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PR BLEEDINGBY HELEN BERMINGHAM
MESENTERIC BLOOD VESSELS
Coeliac trunk T12 foregutleft gastriccommon hepticsplenic
SMA L1 midgutinferiorpancreaticoduodenalmiddle colicright colicintestinalileocolic
IMA L3 hind gutleft colicsigmoidsuperior 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
• SKIP LESIONS
• ANYWHERE ALONG THE GI TRACT
• TRANSMURAL
• ULCERATIVE COLITIS
• CONTINUOUS ULCER
• ONLY LARGE BOWEL
• MUCOSA ONLY
SUMMARY
• COMMON 50% PEOPLE/YEAR
• SELF LIMTING
• REPORTED 2-4%
ANY QUESTIONS?