Lower GI Bleeding Tom Paterson PALi 5th Year Working Group

Name: Lower GI Bleeding Tom Paterson PALi 5th Year Working Group
Uploaded: 2017-07-12T06:02:47+00:00
Duration: PTM31S1
Channel: Alayna Mell
Description: Lower GI Bleeding Tom Paterson PALi 5th Year Working Group

Lower GI Bleeding Tom Paterson PALi 5th Year Working Group
Taken from: Tom Paterson PALi 5th Year Working Group

Lower GI Bleeding A common presentation
Arises from: Small Intestine, Colon, Rectum, Anus 3 categories Occult bleeding – FBC Low Hb or +FOB Moderate bleeding – PR Blood (fresh, mixed with stools or dark) Acute Massive Bleeding (rare) Large Vol. (Fresh PR) Start and stop spontaneously Haemodynamically unstable  Shock A Surgical Emergency! ABC’s OHCM 7th Ed p589

A typical scenario A 68-year old Glaswegian man presents to A+E with a 3 day history of rectal bleeding and lower abdominal pain. On enquiry, he admits to change in bowel habit with recent episodes of constipation and weight loss over the past 3-4 months. He has no past medical or surgical history, is a former smoker of 30 cigs/day for 26 years and does not drink alcohol.

Causes of Lower GI bleeding
Colorectal Cancer IBD (UC, Crohn’s Disease) Diverticulosis Colonic Polyp(s) Rectal Varices Haemorrhoids Anal Fissure Rectal Prolapse Infective diarrhoea Angiodysplasia Ischaemic Colitis

A Good History Age PR Blood (and Mucus)
Colour Type of Blood Quantity Previous episodes of PR bleeding Abdominal Pain or Tenderness Associated Anal pain +/- Defecation Altered Bowel habit Stool Frequency & Consistency Diarrhoea/Constipation/Both Tenesmus Anorexia and Weight Loss Dizziness, Collapse

A Good History PMHx: Gastric Ulcer, IBD, Cancer Metastases
Drug Hx: Aspirin, Warfarin, Steroids, Iron for IDA Family Hx: Crohn’s, UC, Bowel Ca, Polyps, FAP Social Hx: Alcohol intake, Smoker, Anal Intercourse Systemic Enquiry: Mouth ulcers Eye problems Skin changes Joint pains

Examination Inspection Palpation PR exam
Breathlessness, Jaundice, Cachexia Shock? Finger clubbing Signs of Anaemia (Conjunctival pallor, Koilonychia) Mouth Ulcers, Angular Stomatitis in IDA Scars, Stomas Abdominal distension Palpation Abdominal Tenderness or Pain (LIF Div, RIF Crohn/Caecal Ca) Mass felt with examining hand Hepatomegaly  Liver Mets PR exam Haemorrhoids, Prolapse, Fissures or Fistulas Palpable mass per rectum (up to 7cm) Stool colour/consistency Blood on examining finger

Investigations FBC Ferritin & iron studies U+Es LFTs CRP Glucose
Coagulation Screen Group & Save  If extensive bleeding Proctoscopy/Sigmoidoscopy Colonoscopy +/- Biopsy or Barium Enema Others: Upper GI Endoscopy (Melaena) Angiography (Mesenteric bleeding) Tc99 Red cell scan (GI Bleeding & Meckel’s))

Lower GI Bleeding A few examples: Colorectal Cancer
Inflammatory Bowel Disease (Ulcerative Colitis & Crohn’s disease) Others: Diverticulosis, Haemorrhoids, Anal Fissures, Fistula in Ano.... Sample EMQ’s

Colorectal Cancer 3rd commonest malignancy in UK
M:F = 3:1 peak age 45-70yo Risk Factor’s: FH of Colorectal Ca, FAP, HNPCC, Prev Hx of Colon,Breast, Ovarian or Uterine Ca Prev Hx of Adenomatous Polyps Chronic UC or Colonic Crohn’s disease Western diet, Obesity, Smoking Presentation depends on site: Left-sided:Altered bowel habit (constipation & diarrhoea), PR bleeding bright red coating the stool, Tenesmus, Painful defecation? Small diameter of Left Colon  Tendency towards obstruction Right-sided: Present later. Weight loss, Right abdo pain/mass, Tendency to bleed, Blood mixed in with stools, high incidence of IDA Emergency (40%): Obstruction, Perforation w/Peritonitis, Acute Haemorrhage *Taken from: Oxford Handbook of Clinical Medicine 7th Edition p613

