Matthew Charnock Sam Newton Rectal Bleeding Matthew Charnock Sam Newton

History Taking PC HPC RED FLAGS ROS MED Hx FH SOCIAL Hx

Case 1 73 year old female Suffers from T2DM and Ulcerative Colitis Presented 3/52 history of rectal bleeding Mixed in with stool Loose stools for past 6 weeks Lost 2 stone in past 12 weeks Smokes 30/day for 50 years No abdominal pain DVT 4 weeks ago

Diagnosis?

Investigations?? Bloods Imaging

Colorectal Caner

Epidemiology Colorectal cancer is the third most common cancer in the UK 2nd most common cause of cancer death in the UK 75% occur in people aged 65 or over Screening in UK - FOBT

Risk Factors Family history Familial Syndromes IBD Smoking Poor fibre/High fat diet Alcohol Etc

Presentation Right sided colon cancers Change in bowel habit, weight loss, anaemia, occult bleeding, mass in right iliac fossa, disease more likely to be advanced at presentation Left sided colon cancers colicky pain, rectal bleeding, bowel obstruction, mass in left iliac fossa, early change in bowel habit, less advanced disease at presentation Rectal cancers as above + tenesmus

What about? Jaundice? Ascites? Chronic cough?

Clinical Features Abdominal pain Bloody diarrhoea Weight loss Fever Signs of anaemia Tenesmus Peri-anal disease Extra-intestinal manifestations In children – FTT, delayed puberty, malnutrition

Extra-intestinal manifestations

Crohns VS Ulcerative Colitis

Assessing Severity of UC

Investigations Bloods (FBC, LFTs, ESR/CRP, Anti- GGT/endomysial antibodies, Iron Studies, B12/Folate levels) Imaging Colonoscopy + biopsy Barium Follow through Abdominal xray

Management (simplified) Smoking cessation in Crohns Medical 5 aminosalicyclic acid derivatives (5ASA’s – mesalazine) Corticosteroids (in acute flare up) Enteral nutrition Immunosuppressants (cyclosporin/methotraxate/azathioprine) Cytokine modulators (infliximab)

Surgery Indications in UC Failure of medical treatment Toxic megacolon Perforation Haemorrhage Cancer prophylaxis Procedure Temporary – proctocolectomy with ileoanal pouch formation Permanent – panproctocolectomy with end ileostomy

Indications in Crohns Strictures - strictuoplasty Fistulas – lay open (low)/seton suture (high) Abscess – drainage +/- Abx Unresponsive to medical treatment - - segmental resection Intolerable long term symptoms

Stomas – Colostomy vs Ileostomy Site Contents of bag Appearance

CASE 3 Obese 59 year old male No significant past medical history Presented to GP with a 2 week history of rectal bleeding Small amount of blood on the toilet paper after defecating First occurred following straining on the toilet Also itching around the back passage No pain, no change in bowel habit, no N+V Feels otherwise well ROS- none

Investigations Rectal examination? Bloods? Imaging?

Diagnosis?

Haemorrhoids Commonest cause of rectal bleeding Benign condition in which the venous cushions within the rectum become enlarged RF’s - prolonged straining and time on the toilet, raised intra-abdominal pressure eg- pregnancy, obesity, heavy lifting etc Symptoms include- rectal bleeding, rectal itching (pruritus ani), feeling of discomfort or discharge, may feel mass, may be asymptomatic Blood should not be mixed in, usually on toilet paper or streaks in the bowl Classification is broken into internal and external haemorrhoids, internal above the dentate line, external below dentate line.

Classification 1st degree- do not prolapse 2nd degree- prolapse on defecation return spontaneously 3rd degree- prolapse on defecation, need to be manually reduced 4th degree- permanently prolapsed

Rectal examination On rectal exam, typically present at the 3,7 and 11 o clock positions Internal haemorrhoids may be impalpable and not visible on inspection Internal haemorrhoids should be painless Asking the patient to bear down may reveal haemorrhoids on inspection Important to perform to exclude other anal pathology

Management Conservative- increase dietary fibre, decrease time on the toilet, strain less, lose weight, laxative (for 1st and 2nd degree) Non- surgical (for 3rd/4th or 1st/2nd not responding to conservative) Banding Sclerotherapy Infrared coagulation Surgical (3rd/4th not responding or very large) Circular stapled haemorrhoidectomy (better than traditional)

Case 4 64 year old female PMH of IHD and PVD Presented with a 1 month history of LIF abdominal pain, bloating and change in bowel habit- constipated Also noticed single episode of blood mixed in with stool Also noticed intermittent nausea although no vomiting No pyrexia Otherwise well ROS- frothy urine? O/E- patient relatively well, abdo- some tenderness in the LIF, PR- NAD

Investigations Bloods? Imaging?

Diagnosis?

Diverticular disease Herniation's of mucosa through colonic muscle Remember terminology Diverticulosis- ASYPTOMATIC but has diverticula Diverticular disease- SYPTOMATIC with diverticula Diverticulitis- Infection with inflammation of a diverticula RF’s- Age, low dietary fibre, obesity More likely to occur on the left in Caucasians and commonly occur at the insertion points of blood vessels

Presentation Diverticular disease: Abdo pain, usually left sided Abdo bloating Change in bowel habit Rectal bleeding Diverticulitis: More severe LIF pain with localised tenderness Pyrexia, fever, tachycardia- may be in shock Possibly N+V Haemorrhage and other complications

Investigations Bloods- FBC, U+E, CRP, ESR, Clotting, Group+ save Imaging- Colonoscopy- exclude other pathology and confirm diagnosis, NOT in acute presentation- why? Barium enema Erect CXR- why? AXR- may show evidence of complications CT- useful acutely when colonoscopy CI’d

What about frothy urine?

Complications Fistula- Colovesical- pneumaturia- frothy urine Colovaginal Coloenteric Bowel obstruction Abscess Perforation Stricture Haemorrhage

Management Diverticular disease- High fibre diet Good fluid intake May require laxatives, antispasmodics, analgesia Diverticulitis- May require hospital admission Antibiotics- may need broad spectrum Fluids Analgesia Manage complications- eg may require blood transfusion etc

Surgical 15-30% may need surgery Emergency procedure for acute diverticulitis is a HARTMANNS procedure Involves removing affected part and bringing part of the large bowel to the surface of the skin to create a temporary colostomy which can be reversed at a later date upon recovery Surgery may also be performed for complications including: Fistula Obstruction Stricture (possibly)

Red Flags in Rectal Bleeding Person Symptoms and signs 40 years of age and older Rectal bleeding with a change in bowel habit towards looser stools and/or increased stool frequency persisting for 6 weeks or more. 60 years of age and older Rectal bleeding persisting for 6 weeks or more without a change in bowel habit and without anal symptoms. A change in bowel habit to looser stools and/or more frequent stools persisting for 6 weeks or more without rectal bleeding. Of any age A right abdominal mass consistent with involvement of the large bowel. A palpable rectal mass (intraluminal and not pelvic; a pelvic mass outside the bowel would warrant an urgent referral to a urologist or gynaecologist). Women (not menstruating) Unexplained iron deficiency anaemia and haemoglobin 10 g/100 mL or less.* Men of any age Unexplained iron deficiency anaemia and haemoglobin 11 g/100 mL or less.* * Anaemia considered, on the basis of history and examination in primary care, not to be related to other sources of blood loss (e.g. ingestion of nonsteroidal anti-inflammatory drugs) or blood dyscrasia.

Other causes of rectal bleeding Anal fissure Gastroenteritis Angiodysplasia Meckel's diverticulum Polyp Trauma Rectal varices

Thanks Any Questions?