1. Matthew Charnock Sam Newton
Rectal Bleeding
Matthew Charnock
Sam Newton

2. History Taking PC
HPC
RED FLAGS
ROS
MED Hx FH
SOCIAL Hx

3. Case 1 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

4. Diagnosis?

5. Investigations??
Bloods
Imaging

7. Colorectal Caner

8. Epidemiology
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

9. Risk Factors Family history Familial Syndromes IBD Smoking
Poor fibre/High fat diet
Alcohol
Etc

10. Presentation 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

11. What about?
Jaundice?
Ascites?
Chronic cough?

12. Clinical Features Abdominal pain Bloody diarrhoea Weight loss Fever
Signs of anaemia
Tenesmus
Peri-anal disease
Extra-intestinal manifestations
In children – FTT, delayed puberty, malnutrition

13. Extra-intestinal manifestations

18. Crohns VS Ulcerative Colitis

19. Assessing Severity of UC

20. Investigations
Bloods (FBC, LFTs, ESR/CRP, Anti- GGT/endomysial antibodies, Iron Studies, B12/Folate levels)
Imaging
Colonoscopy + biopsy
Barium Follow through
Abdominal xray

21. Management (simplified)
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)

22. Surgery 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

23. 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

25. Stomas – Colostomy vs Ileostomy
Site
Contents of bag
Appearance

26. 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

27. Investigations
Rectal examination?
Bloods?
Imaging?

28. Diagnosis?

29. 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.

30. 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

32. 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

34. 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)
Banding
Sclerotherapy
Infrared coagulation
Surgical (3rd/4th not responding or very large)
Circular stapled haemorrhoidectomy (better than traditional)

35. 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

36. Investigations
Bloods?
Imaging?

37. Diagnosis?

38. Diverticular disease Herniation's of mucosa through colonic muscle
Remember terminology
Diverticulosis- ASYPTOMATIC but has diverticula
Diverticular disease- SYPTOMATIC with diverticula
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

39. Presentation Diverticular disease: Abdo pain, usually left sided
Abdo bloating
Change in bowel habit
Rectal bleeding
Diverticulitis:
More severe LIF pain with localised tenderness
Pyrexia, fever, tachycardia- may be in shock
Possibly N+V
Haemorrhage and other complications

40. Investigations Bloods- FBC, U+E, CRP, ESR, Clotting, Group+ save
Imaging-
Colonoscopy- exclude other pathology and confirm diagnosis, NOT in acute presentation- why?
Barium enema
Erect CXR- why?
AXR- may show evidence of complications
CT- useful acutely when colonoscopy CI’d

42. What about frothy urine?

43. Complications Fistula- Colovesical- pneumaturia- frothy urine
Colovaginal
Coloenteric
Bowel obstruction
Abscess
Perforation
Stricture
Haemorrhage

44. Management Diverticular disease- High fibre diet Good fluid intake
May require laxatives, antispasmodics, analgesia
Diverticulitis-
May require hospital admission
Antibiotics- may need broad spectrum
Fluids
Analgesia
Manage complications- eg may require blood transfusion etc

45. 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:
Fistula
Obstruction
Stricture (possibly)

47. 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.

48. Other causes of rectal bleeding
Anal fissure
Gastroenteritis
Angiodysplasia
Meckel's diverticulum
Polyp
Trauma
Rectal varices

49. Thanks
Any Questions?