2 Presentation Iron deficiency anaemia PR bleeding Acute colonic bleeding
3 Bleeding with defecation HistoryHow 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 malignancyExaminationAnal inspection – external hemorrhoids (internal via straining), anal fissurePR Exam – ulcerative lesion (carcinoma – especially with blood on gloved finger), spasm of Int sphincter may make Ex impossible (anal fissure)Proctoscopy – 1st and 2nd degree haemorrhoids (non palpable), lower rectal carcinoma, anal fissure
5 HaemorrhoidsInternal Haemorrhoids: prolapse of the anal mucosa (anal cushions) containing the internal rectal venous plexus. Prolapse often lead to strangulation and ulcerationExternal Haemorrhoids: thrombosis of external rectal venous plexus. Caused by anything that impedes venous return, pregnancy, constipation and extended toilet sitting and strainingPattern of bleeding: bleeding at the end of defecation, bright red, seen on toilet paperClinically painless – prolapse may lead to moderate discomfortPortal Hypertension
6 Rectal/sigmoid carcinoma Bleeding of recent onset, colour depends on location, mixed with bowel motion, persists without remissionRecent history of increasing tenesmus (feeling of incomplete evacuation)
7 Anal FissureTear in the skin of the lower anal canal – distal to the dentate lineLeads to spasm of the internal sphincter – impedes healingUsually 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 locationLarge benign tumours may cause tenesmus and mucus in bowel motions (diarrhoea)
9 Iron Deficiency Anaemia No clinical evidence pointing towards bleedingMust do a full system review and examination due to many causes of iron deficiency anaemiaDDx: 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 bleedingPerforated peptic ulcer may lead to passage of bright red blood per rectum – VERY SEVERE AND LEADING TO SHOCKUsually spontaneously resolvesDDx: Diverticular disease, angiodysplasia, ischaemic colitis, IBD, polyp/carcinoma (rare), Meckel’s diverticulum
11 AngiodysplasiaVascular malformation of the colon – usually caecum and ascending colon – multiple lesionsGI bleeding (hematochezia/melena) and anaemiaBleeding – risk increased with a coagulation disorderPatients usually over 60
12 Ischaemic ColitisSudden onset crampy left lower quadrant pain followed by hematochezia within 24 hoursSudden and transient reduction of blood flow – usually splenic flexure and left colon - limited collateral supplyUsually mucosal (not transmural) therefore complications of stricture of gangrenous colitis are rareOften misdiagnosed as IBD or infectious colitis
Your consent to our cookies if you continue to use this website.