Rectal Bleeding

  • Upper GI vs Lower GI (distal to ligament of Treitz)

Differential diagnosis

  • Anorectal: Hemorrhoid, Fissure, Proctitis, Cancer of rectum, Polyp, Fistula
  • Vascular: ischemia, angiodysplasia
  • Inflammatory: Inflammatory bowel disease
  • Infectious: Shigella, Salmonella, E.coli, C.diff, Campylobacter, H pylori
  • Neoplasm
  • Congenital: Meckel’s
  • Structural: intussusception, polyps, diverticuli
  • Clotting disorders

HPI

  • Bleeding
    • OLDSCARS
    • What circumstances?
    • How much blood?
    • Tarry, mixed in, on paper
    • Melena? Fe, peptobismol, beets, licorice
    • Previous bleeding?
  • Infection: nausea, vomitting, fevers/chills, diaphoresis
  • Anemia: vertigo/lightheaded, pale, weakness
  • Urgency, tenesmus, anal pain
  • B-symptoms (weight loss, fever, night sweats)
  • Bowel history: polyps, hemorroids, inflammatory bowel disease (IBD), ulcers, cancer, regularity, fissure

Past Medical History– clotting disorder, radiation, coronary artery disease, abdominal aortic anuerysm, H pylori, Gyne history

Family history – bowel cancer, IBD

Medications
 – NSAIDs, anticoagulants, iron, steroids

Social History: smoking, alcohol use

Physical Exam

  • General appearance
  • Vitals: blood pressure, tachycardia, orthostatic changes, temp, respiratory rate
  • Skin: jaundice, liver disease stigmata, ecchymosis, petechiae
  • Mucous membranes
  • Abdomen: distension, caput medusa, bowel sounds, tenderness, masses, ascites, hepatosplenomegaly
  • Rectal: stool, haemorrhoids, rectal mass, fissure, fistula

Laboratory

  • Type and Crossmatch
  • CBCD, lytes, BUN, Cr
  • PT/PTT, LFTs

Imaging

  • Rigid sigmoidoscope
  • Colonoscopy (Family history of bowel cancer, >50 y.o., bleeding, mucous, stools changes)
  • Barium enema
  • Gastroscopy
  • Angiography (Tc labelled RBC scan if indicated)

Management

  • Stabilize hemodynamically (2 large bore IVs, crystalloid, RBCs, foley, NG tube)
  • Monitor for ongoing blood loss (vitals, labs, CVP)

Chracteristic

UC

Crohn’s

Course

Exacerbations and remissions

Smouldering

Bleed

Always

Uncommon

Abdo pain

Uncommon

Common

Perianal

Rare

Up to 40%

Fistulas

Never

Occasional

Abdo mass

Never

Occasional

Rectal involvement

Always

Spared

Distribution

Uniform, confluent

Skip lesions, eccentric

SB

Spared

Often

Strictures

Rare, malignant

Frequent, benign

Mucosa

Shallow ulcers, bleed, pseudopolyps

Longitudinal ulcers, fissures, cobblestone

Extent

Mucosa, submucosa

Transmural

Granuloma

Never

Always

Dysplasia

Yes

Yes

LN

REactive

With granulomas

Crypt abscess

Yes

Yes

Mucous

Less

More

Cancer

30% at 25 yrs

Longer duration

  • Extraintestinal: PSC, psoriasis, RA/AS (UC); colitic arthritis (Crohn’s): erythema nodosum, pyoderma gangrenosum, cholelithiasis (decreased bile salt absorption in distal ileum)
  • Treatment: steroids, 5-ASA, immunosuppressants, surgery (UC)

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