16 Rectal bleeding

PROXIMAL COLON RECTUM Carcinoma/ polyps Proctitis Solitary ulcer ANUS Haemorrhoids Fissure Carcinoma COLON SMALL BOWEL Ischaemic colitis Leiomyoma Meckel's diverticulum Infarction Crohn's disease Enteritis Intussusception Ulcerative colitis Diverticular disease Carcinoma/polyps Angiodysplasia Carcinoma
KEY POINTS Anorectal bleeding is characteristically bright red, associated with defaecation, not mixed with the stool and visible on toilet paperboften associated with other symptoms of anorectal disease. Distal (left-sided/sigmoid) bleeding is characteristically dark red, with clots, may be mixed with the stool. Proximal colonic or ileal bleeding is characteristically dark red, fully mixed with the stool or occultbunless heavy when it may appear as distal or anorectal in type. In children, Meckels diverticulum, intussusception and ileal tumours are common causes. In young adults, colitis, Meckels diverticulum and haemorrhoids are common causes. In the elderly, neoplasia, diverticular disease and angiodysplasia are common causes.

Important diagnostic features

Small intestine

Meckels diverticulum: young adults, painless bleeding, darker red/melaena common. Intussusception: young children, colicky abdominal pain, retching, bright red/mucus stool. Enteritis (infective/radiation/Crohns). Ischaemic: severe abdominal pain, physical examination shows mesenteric ischaemia or AF, few signs, later collapse and shock. Tumours (leiomyoma/lymphoma): rare, intermittent history, often modest volumes lost.

Proximal colon

Angiodysplasia: common in the elderly, painless, no warning, often large volume, fresh and clots mixed. Carcinoma of the caecum: more often causes anaemia than PR bleeding.

Colon
Polyps/carcinoma: may be large volume or small, ?associated change in bowel habit, blood often mixed with stool. Diverticular disease: spontaneous onset, painless, large volume, mostly fresh blood, previous history of constipation. Ulcerative colitis: blood mixed with mucus, associated with systemic upset, long history, intermittent course, diarrhoea prominent. Ischaemic colitis: elderly, severe abdominal pain, AF, bloody diarrhoea, collapse and shock later.

Rectum

Carcinoma of the rectum: change in bowel habit common, rarely large volumes. Proctitis: bloody mucus, purulent diarrhoea in infected, perianal irritation common. Solitary rectal ulcer: bleeding post-defaecation, small volumes, feeling of lump in anus, mucus discharge.

Anus

Haemorrhoids: bright red bleeding post-defaecation, stops spontaneously, perianal irritation. Fissure in ano: extreme pain post-defaecation, small volumes bright red blood on stool and toilet paper. Carcinoma of the anus: elderly, mass in anus, small volumes bloody discharge, anal pain, unhealing ulcers. Perianal Crohns disease.

46 Benign anal and perianal disorders

DIFFERENTIAL DIAGNOSES
Skin tag SMALL Rectal carcinoma Anal carcinoma Polyp/prolapse Prolapse Proctalgia fugax LARGE Diverticular disease Colitis Haemorrhoids Haemorrhoids Haemorrhoids Thrombosed Strangulated Haemorrhoid Wart Perianal haematoma Perianal haematoma Carcinoma Polyp Fissure Fistula Angiodysplasia

BLOOD PER RECTUM 50% Idiopathic 25% Dermatological Psoriasis Eczema Allergic dermatitis 25% Anal Infections Worms Candida Warts Gonorrhoea Inflammatory Haemorrhoids Fistula Ulcerative proctitis Crohn's disease Fissure Abscess Proctitis Infections ANAL DISCHARGE ITCH LUMP IN ANUS PAIN
Benign anal and perianal disorders 105

Clinical features

First degree (1): bleeding/itching only. Second degree (2): prolapse during defaecation. Third degree (3): constantly prolapsed.

Treatment

Simple treatmentbbulk laxatives and high-fibre diet. Bleeding internal pilesbinjection sclerotherapy, Barrons bands, cryosurgery. Prolapsing externalbhaemorrhoidectomy (complications: bleeding, anal stenosis).

Rectal prolapse
Definition

The protrusion from the anus to a variable degree of the rectal mucosa (partial) or rectal wall (full thickness).

Aetiology

Rectal intussusception, poor sphincter tone, chronic straining, pelvic floor injury.

Clinical features Treatment

Mucous discharge, bleeding, tenesmus, obvious prolapse. Stool manipulation and biofeedback, Delormes perianal mucosal resection, abdominal rectopexy (rectum is hitched up onto sacrum).

Perianal haematoma

Very painful subcutaneous haematoma caused by rupture of small blood vessel in the perianal area. Evacuation of the clot provides instant relief.

Anal fissure
Definition
Longitudinal tear in the mucosa of the anal canal, in the midline

posteriorly (90%) or anteriorly (10%).

Aetiology

90% caused by local trauma during passage of constipated stool and potentiated by spasm of the internal anal sphincter. Other causes: pregnancy/delivery, Crohns disease, sexually transmitted infections (often lateral position).

Clinical features

Exquisitely painful on passing bowel motion, small amount of bright red blood on toilet tissue, severe sphincter spasm, skin tag at distal end of tear (sentinel pile).

Treatment

First-line: stool softeners/bulking agents, local anaesthetic (LA) gels, GTN ointment. Second-line: botulinum toxin injection, lateral internal sphincterotomy. Examination under anaesthesia (EUA) and biopsy for atypical/suspicious abnormal fissures.

Perianal abscess
Aetiology
Focus of infection starts in anal glands (cryptoglandular sepsis) and spreads into perianal tissues to cause: perianal abscess: adjacent to anal margin; ischiorectal abscess: in ischiorectal fossa; para-rectal abscess: above levator ani.

Clinical features
Painful, red, tender, swollen mass fever, rigors, sweating, tachycardia.

Treatment

Incision and drainage, antibiotics.

Fistula in ano

Definition and aetiology

Abnormal communication between the perianal skin and the anal canal, established and persisting following drainage of a perianal abscess. May be associated with Crohns disease (multiple fistulae), UC or TB. Low: below 50% of the external anal sphincter (EAS). High: crossing 50% or more of the EAS.

Clinical features Treatment

Chronic perianal discharge, external orifice of track with granulation tissue seen perianally. Low: probing and laying open the track (fistulotomy). High: seton insertion, core removal of the fistula track.

Pilonidal sinus
Definition Aetiology
A blind-ending track containing hairs in the skin of the natal cleft. Movement of buttocks promotes hair migration into a (?congenital) sinus.

Clinical features

May present as: a natal cleft abscess, a discharging sinus in midline posterior to anal margin with hair protruding from orifice, natal cleft itch/pain.

Treatment

Good personal hygiene. Incision and drainage of abscesses, excision of sinus network.