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BLEEDING PER RECTUM
Clinical group 2
34th batch
Faculty of medicine-University of Ruhuna
By-PRJ,MASJ,KM,KK,SWK,SK.
1
• What is bleeding PR ?
• History taking from a patient with bleeding PR
• Common DDs for bleeding PR
• Physical examinati...
Rectal bleeding
A symptom of a problem in the GI tract.
It means any blood passed rectally;
consequently, the blood may co...
Causes of rectal bleeding
• Hemorrhoids
• Anal fissures
• Carcinoma ( colorectal, anal )
• Colorectal polyps
• Inflammator...
• Chronic infections causing colitis
• Diverticular disease
• Ischaemic colitis
• Angiodysplasia of the colon
• Bleeding d...
causes of rectal bleeding according to
the history
• Pattern of bleeding
-Fresh blood- distal lesion (anal canal or rectum...
Important points in the history
• Hemorrhoids- bleeding after defecation
- fresh blood drops on stools
- spurting of blood...
• Colorectal carcinoma-
- fresh blood after defecation- rectal carcinoma
-altered blood mixed with stools – carcinoma in s...
perianal conditions causing rectal
bleeding.
Haemorrhoids
Anal fistula
Anal fissure
9
HAEMORRHOIDS
• These are enlarged vascular cushions in the
lower rectum and anal canal.
• The classical position of haemor...
INTERNAL HAEMORRHOIDS:
-develops above the dentate line.
-covered by anal mucosa.
-lacks sensory innervation (painless)
-...
Clinical features of haemorroids
• Bleeding, is the principal and earliest symptom.
• The nature of the bleeding is charac...
Four degrees of haemorrhoids
• First degree – bleed
only, no prolapse
• Second degree –
prolapse, but reduce
spontaneously...
Complications of haemorrhoids
• Strangulation and thrombosis.
• Ulceration
• Gangrene
• Portal pyaemia
• Fibrosis
14
Treatment of haemorrhoids
• Symptomatic – advice about defaecatory
habits, stool softeners and bulking agents
• Injection ...
Indications
• third- and fourth-degree
haemorrhoids;
• second-degree
haemorrhoids that have not
been cured by
non-operativ...
17
Colorectal tumours
• polyps
• Adenoma
• Adenocarcinoma
Anal tumours
• squamous carcinoma of the lower anal canal
18
Polyps
• Males>Females
• >40yrs
• Classification-Hamartomatous-Peuts-Jeghers
-Juvenile
-Hyperplastic
-Inflammatory
-Neopla...
C/F -:
• Asymtomatic (most)
• Passsage of blood & mucus PR
• Prolaps
• Rarely obstruction/Intussusception
Morphologicaly-:...
Peuts-Jeghers polyps
Common in small IN , but can occur in large IN
Associated with mucocutaneous pigmentation in
lips and...
Adenomatous polyps
• Histological types-Tubular
-Villous (*)
-Tubulovillous
• Solitary/Multiple
• Presentations-diarrhoea
...
Familial polyposis coli
• >100 polyps
• Autosomal dominant
• Colonic & rectal(stomach,duodenum & small IN)
• Around pubert...
Colorectal carcinoma
• Has genetic predisposition
• 5yr survival-30%-40%
• Etiology-dietary animal fat
-Smoking
-Alcohol
-...
• Macroscopy- Anular
Tubular
Ulcer
Cauli flower
• Microscopy-predominatly adenocarcinoma
• Spread-local, lymphatics,haemat...
26
Clinical features:
20%-emergency(intestinal obstrction,peritonitis)
Symptoms depends on the region of the lesion
• Left co...
CARCINOMA OF THE RECTUM
• 75% occur in the lower part of the rectal ampulla
papilliferous or a simple ulcer with everted ...
MICROSCOPIC APPEARANCE:
• *90% are adenocarcinoma
• *9% are colloid – adenocarcinoma with
mucous production-
• *1% highly ...
• Rectal bleeding
•Change in bowel habit
•High annular cancers at the rectosigmoid
junction may cause partial obstruction ...
SIGNS ON EXAMINATION
On Rectal Examination:
the lower edge of a malignant ulcer can be felt
blood and mucous on the gloved...
Anal tumours
• Rare
• Most common-epidermoid tumours(sq cc)
• A malignant tumour protruding through the anal
canal is more...
DIVERTICULAR DISEASE
•Diverticulae are outpouchings of mucosa through the bowel wall
associated with increased intralumina...
•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...
