PR BLEEDING
BY HELEN BERMINGHAM
MESENTERIC BLOOD VESSELS
Coeliac trunk T12 foregut
left gastric
common heptic
splenic
SMA L1 midgut
inferiorpancreaticoduodenal
middle colic
right colic
intestinal
ileocolic
IMA L3 hind gut
left colic
sigmoid
superior rectal
HISTORY
• COLOUR OF BLOOD EG. BRIGHT RED
• MIXED IN WITH STOOLS OR COATING STOOLS
• HOW LONG ITS BEEN HAPPENING FOR
• PAIN
• ABDOMINAL PAIN
• RED FLAG SYMPTOMS EG WEIGHT LOSS, ANOREXIA, CHANGE IN BOWEL HABIT,
• FAMILY HX
• ANTICOAGULATION
• RECENT COLONSCOPY/POLYPECTOMY
EXAMINATION
• DOES THE PATIENT LOOK WELL OR UNWELL?
• OBSERVATIONS
• HANDS/EYES/MOUTH/LYMPH NODES
• ABDOMEN
• LOOK
• PALPATE
• PERCUSS
• LISTEN
• PR
UNWELL PATIENT
• 0XYGEN
• 2X LARGE BORE IV ACCESS AND BLOODS
• FLUID CHALLENGE
• CORRECT WARFARIN AND STOP ANTICOAGULANTS
• TRANEXAMIC ACID 1G
• CATHETER
• CALL SENIOR DOCTOR
WELL PATIENT
• IV ACCESS AND BLOODS
• AXR, ERECT CXR
• CORRECT WARFARIN AND STOP ANTICOAGULANTS
• ENDOSCOPY
• OGD
• FLEXI SIGMIODOSCOPY
• COLONOSCOPY
MANAGEMENT
• CT ANGIOGRAM
• MESENTERIC ANGIOGRAM WITH EMBOLLISATION
• SURGERY
CAUSES OF PR BLEEDING
• DIVERTICULTITS 20-55%
• ISCHAEMIC COLITIS 20%
• CANCER 10-15%
• ANGIODYSPLASIA 10%
• ANORECTAL DISEASE 5-10%
• POST POLYPECTOMY 5%
• SMALL BOWEL PATHOLOGY
• ANGIODYSPLASIA,LYMPHOMA,ULCERS,CROHNS
DIVERTICULAR DISEASE
• DEFINITION
• FORMATION OF OUTPOUCHES OF COLONIC MUCOSA EXTRUDING THROUGH THE MUSCULAR WALL
OF THE BOWEL
• PATHOGENSIS
• HIGH INTRALUMINAL PRESSURE, LOW FIBRE DIET
• POTENTIAL AREAS OF WEAK COLONIC WALL, VESSELS
• COMPLICATIONS
• INFECTION
• FISTULA FORMATION
• ABSCESS FORMATION
• HAEMORRHAGE
• PERFORATION
ISCHAEMIC COLITIS
•
DEFINITION
•
•
•
ACUTE VASCULAR INSUFFICIENCY OF THE COLON
PATHOGENSIS
•
THROMBOEMBOLIC ARTERIAL OCCLUSION
•
VENOUS OCCLUSION
•
SYSTEMIC VASCULITIS
•
ARTHROSCLEROSIS AND CARDIOVASCULAR DISEASE
•
SECONDARY TO INTESTINAL OBSTRUCTION
•
STRANGULATED HERNIA
•
INTUSSUSCEPTION
•
VOLVULUS
PATIENTS COMPLAIN OF
•
ABDOMINAL PAIN
•
BLOODY DIARRHOEA
•
USUALLY ELDERLY PATIENTS
•
USUALLY SETTLES
•
FLEXI SIG/COLONOSCOPY
•
15% DEVELOP GANGRENE- HIGH RISK OF DEATH
COLORECTAL CANCER
• 4TH MOST COMMON CANCER IN THE UK
• APPROX 40,000 CASES A YEAR
• LIFETIME RISK 1IN 14 IN MEN, 1 IN 19 IN WOMEN.
COLORECTAL CANCER
COLORECTAL CANCER
• RISK FACTORS
• GENETIC
• PRE EXISTING POLYPS
• INHERITED BOWEL CANCER SYNDROMES
• FAMILIAL ADENOMATOUS POLYPOSIS (FAP)
• HEREDITARY NON POLYPOSIS COLON CANCER (HNPCC)
• ENVIRONMENTAL
• INFLAMMATORY BOWEL DISEASE
COLORECTAL CANCER
• 37% RECTUM
• 27% SIGMOID
• 14% CAECUM
• 7% ASCENDING
• 3% HEPATIC FLEXURE
• 3% SPLENIC FLEXURE
• 5% CASES SYNCHRONOUS
COLORECTAL CANCER
• SYMPTOMS
•
•
•
•
•
ANAEMIA
CHANGE IN BOWEL HABIT
WEIGHT LOSS
PR BLEEDING/PERFORATION/FISTULA
OBSTRUCTION
• COLONSCOPY
• BIOPSY
• STAGING CT/MRI
ANGIODYSPLASIA
• DEFINITION
•
SMALL VESSEL MALFORMATION IN THE COLON
• MORE COMMON IN THE ELDERLY, RELATED TO DEGENERATION OF THE BLOOD VESSELS
• MORE COMMON ON THE RIGHT SIDE OF THE BOWEL
• COLONOSCOPY/ANGIOGRAPHY
• COLONOSCOPIC ELECTROCOAGULATION
• EMBOLISATION
• SURGICAL RESECTION
HAEMORRHOIDS
• DEFINITION
• SMALL BLOOD FILLED SWELLINGS CAUSED BY DILATED VARICOSE VEINS
• PREDISPOSING FACTORS
• CONSTIPATION
• AGE
• PREGNANCY
• HEREDITARY FACTORS
HAEMORRHOIDS
HAEMORRHOIDS TREATMENT
• TOPICAL OINTMENTS
• BANDING
• SCLEROTHERAPY
• SURGERY
ANAL FISSURE
• DEFINITION
• TEAR OR ULCER IN THE LINING OF THE ANAL CANAL
• CONSTIPATION
• TREATMENT
• LAXATIVES
• GTN/DILTIAZEM CREAM
• BOTOX
• SURGERY
INFLAMMATORY BOWEL DISEASE
• CROHNS
• ULCERATIVE COLITIS
• SKIP LESIONS
• CONTINUOUS ULCER
• ANYWHERE ALONG THE GI TRACT
• ONLY LARGE BOWEL
• TRANSMURAL
• MUCOSA ONLY
SUMMARY
• COMMON 50% PEOPLE/YEAR
• SELF LIMTING
• REPORTED 2-4%
ANY QUESTIONS?
