Matthew Charnock Sam Newton. PC HPC RED FLAGS ROS MED Hx FH SOCIAL Hx.

Rectal Bleeding Matthew Charnock

Sam Newton

PC HPC RED FLAGS ROS

MED Hx FH SOCIAL Hx

History Taking

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

Case 1

Diagnosis?

Bloods

Imaging

Investigations??

Colorectal Caner

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

Epidemiology

Family history Familial Syndromes IBD Smoking Poor fibre/High fat diet Alcohol Etc

Risk Factors

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

Presentation

Jaundice?

Ascites?

Chronic cough?

What about?

Abdominal pain Bloody diarrhoea Weight loss

Fever Signs of anaemia Tenesmus Peri-anal disease Extra-intestinal manifestations

In children – FTT, delayed puberty, malnutrition

Clinical Features

Extra-intestinal manifestations

Crohns VS Ulcerative Colitis

Assessing Severity of UC

Bloods (FBC, LFTs, ESR/CRP, Anti-GGT/endomysial antibodies, Iron Studies, B12/Folate levels)

Imaging Colonoscopy + biopsy Barium Follow through Abdominal xray

Investigations

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)

Management (simplified)

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

Surgery

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

Site Contents of bag Appearance

Stomas – Colostomy vs Ileostomy

CASE 3• 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

Investigations

• Rectal examination?

• Bloods?

• Imaging?

Diagnosis?

Haemorrhoids • 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.

Classification

• 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

Rectal examination

• 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

Management• 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)

Case 4• 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

Investigations

• Bloods?

• Imaging?

Diagnosis?

Diverticular disease• Herniation's of mucosa through colonic muscle • Remember terminology 1. Diverticulosis- ASYPTOMATIC but has diverticula2. 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

Presentation• 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 tenderness2. Pyrexia, fever, tachycardia- may be in shock 3. Possibly N+V 4. Haemorrhage and other complications

Investigations

• Bloods- FBC, U+E, CRP, ESR, Clotting, Group+ save

• Imaging- 1.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

What about frothy urine?

Complications

• Fistula- 1.Colovesical- pneumaturia- frothy urine 2.Colovaginal 3.Coloenteric • Bowel obstruction • Abscess• Perforation • Stricture • Haemorrhage

Management• Diverticular disease- 1. High fibre diet 2. Good fluid intake 3. May require laxatives, antispasmodics, analgesia • Diverticulitis- 1. May require hospital admission 2. Antibiotics- may need broad spectrum 3. Fluids 4. Analgesia 5. Manage complications- eg may require blood

transfusion etc

Surgical • 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)

Red Flags in Rectal Bleeding

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.

Other causes of rectal bleeding1.Anal fissure 2.Gastroenteritis 3.Angiodysplasia 4.Meckel's diverticulum 5.Polyp 6.Trauma 7.Rectal varices

Any Questions?

Thanks