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+ Lower GI Bleeding. + Presentation Iron deficiency anaemia PR bleeding Acute colonic bleeding.

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Presentation on theme: "+ Lower GI Bleeding. + Presentation Iron deficiency anaemia PR bleeding Acute colonic bleeding."— Presentation transcript:

1 + Lower GI Bleeding

2 + Presentation Iron deficiency anaemia PR bleeding Acute colonic bleeding

3 + Bleeding with defecation History How much? Mixed in with the stool? Colour? Pain on defecation? Pattern of bleeding – remissions, exacerbations? Constipation (anal fisure) or diraahoea Ulcerative colitis) Associated symptoms – tenesmus, signs of malignancy Examination Anal inspection – external hemorrhoids (internal via straining), anal fissure PR Exam – ulcerative lesion (carcinoma – especially with blood on gloved finger), spasm of Int sphincter may make Ex impossible (anal fissure) Proctoscopy – 1 st and 2 nd degree haemorrhoids (non palpable), lower rectal carcinoma, anal fissure

4 + DDx Haemorrhoids Carcinoma of rectum/sigmoid colon Anal fissure Adenomatous polyp IBD (with diarrhoea)

5 + Haemorrhoids Internal Haemorrhoids: prolapse of the anal mucosa (anal cushions) containing the internal rectal venous plexus. Prolapse often lead to strangulation and ulceration External Haemorrhoids: thrombosis of external rectal venous plexus. Caused by anything that impedes venous return, pregnancy, constipation and extended toilet sitting and straining Pattern of bleeding: bleeding at the end of defecation, bright red, seen on toilet paper Clinically painless – prolapse may lead to moderate discomfort Portal Hypertension

6 + Rectal/sigmoid carcinoma Bleeding of recent onset, colour depends on location, mixed with bowel motion, persists without remission Recent history of increasing tenesmus (feeling of incomplete evacuation)

7 + Anal Fissure Tear in the skin of the lower anal canal – distal to the dentate line Leads to spasm of the internal sphincter – impedes healing Usually caused by constipation – leads to severe pain, leads to further constipation, exacerbating the condition

8 + Adenomatous Polyp Bleeding without change in bowel habit Intermittent Colour depends on location Large benign tumours may cause tenesmus and mucus in bowel motions (diarrhoea)

9 + Iron Deficiency Anaemia No clinical evidence pointing towards bleeding Must do a full system review and examination due to many causes of iron deficiency anaemia DDx: carcinoma of the caecum, Crohn’s disease (more often normocytic anaemia of chronic disease). Other Upper GI problems.

10 + Acute Haemorrhage Massive Lower GI bleeding is very RARE Is ACUTE but reasonably benign compared to acute UPPER GI bleeding Perforated peptic ulcer may lead to passage of bright red blood per rectum – VERY SEVERE AND LEADING TO SHOCK Usually spontaneously resolves DDx: Diverticular disease, angiodysplasia, ischaemic colitis, IBD, polyp/carcinoma (rare), Meckel’s diverticulum

11 + Angiodysplasia Vascular malformation of the colon – usually caecum and ascending colon – multiple lesions GI bleeding (hematochezia/melena) and anaemia Bleeding – risk increased with a coagulation disorder Patients usually over 60

12 + Ischaemic Colitis Sudden onset crampy left lower quadrant pain followed by hematochezia within 24 hours Sudden and transient reduction of blood flow – usually splenic flexure and left colon - limited collateral supply Usually mucosal (not transmural) therefore complications of stricture of gangrenous colitis are rare Often misdiagnosed as IBD or infectious colitis


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