Rectal bleeding 2

Question 1

What do you look for on general examination of rectal bleeding?

Answer 1

1. Haemodynamically stable?
2. Signs of chronic blood loss?
3. Signs of malignancy?

Question 2

How do you check if patient is haemodynamically stable?

Answer 2

pulse and BP for signs of continuing or new bleeding

Question 3

What would signs of chronic blood loss be?

Answer 3

signs of anaemia e.g. extreme pallor or koilonychia

Question 4

What would signs of malignancy be?

Answer 4

cachexia or obvious lympahdeopathy

Question 5

What do you look for on abdominal exam in rectal bleeding?

Answer 5

focal tenderness or masses: signs of GI malignancy e.g.

1. left supraclavicular lympahedopathy
2. palpable lesions of colon
3. hepatomegaly
4. ascites

Question 6

What do you do during a rectal exam?

Answer 6

1. Inspect anus

2. DRE

Question 7

What do you inspect for on the anus?

Answer 7

1. anal fissure
2. skin tag
3. setinel pile
4. heamorroid
5. fistula

Question 8

When do you not do a DRE?

Answer 8

presence of painful anal fissure or abscess

Question 9

Why do you carry out a DRE?

Answer 9

feel for palpable masses and inspect blood on withdrawn gloved finger

Question 10

When can you feel haemorrhoids on a DRE?

Answer 10

if prolapsed or thrombosed

Question 11

What bloods do you carry out for rectal bleeding?

Answer 11

1. FBC
2. Clotting
3. Group and Save
4. Urea

Question 12

Why do you look at FBC in rectal bleeding?

Answer 12

check for anaemia and low platelets (from chronic blood loss)

Question 13

Why do you measure clotting in rectal bleeding?

Answer 13

check if patient has a bleeding tendency

Question 14

Why do you do a group and save in rectal bleeding?

Answer 14

if patient need blood replacement or may need to go to theatre - or a cross match if urgent

Question 15

Why do you check urea in rectal bleeding?

Answer 15

raise in urea in recent upper GI bleed (urea is a breakdown product of digested rbc)

Question 16

What endoscopy do you always perform?

Answer 16

protoscopy ± rigid sigmoidscopy

Question 17

When would you not peform a protoscopy ± rigid sigmoidscopy?

Answer 17

painful anal lesion

Question 18

What are the downsides of protscopy ± flexible sigmoidscopy?

Answer 18

if too much blood visualistion of rectum may be poor

Question 19

What are the advantages of protscopy ± flexible sigmoidscopy?

Answer 19

1. enable identifcation of bleeding haemorrhoids or a rectal cancer
2. can be done at bedside

Question 20

What are some further main investigations for acute lower GI haemorrhage (frank blood per rectum) that can be considered in stable patients?

Answer 20

1. Colonscopy
2. Mesenteric angiography
3. CT angiography
4. Technetium-99 m-labelled RBC scintigraphy (if available)

Question 21

What are advantages of colonscopy?

Answer 21

1. Diagnostic

2. Can be therapeutic

Question 22

How can a colonscopy be therapeutic?

Answer 22

1. control local haemorrhage by adrenaline injection
2. argon plasma coagulation
3. diathermy
4. clipping

Question 23

What are the disadvanatges of rectal bleeding?

Answer 23

1. Need to prepare bowel

2. Invasive

Question 24

How can you improve visualisation for colonoscopy?

Answer 24

colon can be irrigated via caecal catheter

Question 25

When is mesenteric angiography used?

Answer 25

if haemorrhage obscures view for colonscopy or colonscopy not possible - used in patients that blled, then stop, then bleed

Question 26

What is mesenteric angiography useful to visualise?

Answer 26

angiodysplasia

Question 27

Is mesenteric angiogrpahy widely avilable?

Answer 27

no

Question 28

How can mesenteric angiography be therapeutic?

Answer 28

embolization of bleeding vessel can be peformed during procedure

Question 29

Why is CT angiography useful?

Answer 29

multislice CT can detect even minor bleeds

Question 30

Why is CT angiography better than mesenteric angiography?

Answer 30

1. Venous access not like arterial in mesenteric so fewer complications 2. Provides rapid imaging and enables other abdominal pathology (related or incidental) to be seen

Question 31

What are the disadvantages of CT angiography?

Answer 31

1. no therapeutic opportunity so may need mesenteric or laparotomy 2. involves contract so contradindicated in patients with significant renal impairment

Question 32

When is Technetium-99 m-labelled RBC scintigraphy useful?

Answer 32

for patients where source of bleeding haven't been able to be identified - short lived intermittent bleeds e.g. from Meckel's diverticulum

Question 33

Is Technetium-99 m-labelled RBC scintigraphy widely available?

Answer 33

no

Question 34

What are the disadvantages of Technetium-99 m-labelled RBC scintigraphy?

Answer 34

1. lacks specificity of colonoscopy and mesenteric angiography 2. no therapeutic potential

Question 35

What are the advantages of Technetium-99 m-labelled RBC scintigraphy?

Answer 35

1. non-invasive 2. can detect bleeding lesions up to 24hr after tracer administration 3. no bowel prep needed

Question 36

What is the imaging algorithm for stable patient with rectal bleeding?

Answer 36

1. Protoscopy +/- rigid sigmoidscopy 2. colonscopy 3. Mesenteric angiography / CT angiography 4. Radionuclide imaging

Question 37

When would you do an upper GI endoscopy?

Answer 37

if history and exam suggests 80% of acute GI haemorrhage is upper

Question 38

Why is small bowel visualisation by enteroscopy or video capsule endoscopy not used very often?

Answer 38

limited usage in acute lower GI haemorrhage

Question 39

Which conditions have classic causes of intermittent bleeding can be difficult to visualise?

Answer 39

Angiodysplasia and Dieulafoy lesion

Question 40

What is colonic angiodysplasia?

Answer 40

submucosal ateriovenous malformation

Question 41

What the cause of angiodysplasia?

Answer 41

unknown but predominance in right colon suggests that high wall tension may be factor

Question 42

How big are the lesions in angiodysplasia?

Answer 42

usally less than 1cm in diameter but can bleed out of proportion to size

Question 43

What sort of blood loss is in angiodysplasia?

Answer 43

venous blood loss

Question 44

How does angiodysplasia look on endoscopy?

Answer 44

charactersitic 'cherry red spot' (sometimes too much blood tho)

Question 45

How can angiodysplasia present?

Answer 45

with frank rectal bleeding or occult blood loss and subsequent anaemic symptoms

Question 46

What is the best imaging for angiodysplasia?

Answer 46

mesenteric angiography

Question 47

What is the treatment of angiodysplasia?

Answer 47

1. embolization 2. surgical resection 3. endoscopic laser electrocoagulation

Question 48

What sort of blood loss is in haemorrhage from colonic diverticular disease?

Answer 48

arterial from vasa recta