Taken from: http://radiopaedia.org/images/894115
Colorectal Cancer Investigations: FBC  Microcytic hypochromic anaemia, LFTs  deranged with hepatic spread + Faecal occult blood Sigmoidoscopy/Colonoscopy + biopsy  Lesion (w/ 3-5% synchronous) Barium Enema may show ‘Apple core’ appearance CT/MRI for rectal cancers, local pelvic spread and metastasis Liver US  Hepatic Mets Raised Carcino-embryonic antigen (CEA) used for monitoring Pathology: Adenocarcinoma (95%) Character: ulcerating, stenosing, infiltrating Spread  Local, mesenteric, paracolic, paraaortic nodes, Liver, Lung, Bone & Brain Taken from: Taken from:

Duke’s Modified Criteria
Colorectal Cancer Staging: Duke’s Modified Criteria (1929) & TNM Staging (1958) Treatment: Surgical Resection with curative intent +/- Chemo Right Hemicolectomy  Caecal, Ascending, Proximal Transverse Ca Left Hemicolectomy  Distal Transverse, Descending Sigmoidectomy  Sigmoid Ca Anterior Resection  Low sigmoid/High Rectal Ca Abdominoperineal (A-P) Resection  Low Rectal Tumours <8cm from Anal canal permanent colostomy **Hartmann’s Carcinoma w/ Acute Obstruction (excision, colostomy, rectal stump) Other options: Chemotherapy (5-FU) for Duke’s B&C, RT, Palliation Duke’s Modified Criteria 5yr survival % A Limited to mucosa 90 B1 Involves muscularis propria 70 B2 Penetrates through muscle, extending to serosa and bowel wall 60 C1 Invades muscularis propria with lymph node involvement 30 C2 Penetrates through wall into serosa with lymph node involvement D Distant Metastatic Spread <10 TNM Staging T 1 – Confined to the mucosa and submucosa T2 – Invasion of muscularis propria but no extension into serosa T3 – Extends into serosal - no breach or local spread T4 – Direct invasion through serosa and local structures N0/1/2 – no nodes, 1-3 nodes, >4 nodes M0/1 – Metastases not present/present T1N0M0 & T2N0M0 = Dukes A T3N0M0 & T4N0M0 = Dukes B Any T with N1 or N2 = Dukes C & Any T&N with M1 = Dukes D

Inflammatory Bowel Disease

Ulcerative Colitis A relapsing and remitting inflammatory disease originating in the colonic mucosa and submucosa. UC is limited to the colon. Begins in the rectum and can extend proximally, but rarely beyond ileocaecal junction. M = F but 2 peaks: i) years old ii) 15% of new pts >60 years old at diagnosis Unknown Aetiology Associated RFs: HLA-DR130 association in severe UC 60% UC pt’s + pANCA autoantibodies 3-4 times increased risk in Non-smokers and Ex-smokers NSAIDs and stress implicated in UC flares

Ulcerative Colitis A PIE SAC Presentation Extraintestinal features:
Proctitis (50%) (commonest): Urgency and high frequency of defecation (4-15/day), diarrhoea mixed with blood and mucus, rectal irritability, tenesmus. Left-sided Colitis (30%): Rectal irritation, extensive blood & mucus in stool  Bloody diarrhoea. Pancolitis (20%): Diarrhoea, crampy, distended abdomen with systemic features: pyrexia, anorexia, weight loss, malaise and tachycardia. May involve appendix. Severe Pancolitis  Backwash ileitis into terminal ileum Extraintestinal features: A PIE SAC Complications of UC: Perforation, Haemorrhage, Toxic Megacolon (hypotonic, grossly distended bowel > 5cm) Colorectal Ca & death if complication sinadequately treated

