A Detailed Presentation on BLEEDING PER RECTUM. I made this presentation for my surgery project.

1. WELCOME

2. SURGERY PROJECT
SESSION 2016-2017
TOPIC: BLEEDING PER
RECTUM
SUBMITTED BY:
 ILA YADAV
 BHMS-III
 ROLL NO. 33

3. Contents
History taking of rectal bleeding
Introduction
Aetiology
Special investigations
Diseases causing rectal bleeding
Haemorrhoids
Acute Haemorrhagic Rectal Ulcers
Fissure in ano
Fistula in ano
Peri-anal Haematoma
CA rectum
Colorectal Polyps
Inflammatory Bowel Disease
Diverticular Disease
Crohn’s Disease
Solitary Rectal Ulcer Syndrome
Discussion
Conclusion

4. Introduction
The rectum is the last portion of the large bowel (colon) that
ends just before the anus. Bleeding from this area may result in
the appearance of blood in stools. Rectal bleeding can take any
of these forms: bright red blood coating the stools or in the
stools blood in the toilet bowl after motion dark or black tarry
stools, maroon stools blood on the toilet paper.
Despite the name ‘rectal bleeding’ blood in the stools does
not always originate within the rectum. The source of the bleed
could be anywhere along the gastrointestinal tract (even as far
up as stomach).

5. RECTAL BLEEDING
Blood on its own or streaking the stool:
Rectum: polyps or carcinoma, prolapsed
Anus : Hemorrhoids, Fissure-in-ano, Anal carcinoma.
Stool mixed with blood:
GIT above sigmoid colon.
Sigmoid carcinoma or diverticular disease.
Blood separate from the stool:
Follows defecation: Anal condition eg: Hemorrhoids.
Blood is passed by itself : Rapidly bleeding carcinoma,
inflammatory bowel disease, diverticulitis, or passed down
from high up in the gut.
Blood is on the surface of the stool: suggest a lesion such as
polyp or carcinoma further proximally either in the rectum or
descending colon
Blood on the toilet paper: Fissure-in-ano, Hemorrhoids.
Loose, black, tarry, foul smelling stool: from the proximal of DJ
flexure

6. COLOUR OF BLOOD/ DISCHARGE
Bright red/ Fresh blood: Rectum and anus.
Dark blood: Upper GIT to above rectum.
Drugs eg: iron tablets- appear as greenish black
formed stool.
Discharge apart from blood:-
Mucus- irritable bowel syndrome
Copious mucus- villous adenoma, frank cancer of the
rectum
Mucus and pus- IBD, diverticular disease

7. HISTORY TAKING
Previous perianal disease
Inflammatory bowel
disease
Peptic ulcer disease
Liver disease
Coagulopathy
• Laxative agent
• Anti-parkinson agent
• Anti-coagulant therapy eg:
warfarin
• NSAID’s-risk factor of PUD
• Low fiber diet
• Smoking
PREVIOUS HISTORY
•History of malignancy
•Familial Adenomatous
Polyposis
FAMILY HISTORY
DRUGS HISTORY
SOCIAL HISTORY

8. AETIOLOGOY:
Common causes of rectal bleeding
 Benign ano-rectal disease:-
Hemorrhoids
Anal fissure
Fistula-in-ano
• Diverticular disease.
• Inflammatory bowel disease
Crohn’s disease
Ulcerative colitis
 Colonic polyps
 Colorectal or anal cancer

9. Less common causes of rectal bleeding:-
 Infectious gastroenteritis
 Coagulopathy
 Arterio-venous malformation (angio-dysplasia)
 Radiaton proctitis.
 Ischaemic colitis(mesenteric vascular insufficiency)
 Solitary rectal ulcer.
 Meckel’s diverticulum.
 Rectal varices.
 Trauma(possible sexual abuse)
 STD

10. Special
Investigations
 Proctoscopy
 Colonoscopy
 X Ray
 Barium enema X Ray
 CT scan
 Ultrasonography

11. Proctoscopy
A proctoscope is a hollow, tube-
like speculum that is used for visual
inspection of the rectum. The proctoscope
is inserted into the anal canal with the
patient in Sims' position.
 Fibre optic proctoscopes are now
available which cause less discomfort to
the patient.
 The proctoscope is used in the diagnosis
of hemorrhoid ,carcinoma of anal canal
or rectum and rectal polyp.
 It is used therapeutically
for polypectomy and rectal biopsy.

