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BLEEDING PER RECTUM

Clinical group 234th batch

Faculty of medicine-University of RuhunaBy-PRJ,MASJ,KM,KK,SWK,SK.

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• What is bleeding PR ?• History taking from a patient with bleeding PR• Common DDs for bleeding PR• Physical examination of a patient with

bleeding PR• Investigations (lab/endoscopic/radiological)• Treatment options

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Rectal bleeding

A symptom of a problem in the GI tract.It means any blood passed rectally; consequently, the blood may come from any area or structure in the GI tract that allows blood to leak into the GI lumen.

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Causes of rectal bleeding

• Hemorrhoids• Anal fissures• Carcinoma ( colorectal, anal )• Colorectal polyps• Inflammatory bowel disease ( chron’s disease,

ulcerative colitis)• Rectal prolapse

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• Chronic infections causing colitis• Diverticular disease• Ischaemic colitis• Angiodysplasia of the colon• Bleeding diathesis

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causes of rectal bleeding according to the history

• Pattern of bleeding -Fresh blood- distal lesion (anal canal or rectum) -Altered blood- proximal lesion • Amount of blood passed• Duration & progression• Associated symptoms- pain, lump,

alteration in bowel habits, etc.

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Important points in the history• Hemorrhoids- bleeding after defecation - fresh blood drops on stools - spurting of blood - lump coming out of anus - perianal discomfort• Anal fissure- fresh blood streaked on stools - pain( sharp, severe, start with defecation & last for hours) • Inflammatory bowel disease- blood & mucus diarrhea - painless unless co-exist fissure - systemic symptoms; low grade fever

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• Colorectal carcinoma- - fresh blood after defecation- rectal carcinoma -altered blood mixed with stools – carcinoma in sigmoid colon or descending colon - painless - tenesmus & sense of incomplete ivacuation (rectal CA)

- altered bowel habits (early morning blood & mucus diarrhea, constipation or altering constipation &

diarrhea. - features of complications ( intestinal obstruction, local

spread, distant metastasis)• Diverticular disease- large volume of blood - painless

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perianal conditions causing rectal bleeding.

HaemorrhoidsAnal fistulaAnal fissure

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HAEMORRHOIDS

• These are enlarged vascular cushions in the lower rectum and anal canal.

• The classical position of haemorrhoids corresponds to the 3 o’clock, 7 o’clock and 11 o’clock positions with the patient in the lithotomy position.

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INTERNAL HAEMORRHOIDS: -develops above the dentate line. -covered by anal mucosa. -lacks sensory innervation (painless) -bright red or purple in color. EXTERNAL HAEMORRHOIDS: -arise below the dentate line. -covered by St. sq. epith. -innervated by the inferior rectal nerve. Internal H. drains into sup. Rectal veins portal systemExternal H. drains into inf. Rectal veins I.V.C.

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Clinical features of haemorroids

• Bleeding, is the principal and earliest symptom.• The nature of the bleeding is characteristically separate

from the motion and is seen either on the paper on wiping or as a fresh splash in the pan.

• rarely, the bleeding may be sufficient to cause anaemia.• pain may result from congestion of pile masses below a

hypertonic sphincter.• mucous discharge• prolapse

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Four degrees of haemorrhoids

• First degree – bleed only, no prolapse

• Second degree – prolapse, but reduce spontaneously

• Third degree – prolapse and have to be manually reduced

• Fourth degree – permanently prolapsed

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Complications of haemorrhoids

• Strangulation and thrombosis.• Ulceration• Gangrene• Portal pyaemia• Fibrosis

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Treatment of haemorrhoids

• Symptomatic – advice about defaecatory habits, stool softeners and bulking agents

• Injection of sclerosant• Banding• Transanal haemorrhoidal

dearterialisation/haemorrhoidopexy• Haemorrhoidectomy

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Indications• third- and fourth-degree

haemorrhoids;• second-degree haemorrhoids that have not been cured bynon-operative treatments;• fibrosed haemorrhoids;• interoexternal haemorrhoids when the external haemorrhoidis well defined.