Extraintestinal Manifestations in IBD
A PIE SAC Aphthous Ulcers (CD only) Pyoderma Gangrenosum I (Eye): Iritis,Uveitis, Episcleritis, Conjunctivitis (CD>UC) Erythema Nodosum (Primary) Sclerosing Cholangitis (pANCA UC>CD) / Sacroilitis Arthritis (HLA-B27: AnkSpo) Clubbing of Fingers (CD>UC) Taken from:

Ulcerative Colitis Investigations:
FBC  Low Hb due to blood loss, Raised WCC & Platelet count U+E’s  hypokalaemia due to mucus loss Raised CRP & ESR Low Albumin espec. during inflammation Stool Microscopy, Culture & Sensitivity Barium enema indicates disease extent. Chronic UC: loss of haustrations, rigidity & shortening of colon  ‘Lead-pipe’ appearance. Excludes toxic megacolon in severe UC. Colonoscopy + Biopsy  Inflamed, easily bleeding mucosa in rectum/distal colon. Inflammation limited to the mucosa with crypt distortion & abscess. Chronic UC Pseudopolyp formation. Taken from: www. Radiopedia.org Taken from: web2.airmail.net/uthman/specimens/images/uc.html Taken from: www. ulcerativecolitistreatment.net

Ulcerative Colitis Treatment aims: Induce disease remission & maintain remission and disease symptoms Medical Therapy Correct anaemia, hypokalaemia, hypoalbuminaemia, Corticosteroids: Oral Prednisolone induces remission. IV Hydrocortisone used in severe flares of colitis - Long-term avoided. Sulfasalazine or Mesalazine (5-ASA metabolites) have anti-inflammatory effect to induce remission. Also Rectal suppositories for distal colitis Azathioprine, 6-mercaptopurine – immunosupression to prevent disease relapse or in cases of intolerance to steroids Anti-TNF  Infliximab good in moderate-severe UC Surgery indicated when: Acute colitis fails to respond to medical Tx. Chronic Colitis persists despite treatment, unacceptable Tx SE’s, developmental delay, poor quality of life. Toxic megacolon (within 24hrs) Partial or Total Colectomy with Ileostomy usually cures

Crohn’s Disease Chronic transmural inflammatory GI Disease which is non-caseating & granulomatous in nature. Associated with recurrence in severe disease and extraintestinal manifestations. Can affect any portion of GI tract Termimal Ileum (50%) & Proximal Colon common. Inflammation is discontinuous and separated by normal gut mucosa (‘skip lesions’). M = F affects any age but majority of cases between years old Unknown aetiology. Commonest in White Anglo-Saxon & Ashkenzai Jews Associated Risk Factors: CARD 15/NOD-2 mutations Family Hx of Crohn’s or UC Altered cell mediated immunity  abnormal Th1 activity (IL-2, IFN-γ) x3-4 risk in Smokers High sugar, low-fibre diet

Crohn’s Disease Presentation Variable & dependent on site
Diarrhoea, Abdominal Pain + Tenderness (terminal ileitis), RIF mass (inflamed bowel or abscess), Perianal abscesses/ fistulae/skin tags. Weight loss, malaise, fever occur in active disease. Failure To Thrive in children NB: Rectal bleeding less common in CD than UC Extraintestinal signs: Aphthous ulcers,Uveitis, Iritis , pyoderma gangrenosum, erythema nodosum, polyarthritis, ankylosing spondylitis, sacroilitis Complications in CD: Full-thickness mucosal inflammationStrictureSmall bowel obstruction Abscess formation between loops of intestine Perforation Fistula formation: Enteroenteric, Enterocutaneous and Vesicocolic

