A little bit of bleeding

Magdalena Ole FY1

Aims and Objectives

What is PR bleed and what to ask your patient Anatomy revision Causes Investigations Treatment Summary

Anatomy revision

PR bleeding
Useful questions:
Painful vs. painless Amount Relation to passing motion Mixed in or not Ass. abdominal pain Previous episodes Bright or dark

Blood bright red or dark from the rectum/anus/colon

Bright anus/rectum Dark/mixed in stool colon Melaena upper GI (for another time)

Causes
Colorectal conditions
Haemorrhoids Diverticular disease Colorectal polyps Colorectal Ca AV malformation Angiodysplasia Ischaemia Trauma UC bloody diarrhoea

Anal conditions
Fissure Fistula Thrombosis Squamous carcinoma Warts

Anal fissure

Small tear/cut in the skin lining the anus Very painful +/- bleeding Constipation +/- pus discharge Acute or chronic

Vicious cycle of anal fissure

Pain

Bigger fissure

No toilet

Tearing

Constipation

Anal fissure

ACUTE:
Local anaesthetic gel Bulk laxatives GTN ointment

CHRONIC:
Operative treatment Effective

Anal Fistula
Usually associated with underlying abscess Two types:
Intersphincteric (medial) Transsphincteric (across) Or Superficial (cutaneous) Suprasphincteric (rare) Extrasphincteric

Squamous cell Ca

Skin cancer Invasive locally Widespread destruction Lesion bleeds, but appears as PR bleed Rx with incision biopsy

Anal warts

Condylomata acuminata Can bleed HPV Sexually trasmitted Common in HIV +ve patients

Haemorrhoids
Enlarged anal cushions, NOT VEINS!!! Usually at 3, 7, 11 oclock Enlarge due to straining Only painful when thrombosed or gripped by anal sphincter Bright red blood
Capillaries Coats or drips

1st degree

2nd degree 3rd degree

Bleeding only Prolapse, reduces spontaneously Prolapse, need pushing in Permanently prolapsed ?metaplastic changes at margins

4th degree

Haemorrhoids

1st degree

2nd degree

Haemorrhoids

3rd degree

4th degree

Haemorrhoids

Investigations
Sigmoidoscopy
BEWARE strangulated haemorrhoids!!!
LA cream GTN cream Attempt reduction

Management
Sclerosant injection (phenol) Rubber bang ligation High fibre diet haemorrhoidectomy

Diverticular disease

Rare in <35s Mostly asymptomatic Mostly acquired Serosa-covered outpouchings of mucosa Usually left colon (sigmoid)

Haemorrhage
Iron-deficiency anaemia Erosion of vessels in the neck of diverticulum Rapid exsanguination Can be difficult to localise

Colorectal Ca

Aetiology
2nd most common ca Peaks 8th + 9th decade in western world 1/3 presents as emergency 20% mets 5-year survival 50-60% FAP

Associations
Autosomal dominant 100s polyps Gene testing

HNPCC
Autosomal dominant Other malignancies

Mostly spontaneous

Colorectal Ca

Patient Journey
GP 2ww Rigid sigi

Symptoms
Change in bowel habit (Lsided) Anaemia (R-sided) Weight loss Rectal bleeding Abdominal mass Hepatomegaly if mets

Chemo/radio

Ba enema

colo

op

MDM

f/u

Colorectal Ca

Rectal bleeding
Dark Mixed in stool

AV malformations

Angiodysplasia

Stretched and fragile vessels in the colon Degeneration of small vessels lining the bowel Also presents with anaemia, fatigue and SoB

Ischaemic colitis
Uncommon in <50s Splenic flexure Reduced arterial input
AXR
distended splenic flexure, oedematous mucosa

L-sided abdo pain Dark red blood PR Fever HTN Tenderness

Ba Enema
thumbprinting

Ischaemic colitis

Thumbprinting

Ulcerative colitis

Symptoms
Classical presentation with bloody diarrhoea Remission, followed by another acute attack Complications:
Massive haemorrhage Ca TOXIC MEGACOLON

Management
Mostly medical Rx
Prednisolone sulfasalazine

Surgical Rx
Proctocolectomy + ileostomy Total colectomy +/-ileal pouch Total colectomy + temporary ileostomy

Summary

Multiple causes of PR bleeding Some more sinister than others

Take home messages

Thorough history and examination is essential Choose appropriate investigations Think what is the most likely cause Never dismiss PR bleeding

Thank you very much

Any questions?