WEEK 14 - Per Rectum Bleeding

Question 1

What is constipation with overflow diarrhoea? Would it cause bleeding?

Answer 1

This would not cause bleeding. It results from the escape of liquid stool around impacted faeces

Question 2

Does coeliac disease cause bleeding?

Answer 2

No

Although diarrhoea and anaemia are features of coeliac disease, anaemia is due to poor absorption of iron in the inflamed small bowel, rather than direct blood loss.

Question 3

What is Noravirus and would it cause bleeding?

Answer 3

A highly contagious viral gastroenteritis spread by the faecal oral route. Typical symptoms are vomiting, diarrhoea and abdominal pain lasting 24 -72 hours. It does not cause blood in the stool.

Question 4

What is a Giardia infection? Would it cause bleeding?

Answer 4

A parasitic infection of the bowel, causing symptoms of foul smelling diarrhoea, bloating, cramping abdominal pain, weight loss and fatigue that can last for many weeks. It does not cause bloody diarrhoea. It is transmitted by exposure to contaminated food and water or faeces.

Question 5

What is the first line treatment for a giardia infection?

Answer 5

Metronidazole

Question 6

What is lactose intolerance and would it cause bleeding?

Answer 6

Deficiency of the enzyme lactase, resulting in the inability to break down the sugar lactose, found in dairy products. Symptoms include bloating, abdominal cramps and diarrhoea, as a result of the high osmotic load of undigested and fermenting lactose in the bowel. It does not cause bloody diarrhoea

Question 7

Describe pancreatic exocrine insufficiency

Would it cause bleeding?

Answer 7

Reduced secretion of pancreatic digestive enzymes means that food cannot be broken down and absorbed. This causes weight loss, bloating, abdominal pain, foul smelling diarrhoea and steatorrhea (stools that are bulky, pale, oily and difficult to fish due to their fat content). It would not cause bleeding in the GI tract. Causes include pancreatitis, malignancy, previous surgery, diabetes and cystic fibrosis.

Question 8

Does IBS cause bleeding?

Answer 8

No

A functional bowel disorder that can cause a variety of symptoms including constipation, diarrhoea, bloating, abdominal pain and lethargy. It does not cause PR blood loss.

Question 9

Would hyperthyroidism cause rectal bleeding?

Answer 9

Can cause diarrhoea through increased bowel motility. It would not cause rectal bleeding.

Question 10

What is bile acid diarrhoea and would it cause bleeding?

Answer 10

Can cause diarrhoea through increased bowel motility. It would not cause rectal bleeding.

Question 11

Rectal bleeding is a red flag symptom of ___________, especially when associated with a change in ___________

Answer 11

• malignancy
• bowel habit

Question 12

Describe IBD

Answer 12

Ulcerative colitis and Crohn’s disease are both inflammatory bowel diseases. Ulcerative colitis affects the colon, almost always involves the rectum and causes continuous inflammation spreading proximally from the rectum. Crohn’s disease can affect any part of the digestive system, from the mouth to the anus, and tends to occur in discontinuous patches. In around 10% of cases, it is difficult to distinguish between the two. These cases are known as indeterminate colitis. The exact cause of inflammatory bowel disease is not known but family history is a risk factor and an abnormal immune response to infection is thought to play a role, more so in ulcerative colitis. Diagnosis is most common between ages of 15 and 40. Symptoms can include a combination of abdominal pain and bloating, bloody diarrhoea, weight loss and extreme tiredness. Extraintestinal manifestations of disease are common

Potential for visible blood loss

Question 13

Describe ischaemic colitis

Answer 13

When the blood supply becomes insufficient to meet the metabolic demands of the colon, mucosal inflammation, ulceration and haemorrhage occur. Causes include profound hypotension, vasoconstriction, chronic atherosclerotic disease and acute thromboembolism. Onset of symptoms can be acute or more insidious depending on the underlying cause and include abdominal pain, diarrhoea and rectal bleeding. It is much more common in older people.

Question 14

What are 2 rarer causes of ischaemic colitis in younger people?

Answer 14

Sickle cell disease and vasculitis

Question 15

Can you get bloody diarrhoea from diverticulitis?

