Bleeding per rectum - Clinicals, Diagnosis, and Management

Colorectal

Clinicals - History

Fact Explanation
Bleeding per rectum Fresh blood may be found in hemorrohids, anal fissures etc. Passage of formed stool mixed with blood is suggestive of an anorectal bleeding. Altered black blood is associated with right sided colonic malignancies. Melena is black tarry stools, may be due to upper GI bleeding. Hemochezia is the passing of red blood via the rectum usually from the lower gastrointestinal tract, and usually associated with angiodysplasia like conditions. Bleeding per rectum
Fresh blood may be found in hemorrohids, anal fissures etc. Passage of formed stool mixed with blood is suggestive of an anorectal bleeding. Altered black blood is associated with right sided colonic malignancies. Melena is black tarry stools, may be due to upper GI bleeding. Hemochezia is the passing of red blood via the rectum usually from the lower gastrointestinal tract, and usually associated with angiodysplasia like conditions.
Frequency and duration of bleeding Bleeding per rectum which is persistent or intermittent is a common symptom in polyps. Acute onset may be due to diverticular disease, angiodysplasia, jejunoileal diverticula, meckel’s diverticulum, neoplasms/lymphomas, enteritis/Crohn’s disease.
Peptic ulcer disease, gastritis/duodenitis and esophageal varices are the causes of upper gastrointestinal causes for the acute rectal bleeding. Angiodysplasia, small bowel tumors, small bowel ulcers and erosions, crohn’s disease, small bowel diverticulosis, and radiation enteritis are causes for chronic intermittent bleeding.
Frequency and duration of bleeding
Bleeding per rectum which is persistent or intermittent is a common symptom in polyps. Acute onset may be due to diverticular disease, angiodysplasia, jejunoileal diverticula, meckel’s diverticulum, neoplasms/lymphomas, enteritis/Crohn’s disease.
Peptic ulcer disease, gastritis/duodenitis and esophageal varices are the causes of upper gastrointestinal causes for the acute rectal bleeding. Angiodysplasia, small bowel tumors, small bowel ulcers and erosions, crohn’s disease, small bowel diverticulosis, and radiation enteritis are causes for chronic intermittent bleeding.
Pain Painless bleeding may be due to hemorrohids, colorectal carcinoma, polps, diverticular disease and Bleeding will be painful in anal fissure which is a severe sharp pain occurring with straining on defecation and resolves within an hour after defecation. Strangulated hemorrhoids are usually associated with pain. Pain
Painless bleeding may be due to hemorrohids, colorectal carcinoma, polps, diverticular disease and Bleeding will be painful in anal fissure which is a severe sharp pain occurring with straining on defecation and resolves within an hour after defecation. Strangulated hemorrhoids are usually associated with pain.
Age Diverticular disease, arteriovenous malformations, colorectal carcinoma and polyps are known to be more common in elderly people. Meckel's diverticulitis, intussuseption is more common in infants and young children. Inflammatory bowel disease is common in the age between 20-40 years. Anal fissures and hemorrhoids are also common in young age group. Age
Diverticular disease, arteriovenous malformations, colorectal carcinoma and polyps are known to be more common in elderly people. Meckel's diverticulitis, intussuseption is more common in infants and young children. Inflammatory bowel disease is common in the age between 20-40 years. Anal fissures and hemorrhoids are also common in young age group.
Tenesmus and sense incomplete evacuation of the rectum Tenesmus is painful desira to defecate without passage of stools. Constipation may be chronic. These symptoms are usually occurred in lower GI neoplasms. Tenesmus and sense incomplete evacuation of the rectum
Tenesmus is painful desira to defecate without passage of stools. Constipation may be chronic. These symptoms are usually occurred in lower GI neoplasms.
Constipation and diarrhoea Alternating constipation and diarrhoea is a feature of lower GI malignancies. Anal fissures are more common in patients with history of constipation. Inflammatory bowel disease may also cause diarrhoea. Constipation and diarrhoea
Alternating constipation and diarrhoea is a feature of lower GI malignancies. Anal fissures are more common in patients with history of constipation. Inflammatory bowel disease may also cause diarrhoea.
Lump at anus Is due to the haemorrhoids. Occasionally a polyp or rectal prolapse may be the cause. Lump at anus
Is due to the haemorrhoids. Occasionally a polyp or rectal prolapse may be the cause.
Haematomesis Passage of blood with vomitus may be indicative of upper GI bleeding. Peptic ulcer disease may occasionally presents with lower GI bleeding. Haematomesis
Passage of blood with vomitus may be indicative of upper GI bleeding. Peptic ulcer disease may occasionally presents with lower GI bleeding.
Abdomonal pain Right sided colonic malignancies can cause right sided abdominal pain. Intestinal obstructuin by an annular growth also may be possible. Abdomonal pain
Right sided colonic malignancies can cause right sided abdominal pain. Intestinal obstructuin by an annular growth also may be possible.
History of radiation to abdomen and/or pelvis Radiation colitis may be due to radiation treatment. History of radiation to abdomen and/or pelvis
Radiation colitis may be due to radiation treatment.
Extraintestinal features:uveitis, joint pain Associated features in autoimmune conditions like Inflammatory bowel disease. Extraintestinal features:uveitis, joint pain
Associated features in autoimmune conditions like Inflammatory bowel disease.
Shortness of breath on exertion, lethargy Intermittent chronic blood loss may cause amaemia. Low oxygen to the tissues due to the anaemia, causes lack of energy. Shortness of breath on exertion, lethargy
Intermittent chronic blood loss may cause amaemia. Low oxygen to the tissues due to the anaemia, causes lack of energy.
Diet Increased fat in diet, high intake of red and processed meats, highly refined grains and starches, and reduced fibre are known to increase the risk of colorectal carcinoma. Fiber dilutes or adsorbs fecal carcinogens, modulates colonic transit time, alter bile acid metabolism, reduce colonic pH, or increase the production of short-chain fatty acids, by which it reduces the risk of colorectal cancers. Diet
Increased fat in diet, high intake of red and processed meats, highly refined grains and starches, and reduced fibre are known to increase the risk of colorectal carcinoma. Fiber dilutes or adsorbs fecal carcinogens, modulates colonic transit time, alter bile acid metabolism, reduce colonic pH, or increase the production of short-chain fatty acids, by which it reduces the risk of colorectal cancers.

