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
-
May need rapid resuscitation if bleeding heavily (see massive upper GI bleed)
-
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
-
Large venflons & Crystalloid infusion
-
Check HB, U&E, Clotting
-
Check for PMH of Crohn’s / Colitis, recent foreign travel etc
-
Do a PR
-
If bleeding ++ call a senior
-
Catheterise
Continuing Management
-
If bleeding ++ and once an upper GI source has been excluded then a mesenteric angiogram is required.
-
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.
-
There is a potential role for on-table lavage and pan-endoscopy
We have 45 guests and no members online