Lower GI Bleeding

Taken from: http://waterforlifeusa.com/re sources/the-primary-causeand-prevention-of-disease

Tom Paterson PALi 5th Year Working Group tom@peerassisted.org

Lower GI Bleeding
A common presentation
Arises from: Small Intestine, Colon, Rectum, Anus

3 categories Occult bleeding FBC Low Hb or +FOB Moderate bleeding PR Blood (fresh, mixed with stools or dark) Acute Massive Bleeding (rare) Large Vol. (Fresh PR) Start and stop spontaneously Haemodynamically unstable Shock A Surgical Emergency! ABCs OHCM 7th Ed p589

A typical scenario
A 68-year old Glaswegian man presents to A+E with a 3 day history of rectal bleeding and lower abdominal pain. On enquiry, he admits to change in bowel habit with recent episodes of constipation and weight loss over the past 3-4 months. He has no past medical or surgical history, is a former smoker of 30 cigs/day for 26 years and does not drink alcohol.

Causes of Lower GI bleeding

Colorectal Cancer IBD (UC, Crohns Disease) Diverticulosis Colonic Polyp(s) Rectal Varices Haemorrhoids Anal Fissure Rectal Prolapse Infective diarrhoea Angiodysplasia Ischaemic Colitis

A Good History
Age PR Blood (and Mucus)
Colour Type of Blood Quantity

Previous episodes of PR bleeding Abdominal Pain or Tenderness Associated Anal pain +/- Defecation Altered Bowel habit
Stool Frequency & Consistency Diarrhoea/Constipation/Both

Tenesmus Anorexia and Weight Loss Dizziness, Collapse

A Good History
PMHx: Gastric Ulcer, IBD, Cancer Metastases Drug Hx: Aspirin, Warfarin, Steroids, Iron for IDA

Family Hx: Crohns, UC, Bowel Ca, Polyps, FAP

Social Hx: Alcohol intake, Smoker, Anal Intercourse Systemic Enquiry:
Mouth ulcers Eye problems Skin changes Joint pains

Examination
Inspection
Breathlessness, Jaundice, Cachexia Shock? Finger clubbing Signs of Anaemia (Conjunctival pallor, Koilonychia) Mouth Ulcers, Angular Stomatitis in IDA Scars, Stomas Abdominal distension

Palpation
Abdominal Tenderness or Pain (LIF Div, RIF Crohn/Caecal Ca) Mass felt with examining hand Hepatomegaly Liver Mets

PR exam
Haemorrhoids, Prolapse, Fissures or Fistulas Palpable mass per rectum (up to 7cm) Stool colour/consistency Blood on examining finger

Investigations
FBC Ferritin & iron studies U+Es LFTs CRP Glucose Coagulation Screen Group & Save If extensive bleeding Proctoscopy/Sigmoidoscopy Colonoscopy +/- Biopsy or Barium Enema Others:
Upper GI Endoscopy (Melaena) Angiography (Mesenteric bleeding) Tc99 Red cell scan (GI Bleeding & Meckels))

Lower GI Bleeding
A few examples:
Colorectal Cancer

Inflammatory Bowel Disease

(Ulcerative Colitis & Crohns disease) Others: Diverticulosis, Haemorrhoids, Anal Fissures,
Fistula in Ano....

Sample EMQs

Colorectal Cancer
3rd commonest malignancy in UK
M:F = 3:1 peak age 45-70yo Risk Factors:

FH of Colorectal Ca, FAP, HNPCC, Prev Hx of Colon,Breast, Ovarian or Uterine Ca Prev Hx of Adenomatous Polyps Chronic UC or Colonic Crohns disease Western diet, Obesity, Smoking *Taken from: Oxford Handbook of Clinical Medicine 7

th

Edition p613

Presentation depends on site:

Left-sided:Altered bowel habit (constipation & diarrhoea), PR bleeding bright red coating the stool, Tenesmus, Painful defecation? Small diameter of Left Colon Tendency towards obstruction Right-sided: Present later. Weight loss, Right abdo pain/mass, Tendency to bleed, Blood mixed in with stools, high incidence of IDA

Emergency (40%): Obstruction, Perforation w/Peritonitis, Acute Haemorrhage

Colorectal Cancer
Investigations:
FBC Microcytic hypochromic anaemia, LFTs deranged with hepatic spread + Faecal occult blood Sigmoidoscopy/Colonoscopy + biopsy Lesion (w/ 3-5% synchronous) Barium Enema may show Apple core appearance CT/MRI for rectal cancers, local pelvic spread and metastasis Liver US Hepatic Mets Raised Carcino-embryonic antigen (CEA) used for monitoring