12. Colonoscopy
 With the advent of fibre optic colonoscope, the whole of the colon up to the
caecum can be viewed for practical purposes. This instrument is preferred to
sigmoidoscope by majority of the patients.
 Colonoscopy and the contrast enema are complementary procedures.
 It is used when
(i) X ray study negative, but the symptoms persist including occult blood and
anaemia.
(ii) X ray study positive yet for confirmation.
(iii)X-ray study positive for cancer, but for taking biopsy.
(iv) X-ray study positive for cancer yet to exclude synchronous cancer or
associated polyps.
(v)X-ray study positive for polyp, but to exclude malignant change or for
additional polyps.
(vi)X-ray study positive for inflammatory disease, but to know the extent of
disease and for biopsy.
 It is also used in –
 Ulcerative colitis, Diverticulitis ,Radiation necrosis, Recent bowel anastomosis
etc.

14. X-ray
 Straight X-ray of the abdomen may
indicate evidence of intestinal obstruction
due to annular growth at the recto-
sigmoid junction.
 Chest X-ray is performed in an established
case of carcinoma of the rectum to
exclude pulmonary metastasis.

15. Barium enema X Ray
 The importance of this examination in a case of bleeding per
anal and in pathologies of the rectum and anal canal cannot
be over-emphasised.
 In any case of internal haemorrhoid barium enema X-ray must
be performed to exclude any carcinoma above the rectum to
be the cause of this condition.
 In case of rectal polyp may be one of the multiple polyps in
the colon which should be excluded by barium enema.
 Other pathologies like Crohn’s disease, ulcerative colitis etc.

16. Haemorrhoids
 Varicosities of the veins of the anal canal are known as
haemorrhoids.
 It may be internal or external depending on the position of
the varicosity.
 If it is above the Hilton’s line it is called ‘internal
haemorrhoid’ and if it is below the Hilton’s line it is called
‘external haemorrhoid’.
 So, internal haemorrhoid is covered by mucous membrane
whereas the external haemorrhoid is covered with skin.

17. HEMORRHOIDS-Types
INTERNAL HAEMORRHOIDS:
-develops above the dentate line.
-covered by anal mucosa.
-lacks sensory innervation (painless)
-bright red or purple in color.
EXTERNAL HAEMORRHOIDS:
-arise below the dentate line.
-covered by St. sq. epithelium
-innervated by the inferior rectal nerve.

18. Internal H. drains into sup. Rectal veins 
portal system
External H. drains into inf. Rectal veins
I.V.C.

19. HEMORRHOIDS
Grading for Internal type
Internal H. are classified by the degree of tissue prolapse
into the anal canal.
GRADE 1:they are confined to the anal canal with minimal
bleeding or maybe asymptomatic but do not prolapse.
GRADE 2: they prolapse on defecating or straining then reduce
spontaneously.
GRADE 3: prolapse with or without straining and require manual
reduction.
GRADE 4: chronically prolapsed and if reducible fall out again.
Others fall out of the anus and are irreducible
(strangulated) surgical emergency.

20. HEMORRHOIDS -Symptoms
Grade 1 usually are asymptomatic or with minimal bright red bleeding on
defecation.
1-bleeding: -the main and earliest symptom
-starts as bright red bleeding on the surface of the
stool or on the toilet paper.
2-prolapse: -a much later symptom
-starts transiently on defecation, but occurs with
increasing frequency until 3rd degree H. develop.
3-discharge: -a mucous discharge accompanies a
prolapsed pile.
4-pruritis
5-pain

21. HEMORRHOIDS-Signs
INSPECTION:
-1st degree H. show no outward abnormality
-2nd degree H. may show the skin covered components
when the buttocks are separated or piles may
prolapse when the pt. strains.
-3rd degree H. shows the red anal mucosa in their
position (3,7,11)
DIGITAL EXAMINATION: internal H. can’t be felt unless they are thrombosed or in the
long standing thickened piles.
And should not apply PR

22. Investigation
1-sigmoidscopy: essential to exclude co-exclude rectal
pathology as carcinoma or polyps.
2-barium enema: indicated when sigmoidscopy and proctoscopy
can’t explain the symptoms.
3-CBC: anaemia, rarely happen in longstanding piles.