Complications of haemorrhoidectomy Early• Pain• Acute retention of urine• Reactionary haemorrhage Late• Secondary haemorrhage• Anal stricture• Anal fissure• Incontinence

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Colorectal tumours• polyps• Adenoma• AdenocarcinomaAnal tumours• squamous carcinoma of the lower anal canal

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Polyps• Males>Females• >40yrs• Classification-Hamartomatous-Peuts-Jeghers -Juvenile -Hyperplastic -Inflammatory -Neoplastic- Adenoma

-Familial polyposis coli

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C/F -: • Asymtomatic (most)• Passsage of blood & mucus PR• Prolaps• Rarely obstruction/Intussusception

Morphologicaly-:• pedunculated/sessile

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Peuts-Jeghers polypsCommon in small IN , but can occur in large INAssociated with mucocutaneous pigmentation in lips and gums MultipleJuvenile polypsCause bleeding or obstructionPain if prolaps during deficationHyperplastic polypsComprise 90% of all polypsMultipleInflammatory polypsPseudopolypsUsually associated with colitis

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Adenomatous polyps• Histological types-Tubular -Villous (*)

-Tubulovillous• Solitary/Multiple• Presentations-diarrhoea -mucous discharge -hypokalaemia -bleeding• Risk of malignancy is increased with the increased size

of adenoma(>1cm) , with the sessile nature,villous architecture & dysplasia

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Familial polyposis coli

• >100 polyps• Autosomal dominant• Colonic & rectal(stomach,duodenum & small IN)• Around puberty• 100% chance of malignancy & 40yrs

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Colorectal carcinoma• Has genetic predisposition• 5yr survival-30%-40%• Etiology-dietary animal fat -Smoking -Alcohol -cholecystectomy

-low fiber diet• M:F-3:1• Common age-45-65yrs

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• Macroscopy- AnularTubular

Ulcer Cauli flower

• Microscopy-predominatly adenocarcinoma

• Spread-local, lymphatics,haematogenous,transcoelomic

• Staging-Dukes TNM

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Clinical features:

20%-emergency(intestinal obstrction,peritonitis)

Symptoms depends on the region of the lesion

• Left colon• Right colon• Metastasis• Rectal cancer

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CARCINOMA OF THE RECTUM• 75% occur in the lower part of the rectal ampulla

papilliferous or a simple ulcer with everted edges. • 25% in the upper part of the rectum annular in shape. • 90% or rectal cancers can be felt with a finger during PR.

MACROSCOPIC APPEARANCE: It may be as follows: • papilliferous • ulcerating commonest • stenosing at rectosigmoid • colloid

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MICROSCOPIC APPEARANCE: • *90% are adenocarcinoma • *9% are colloid – adenocarcinoma with

mucous production-• *1% highly anaplastic carcinoma simplex

• Rectal ca is common in middle and old age (50-70 yrs) but can occur in young adults.

• It is equally common in both sexes.

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• Rectal bleeding •Change in bowel habit •High annular cancers at the rectosigmoid junction may cause partial obstruction presenting as alternating constipation and diarrhoea.

•Tenesmus

•Pain is an uncommon symptom.

Symptoms

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SIGNS ON EXAMINATION On Rectal Examination:

the lower edge of a malignant ulcer can be felt blood and mucous on the gloved finger. If the tumour is in the upper part of the rectum, only the lower edge is felt.

On general examination:

The liver Other sites for metastasis are: supraclavicular lymph glands, the lungs and the skin.

The inguinal LN are involved only if the tumour is below the Hiltons line to involve the skin. If the pt. has palpable inguinal LN, the tumour is most likely to be sq. cc. of the anal skin.

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Anal tumours• Rare• Most common-epidermoid tumours(sq cc)• A malignant tumour protruding through the anal

canal is more likely to be an adenocarcinoma of the rectum invading the anal skin.

DIVERTICULAR DISEASE•Diverticulae are outpouchings of mucosa through the bowel wall associated with increased intraluminal pressure.•May occur anywhere in the colon.•But commonly occur in the sigmoid and descending colon. •May be asymptomatic. May present with •Rectal bleeding: acute, massive and fresh blood ; often required blood transfusion.•chronic left sided abdominal pain + changes in bowel habits •acute abdominal symptoms

•It is diagnosed via barium enema or colonscopy.

Inflammatory Bowel Disease

Chronic inflammatory disease occur anywhere in the alimentary tract from mouth to anus.

Chronic inflammatory disease that involves the whole or part of the colon.

Transmural disease. Confined to the mucosa.

Common sites; terminal ileum colon rectum

Nearly always involves the rectum, extending to involve distal or total colon.