Taken from: www.WebMD.com

Taken from: http://radiopaedia.org/images/894115

Pathology: Adenocarcinoma (95%) Character: ulcerating, stenosing, infiltrating Spread Local, mesenteric, paracolic, paraaortic nodes, Liver, Lung, Bone & Brain

Colorectal Cancer
Staging: Dukes Modified Criteria (1929) & TNM Staging (1958)
Dukes Modified Criteria A Limited to mucosa B1 Involves muscularis propria B2 Penetrates through muscle, extending to serosa and bowel wall C1 Invades muscularis propria with lymph node involvement C2 Penetrates through wall into serosa with lymph node involvement D Distant Metastatic Spread 5yr survival % 90 70 60 30 30 <10 TNM Staging T 1 Confined to the mucosa and submucosa T2 Invasion of muscularis propria but no extension into serosa T3 Extends into serosal - no breach or local spread T4 Direct invasion through serosa and local structures N0/1/2 no nodes, 1-3 nodes, >4 nodes M0/1 Metastases not present/present

T1N0M0 & T2N0M0 = Dukes A T3N0M0 & T4N0M0 = Dukes B Any T with N1 or N2 = Dukes C & Any T&N with M1 = Dukes D

Treatment: Surgical Resection with curative intent +/- Chemo

Right Hemicolectomy Caecal, Ascending, Proximal Transverse Ca Left Hemicolectomy Distal Transverse, Descending Sigmoidectomy Sigmoid Ca Anterior Resection Low sigmoid/High Rectal Ca Abdominoperineal (A-P) Resection Low Rectal Tumours <8cm from Anal canal permanent colostomy

**Hartmanns Carcinoma w/ Acute Obstruction (excision, colostomy, rectal stump)

Other options: Chemotherapy (5-FU) for Dukes B&C, RT, Palliation

Inflammatory Bowel Disease

Ulcerative Colitis
A relapsing and remitting inflammatory disease originating in the colonic mucosa and submucosa.

UC is limited to the colon. Begins in the rectum and can extend proximally, but rarely beyond ileocaecal junction.
M = F but 2 peaks: i) 14-40 years old ii) 15% of new pts >60 years old at diagnosis Unknown Aetiology

Associated RFs: HLA-DR130 association in severe UC 60% UC pts + pANCA autoantibodies 3-4 times increased risk in Non-smokers and Ex-smokers NSAIDs and stress implicated in UC flares

Ulcerative Colitis
Presentation
Proctitis (50%) (commonest): Urgency and high frequency of defecation (4-15/day), diarrhoea mixed with blood and mucus, rectal irritability, tenesmus. Left-sided Colitis (30%): Rectal irritation, extensive blood & mucus in stool Bloody diarrhoea. Pancolitis (20%): Diarrhoea, crampy, distended abdomen with systemic features: pyrexia, anorexia, weight loss, malaise and tachycardia. May involve appendix. Severe Pancolitis Backwash ileitis into terminal ileum

Extraintestinal features:

A PIE SAC
Complications of UC: Perforation, Haemorrhage, Toxic Megacolon
(hypotonic, grossly distended bowel > 5cm) Colorectal Ca & death if complication sinadequately treated

Extraintestinal Manifestations in IBD

A PIE SAC
Aphthous Ulcers (CD only) Pyoderma Gangrenosum I (Eye): Iritis,Uveitis, Episcleritis, Conjunctivitis

(CD>UC)
Erythema Nodosum (Primary) Sclerosing Cholangitis (pANCA

UC>CD) / Sacroilitis
Arthritis (HLA-B27: AnkSpo) Clubbing of Fingers (CD>UC)
Taken from: http://surgery.med.umich.edu/pediatric/clinical/physician_content/n-z/ulcerative_colitis.shtml

Ulcerative Colitis
Investigations:
FBC Low Hb due to blood loss, Raised WCC & Platelet count U+Es hypokalaemia due to mucus loss Raised CRP & ESR Low Albumin espec. during inflammation Stool Microscopy, Culture & Sensitivity

http://web2.airma
Taken from: www. Radiopedia.org

Taken from: www. ulcerativecolitistreatment.net

Barium enema indicates disease extent. Chronic UC: loss of haustrations, rigidity & shortening of colon Lead-pipe appearance. Excludes toxic megacolon in severe UC. Colonoscopy + Biopsy Inflamed, easily bleeding mucosa in rectum/distal colon. Inflammation limited to the mucosa with crypt distortion & abscess. Chronic UC Pseudopolyp formation.

