Rectal bleeding (oxford clin cases)

Question 1

What are some differentials that come to mind when someone presents with rectal bleeding?

Answer 1

Anal fissure
Haemorrhoids 
Colonic tumor 
Anal tumor
Rectal tumor 
Colitis
IBD
Diverticular disease

Question 2

What are some questions you might want to ask in pmx when someone presents with GI bleed?

Answer 2

Have they had any previous episodes and if so what was the outcome?
Have they had any recent GI surgery?
Have they had a hx of GI cancer?
Do they have any GI conditions (that might cause bleeding eg peptic ulcer disease, IBD)?
Do they have any bleeding disorders?

Question 3

What medication is known to increase bleeds from diverticular disease?

Answer 3

NSAIDs

Question 4

What drugs are important in dx when someone presents with rectal bleeds and why?

Answer 4

NSAIDs/ bisphosphonates/steroids- these increase the risk of peptic ulcer disease
Antiplatelets/ anticoagulants- increase bleeding
Antibiotics- they increase the risk of c diff infectious colitis
Beta blockers- if someone is haemodynamically compromised or hypovolemic they prevent the usual response of tachycardia

Question 5

What common cause of rectal bleeding is not palpable during a DRE?

Answer 5

Haemorrhoids

Question 6

What in the bloods will be slightly raised when someone has a GI bleed and why?

Answer 6

Urea because it is a product of the breakdown of RBCs

Question 7

What investigations might you do in someone with rectal bleeding? Explain why

Answer 7

Bloods:
FBC- check for anaemia or low platelets
Urea- may be slightly raised due to breakdown of RBC
Clotting- to check for bleeding disorders
Group and save- in case there is excessive loss of blood or in surgery
Endoscopy- to visualise possible cancer or haemorrhoids etc (lower GI= protoscopy and rigid sigmoidoscopy, could also do an upper GI OGD if upper GI cause of bleeding is suspected)

Question 8

What is colonic angiodysplasia? What does it look like on endoscopy and how is it managed?

Answer 8

A submucosal arteriovenous malformation that results in venous blood loss.
On endoscopy it looks like a bright red cherry spot
It is managed via embolisation or surgical resection

Question 9

How are haemorrhoids managed?

Answer 9

Lifestyle advice= increase dietary fibre to loosten stool, avoid straining when defecating, keep hydrated
Medications- local anaethesia, steroid creams/suppositiories to reduce pain
Surgery- band ligation, haemorrhoidectomy

Question 10

What scoring system is used to calculate risk of stroke from AF?

Answer 10

CHADS-VASC score

Question 11

What are common causes of rectal bleeding in an older patient where there are large volumes of bright red blood?

Answer 11

Angiodysplasia

Diverticular disease