Rectal Bleeding

Report
Matthew Charnock
Sam Newton
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PC
HPC
RED FLAGS
ROS
MED Hx
FH
SOCIAL Hx
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73 year old female
Suffers from T2DM and Ulcerative Colitis
Presented 3/52 history of rectal bleeding
Mixed in with stool
Loose stools for past 6 weeks
Lost 2 stone in past 12 weeks
Smokes 30/day for 50 years
No abdominal pain
DVT 4 weeks ago
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Bloods
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Imaging
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Colorectal cancer is the third most common
cancer in the UK
2nd most common cause of cancer death in
the UK
75% occur in people aged 65 or over
Screening in UK - FOBT
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Family history
Familial Syndromes
IBD
Smoking
Poor fibre/High fat diet
Alcohol
Etc
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Right sided colon cancers
Change in bowel habit, weight loss, anaemia,
occult bleeding, mass in right iliac fossa, disease
more likely to be advanced at presentation
Left sided colon cancers
colicky pain, rectal bleeding, bowel obstruction,
mass in left iliac fossa, early change in bowel
habit, less advanced disease at presentation
Rectal cancers
as above + tenesmus
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Jaundice?
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Ascites?
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Chronic cough?
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Abdominal pain
Bloody diarrhoea
Weight loss
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Fever
Signs of anaemia
Tenesmus
Peri-anal disease
Extra-intestinal manifestations
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In children – FTT, delayed puberty, malnutrition
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Crohns VS Ulcerative Colitis
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Bloods (FBC, LFTs, ESR/CRP, AntiGGT/endomysial antibodies, Iron Studies,
B12/Folate levels)
Imaging
 Colonoscopy + biopsy
 Barium Follow through
 Abdominal xray
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Smoking cessation in Crohns
Medical
 5 aminosalicyclic acid derivatives
(5ASA’s – mesalazine)
 Corticosteroids (in acute flare up)
 Enteral nutrition
 Immunosuppressants
(cyclosporin/methotraxate/azathioprine)
 Cytokine modulators (infliximab)
Indications in UC
 Failure of medical treatment
 Toxic megacolon
 Perforation
 Haemorrhage
 Cancer prophylaxis
Procedure
 Temporary – proctocolectomy with ileoanal
pouch formation
 Permanent – panproctocolectomy with end
ileostomy
Indications in Crohns
 Strictures - strictuoplasty
 Fistulas – lay open (low)/seton suture (high)
 Abscess – drainage +/- Abx
 Unresponsive to medical treatment - segmental resection
 Intolerable long term symptoms
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Site
Contents of bag
Appearance
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Obese 59 year old male
No significant past medical history
Presented to GP with a 2 week history of rectal
bleeding
Small amount of blood on the toilet paper after
defecating
First occurred following straining on the toilet
Also itching around the back passage
No pain, no change in bowel habit, no N+V
Feels otherwise well
ROS- none
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Rectal examination?
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Bloods?
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Imaging?
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Commonest cause of rectal bleeding
Benign condition in which the venous cushions within
the rectum become enlarged
RF’s - prolonged straining and time on the toilet,
raised intra-abdominal pressure eg- pregnancy,
obesity, heavy lifting etc
Symptoms include- rectal bleeding, rectal itching
(pruritus ani), feeling of discomfort or discharge, may
feel mass, may be asymptomatic
Blood should not be mixed in, usually on toilet paper
or streaks in the bowl
Classification is broken into internal and external
haemorrhoids, internal above the dentate line,
external below dentate line.