Taken from: web2.airmail.net/uthman/specimens/images/u c.html

Ulcerative Colitis
Treatment aims: Induce disease remission & maintain remission and disease symptoms Medical Therapy Correct anaemia, hypokalaemia, hypoalbuminaemia, Corticosteroids: Oral Prednisolone induces remission. IV Hydrocortisone used in severe flares of colitis - Long-term avoided. Sulfasalazine or Mesalazine (5-ASA metabolites) have anti-inflammatory effect to induce remission. Also Rectal suppositories for distal colitis Azathioprine, 6-mercaptopurine immunosupression to prevent disease relapse or in cases of intolerance to steroids Anti-TNF Infliximab good in moderate-severe UC Surgery indicated when: Acute colitis fails to respond to medical Tx. Chronic Colitis persists despite treatment, unacceptable Tx SEs, developmental delay, poor quality of life. Toxic megacolon (within 24hrs)

Partial or Total Colectomy with Ileostomy usually cures

Crohns Disease
Chronic transmural inflammatory GI Disease which is non-caseating & granulomatous in nature. Associated with recurrence in severe disease and extraintestinal manifestations. Can affect any portion of GI tract Termimal Ileum (50%) & Proximal Colon common. Inflammation is discontinuous and separated by normal gut mucosa (skip lesions).

M = F affects any age but majority of cases between 11-35 years old
Unknown aetiology. Commonest in White Anglo-Saxon & Ashkenzai Jews Associated Risk Factors:
CARD 15/NOD-2 mutations Family Hx of Crohns or UC Altered cell mediated immunity abnormal Th1 activity (IL-2, IFN-) x3-4 risk in Smokers High sugar, low-fibre diet

Crohns Disease
Presentation Variable & dependent on site Diarrhoea, Abdominal Pain + Tenderness (terminal ileitis), RIF mass (inflamed bowel or abscess), Perianal abscesses/ fistulae/skin tags. Weight loss, malaise, fever occur in active disease. Failure To Thrive in children NB: Rectal bleeding less common in CD than UC Extraintestinal signs: Aphthous ulcers,Uveitis, Iritis , pyoderma gangrenosum,
erythema nodosum, polyarthritis, ankylosing spondylitis, sacroilitis

Complications in CD: Full-thickness mucosal inflammationStrictureSmall bowel obstruction Abscess formation between loops of intestine Perforation Fistula formation: Enteroenteric, Enterocutaneous and Vesicocolic

Crohns Disease
Investigations:
FBC Low Hb (Vit B12 def., blood loss), High WCC Raised CRP & ESR Low Albumin due to malabsorption Stool Microscopy, Culture & Sensitivity

*Taken from: James Going -SSC in Pathology IBD Lecture

Taken from: www. Learningradiology.com Taken from: www. Flickr.com/photos/robhengxr/159283669

Barium Enema shows Kantors String sign of the terminal ileum. Also Rose-thorn ulcers Colonoscopy/Sigmoidoscopy+ Biopsy Red, oedematous thickened mucosa with deep ulcerations and erosions, separated by normal mucosa producing a cobblestone appearance. Histology shows transmural inflammation, fissuring ulcers and non-caesating granulomas

Crohns Disease
Management: Medical vs Surgical

Medical Mx aims to reduce inflammation & control complications. Also treat abnormal blood results eg. Anaemia
Corticosteroids (Hydrocort, Predn) control inflammation exacerbations in moderate-severe disease Azathioprine or Cyclosporin immunosupression Methotrexate Anti-TNF Infliximab prevent fistula formation Metrondiazole used to treat Colonic fistulas Nutritional therapy - elemental diet to limit antigens & reduce inflamm

Surgical Mx aims to treat complications such as strictures, bowel obstruction, sepsis, perforation or fistula formation with minimal compromise to bowel. SURGERY MAY CAUSE NEW LESIONS
50-80% patients will require surgery throughout their lives

Summary of other causes of Lower GI Bleeding

Adapted from: Oxford Handbook of The Foundation Programme 2nd Edition

DESCRIPTION
Outpouching in bowel wall weakest point vasa recta meet muscular propria Marfan, EhlersDanlos, Polycystic Kidney ANGIODYSPLASIA AVM in colonic submucosa Usually proximal transverse colon

