Bleeding Per Rectum

Omar Tawfiq Rotherham General Hospital 2009

Objectives :-

- Review the common causes of PR bleed

- Review the way of presentation and Management

- Discuss Clinical Scenarios

Bleeding Per Rectum

Common causes :1- Haemorrhoids :- After full examination and investigation . - piles more common to bleed in:- late pregnancy, portal hypertension, large pelvic masses . - bleeding associated with defecation specially with the patient is constipated - the blood is fresh , dark red( venous in colour) - not mixed with faeces - blood is splattered around the pan after defecation - blood is also noted on the toilet paper after wiping - the patient may notice lump at the anus when haemorrhoids are more sever

Bleeding Per Rectum

2- Rectal Carcinomas Usually in middle age and old age . The red flag warning symptoms that should alert you to the fact that you are not dealing with simple haemorrhoids :- bleeding is not usually profuse but the blood is mixed with the stool - stool contain mucus - the patient may complain of apparent incomplete emptying of the bowel after defecation. - Perineal pain or tenesmus is common - Diarrhoea may occur ( also in carcinoma of descending colon )

Bleeding Per Rectum

3- Rectal and Colonic Polyps: Theses are common causes of rectal bleeding with out bowel upset Always ask if other member of the family have had bowel polyps as there is a rare syndrome of familial polyposis. Scanty red blood mixed with the stool May be FOB Diagnosis by colonoscopy

Bleeding Per Rectum

4-Diverticulitis : Usually present with pain in Left iliac fossa. Patient may be constipated , or loos motion It may be presented as an acute abdominal emergency Its usually associated with profuse rectal bleeding, fresh and unheralded Bleeding mat be massive and associated with shock. Diagnosis by colonoscopy , CT scan may be needed to exclude perforation good resuscitation and close observation is needed .

Bleeding Per Rectum

5- Infective Diarrhoeas: salmonella , shigella, entamoeba histolytica are the common causes Fever , abdominal pain ,anorexia , vomiting and malaise Ask about the family and friends, travel abroad Take stool culture Patient may need colonoscopy Antibiotics can induce psuedomembramous colitis .

Bleeding Per Rectum

6- Ischemic colitis: Found usually at the splenic flexure these are relatively rare causes of rectal bleeding ..

Bleeding Per Rectum

7- chronic inflammatory bowel disease :
Bleeding is commonly associated with diarrhoeaans mucus More in ulcerative colitis than crohns disease associated with abdominal pain. may present as emergency . colonoscopy and biopsy needed . May be complicated with perianal sepsis.

Bleeding Per Rectum

Could the bleeding be from higher up in the gastrointestinal tract ?
Usually is black and sticky with the consistency of tar ( melaena ) Iron tablet and bismuth salts also turn the stools black. Make sure you take a good drug history will save you from embarrassment .

Bleeding Per Rectum

What to look for in the patient who complains of rectal bleeding? In your General examination :
Look for Pallor Look for signs of weight loss , dehydration Jaundice Bleeding from else where

Bleeding Per Rectum

Local abdominal examination : Abdominal mass Hepatomegally Inguinal lymphadenopathy Second and third degree piles Anal fissure Anal carcinoma and polyps Fistulae suggestive of anal Crohns disease Perform proctoscopy and rigid sigmoidoscopy Send for blood tests : Hb , WBC , CRP, ESR, LFT, Clotting factors , amylase , Us& Es.

Bleeding Per Rectum

Management: Resuscitation . Investigation Conservative management Semi surgical management Surgical management.

Bleeding from haemorrhoids

Bleeding diverticulum

Summery

Management of PR Bleed :History Examination Resuscitation Investigation Definitive Treatment .