Clinicals - Examination

Fact Explanation
Pallor Anaemia is due to intermittent chronic blood loss , or malignancy induced inflammation. Pallor
Anaemia is due to intermittent chronic blood loss , or malignancy induced inflammation.
Low blood pressure Sometimes bleeding may be massive; causing hypotension and shock. Low blood pressure
Sometimes bleeding may be massive; causing hypotension and shock.
Tachycardia Due to massive bleeding and shock. Tachycardia
Due to massive bleeding and shock.
Lump at anus May be there with haemorrhoids. Lump at anus
May be there with haemorrhoids.
Ejection systolic murmer at aortic area radiating to the neck Some studies have shown that there is increased incidence of aortic stenosis among the patients with angiodysplasia and other vascular malformations. Ejection systolic murmer at aortic area radiating to the neck
Some studies have shown that there is increased incidence of aortic stenosis among the patients with angiodysplasia and other vascular malformations.
Digital rectal examination DRE will reveal any polyps, groths, haemorrhoids and ulcers in the anorectal region. Digital rectal examination
DRE will reveal any polyps, groths, haemorrhoids and ulcers in the anorectal region.
Abdominal mass Abdominal mass may be palpated in right sided colonic/caecal tumours. Abdominal mass
Abdominal mass may be palpated in right sided colonic/caecal tumours.

Investigations - Diagnosis

Fact Explanation
Sigmoidoscopy This is the first line investigation in lower GI bleeding. It usually examine upto splenic flexure of the colon. Intestinal growths, ulcers, polyps etc may be found on sigmoidoscopy. Sigmoidoscopy
This is the first line investigation in lower GI bleeding. It usually examine upto splenic flexure of the colon. Intestinal growths, ulcers, polyps etc may be found on sigmoidoscopy.
Colonoscopy This is an important diagnostic tools to evaluate acute lower gastrointestinal bleeding. Colonoscopy is more sensitive and accurate than sigmoidoscopy in diagnosis. These may be operator dependent. Active bleeding will limit the use of the investigation. It is also important as to exclude the other lesions in the colon before the hemicolectomy. Colonoscopy
This is an important diagnostic tools to evaluate acute lower gastrointestinal bleeding. Colonoscopy is more sensitive and accurate than sigmoidoscopy in diagnosis. These may be operator dependent. Active bleeding will limit the use of the investigation. It is also important as to exclude the other lesions in the colon before the hemicolectomy.
Stool occult blood test Stool for occult blood is positive even in asymptomatic people. Stool occult blood test
Stool for occult blood is positive even in asymptomatic people.
Angiography Clusters of small arteries during the arterial phase at the antimesenteric border, accumulation of vascular spaces and opacification of the bowel during the capillary phase, early opacification of the veins draining the caecum and ascending colon are the features for the diagnosis of angiodysplasia on angiography. Angiography
Clusters of small arteries during the arterial phase at the antimesenteric border, accumulation of vascular spaces and opacification of the bowel during the capillary phase, early opacification of the veins draining the caecum and ascending colon are the features for the diagnosis of angiodysplasia on angiography.
Technetium-labeled red blood cell scintigraphy Is able to detect active gastrointestinal bleeding even at a low rate. Technetium-labeled red blood cell scintigraphy
Is able to detect active gastrointestinal bleeding even at a low rate.