HISTORY
Low fibre diet & constipation Abdominal Pain (LIF) Sigmoid Colon Massive painless dark red PR Bleeding Irregular Bowel Habit (diarrhoea constipation) Fever/Pyrexia Old Age Often Asymptomatic Recurrent & brisk Fresh Blood PR

EXAMINATION
Tenderness (LIF) +/- Peritonism PR Blood or Mucus Bleeding selflimiting

INVESTIGATIONS & TREATMENT

Low Hb Diverticulae on Colonscopy Tx: High fibre diet Abx in acute disease (co-amox/metro/cipro) Surgical resection if persistent bleeding (recurrent diverticulitis, abscess/fistula/obstruction

DIVERTICULAR DISEASE (DIVERTICULOSIS)

PR Blood or Melaena Ex may be Normal

Low Hb give FeSO4 FOB+ Lesion on Colonoscopy Consider Angiography Tx: Arterial Embolisation, Endoscopic coagulation Haemorrhoids on Proctoscopy Tx: High fibre diet, Anusol, Sclerosant, Band ligation or Haemorrhoidectomy

Dilated& displaced vascular anal cushions Multiple vaginal deliveries

Multiple pregancies, obese, anal sex Straining at Stool Painless Fresh Blood on Toilet Paper or stools Perianal Itch

HAEMORRHOIDS

Often not Palpable on PR unless prolapsed Perianal tags

May have rectal Prolapse

DESCRIPTION
Descent of mucosa or entire rectum through anus

HISTORY
Something coming down ++mucus PR Usually small vol. bright red bleed

EXAMINATION
Prolapse may be demonstrated on straining in clinic Prolapse may be ulcerated & bleeding

INVESTIGATIONS

Sigmoidoscopy mucosal inflamm

RECTAL PROLAPSE

Weak rectal support lax of pelvic floor and anal sphincters due to chronic straining Elderly, postmenopausal pts, multiple vaginal deliveries Children constipation, CF, whooping cough Anal tear posteriorly May be associated with Crohns or Cancer Previous Pregnancy

Defecating proctogram if uncl diagnosis MedMx: Stool softeners for constipation

Repeated defecation (mucosal) or Incontinence (full)

ANAL FISSURE

SurgMx: Rectoplex fix rectum to sacrum Sigmoidoscopy if Colorectal Ca Tx: High fibre diet 5% lignocaine therapy Botox injection Sphincerotomy Surgery Fistulotomy or Staged sphincter repair

Severe knife-like pain on defecation Deep throbbing pain Hx Constipation, Straining ++ Fresh Blood on Toilet paper Pain Bloody or Purulent anal discharge Anal itching Systemic symptoms if infected abscess

Posterior/Anterior tear at anal margin Associated: Perianal tags, ulcers, fistulae PR Tenderness PR blood on examining finger Abnormal epithelial connection seen between anus and skin Erythema

ANAL FISTULAS

All ages Infection commonest IBD (CD>UC) Trauma:episiotomy, prostatectomy, anal sex

Extended Matching Questions

MEQs Rectal Bleeding

1) A 30 yo male with bloody diarrhoea 20 times/day, weight loss and colonoscopy showing inflammation from the rectum to caecum
(a) (b) (d) (e) (f) (g) (h) (i) (j) Colon Ca Crohns Disease Fissure in ano Fistula in ano Gastroenteritis Haemorrhoids Rectal proplase Diverticulosis Ulcerative colitis

MEQs Rectal Bleeding

1) A 30 yo male with bloody diarrhoea 20 times/day, weight loss and colonoscopy showing inflammation from the rectum to caecum
(a) (b) (d) (e) (f) (g) (h) (i) (j) Colon Ca Crohns Disease Fissure in ano Fistula in ano Gastroenteritis Haemorrhoids Rectal proplase Diverticulosis Ulcerative colitis

MEQs Rectal Bleeding

2) A 25 yo woman, 6 weeks post-partum with PR bleeding, puritis and perianal pain
(a) (b) (d) (e) (f) (g) (h) (i) (j) Colon Ca Crohns Disease Fissure in ano Fistula in ano Gastroenteritis Haemorrhoids Rectal proplase Diverticulosis Ulcerative colitis

