Download Rectal bleeding - FK UWKS 2012 C

Sigid djuniawan,spB.FINACS
Overview
Classification of the causes of bleeding
per rectum
Evaluation of patient with bleeding per
rectum
Management of patient with bleeding per
rectum
OVERVIEW:

The passage of blood per rectum is common
symptom due to lesion of the distal small or large bowel.
 Fresh bleeding per rectum often presents as surgical
emergency.
 The management involving:
a. Resuscitation
b. Determining the source of bleeding
c. Controlling the bleeding
 The management is the combined effort of gasteroenterologist and surgeon with an emphasis on early
intervention.
THE CAUSES OF BLEEDING PER RECTUM
According to the age
According to the Site
According to the age:
(a) Rectal bleeding in children is due to:
 Meckel’s diverticulum
 Juvenile polyps
 Haemangioma
 Anal fissure
 Worms
 Rectal prolapse
 Intussusception
(b) Rectal bleeding in adult is due to:











Haemorrhoids
Anal fissure
Inflammatory bowel disease
Meckel’s diverticulum
Diverticulitis
Angiodysplasia
Aorto-intestinal fistula
Ischemic colitis
Neoplasm (Benign & Malignant)
Coagulation disorder
Chemotherapy
According to the Site:
Small bowel
Large bowel
The common causes of massive lower
GI-Bleeding are:
(a) Diverticular disease
(b) Angiodysplasia
(c) Aorto-enteric fistula
The causes of bleeding per rectum are:
(a) Haemorrhoids
(b) Anal fissure
(c) Large bowel cancer
Surgical Pathology (Bleeding Per Rectum):

Diverticular haemorrhage

Angiodysplasia (Arteriovenous malformations)

Meckel’s diverticulum

Ischaemic bowel disease:
(a) Acute infarctions
(b) Ischaemic colitis

Aorto-enteric fistula
Surgical Pathology (Causes of bleeding per rectum):
 Internal haemorrhoids
 Anal fissure
 Large bowel cancer
PATIENT WITH BLEEDING PER RECTUM
History
Clinical Examination
Investigations
History:
 Age of the patient
 Nature of haemorrhage:






