Value of digital rectal examination and bedside anorectoscopy in the evaluation of patients with lower gastro-intestinal bleeding F Cherbanyk and G Lombardo A Meyer, JM Michel, B Egger

Background Incidence of acute lower gastrointestinal bleeding: 21 patients/100.000/year This incidence increases 200-fold between the 3rd and 9th decade The assessment of hematochezia is often expensive and invasive (endoscopy, CT scan, angiography, scintigraphy). Digital rectal examination and anorectoscopy are minimally invasive and inexpensive tools for the diagnosis of hematochezia Longstreth et al., Am J Gastroenterol 1997;92:419

Objective To assess the value of digital rectal examination and bedside anorectoscopy for the evaluation of hematochezia at our Emergency Department (ED) fr To determinate the proportion of patients presenting with lower gastrointestinal bleeding related to the underlying pathology (benign or malignant) in the anorectal region

Patients & Methods Retrospective analysis of an ongoing prospective database in our Surgical Department Study period: 07.2007 - 04.2009 Inclusions criteria’s: all patients > 18 years old admitted to the ED with hematochezia and hospitalized on our surgical ward Exclusions criteria’s: hemodynamic instability, pediatric cases Patients underwent digital rectal examination and anorectoscopy at the ED by a incensed surgeon All patients underwent colonoscopy (Gastroenterologist) during hospitalization in order to exclude synchronous colonic lesions

Results n=105 Study Group All lesions were confirmed by colonoscopy! Anorectal localisation n=54 (51%) Non anorectal localisation n=51 (49%) Neoplastic n=28 (26,6%) Non neoplastic n=26 (24,4%) Neoplastic n=32 (30,2%) Non neoplastic n=19 (18,8%) Study Group All lesions were confirmed by colonoscopy!

Results Anorectal lesions situated between 0 and 15cm from the anal marge (n =54) No synchronous lesions found at colonoscopy Non-Neoplasic Lesions n=26 (24,4%) 8 Hemorroids 5 Ulcerations-erosions Others ** 4 Rectocolitis Post polypectomy Neoplasic Lesions* n=28 (26,6%) 17 Cancer 11 Benign polyps * proven at histology ** Cryptogenic, anastomotic bleeding, post actinic, prolapsus

Conclusions 50% of stable patients presenting with hematochezia at our ED had lesions, confirmed by colonoscopy, in the anorectal region Digital rectal examination and anorectoscopy at the ED allows to make a preliminary diagnosis in 50% of patients Additional time-consuming and expensive investigations, as CT-scan, gastroscopy, angiography and others may be even avoided However, 50% of patients require additional investigations such as colonoscopy or others due to lesions situated higher up in the colon

Take Home Message In patients presenting with hematochezia at the ED, simple digital rectal examination combined with bedside anorectoscopy allows to make a preliminary diagnosis in 50%