Crohn's Disease Ulcerative Colitis
Discontinuous, "Skip" lesions Continuous lesions.
Risk of malignancy is rare. Malignanc...
•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 examination
lPallor
lIcterus
lPeripheral stigmata of inflammatory bowel disease
l skin - erythema nodosum, pyoderm...
Abdominal examination
• Hepatomegally
• Palpable masses
• Ascitis
Digital rectal examination
lInspection – anal fissures, skin tags, prolapse, opening of fistula
lPalpate – masses (size, ulceration, pararectal lymph...
inspection
Rectal carcinoma
on Rectal Examination:
It feels hard and bulges into the lumen of the
rectum, the edges are everted and t...
Proctoscopy
lFor diagnosis and treatment of haemorrhoids
lExtact locaton of the tumor in relation to the sphincter
mechani...
sigmoidoscopy:
2 types – rigid sigmoidoscopy
flexible sigmoidoscopy
essential to exclude rectal pathology as
carcinoma or ...
Flexible sigmoidoscopy
Barium Enema
Double-contrast barium enema examinations can be
justified only for elective evaluation of previous unexplain...
Single-contrast enema study in a patient with total colitis shows mucosal ulcers with a
variety of shapes, including colla...
Crohn disease. Aphthous ulcers. Double-contrast barium enema examination in Crohn colitis demonstrates
numerous aphthous u...
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 as...
Management of the diverticular disease
•Uncomplicated symptomatic diverticular disease
High fiber diet
Antispasmodic eg- C...
•Perforation with generalized fecal peritonitis
Laparotomy
Peritoneal lavage
Resect perforated area
Antibiotics as for acu...
Crohn’s disease
Medical Mx Surgical Mx
•Correction of fluid & electrolyte
•Steroids-40mg/d prednisolone
•Mesalazine-reduce...
Ulcerative colitis
Medical management Surgical management
Acute severe UC is treated with
-IV fluids
-parenteral nutrition...
Colonic polyps
•Pedunculated or small sessile polyps may be removed at
sigmoidoscopy or colonoscopy
•If invasive CA is fou...
Surgical management of large bowel
carcinoma
•CA of the caecum and the colon :- Right hemicolectomy
•CA of the hepatic fle...
CA of the rectum
Sphincter saving surgery – Anterior resection
Tumour should be more than 1-2cm above the anal sphincter
S...
THANK YOU…!!!
71
Rectal bleeding
Rectal bleeding
Rectal bleeding
Rectal bleeding
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Rectal bleeding

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Rectal bleeding

  1. 1. BLEEDING PER RECTUM Clinical group 2 34th batch Faculty of medicine-University of Ruhuna By-PRJ,MASJ,KM,KK,SWK,SK. 1
  2. 2. • 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 2
  3. 3. 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. 3
  4. 4. Causes of rectal bleeding • Hemorrhoids • Anal fissures • Carcinoma ( colorectal, anal ) • Colorectal polyps • Inflammatory bowel disease ( chron’s disease, ulcerative colitis) • Rectal prolapse 4
  5. 5. • Chronic infections causing colitis • Diverticular disease • Ischaemic colitis • Angiodysplasia of the colon • Bleeding diathesis 5
  6. 6. 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. 6
  7. 7. 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 7
  8. 8. • 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 8
  9. 9. perianal conditions causing rectal bleeding. Haemorrhoids Anal fistula Anal fissure 9
  10. 10. 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. 10
  11. 11. 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 system External H. drains into inf. Rectal veins I.V.C. 11
  12. 12. 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 12
  13. 13. 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 13
  14. 14. Complications of haemorrhoids • Strangulation and thrombosis. • Ulceration • Gangrene • Portal pyaemia • Fibrosis 14
  15. 15. Treatment of haemorrhoids • Symptomatic – advice about defaecatory habits, stool softeners and bulking agents • Injection of sclerosant • Banding • Transanal haemorrhoidal dearterialisation/haemorrhoidopexy • Haemorrhoidectomy 15
  16. 16. Indications • third- and fourth-degree haemorrhoids; • second-degree haemorrhoids that have not been cured by non-operative treatments; • fibrosed haemorrhoids; • interoexternal haemorrhoids when the external haemorrhoid is well defined. Complications of haemorrhoidectomy Early • Pain • Acute retention of urine • Reactionary haemorrhage Late • Secondary haemorrhage • Anal stricture • Anal fissure • Incontinence 16
  17. 17. 17
  18. 18. Colorectal tumours • polyps • Adenoma • Adenocarcinoma Anal tumours • squamous carcinoma of the lower anal canal 18
  19. 19. Polyps • Males>Females • >40yrs • Classification-Hamartomatous-Peuts-Jeghers -Juvenile -Hyperplastic -Inflammatory -Neoplastic- Adenoma -Familial polyposis coli 19
