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Overview

  • Very common surgical referral
  • Seen mainly in the elderly
  • Underlying cause is influenced by age
  • rarely requires surgical intervention (at least in the acute phase)
  • Essential to establish a good history from the patient and/or relative as to the amount and colour, clots, duration, mixed with stool or separate, in the pan or on the toilet tissue, any other symptoms e.g. pain, melaena/haematemesis, pruritis ani, tenesmus, urgency, weight/appetite loss, family history of cancer, change in bowel habit from normal for them, urinary symptoms etc.

Possible Causes

  • Diverticular Disease
  • Angiodysplasia  
  • Ischemic colitis  
  • Radiation-induced colitis/proctits (esp in men with Rx for prostate cancer) 
  • Rectal or colonic cancer
  • Ischaemic colitis
  • Infectious colitis 
  • Inflammatory Bowel Disease
  • Idiopathic colitis  
  • Anorectal causes
    • hemorrhoids
    • fistula
    • fissures
    • polyps
  • Drug-induced bleeding is caused mainly by NSAIDs
  • Other vascular causes
    • polyarteritis nodosa
    • Wegener granulomatosis
    • Aortocolonic fistula (post AAA surgery)

Investigations

  • As most patients tend to be stable they can be investigated once bleeding has stopped as an outpatient
  • In the actively bleeding patient consider:
    • Colonoscopy - experienced endoscopist required
    • Upper GI endoscopy for brisk bleeds
    • Selective mesenteric angiography - experienced radilogist required andthe above need to be done first

Initial Management

  1. May need rapid resuscitation if bleeding heavily (see massive upper GI bleed)
  2. If bleeding ++ and bright red there is a good chance it is from an upper GI source – get hold of the on-call endoscopist ASAP
  3. Large venflons & Crystalloid infusion
  4. Check HB, U&E, Clotting
  5. Check for PMH of Crohn’s / Colitis, recent foreign travel etc
  6. Do a PR
  7. If bleeding ++ call a senior
  8. Catheterise

Continuing Management

  1. If bleeding ++ and once an upper GI source has been excluded then a mesenteric angiogram is required. 
  2. Blind colectomy has no place as there is a good chance the wrong piece of bowel will be removed, and access to localising investigations is much easier now than in years gone by.
  3. There is a potential role for on-table lavage and pan-endoscopy

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