Colour
Clots
Drip with defecation
Smear on paper
Profuse loss
Mixed with stool
 Perineal pain
 Abdominal pain
 Prolapse
 Diarrhoea
 Alteration in the bowel habit
 Abdominal distension
 Symptoms of anemia
 Miscellaneous symptoms:
 Weight loss
 Disturbance of micturation
 Family history
Clinical Examination:
 General physical examination:
- Anaemia, Weight loss, LN enlargement
 Abdominal Examination:
- Abdominal mass, Distension
 Anorectal Examination:
-
Position of the patient left lateral with hips
and knee flexed and the buttocks over the
edge of examination couch.
-
Inspection
-
Patient straining
-
Palpation (Digital examination)
-
Proctoscopy
-
Sigmoidoscopy (Rigid)
-
F.O. Flexible sigmoidoscopy
-
Colonoscopy
Special Investigations:
 CT Scan
 Selective angiography
 Isotope studies
 Barium enema
 Diagnostic laparoscopy / laparotomy
MASSIVE BLEEDING PER RECTUM
The principles of surgical management are similar to those for
acute upper GI bleeding.
Resuscitation
Diagnosis of the cause
Definitive surgical treatment
Exclude upper GI source of bleeding
Test for any bleeding diathesis
Haemorrhoids
The severity is graded by the degree of
prolapse
Grade 1 -no prolapse and cause painless
bleeding.
Grade 2 - prolapse on defecation, go back
spontaneously. Seen on straining.
Grade 3 - prolapse and have to be pushed
back leading to bleeding and aching pain.
Grade 4 - Can’t be pushed back leading to
mucoid discharge, bleeding, pain, necrosis.
Lack of soluble fiber and enough water in the diet,
straining, and sitting longer than 2 minutes on the
toilet which promotes prolapse of the anal cushions.
Hemorrhoids may be inherited, but it may only be
the behaviors and diet habits that are passed along.
Failure to eat breakfast.
Increase in abdominal pressure e.g. pregnancy,
obesity, pelvic tumors, lifting, sitting, coughing,
constipation, diarrhea, anal intercourse, aging.
Correlation with decreased connective tissue strength
as seen in hernias and genitourinary prolapse.
Hemorrhoids can be exacerbated by excessive
cleaning, rubbing, steroids, and hemorrhoid creams.
Enlargement comes from the dragging of the
hemorrhoids downward, weakened supporting
tissue. Elevated sphincter tone increases straining.
Risk Factors
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
Past history of hemorrhoid symptoms or anal fissure
Age 30-65
Heavy lifting, prolonged sitting
Constipation/Diarrhea
Pregnancy
Failure to eat breakfeast.
Diet-Spicy food, fats, alcohol, smoking, low water intake.
Obesity
Spinal cord injuries
Increased sphincter tone
Typical Hemorrhoid Symptoms
Internal Hemorrhoids
1. chronic intermittent bright red
bleeding with bowel movements.
On tissue, in commode, or
streaked on stool surface.
2. Feeling of fullness, swelling, extra
tissue, incomplete BM.
3. Irritation or itching from seepage
of mucus, fecal soiling or
dermatitis from hemorrhoid
creams causes rash.
4. Pain may occur with prolapse,
associated external hemorrhoids
or anal fissure. Visceral nerves
above dentate line sense pressure
not pain.
External Hemorrhoids
1. Rectal pain from stimulation of
2.
3.
4.
5.
somatic nerves of anal skin.
Bulge of tissue on anal skin
Blood on toilet tissue.
Thrombosis leading to a hard
painful lump.
Skin tags left over after dilated
external hemorrhoids,
hemorrhoidectomy, or resolved
thrombosis. Can trap stool and
cause dermatitis and pruritus.
History and Physical
Name:_______________________
Date:_____________________________
Weight:______________________
BP:_______________________________
LOS:_________________________
Past RX:___________________________
CC:__________________________
Family Hx:_________________________
ROS:________________________________________________________________________
Bleeding:________________________
Pain:_______________________________
Irritation/Itching:__________________
Swelling:____________________________
Constipation:_____________________
Diarrhea:____________________________
Time on Commode:_________________
Straining:____________________________
OTC RX:__________________________
RX:_________________________________
Abdomen:______________________
Heart:____________________________
Fissure:_________________________
Sentinel Pile:_________________________
Ext Hem:__________________________________
Skin :___________________________
Int Hem: LL___ RA___ RP___
Spasm:_____________________________
Proctosigmoidoscopy;_________________________________________________________
Anoscopy:__________________________________________________________________
Anal Fissure
Complete Rectal ProlapseProcidentia
Anal Cancer
Hypertrophic Anal Papillae
Colorectal Polyp
Rectal Villous Adenoma
Colorectal Cancer
Rectal Cancer
Inflammatory Bowel Disease
A. Dull mucosa and lack of normal vascular pattern. B. After Rx
Crohn’s Disease
Ulcerative Colitis
Rectal Varices
Rectal Hemangioma
Radiation Proctitis
Hemorrhoids or Not?
Raise your level of suspicion
1. Recent changes in bowel habits, constipation, diarrhea,
small caliber.
2. Abdominal Pain
3. Weight Loss
4. Anemia
5. Family history of Colo-rectal cancer
6. HIV infection, genital warts-HPV, rectal sex, cigarette
smoking and increased risk of anal cancer
7. First-degree-only hemorrhoids.
8. Proctitis
Bloody Stools-Lower GI Hemorrhage in Adults
Melena-Black Tarry stools due to digested blood from upper digestive tract,
esophagus, stomach, and jejunum. Esophagitis, varices, gastritis, gastric ulcer,
peptic ulcer, angiodysplasia, jejunal diverticulum. Rarely from a slow bleeding
right colon lesion. Black licorice, lead, iron, bismuth medicines-Pepto Bismol
can also cause black stools.
Hematochezia-Red or maroon-colored stools frequently foul smelling.
Diverticulosis, angiodysplasia, inflammatory bowel disease, anorectal disease
such as hemorrhoids, anal fissure, fistula in ano, colorectal polyps or cancer,
ischemic colitis, infectious colitis, radiation enteritis, coagulopathy,
