormality identified on colonscopy -> OGD should be done.

If this proves inconclusive further ix with capsule endoscopy or MRI small bowel should be done.

Question 10

General management

Answer 10

95% of cases will settle spontaneously

Young and stable patients with a low risk score can be discharged and investigated as outpatient.

Unstable -> urgent resus with ABCDE, IV fluids and blood products

Any Hb <70 should be transfused with blood, unless CVD then <80 is the threshold.

Discontinue anti-coag with guidance from a haematologist

Question 11

What medical managements can be done?

Answer 11

Endoscopic haemostasis with e.g. injection like diluted adrenaline, electrocoagulation or agron plasma coagulation.

Arterial embolisation can be done as well

Question 12

Indications of surgical intervention

Answer 12

Ongoing lower GI bleed with instability

Endoscopic and radiographic treatment has failed