  20. 20. C/F -: • Asymtomatic (most) • Passsage of blood & mucus PR • Prolaps • Rarely obstruction/Intussusception Morphologicaly-: • pedunculated/sessile 20
  21. 21. Peuts-Jeghers polyps Common in small IN , but can occur in large IN Associated with mucocutaneous pigmentation in lips and gums Multiple Juvenile polyps Cause bleeding or obstruction Pain if prolaps during defication Hyperplastic polyps Comprise 90% of all polyps Multiple Inflammatory polyps Pseudopolyps Usually associated with colitis 21
  22. 22. 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 22
  23. 23. Familial polyposis coli • >100 polyps • Autosomal dominant • Colonic & rectal(stomach,duodenum & small IN) • Around puberty • 100% chance of malignancy & 40yrs 23
  24. 24. 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 24
  25. 25. • Macroscopy- Anular Tubular Ulcer Cauli flower • Microscopy-predominatly adenocarcinoma • Spread-local, lymphatics,haematogenous,transcoelomic • Staging-Dukes TNM 25
  26. 26. 26
  27. 27. Clinical features: 20%-emergency(intestinal obstrction,peritonitis) Symptoms depends on the region of the lesion • Left colon • Right colon • Metastasis • Rectal cancer 27
  28. 28. 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 28
  29. 29. 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. 29
  30. 30. • 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 30
  31. 31. 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. 31
  32. 32. 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. 32
  33. 33. 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
  34. 34. •It is diagnosed via barium enema or colonscopy.
  35. 35. 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
  36. 36. 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 involvement In 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
  37. 37. •Ischaemic colitis
  38. 38. •Angiodysplasia
  39. 39. •Irradiation colitis / Proctitis
  40. 40. •Aortoenteric fistula
  41. 41. •Rectal prolapse •Intussusception •Mesenteric infarction •Massive upper GI bleeding •Trauma •Bleeding diathesis
  42. 42. Physical examination and lab investigations
  43. 43. General examination lPallor lIcterus lPeripheral stigmata of inflammatory bowel disease l skin - erythema nodosum, pyoderma gangrenosum l Eye - sleritis, uveitis lLymphadenopathy - left supraclavicular node
  44. 44. Abdominal examination • Hepatomegally • Palpable masses • Ascitis
  45. 45. Digital rectal examination
  46. 46. lInspection – anal fissures, skin tags, prolapse, opening of fistula lPalpate – masses (size, ulceration, pararectal lymphnodes) , mucosa , prostate gland, lAnal sphincter tone lLook at finger for blood, stool, mucous
  47. 47. inspection
  48. 48. Rectal carcinoma on 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.
  49. 49. Proctoscopy lFor diagnosis and treatment of haemorrhoids lExtact locaton of the tumor in relation to the sphincter mechanism
  50. 50. sigmoidoscopy: 2 types – rigid sigmoidoscopy flexible sigmoidoscopy essential to exclude rectal pathology as carcinoma or polyps. should be taken tissue biopsies for histology
  51. 51. Flexible sigmoidoscopy
  52. 52. 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.
  53. 53. 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
  54. 54. Crohn disease. Aphthous ulcers. Double-contrast barium enema examination in Crohn colitis demonstrates numerous aphthous ulcers.
  55. 55. Crohn disease. Cobblestoning.
  56. 56. Colorectal carcinoma - Barium enema
  57. 57. 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
  58. 58. Management of the diverticular disease •Uncomplicated symptomatic diverticular disease High fiber diet Antispasmodic eg- Colofac Bulking agent eg - Fybogel •Acute diverticulitis Bed rest Fluid only or nil orally Analgesic Antibiotics – cefuroxime and metronidazole
  59. 59. •Perforation with generalized fecal peritonitis Laparotomy Peritoneal lavage Resect perforated area Antibiotics as for acute diverticulitis
  60. 60. Crohn’s disease Medical 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
  61. 61. Ulcerative colitis Medical management Surgical management Acute 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
  62. 62. Colonic polyps •Pedunculated or small sessile polyps may be removed at sigmoidoscopy or colonoscopy •If invasive CA is found – colectomy is required
  63. 63. 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
  64. 64. CA of the rectum Sphincter 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)
  65. 65. THANK YOU…!!! 71

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