Investigations - Management

Fact Explanation
Full blood count Chronic intermittent bleeding can cause iron deficiency anaemia, which will manifest as low haemoglobin. Full blood count
Chronic intermittent bleeding can cause iron deficiency anaemia, which will manifest as low haemoglobin.
Colonoscopy Syndromes like heredetery non polyposis colorectal carcinoma (HNPCC) has a high risk of malignant transformation and need regular follow up. It is recommended to screen every 2 yearly from the age of 25, and5 years younger than the earliest affected case in the family up to 75 years. Colonoscopy
Syndromes like heredetery non polyposis colorectal carcinoma (HNPCC) has a high risk of malignant transformation and need regular follow up. It is recommended to screen every 2 yearly from the age of 25, and5 years younger than the earliest affected case in the family up to 75 years.
Full blood count Chronic intermittent bleeding can cause iron deficiency anaemia, which will manifest as low haemoglobin, reduced mean corpuscular volume and mean corpuscular haemoglobin with microcytic anaemia and increased red cell distribution width. Full blood count
Chronic intermittent bleeding can cause iron deficiency anaemia, which will manifest as low haemoglobin, reduced mean corpuscular volume and mean corpuscular haemoglobin with microcytic anaemia and increased red cell distribution width.
Echocardiogram Some patients have the underlying cardiac disorders that can cause low perfusion and ischaemia of the walls of intestines. Echocardiogram
Some patients have the underlying cardiac disorders that can cause low perfusion and ischaemia of the walls of intestines.
CT scan, MRI scan To stage the disease in colorectal carcinoma. CT scan, MRI scan
To stage the disease in colorectal carcinoma.
Carcinoembryonic antigen (CEA) Plasma level of carcinoembryonic antigen (CEA) is measured preoperatively in a suspected case of colorectal malignancy. It may also be elevated in other conditions like gastric carcinoma, pancreatic carcinoma, lung carcinoma, breast carcinoma, and medullary thyroid carcinoma, as well as some non-neoplastic conditions like ulcerative colitis, pancreatitis, cirrhosis, COPD, Crohn's disease. Carcinoembryonic antigen (CEA)
Plasma level of carcinoembryonic antigen (CEA) is measured preoperatively in a suspected case of colorectal malignancy. It may also be elevated in other conditions like gastric carcinoma, pancreatic carcinoma, lung carcinoma, breast carcinoma, and medullary thyroid carcinoma, as well as some non-neoplastic conditions like ulcerative colitis, pancreatitis, cirrhosis, COPD, Crohn's disease.

Management - Supportive

Fact Explanation
Resuscitation Patients can present with acute massive gastrointestinal haemorrhage needing resuscitation. Special attention should be focused on circulation due to the massive blood loss. Volume resuscitation may be needed. Resuscitation
Patients can present with acute massive gastrointestinal haemorrhage needing resuscitation. Special attention should be focused on circulation due to the massive blood loss. Volume resuscitation may be needed.
Management of anaemia Anaemia can be due to chronic intermittent blood loss from gastrointestinal tract, malignancy induced inflammation and underlying comorbidities. If significant anaemia present with clinical features they need to get treatment and if needed even blood transfusion. Management of anaemia
Anaemia can be due to chronic intermittent blood loss from gastrointestinal tract, malignancy induced inflammation and underlying comorbidities. If significant anaemia present with clinical features they need to get treatment and if needed even blood transfusion.
Pre op angiography Selective angiography is recommended for the preoperative localization of bleeding sites. Pre op angiography
Selective angiography is recommended for the preoperative localization of bleeding sites.
Reducing the risk of colorectal carcinoma Clinical trials have shown that aspirin in doses as low as 325 mg per day reduces risk of colorectal carcinoma. Reduction of fat in diet is also an important measure. Avoidance of smoking and heavy alcohol use, prevention of weight gain, and the maintenance of a reasonable level of physical activity are known to lower the risks of colorectal cancer. Reducing the risk of colorectal carcinoma
Clinical trials have shown that aspirin in doses as low as 325 mg per day reduces risk of colorectal carcinoma. Reduction of fat in diet is also an important measure. Avoidance of smoking and heavy alcohol use, prevention of weight gain, and the maintenance of a reasonable level of physical activity are known to lower the risks of colorectal cancer.
Management and prevention of constipation Constipation can be an aetiology for various diseases. Therefore simple measures like maintaining adequate fluid intake, eating fresh vegetables, fruits and green leaves, adequate fibre intake and maintaining proper toilet habits are important. Management and prevention of constipation
Constipation can be an aetiology for various diseases. Therefore simple measures like maintaining adequate fluid intake, eating fresh vegetables, fruits and green leaves, adequate fibre intake and maintaining proper toilet habits are important.