Answer 15

Yes

Diverticulitis refers to infection or inflammation of diverticula, small bulges or pouches within the bowel wall that occur with advancing age. Left lower quadrant pain, bloating and fever are common symptoms but bloody diarrhoea can arise occasionally. Onset of symptoms is often acute.

Question 16

Describe a shigella infection

Answer 16

Shigella is a bacteria spread by contact with contaminated food, water or faeces. It is very infectious and can also easily be acquired through sexual contact with an infected person. It frequently causes bloody diarrhoea, crampy abdominal pain and fever. In immunocompetent hosts, symptoms usually resolve within a week. Those with severe symptoms and immunocompromised patients should be treated with antibiotics

Question 17

What is 1st line therapy for a shigella infection?

Answer 17

Azithromycin

(Used to be ciprofloxin but no longer due to increasing antibiotic resistance)

Question 18

Describe a shiga toxin producing E.coli infection

Answer 18

Some strains of E.coli bacteria produce a potent toxin, known as Shiga toxin. You may also hear these organisms referred to verocytotoxic E.coli or enterohemorrhagic E.coli. The Shiga toxin damages the bowel wall causing abdominal pain, diarrhoea and bleeding. Fever is usually mild if present and symptoms typically last around 5 to 7 days. It is contracted via contaminated food, water or faeces.

Question 19

Why is a shiga toxin producing E.coli infection not treated with antibiotics?

Answer 19

increases the risk of a potentially fatal complication – haemolytic uraemic syndrome, more common in children

Question 20

Describe a clostridium difficile infection

Answer 20

A bacterial infection of the colon that usually occurs when normal bowel flora has been disrupted by antibiotic use. It produces toxins that cause inflammation, resulting in profuse and often bloody diarrhoea, abdominal pain and fever. In severe cases the bowel can become dilated, resulting in a toxic megacolon and perforation. A characteristic appearance of raised whitish yellow plaques on endoscopy is known as pseudomembranous colitis and results from an exudate of inflammatory cells and mucus. Severe C.difficile infection is by far the most common cause, although other pathology causing decreased oxygenation and endothelial damage can also give rise to this pattern of injury

Question 21

What is the treatment for a C.diff infection?

Answer 21

Vancomycin. The oral route is preferred if possible

Question 22

Describe an anal fissure

Answer 22

A small tear in the lining of the anal canal. It is usually associated with sharp pain on defecation and bright red blood on the stool or on wiping.

Question 23

Describe haemorrhoids

Answer 23

These are normal vascular rich connective tissue cushions in the anal canal. If they become swollen or inflamed, they can protrude and cause pain and bleeding. Haemorrhoids do not cause diarrhoea.

Question 24

How does the diarrhoea associated with IBS often change overnight?

Answer 24

Often improves overnight with fasting, as it is due to increased motility rather than excess secretions, osmotic effects of inflammation

Question 25

Smoking and ulcerative colitis

Answer 25

Smokers are less likely to develop Ulcerative Colitis than non-smokers. Stopping smoking increases your risk of developing Ulcerative Colitis.

It is a RF for Crohn’s however

Question 26

Extra intestinal manifestations occur in __-__% of patients with inflammatory bowel disease and include _______, _____ lesions, ___ disease and ______ disease. There is much overlap in the extraintestinal features of Crohn’s and ulcerative colitis.

Answer 26

Extra intestinal manifestations occur in 20-40% of patients with inflammatory bowel disease and include arthritis, skin lesions, eye disease and liver disease. There is much overlap in the extraintestinal features of Crohn’s and ulcerative colitis.

Question 27

Name 2 medication classes that can elevated faecal calprotectin

Answer 27

PPIs and NSAIDs

Question 28

What is loperamide and why is it contraindicated in suspected IBD?

Answer 28

Loperamide is an antimotility drug used to treat diarrhoea. However, when inflammatory bowel disease is strongly suspected it is contraindicated, as it can increase the risk of bowel dilation and a toxic megacolon.

Question 29

What is faecal calprotectin and when are levels elevated?