23. Acute hemorrhagic rectal ulcer (AHRU)
Clinical features of AHRU are as follows:
Most common in elderly women;
Accompanies serious underlying disorders
Onset is sudden, painless, and
accompanied by massive rectal bleeding
Most of the patients are bed-ridden

24. Clinical characteristics of the patients with
AHRU (III)
 Endoscopic appearances of AHRU are
as follows:
 Shallow and irregular or
circumferential ulcer, which is situated
in the terminal rectum immediately
proximal to the dentate line,
occupying from one third to the entire
circumference of the rectum

25. Fissure in ano
 Fissure is a longitudinal ulcer in the anal canal posteriorly
situated in majority of cases.
 Fissure may be of two varieties:-
(a)Acute Fissure:- It is a deep tear in the anal canal with
surrounding oedima and inflammatory induration.It is always
association with spasm of the anal sphincters.
 Bright streak of blood with the passage of stool and pain after
defaecation are the characteristic feature.
(b)Chronic Fissure:- When acute fissure fails to heal,it will
gradually develop into a deep undermined ulcer with
continuing infection and oedima.This ulcer stops above at the
pectinate line.Below,there is hypertrophied papilla and skin
tag known as ‘sentinel pile’.

27. SYMPTOMS
1-Pain:
fissures are the commonest cause of pain in the anal verge
both acute and chronic fissures are very painful
it begins at defecation and is described as tearing
it persists for minutes to hours after defecation
it is throbbing or aching in nature
2- Bleeding:
acute fissures may streak the stool with blood and stain the toilet
paper
Chronic fissures bleed less and may produce little blood stain of
the toilet paper if any.
3- A small skin tag called sentinel tag or sentinel pile may form at the
lower end of a chronic fissure. This tag may be felt by the patient.

28. 4- Because of the pain, the pt. is usually constipated.
5-the fibrosis around the chronic fissure prevents a good seal
around the anus leading to small amounts of mucous leak on
the peri-anal skin pruritus –could be the presenting
symptom of a chronic fissure-
6-the symptoms are slow to develop and become long
standing, there may be periods of remission

29. Fistula in ano
 A fistula is a track lined with epithelium
Or granulation tissue, connecting two
epithelial surfaces. It may connect two
body cavities or one cavity and the body’s
external surface.
 A fistula-in-ano connects the lumen of the
rectum or anal canal with the external
surface. It is usually lined by granulation
tissue.

30. Fistula in ano
LOW LEVEL FISTULAS:
The internal opening is below the ano-rectal ring.
They could be of the following:
1-trans sphincteric
2-inter sphinteric
3-subcutaneous or submucous
HIGH LEVEL FISTULAS:
The internal opening is above the ano-rectal ring.
They could be of the following:
1-extra sphincteric (pelvi-rectal supralevator)
2-trans sphincteric
3-inter sphincteric

32. Fistula in ano
SYMPTOMS:
 Watery or purulent discharge from the
external opening of the fistula
 Pain is episodic as the fistula fills with pus. If
the pus doesn’t discharge pain is more
intense and throbbing
 The discharge causes pruritus ani.
 There may be minor bleeding from the
external opening
 The symptoms in general are episodic but the
condition hardly ever cures itself

33. Fistula in ano
GOODSALL’S RULE:
 The internal opening of an anterior fistula
lies along a radial line drawn from the
external opening to the anus, whereas the
internal opening of a posterior fistula lies
in the mid line posteriorly.

34. Fistula in ano
ON PR EXAMINATION:
 The external opening is visible anywhere around the anus usually close to
the anal margin but sometimes a few centimetres away.
 The opening is not tender but the thickened tissue around it may be.
 The serous or purulent discharge may be visible.
 Rectal examination is not painful.
 The internal opening may be felt. 2/3 are posterior, 1/3 are anterior.
 Sigmoidscopy and protoscopy are essential to exclude underlying disease as
chron’s or carcinoma or TB.
 The inguinal LN are not enlarged except if there is inflammation or
secondary infiltration by carcinoma.
 Don’t forget general examination if there is a suspected systemic
underlying cause.

35. Fistula in ano
 INVESTIGATIONS:
fistulogram, endoanal ultrasound, MRI
 DDx:
pilonidal sinus, hidradenitis, suppurative,
incontinence, crohn’s, trauma.

36. PERI-ANAL HEMATOMA
It is not a true hematoma but a thrombosis of a vein in the
subcutaneous plexus.
SYMPTOMS:
1-Pain: usually due to the tension
*it begins gradually increasing in severity over a few hours and
subsiding gradually over few days
*it is continuous.
*made worse by sitting, moving and defecating
*localized to the lump
2-Swelling:
*appears at the same time as the lump
*First it is small and spherical
* Then it may enlarge and become more painful

37. SYMPTOMS:
3-Bleeding: this happens only if:
*the lump bursts
*the skin over the lump ulcerates
4- The skin around the lump is itchy and moist due to the
leakage of the mucous because the lump doesn’t allow the anus
to close properly.