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1st degree- do not prolapse
2nd degree- prolapse on defecation return
spontaneously
3rd degree- prolapse on defecation, need to
be manually reduced
4th degree- permanently prolapsed
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On rectal exam, typically present at the 3,7
and 11 o clock positions
Internal haemorrhoids may be impalpable and
not visible on inspection
Internal haemorrhoids should be painless
Asking the patient to bear down may reveal
haemorrhoids on inspection
Important to perform to exclude other anal
pathology
Conservative- increase dietary fibre, decrease
time on the toilet, strain less, lose weight,
laxative (for 1st and 2nd degree)
• Non- surgical (for 3rd/4th or 1st/2nd not
responding to conservative)
1. Banding
2. Sclerotherapy
3. Infrared coagulation
• Surgical (3rd/4th not responding or very large)
1. Circular stapled haemorrhoidectomy (better
than traditional)
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64 year old female
PMH of IHD and PVD
Presented with a 1 month history of LIF abdominal pain,
bloating and change in bowel habit- constipated
Also noticed single episode of blood mixed in with stool
Also noticed intermittent nausea although no vomiting
No pyrexia
Otherwise well
ROS- frothy urine?
O/E- patient relatively well, abdo- some tenderness in the
LIF, PR- NAD
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Bloods?
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Imaging?
Herniation's of mucosa through colonic muscle
• Remember terminology
1. Diverticulosis- ASYPTOMATIC but has diverticula
2. Diverticular disease- SYPTOMATIC with
diverticula
3. Diverticulitis- Infection with inflammation of a
diverticula
• RF’s- Age, low dietary fibre, obesity
• More likely to occur on the left in Caucasians and
commonly occur at the insertion points of blood
vessels
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Diverticular disease:
1. Abdo pain, usually left sided
2. Abdo bloating
3. Change in bowel habit
4. Rectal bleeding
• Diverticulitis:
1. More severe LIF pain with localised tenderness
2. Pyrexia, fever, tachycardia- may be in shock
3. Possibly N+V
4. Haemorrhage and other complications
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Bloods- FBC, U+E, CRP, ESR, Clotting, Group+
save
• Imaging1. Colonoscopy- exclude other pathology and
confirm diagnosis, NOT in acute
presentation- why?
2. Barium enema
3. Erect CXR- why?
4. AXR- may show evidence of complications
5. CT- useful acutely when colonoscopy CI’d
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Fistula1. Colovesical- pneumaturia- frothy urine
2. Colovaginal
3. Coloenteric
• Bowel obstruction
• Abscess
• Perforation
• Stricture
• Haemorrhage
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Diverticular disease1. High fibre diet
2. Good fluid intake
3. May require laxatives, antispasmodics, analgesia
• Diverticulitis1. May require hospital admission
2. Antibiotics- may need broad spectrum
3. Fluids
4. Analgesia
5. Manage complications- eg may require blood
transfusion etc
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15-30% may need surgery
• Emergency procedure for acute diverticulitis is a
HARTMANNS procedure
• Involves removing affected part and bringing part
of the large bowel to the surface of the skin to
create a temporary colostomy which can be
reversed at a later date upon recovery
• Surgery may also be performed for complications
including:
1. Fistula
2. Obstruction
3. Stricture (possibly)
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Person
Symptoms and signs
40 years of age and older
Rectal bleeding with a change in bowel habit towards looser
stools and/or increased stool frequency persisting for
6 weeks or more.
60 years of age and older
Rectal bleeding persisting for 6 weeks or more without a
change in bowel habit and without anal symptoms. A
change in bowel habit to looser stools and/or more
frequent stools persisting for 6 weeks or more without
rectal bleeding.
Of any age
A right abdominal mass consistent with involvement of the
large bowel. A palpable rectal mass (intraluminal and not
pelvic; a pelvic mass outside the bowel would warrant an
urgent referral to a urologist or gynaecologist).
Women (not menstruating)
Unexplained iron deficiency anaemia and haemoglobin
10 g/100 mL or less.*
Men of any age
Unexplained iron deficiency anaemia and haemoglobin
11 g/100 mL or less.*
* Anaemia considered, on the basis of history and examination in primary care, not to be related to other sources of
blood loss (e.g. ingestion of nonsteroidal anti-inflammatory drugs) or blood dyscrasia.
1. Anal
fissure
2. Gastroenteritis
3. Angiodysplasia
4. Meckel's diverticulum
5. Polyp
6. Trauma
7. Rectal varices
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Any Questions?

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