Ulcerative colitisCrohn’s disease

Crohn's Disease Ulcerative Colitis

Discontinuous, "Skip" lesions Continuous lesions.Risk of malignancy is rare. Malignancy changes occur with

time.Presentation depends upon the area of involvementIn chronic disease,•Mild diarrhea over many months•Pain and tender mass in RIF•Rectal bleeding•fever•Weight loss

•Watery or bloody diarrhoea•Rectal discharge of blood stained mucus or purulent discharge•Abdominal pain•Fever•Weight loss

•Ischaemic colitis

•Angiodysplasia

•Irradiation colitis / Proctitis

•Aortoenteric fistula

•Rectal prolapse•Intussusception•Mesenteric infarction•Massive upper GI bleeding•Trauma•Bleeding diathesis

Physical examination and lab investigations

General examinationlPallorlIcteruslPeripheral stigmata of inflammatory bowel disease l skin - erythema nodosum, pyoderma gangrenosuml Eye - sleritis, uveitislLymphadenopathy - left supraclavicular node

Abdominal examination

• Hepatomegally• Palpable masses• Ascitis

Digital rectal examination

lInspection – anal fissures, skin tags, prolapse, opening of fistula lPalpate – masses (size, ulceration, pararectal lymphnodes) , mucosa , prostate gland, lAnal sphincter tonelLook at finger for blood, stool, mucous

inspection

Rectal carcinomaon Rectal Examination: It feels hard and bulges into the lumen of the rectum, the edges are everted and the base is irregular and friable. Upon withdrawal of the finger, you will have blood and mucous on the gloved finger. If the tumour is in the upper part of the rectum, only the lower edge is felt.

Proctoscopy

lFor diagnosis and treatment of haemorrhoids

lExtact locaton of the tumor in relation to the sphincter mechanism

sigmoidoscopy:

2 types – rigid sigmoidoscopyflexible sigmoidoscopy

essential to exclude rectal pathology as carcinoma or polyps.

should be taken tissue biopsies for histology

Flexible sigmoidoscopy

Barium Enema

Double-contrast barium enema examinations can be justified only for elective evaluation of previous unexplained LGIB.Do not use barium enema examination in the acute hemorrhage phase, because it makes subsequent diagnostic evaluations, including angiography and colonoscopy, impossible.

Single-contrast enema study in a patient with total colitis shows mucosal ulcers with a variety of shapes, including collar-button ulcers, in which undermining of the ulcers occurs, and double-tracking ulcers, in which the ulcers are longitudinally orientated.

Ulcerative colitis

Crohn disease. Aphthous ulcers. Double-contrast barium enema examination in Crohn colitis demonstrates numerous aphthous ulcers.

Crohn disease. Cobblestoning.

Colorectal carcinoma - Barium enema

Lab investigations•FBC•ESR•U&E•LFT(liver metastases)•Carcinoembryonic antigen (CEA) test•Cancer anrigen - CA 19-9 assay •Clotting screen•Fecal occult blood testing•Histology

Management of the diverticular disease•Uncomplicated symptomatic diverticular diseaseHigh fiber dietAntispasmodic eg- ColofacBulking agent eg - Fybogel•Acute diverticulitisBed restFluid only or nil orallyAnalgesicAntibiotics – cefuroxime and metronidazole

•Perforation with generalized fecal peritonitisLaparotomyPeritoneal lavageResect perforated areaAntibiotics as for acute diverticulitis

Crohn’s diseaseMedical Mx Surgical Mx

•Correction of fluid & electrolyte •Steroids-40mg/d prednisolone •Mesalazine-reduce the frequency •Other drugs-Asathioprine Cyclosporin,Metronidazole•Antidiarrhoeal agent

• Segmental resection of the bowel as much as possible • For short strictures-stricturoplasty• Proctocolectomy with ileostomy

Ulcerative colitisMedical management Surgical managementAcute severe UC is treated with -IV fluids-parenteral nutrition-parenteral steroids

For less ill patients – oral antibiotics

To maintain the remission-sulphasalazine-mesalazine

Panproctocolectomy with ileostomy

Other procedures-retention of the rectum with proctectomy-fashioning of an ileal pouch with with maintenance of anal sphincter

Colonic polyps•Pedunculated or small sessile polyps may be removed at sigmoidoscopy or colonoscopy•If invasive CA is found – colectomy is required

Surgical management of large bowel carcinoma•CA of the caecum and the colon :- Right hemicolectomy•CA of the hepatic flexure :- Extended right hemicolectomy•CA of the transverse colon :- Transverse colectomy or extended right hemicolectomy •CA of the splenic flexure and the descending colon :-Left hemicolectomy•CA of the sigmoid colon :- Sigmoid colectomy

CA of the rectumSphincter saving surgery – Anterior resection Tumour should be more than 1-2cm above the anal sphincter Sphincter loosing surgery – Abdomino perineal resection with permanent colostomy.This is combined with a total mesorectal excision (TME)

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