aortoenteric fistula, post-polypectomy, post-hemorrhoidectomy, hemobilia, or
massive UGI bleeding. Massive lower GI bleeding causes shock and may require
transfusion. Diverticulosis is the most common cause of major lower GI
bleeding. Blood mixed with stool, shorter duration of sx, and more episodes per
month are more common with cancer, polyps, IBD when compared to
hemorrhoids.
Rectal Bleeding from Hemorrhoids or Anal Fissure-Blood on tissue, on
outside of formed stool, or drips into commode after bowel movement. Blood is
bright red in color. Typically mild and intermittent but occasionally massive.
Hemorrhoids are the most common cause of chronic intermittent minor or
non-massive lower GI bleeding associated with bowel movements.
Hemorrhoid Procedures
1.
2.
3.
4.
5.
6.
7.
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9.
Hemorrhoidectomy: Milligan-Morgan(open), Ferguson(closed). 1-2 days in
hospital. Anesthesia required. Effective but more expense, pain, complications,
and disability compared to office treatments. Its reputation causes many to avoid
effective Rx and to buy ineffective hemorrhoid creams.
PPH-Procedure for Prolapse and Hemorrhoids. Introduced in 1998. Lower pain
than above but may have higher recurrence rate and similar complication rate.
Learning curve. Perforations, stenosis, bleeding, or chronic pain may occur.
Rubber Band Ligation causes ischemic necrosis and scarring, which results in
shrinkage of tissue and fixation to rectal wall. Office procedure with minimal pain
and complications. Low recurrence rate which can be Rx with rebanding.
IRC-infrared coagulation requires 5-7 Rx, is more expensive than banding, higher
recurrence rate, and may make external disease worse. Coagulates and scleroses
tissue with heat. Less painful than old banders but more painful than CRH
bander.
Sclerotherapy-Phenol or vegetable oil, urea hydrochloride or hypertonic salt
injected into base. Out of favor 2nd to complications and high recurrence rate.
Bipolar diathermy-Coagulates and fibroses with heat.
Direct-current electrotherapy-Coagulates and fibroses with heat.
Doppler ligation-more expensive and no proven advantage over banding.
Cryosurgery and anal stretch no longer recommended because of complications
CRH Banding - by position
Rubber Band Ligation
Rectal Bleeding and Colonoscopy
Bright red rectal bleeding with bowel movements is a common
complaint. Benign lesions are the most common cause.
1. Incidence of Colon Cancer in patients with chronic
intermittent rectal bleeding that is typical of hemorrhoids
with no abdominal pain, change in bowel habits and rectal
cancer not present on anoscopy is .8 - 3 %. In those under
the age of 50 it is 0-3%. Other causes include polyps,
fissures, diverticulosis, IBD.
2. The average approved reimbursement for colonoscopy is
approximately $2200 compared to $1200 for banding.
3. Complications occur in 1-5% including perforation at a rate
of .05-.3% and bleeding at a rate of .1-2%.
4. Colonoscopy misses 2-6% of colon cancers
Do All Patients with Rectal Bleeding Typical of
Hemorrhoids Need Colonoscopy
Yes. Symptoms are unreliable and significant
pathology is found in 20-40%; CRC, polyps,
IBD, fissure, diverticulosis, angiodysplasia,
rectal ulcers or proctitis, infectious or ischemic
colitis.
No. Having an effective office hemorrhoid
treatment changes the approach. Banding the
hemorrhoids first and restricting colonoscopy
to those with positive FIT post banding is safe,
cost effective, provides effective treatment, and
avoids colonoscopy in over 90% of patients.
Indications for Colonoscopy in
Evaluation of Hemorrhoids
1. History or physical findings suggestive of cancer
2.
3.
4.
5.
or IBD. Abdominal pain, weight loss, change in
bowel habits, no obvious source of bleeding.
Iron deficiency anemia
Positive FIT/after RX
Age over 40 with 1st degree relative with CRC or
adenoma<60 and no BE or colonoscopy within 10
years.
Age over 40 with two 1st degree relatives and no
evaluation within 3-5 years.
American Cancer Society Colorectal Cancer Screening Guidelines
Beginning at age 50 (45 for African Americans), men and women who are at
average risk for developing colorectal cancer should have 1 of the 5 screening
options below:
a fecal occult blood test (FOBT)* or fecal immunochemical test (iFOBT or
FIT)* every year**, OR
flexible sigmoidoscopy every 5 years, OR
an FOBT* or FIT* every year plus flexible sigmoidoscopy every 5 years**, OR
(Of these first 3 options, the combination of FOBT or FIT every year plus
flexible sigmoidoscopy every 5 years is preferable.)
double-contrast barium enema every 5 years**, OR
colonoscopy every 10 years
*For FOBT or FIT, the take-home multiple sample method should be used.
**Colonoscopy should be done if the FOBT or FIT shows blood in the stool, if
sigmoidoscopy results show a polyp, or if double-contrast barium enema
studies show anything abnormal. If possible, polyps should be removed
during the colonoscopy.
CT Colonography
1. Helical CT scan creates two and three-dimensional images.
Prepare with phospha-soda and bisacodyl. Air insufflation.
2. Accurate in detection of polyps greater than 10 mm and colon
cancer.
3. False positives 15% unnecessary colonoscopy from retained
stool, diverticular disease, thick or complex haustral folds,
metal or motion artifacts.
4. May miss flat adenomas which are more aggressive.
5. Non therapeutic.
6. More expensive and not covered by insurance.
Fissure
Skin tags
 Skin tags are extra folds of skin around the anal verge.
Caused by stretching of skin from dilated external
hemorrhoids. May interfere with cleaning and add to
pruritus ani. Cosmetic issue to some.
 Skin tag and can be removed or left alone depending on
preference.
 Removal requires local anesthesia and office excision.
Takes 15 minutes and leads to 2-3 days of discomfort.
Associated skin tags