Rectal bleeding and bum stuff

Question 1

Bright red or mixed blood
Hx: bleeding that is accompanied by other symptoms such as altered bowel habit, malaise, history of fissures (especially anterior) and abscesses

Answer 1

Crohns

Question 2

Bright red bleeding, often mixed with stool

Hx: Diarrhoea, weight loss, nocturnal incontinence, passage of mucous PR

Answer 2

Ulcerative colitis

perianal disease is usually absent

Question 3

Bright red blood mixed volumes

Hx: alteration of bowel habit. Tenesmus may be present. Symptoms of metastatic disease

Answer 3

Rectal cancer

Question 4

Bright red rectal bleeding.
Hx: post defecation bleeding noted both on toilet paper and drips into pan. May be altered bowel habit and history of straining. No blood mixed with stool, no local pain.

Answer 4

Haemorroids

-usually impalpable

Question 5

Bright red rectal bleeding.

Hx: Painful bleeding that occurs post defecation in small volumes. Usually antecedent features of constipation.

Answer 5

Fissure in ano

Question 6

Investigation for rectal bleeding

Answer 6

All patients presenting with rectal bleeding require a digital rectal examination and procto-sigmoidoscopy as minimal baseline.

IF FEATURES OF ALTERED BOWEL HABIT or suspicion of inflammatory bowel disease -> MUST DO COLONOSCOPY AS BASE TEST

In young patients with fissure, it is acceptable to treat medically and defer internal examination until the fissure is healed

Question 7

Grade 1 haemorrhoid

Answer 7

Do not prolapse out of the anal canal

Question 8

Grade 2 haemorrhoid

Answer 8

Prolapse on defecation but reduce spontaneously

Question 9

Grade 3 haemorrhoid

Answer 9

Can be manually reduced

Question 10

Grade 4 haemorrhoid

Answer 10

Cannot be reduced

Question 11

Examination reveals a purplish, oedematous, tender subcutaneous perianal mass.
Lots of pain

Answer 11

Acutely thrombosed external haemorrhage

(if patient presents within 72 hours, then referral can be made for excision. Otherwise give stool softeners, ice packs and analgesia)

Symptoms should settle within 10 days

Question 12

Treatment for anal cancer

Answer 12

Chemoradiotherapy

Question 13

Nocturnal diarrhoea and incontinence are typical of what?

Answer 13

Inflammatory bowel disease

Question 14

Name some patients who might need a temporary stoma?

Answer 14

Patients who have an anterior resection often need a temporary stoma for a few weeks or months to allow the join in the rectum to heal

Question 15

When is a hartmanns procedure normally performed and what is it?

Answer 15

Normally performed in an emergency - sigmoid and upper rectum are removed and an end colostomy formed

Question 16

Risk factors for caecal volvulus and what does it look like on x-ray?

Answer 16

X-ray will show a large dilated loop of bowel centrally

Risk factors include adhesions secondary to Crohns disease and previous surgery

Question 17

Which condition are you likely to see toxic megacolon in?

Answer 17

Ulcerative colitis

Question 18

Location 3,7, 11 o’clock position

Internal or external

Answer 18

Haemorrhoids

Question 19

Location: midline 6 (posterior midline 90%) & 12 o’clock position. Distal to the dentate line
Chronic fissure > 6/52: triad: Ulcer, sentinel pile, enlarged anal papillae

Answer 19

Fissure in ano

Question 20

Causes of proctitis

Answer 20

Crohn’s, ulcerative colitis, clostridium difficile

Question 21

Which bacteria are responsible for ano rectal abscess?

Answer 21

E. coli, staph aureus

Question 22

Why might you get an anal fistula?

Answer 22

If you’ve had previous anorectal abscesses

Question 23

Associated with childbirth and rectal intussception

Answer 23

Rectal prolapse

Question 24

Difference between anal and rectal cancer?

Answer 24

Anal cancer - squamous

Rectal cancer - adenocarcinoma

Question 25

Associated with chronic straining and constipation. Histology shows mucosal thickening, lamina propria replaced with collagen and smooth muscle (fibromuscular obliteration)

Answer 25

Solitary rectal ulcer

Question 26

Difference between bum cancer screening in scotland and england

Answer 26

Scotland care for you and screen from 50-74
England don’t and only screen from 60-74

Send poo every two years

Question 27

Treatment for haemorrhoids

Answer 27

Soften stools - increase dietary fibre and fluid intake
Topical local anaesthetics and steroids may be used to help symptoms
(NOTE IN ANAL FISSURES STEROIDS ARE USELESS)

Question 28

A 74 year old lady has been admitted with sudden onset profuse dark red rectal bleeding, she was previously well. At time of assessment her bleeding had stopped but haemoglobin was 10.5

Answer 28

Diverticular bleed

- this pattern of sudden onset profuse bleeding is typical of diverticular bleeding - this often ceases spontaneously.

Question 29

A 56 year old lady has undergone a Hartman’s procedure for diverticulitis. 6 months post operatively she complains of painless passage of blood stained mucous per rectum.

Answer 29

Diversion proctitis - rectal diversion may result in proctitis

Question 30

Investigation to check anastamosis (e.g. in anstamosis performed to attach colon to rectum)

Answer 30

Gastrogafin enema

water soluble radiopaque liquid

Question 31

Treatment for pseudo-obstruction

Answer 31

Anti-muscarinics