MEQs Rectal Bleeding

2) A 25 yo woman, 6 weeks post-partum with PR bleeding, puritis and perianal pain
(a) (b) (d) (e) (f) (g) (h) (i) (j) Colon Ca Crohns Disease Fissure in ano Fistula in ano Gastroenteritis Haemorrhoids Rectal proplase Diverticulosis Ulcerative colitis

MEQs Rectal Bleeding

3) A 21 yo lady with rectal bleeding and severe pain on defecation
(a) (b) (d) (e) (f) (g) (h) (i) (j) Colon Ca Crohns Disease Fissure in ano Fistula in ano Gastroenteritis Haemorrhoids Rectal proplase Diverticulosis Ulcerative colitis

MEQs Rectal Bleeding

3) A 21 yo lady with rectal bleeding and severe pain on defecation
(a) (b) (d) (e) (f) (g) (h) (i) (j) Colon Ca Crohns Disease Fissure in ano Fistula in ano Gastroenteritis Haemorrhoids Rectal proplase Diverticulosis Ulcerative colitis

MEQs Rectal Bleeding

4) A 90 yo woman with PR bleeding and something coming down every time she defecates
(a) (b) (d) (e) (f) (g) (h) (i) (j) Colon Ca Crohns Disease Fissure in ano Fistula in ano Gastroenteritis Haemorrhoids Rectal proplase Diverticulosis Ulcerative colitis

MEQs Rectal Bleeding

4) A 90 yo woman with PR bleeding and something coming down every time she defecates
(a) (b) (d) (e) (f) (g) (h) (i) (j) Colon Ca Crohns Disease Fissure in ano Fistula in ano Gastroenteritis Haemorrhoids Rectal proplase Diverticulosis Ulcerative colitis

MEQs Rectal Bleeding

5) A 26 yo man presents with chronic bloody diarrhoea and RIF pain. He has lost weight recently and feels generally unwell and pyrexial. He is also complaining of joint pains and barium enema shows altered mucosal pattern with deep-fissured ulcers.
(a) (b) (d) (e) (f) (g) (h) (i) (j) Colon Ca Crohns Disease Fissure in ano Fistula in ano Gastroenteritis Haemorrhoids Rectal proplase Diverticulosis Ulcerative colitis

MEQs Rectal Bleeding

5) A 26 yo man presents with chronic bloody diarrhoea and RIF pain. He has lost weight recently and feels generally unwell and pyrexial. He is also complaining of joint pains and barium enema shows altered mucosal pattern with deep-fissured ulcers.
(a) (b) (d) (e) (f) (g) (h) (i) (j) Colon Ca Crohns Disease Fissure in ano Fistula in ano Gastroenteritis Haemorrhoids Rectal proplase Diverticulosis Ulcerative colitis

MEQs Rectal Bleeding

6) A 32 yo woman presents with rectal bleeding, which occurs post-defecation. The bleeding is bright red and painless. Endoscopy is normal.
(a) (b) (d) (e) (f) (g) (h) (i) (j) Colon Ca Crohns Disease Fissure in ano Fistula in ano Gastroenteritis Haemorrhoids Rectal proplase Diverticulosis Ulcerative colitis

MEQs Rectal Bleeding

6) A 32 yo woman presents with rectal bleeding, which occurs post-defecation. The bleeding is bright red and painless. Endoscopy is normal.
(a) (b) (d) (e) (f) (g) (h) (i) (j) Colon Ca Crohns Disease Fissure in ano Fistula in ano Gastroenteritis Haemorrhoids Rectal proplase Diverticulosis Ulcerative colitis

Thank You

Courtesy of Monkey Tennis by Slap www.Hallmarkuk.com

References
Garden, O.J. et al(2009) Principles & Practice of Surgery 5th Edition, Edinburgh, UK: Elsevier
Goljan, E.F (2010) Rapid Review: Pathology 3rd Edition, Philadelphia, USA: Mosby: Elsevier Hurley, N. et al (2008) Oxford Handbook of The Foundation Programme 2nd Edition, Oxford, UK: Oxford University Press Kontoyannis, A. Et al (2008) Crash Course: Surgery 3rd Edition Edinburgh, UK: Mosby Elsevier Longmore, M. et al (2007) Oxford Handbook of Clinical Medicine 7th Edition, Oxford, UK: Oxford University Press McLatchie, G. et al (2007) Oxford Handbook of Clinical Surgery 3rd Edition, Oxford, UK: Oxford University Press