⛑️ Bleeding per rectum

Bleeding per Rectum History #

Bleeding per Rectum #

  • Onset & Duration
  • Colour
    • Bright red
    • Altered
    • Mixed (fresh + altered) → PPV higher when dark and bright mixed blood than dark or bright blood alone
    • Melena (Sticky, blackish, difficult to flush)
  • Timing with Defecation
    • Before
    • Mixed (towards malignancy)
    • Streaky (fissure, low rectal CA)
    • After
      • Dribbling
      • Spurting
  • Amount?
    • Cup/diapers/clots
  • Any Other Bleeding Manifestations
  • Associated Anal Pain?
    • Fissure, abscess, hematoma, anal carcinoma
    • Uncomplicated hemorrhoids or rectal cancer are not usually painful
  • Any Lump at Anus?

Lower Rectal Symptoms #

  • Tenesmus
    • Intense desire to defecate without resultant evacuation
    • Either nothing or only pass flatus and little blood-stained mucus
    • May also be caused by IBD
  • Sense of Incomplete Evacuation
  • Incontinence
    • Urge (external sphincter failure) – more towards malignancy
    • Passive (internal sphincter failure)
    • Nature – gas, liquid, solid
  • Fecal Soiling
  • Mucus Discharge
  • Itching

Alteration of Bowel Habits #

  • Duration
  • Normal Pattern
  • Alteration in Frequency?
    • Volume
    • Copious volume & very short history – dysentery
    • Small amount with some blood & mucus - likely Ca
    • Intermediate volume with a history of weeks to months – UC likely
  • Alteration in Consistency?
    • Constipation prominent? – annular carcinoma at the rectosigmoid junction
  • Straining, Feeling of Obstruction, Digital Evacuation
  • Diarrhea Prominent?
    • Early morning bloody diarrhea
    • Spurious diarrhea (passing mucus and small amount of stool several times a day) – occurs with growth at the ampulla
    • Frequent passage of loose stools along with blood and mucus – IBD
    • Post-constipation diarrhea?
  • Alteration in Shape?
    • Pencil-like feces passing in constricting growths
  • Pain
    • Colicky abdominal – left colonic growth causing some degree of obstruction
    • Severe persistent pain – prostate/bladder eroded by deep carcinomatous ulcer in rectum
  • Postprandial Fullness and Bloating?

Aetiology #

  • FHx of CRC, breast, ovarian, colon cancer
    • Generation
    • Age at diagnosis
    • Number
  • Alcohol
    • Male - 4 units
    • Female - 3 units
  • Smoking
    • Pack year calculation
  • IBD
    • History of blood and mucus diarrhea, previous colonoscopies
    • Extraintestinal manifestation (arthritis, uveitis – painful red eye)
  • Diet
    • High red meat consumption
    • Low fiber diet
  • Diverticulitis
    • Recurrent LIF pain, fever
  • Intestinal TB
    • Contact history of TB
    • Any TB drug history?
  • Bleeding Diathesis
    • History of prolonged bleeding after trauma
    • Anticoagulant use?

Spread #

  • Local
    • Bladder → fecaluria, pneumaturia, hematuria, recurrent UTI
    • Left flank pain for obstruction with HN
    • Sacral nerve involvement – perineal pain, back pain, impotence, B/L lower limb numbness and pain
    • Fecal incontinence due to sphincter involvement
  • Metastatic
    • Liver
      • LOA
      • LOW
      • RHC pain
      • Jaundice is late
    • Lung
      • Pleuritic type chest pain
      • SOB
      • Hemoptysis late
    • Brain
      • Early morning headache
      • Vomiting
      • Focal fits or focal neurological weaknesses
    • Bone
      • Severe, persistent/intractable, non-mechanical, nocturnal lower back ache not responding to analgesics

Complications #

  • Bowel Obstruction?
  • Anemia Features?
    • Blood transfusions had to be given?

Interventions Done So Far #

  • Colonoscopy
  • Biopsy
  • CECT
  • CEA
  • Neoadjuvant Chemo/CRT/RT
    • Last dose
    • Response
    • Side effects – bleeding, fever, numbness
  • Diversion

PMHx and Fitness #

  • Surgical Fitness
    • ASA (any co-morbidities)
    • MET (can climb 2 flights of stairs without stopping)
    • Fitness for chemo
  • ECOG
  • PSHx
    • Sphincter function
      • Surgery at anorectal region
      • Hx of obstructed labor
  • Allergy
    • Drug, food, plaster, contrast, metal prosthesis allergies

Social History #

  • Support