Crohn’s Disease Investigations:
FBC  Low Hb (Vit B12 def., blood loss), High WCC Raised CRP & ESR Low Albumin due to malabsorption Stool Microscopy, Culture & Sensitivity Barium Enema shows ‘Kantors String sign’ of the terminal ileum. Also Rose-thorn ulcers Colonoscopy/Sigmoidoscopy+ Biopsy  Red, oedematous thickened mucosa with deep ulcerations and erosions, separated by normal mucosa producing a cobblestone appearance. Histology shows transmural inflammation, fissuring ulcers and non-caesating granulomas *Taken from: James Going -SSC in Pathology IBD Lecture Taken from: www. Learningradiology.com Taken from: www. Flickr.com/photos/robhengxr/

Crohn’s Disease Management: Medical vs Surgical
Medical Mx aims to reduce inflammation & control complications. Also treat abnormal blood results eg. Anaemia Corticosteroids (Hydrocort, Predn)– control inflammation exacerbations in moderate-severe disease Azathioprine or Cyclosporin – immunosupression Methotrexate Anti-TNF Infliximab – prevent fistula formation Metrondiazole used to treat Colonic fistulas Nutritional therapy - elemental diet to limit antigens & reduce inflamm Surgical Mx aims to treat complications such as strictures, bowel obstruction, sepsis, perforation or fistula formation with minimal compromise to bowel. SURGERY MAY CAUSE NEW LESIONS 50-80% patients will require surgery throughout their lives

Summary of other causes of Lower GI Bleeding
Adapted from: Oxford Handbook of The Foundation Programme 2nd Edition

INVESTIGATIONS & TREATMENT
DESCRIPTION HISTORY EXAMINATION INVESTIGATIONS & TREATMENT DIVERTICULAR DISEASE (DIVERTICULOSIS) Outpouching in bowel wall  weakest point vasa recta meet muscular propria Marfan, Ehlers- Danlos, Polycystic Kidney Low fibre diet & constipation Abdominal Pain (LIF)  Sigmoid Colon Massive painless dark red PR Bleeding Irregular Bowel Habit (diarrhoea constipation) Fever/Pyrexia Tenderness (LIF) +/- Peritonism PR Blood or Mucus Bleeding self- limiting Low Hb Diverticulae on Colonscopy Tx: High fibre diet Abx in acute disease (co-amox/metro/cipro) Surgical resection if persistent bleeding (recurrent diverticulitis, abscess/fistula/obstruction ANGIODYSPLASIA AVM in colonic submucosa Usually proximal transverse colon Old Age Often Asymptomatic Recurrent & brisk Fresh Blood PR PR Blood or Melaena Ex may be Normal Low Hb  give FeSO4 FOB+ Lesion on Colonoscopy Consider Angiography Tx: Arterial Embolisation, Endoscopic coagulation HAEMORRHOIDS Dilated& displaced vascular ‘anal cushions’ Multiple vaginal deliveries Multiple pregancies, obese, anal sex Straining at Stool Painless Fresh Blood on Toilet Paper or stools Perianal Itch Often not Palpable on PR unless prolapsed Perianal tags May have rectal Prolapse Haemorrhoids on Proctoscopy Tx: High fibre diet, Anusol, Sclerosant, Band ligation or Haemorrhoidectomy

DESCRIPTION HISTORY EXAMINATION INVESTIGATIONS
RECTAL PROLAPSE Descent of mucosa or entire rectum through anus Weak rectal support  lax of pelvic floor and anal sphincters due to chronic straining Elderly, postmenopausal pts, multiple vaginal deliveries Children  constipation, CF, whooping cough “Something coming down” ++mucus PR Usually small vol. bright red bleed Repeated defecation (mucosal) or Incontinence (full) Prolapse may be demonstrated on straining in clinic Prolapse may be ulcerated & bleeding Sigmoidoscopy  mucosal inflamm Defecating proctogram if unclear diagnosis MedMx: Stool softeners for constipation SurgMx: Rectoplexy  fix rectum to sacrum ANAL FISSURE Anal tear posteriorly May be associated with Crohn’s or Cancer Previous Pregnancy Severe knife-like pain on defecation Deep throbbing pain Hx Constipation, Straining ++ Fresh Blood on Toilet paper Posterior/Anterior tear at anal margin Associated: Perianal tags, ulcers, fistulae PR Tenderness PR blood on examining finger Sigmoidoscopy if Colorectal Ca Tx: High fibre diet 5% lignocaine therapy Botox injection Sphincerotomy ANAL FISTULAS All ages Infection commonest IBD (CD>UC) Trauma:episiotomy, prostatectomy, anal sex Anal Ca Pain Bloody or Purulent anal discharge Anal itching Systemic symptoms if infected abscess Abnormal epithelial connection seen between anus and skin Erythema Surgery  Fistulotomy or Staged sphincter repair