Management - Specific

Fact Explanation
Management of colorectal carcinoma Surgery is the most important part in the treatment of rectal cancer. Stage T1 and T2 local excision is possible. Local excision combine with pre- or postoperative radio-chemotherapy gives the good the outcome. Transanal endoscopic microsurgery (TEM), is a new technique that provides a locally curative operation. High ligation of the interior mesenteric artery, will be beneficial. Minimum margin of mesorectum should be 5 cm. There are main 2 types of surgical options available: Abdominoperineal resection (APR) and anterior resection. Anterior resection is a sphincter-sparing operation that gaining the popularity. Abdominoperineal resection (APR) does not preserve the sphincters.
Intravenous Fluorouracil, oral fluoropyrimidines, angiogenesis Inhibitors, epidermal Growth Factor Receptor Inhibitors in isolation or as combined treatment is used as systemic therapy for the colorectal cancers.
Management of colorectal carcinoma
Surgery is the most important part in the treatment of rectal cancer. Stage T1 and T2 local excision is possible. Local excision combine with pre- or postoperative radio-chemotherapy gives the good the outcome. Transanal endoscopic microsurgery (TEM), is a new technique that provides a locally curative operation. High ligation of the interior mesenteric artery, will be beneficial. Minimum margin of mesorectum should be 5 cm. There are main 2 types of surgical options available: Abdominoperineal resection (APR) and anterior resection. Anterior resection is a sphincter-sparing operation that gaining the popularity. Abdominoperineal resection (APR) does not preserve the sphincters.
Intravenous Fluorouracil, oral fluoropyrimidines, angiogenesis Inhibitors, epidermal Growth Factor Receptor Inhibitors in isolation or as combined treatment is used as systemic therapy for the colorectal cancers.
Management of polyps HNPCC is an autosomal dominant condition with a mutation in DNA mismatch repair genes. This condition has a high chance of developing colorectal carcinomas. Prophylactic colectomy will be needed in high risk people. Single staged subtotal colectomy with ileosigmoidostomy is the treatment for multiple polyps. Management of polyps
HNPCC is an autosomal dominant condition with a mutation in DNA mismatch repair genes. This condition has a high chance of developing colorectal carcinomas. Prophylactic colectomy will be needed in high risk people. Single staged subtotal colectomy with ileosigmoidostomy is the treatment for multiple polyps.
Management of haemorrohids Constipation or other causative factors needs to be corrected. Sitz baths are used to reduce swelling and sphincter spasm. Injection sclerotherapy, band ligation and surgical treatment are the other options available. Management of haemorrohids
Constipation or other causative factors needs to be corrected. Sitz baths are used to reduce swelling and sphincter spasm. Injection sclerotherapy, band ligation and surgical treatment are the other options available.
Management of angiodysplasia Conservative approach is suitable for the hemodynamically stable patients as bleeding can stop spontaneously in the majority of patients. Surgery is the management option with highest cure rate. It is done when the endoscopic ablation is not suitable or if life-threatening hemorrhage occurs. Right hemicolectomy or if relevant total colectomy is done. Management of angiodysplasia
Conservative approach is suitable for the hemodynamically stable patients as bleeding can stop spontaneously in the majority of patients. Surgery is the management option with highest cure rate. It is done when the endoscopic ablation is not suitable or if life-threatening hemorrhage occurs. Right hemicolectomy or if relevant total colectomy is done.
Management of diverticular disease Endoscopic therapy, includes epinephrine injection, thermal application, or band ligation. Management of diverticular disease
Endoscopic therapy, includes epinephrine injection, thermal application, or band ligation.
Treatment of radiation proctits Argon plasma coagulation , formalin application, sucralfate enemas, and hyperbaric oxygen therapy is used to treat radiation proctits. However endoscopic therapies are now becoming the treatment of choice in chronic radiation proctitis. Treatment of radiation proctits
Argon plasma coagulation , formalin application, sucralfate enemas, and hyperbaric oxygen therapy is used to treat radiation proctits. However endoscopic therapies are now becoming the treatment of choice in chronic radiation proctitis.

Concise, fact-based medical articles to refresh your knowledge

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