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