Extended Matching Questions

MEQ’s Rectal Bleeding 1) A 30 yo male with bloody diarrhoea 20 times/day, weight loss and colonoscopy showing inflammation from the rectum to caecum (a) Colon Ca (b) Crohn’s Disease (d) Fissure in ano (e) Fistula in ano (f) Gastroenteritis (g) Haemorrhoids (h) Rectal proplase (i) Diverticulosis (j) Ulcerative colitis

MEQ’s Rectal Bleeding 2) A 25 yo woman, 6 weeks post-partum with PR bleeding, puritis and perianal pain (a) Colon Ca (b) Crohn’s Disease (d) Fissure in ano (e) Fistula in ano (f) Gastroenteritis (g) Haemorrhoids (h) Rectal proplase (i) Diverticulosis (j) Ulcerative colitis

MEQ’s Rectal Bleeding 3) A 21 yo lady with rectal bleeding and severe pain on defecation (a) Colon Ca (b) Crohn’s Disease (d) Fissure in ano (e) Fistula in ano (f) Gastroenteritis (g) Haemorrhoids (h) Rectal proplase (i) Diverticulosis (j) Ulcerative colitis

MEQ’s Rectal Bleeding 4) A 90 yo woman with PR bleeding and something coming down every time she defecates (a) Colon Ca (b) Crohn’s Disease (d) Fissure in ano (e) Fistula in ano (f) Gastroenteritis (g) Haemorrhoids (h) Rectal proplase (i) Diverticulosis (j) Ulcerative colitis

MEQ’s Rectal Bleeding 5) A 26 yo man presents with chronic bloody diarrhoea and RIF pain. He has lost weight recently and feels generally unwell and pyrexial. He is also complaining of joint pains and barium enema shows altered mucosal pattern with deep-fissured ulcers. (a) Colon Ca (b) Crohn’s Disease (d) Fissure in ano (e) Fistula in ano (f) Gastroenteritis (g) Haemorrhoids (h) Rectal proplase (i) Diverticulosis (j) Ulcerative colitis

MEQ’s Rectal Bleeding 6) A 32 yo woman presents with rectal bleeding, which occurs post-defecation. The bleeding is bright red and painless. Endoscopy is normal. (a) Colon Ca (b) Crohn’s Disease (d) Fissure in ano (e) Fistula in ano (f) Gastroenteritis (g) Haemorrhoids (h) Rectal proplase (i) Diverticulosis (j) Ulcerative colitis

Courtesy of Monkey Tennis by Slap www.Hallmarkuk.com
Thank You Courtesy of Monkey Tennis by Slap

References Garden, O.J. et al(2009) ‘Principles & Practice of Surgery’ 5th Edition, Edinburgh, UK: Elsevier Goljan, E.F (2010) ‘Rapid Review: Pathology’ 3rd Edition, Philadelphia, USA: Mosby: Elsevier Hurley, N. et al (2008) ‘Oxford Handbook of The Foundation Programme’ 2nd Edition, Oxford, UK: Oxford University Press Kontoyannis, A. Et al (2008) ‘Crash Course: Surgery’ 3rd Edition Edinburgh, UK: Mosby Elsevier Longmore, M. et al (2007) ‘Oxford Handbook of Clinical Medicine’ 7th Edition, Oxford, UK: Oxford University Press McLatchie, G. et al (2007) ‘Oxford Handbook of Clinical Surgery’ 3rd Edition, Oxford, UK: Oxford University Press

Lower GI Bleeding Tom Paterson PALi 5th Year Working Group

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