Answer 29

Faecal calprotectin is a very sensitive biomarker of bowel inflammation. It can be elevated early during inflammatory bowel disease, even if CRP is normal. However, it is not specific for ulcerative colitis and Crohn’s disease. Any bowel inflammation would cause the levels to rise

Eg elevated in:
- IBD
- ischaemic colitis
- PPIs
- severe C.diff toxin mediated diarrhoea
- acute appendicitis
- severe diverticulitis

Question 30

Albumin levels in acute inflammation? Why?

Answer 30

Low

Severe inflammation is a catabolic state and there is increased degradation of albumin. Also, pro inflammatory cytokines increase vascular permeability, allowing diffusion of albumin to the extracellular space.

Question 31

What are two very important situations in which you should ALWAYS give intravenous steroids to an acutely unwell patient, regardless of whether they have infection?

Answer 31

1. If you suspect an acute adrenal crisis
2. If the patient is on long term steroids and now cannot take them orally – missing doses could precipitate an acute adrenal crisis

Question 32

What are 3 potential complications of UC?

Answer 32

1. Colorectal cancer
2. Primary sclerosing cholangitis
3. Iron deficiency anaemia

Question 33

What are small bowel strictures a potential complication of?

Answer 33

Crohns disease

Question 34

What is primary sclerosing cholangitis?

Answer 34

Progressive inflammation and fibrosis of the bile ducts, leading to strictures, blockage and liver damage.

The cause is not known, but more than 70% of patients with the condition have underlying ulcerative colitis and between 3% and 7% of patients with ulcerative colitis develop primary sclerosing cholangitis.

Question 35

What is a perinatal haematoma?

Answer 35

ainful pea sized lumps caused by blood from a ruptured vein collecting under the mucosa around the anus

Question 36

What are the key clinical features of necrotising fasciitis?

Answer 36

• skin necrosis
• septic shock
• skein crepitus

Question 37

Internal vs external haemorrhoids

Answer 37

Internal haemorrhoids:

These are within the anal canal and are above the dentate line and so are usually painless but can present with bright red rectal bleeding associated with bowel movements. The blood is usually not mixed in with the stool, and only coats the outside surface of the stool (haematochezia).

External haemorrhoids:

This is when the haemorrhoid originates below the dentate line, and prolapses outwards and is palpable by the patient. They are usually painless, unless they become acutely thrombosed where patients will present with swelling and pain.

Question 38

Internal haemorrhoids occur above the __________

Answer 38

Dentate line

Question 39

What are the 4 grades of severity of internal haemorrhoids?

Answer 39

1 – No prolapse of mucosa

2 – Haemorrhoid prolapses on bearing down, but reduces spontaneously

3 – Haemorrhoid prolapses on bearing down, but requires manual reduction

4 – Haemorrhoid prolapses but cannot be reduced

Question 40

How are haemorrhoids treated?

Answer 40

> Medical (Grade 1-2 internal haemorrhoids):

• Lifestyle modifications (high fibre diet, laxatives)
• Rubber band ligation of internal haemorrhoids using a proctoscope or endoscope (above the dentate line)

> Surgical (Grade 2-3 internal haemorrhoids):

• The Rafaelo Procedure (Radiofrequency Ablation of Haemorrhoids under Local Anaesthetic) uses radiofrequency energy to cauterise the blood supply to the haemorrhoid causing it to contract
• Haemorrhoidal Artery Ligation Operation (HALO) where an ultrasound probe is used to identify the feeding haemorrhoidal artery, which is then ligated with a suture to cut the blood supply off to the haemorrhoid which then causes thrombosis, fibrosis and retraction of the haemorrhoid

> Surgical (Grade 4 internal haemorrhoids and external haemorrhoids):

• Excisional haemorrhoidectomy to physically excise the haemorrhoid, either with an energy device or a stapler.

Question 41

How are anal fissures treated?

Answer 41

1. Stool softeners and/or laxatives to reduce straining
2. Medical
   - Glyceryl trinitrate (GTN) ointment (0.4%)
   - Stool softeners
   - Botox to the anal sphincter to help relax the sphincter and reduce spasm
3. Surgery (where conservative and medical treatments fail) involves a lateral sphincterotomy where the internal sphincter is divided to reduce sphincter spasm. This operation has a risk of incontinence to both flatus and faeces