38. SIGNS ON EXAMINATION:
*Colour: if it is close to the overlying skin which is not edematous,
it is deep red-purple. But if the skin is edematous then its colour
can’t be seen.
*The lump is tender especially if it ulcerates.
*Shape and size: initially the lump is spherical and up to 1cm in
diameter. If the skin is lax or edematous then the lump is polypoid.
*Surface: covered by skin and the surface beneath it is smooth
*Composition: solid, hard hemispherical mass
*Relations: the lump is superficial to the external sphincter. Not
fixed to the skin or other structures. Cannot be reduced to the anal
canal.

39. CARCINOMA OF THE RECTUM
 75% occur in the lower part of the rectal ampulla
papilliferous or a simple ulcer with everted edges.
 25% in the upper part of the rectum annular in shape.
 90% or rectal cancers can be felt with a finger during PR.
MACROSCOPIC APPEARANCE:
It may be as follows:
 papilliferous
 ulcerating commonest
 stenosing at rectosigmoid
 colloid

40. MICROSCOPIC APPEARANCE:
 *90% are adenocarcinoma
 *9% are colloid – adenocarcinoma with mucous production-
 *1% highly anaplastic carcinoma simplex
 *at the anus, sq. cc occur but, a malignant tumour protruding
through the anal canal is more likely to be an adenocarcinoma
of the rectum invading the anal skin.
 Rectal ca is common in middle and old age (50-70 yrs) but can
occur in young adults.
 It is equally common in both sexes.

41. CARCINOMA OF THE RECTUM
Symptoms
Rectal bleeding: small dark red streak on the stool. If a
lot of blood accumulates it can pass as such but this is
uncommon.
The surface of the tumour produces mucous which is
expressed in a more liquid motion – diarrhea like- but
if it pools it can be passed as liquid faeces.
There may be change in bowel habit usually towards
constipation.
High annular cancers at the recto-sigmoid junction may
cause partial obstruction  presenting as alternating
constipation and diarrhoea.

42. Symptoms
Tenesmus  tumour in the lower part of
the rectum is large to fool the sensory
mechanisims into thinking it is faeces.
Weight loss: this is common even if there
isn’t any metastasis.
Small primary lesions maybe symptom
less but associated with multiple
metastasis especially to the liver. Here
the pt. has upper abdominal pain, malaise
and a palpable mass.
Pain is an uncommon symptom.

43. CARCINOMA OF THE RECTUM
SIGNS ON EXAMINATION
On Rectal Examination:
More commonly, only the lower edge of a malignant
ulcer can be felt. It feels hard and bulges into the
lumen of the rectum, the edges are averted and the
base is irregular and friable.
Upon withdrawal of the finger, you will have blood
and mucous on the gloved finger.
If the tumour is in the upper part of the rectum, only
the lower edge is felt.
This position of the lesion makes it hard to decide
if the tumour is in the rectum or out of it 
sigmoidoscopy is the answer.

44. PR is not reliable in fat people.
On general examination: the liver is the most common site
for metastasis.
Other sites for metastasis are: supraclavicular lymph
glands, the lungs and the skin.
Lung metastasis is uncommon, a chest x-ray is mandatory.
The inguinal LN are involved only if the tumour is below the
Hiltons line to involve the skin.
If the pt. has palpable inguinal LN, the tumour is most likely to
be sq. cc. of the anal skin

45.  SPECIAL INVESTIGATIONS
1-Sigmoidscopy: to inspect and take a biopsy.
2-Barium Enema: the indications for this procedure
are:
* The growth isn’t visualized by sigmoidoscopy
*if a second tumour is suspected
*ulcerative colitis
*familial polyposis
3-Ultrasound of the abdomen to check liver metastasis
and ascites.

46. Colorectal polyps
 Adenomatous polyps and adenomas
 Has malignant potential
 Morphology:
-polypoid and pedunculated
-dome-shaped and sessile
 Histology:
-degree of epithelial dysplasia is
highly variable
-carcinoma in situ
-early invasive cancer:-
invasion of tumour cells through basement
membrane→muscularis mucosa→submucosa

47. TYPES OF COLORECTAL POLYPS
1.Tubular adenomas
- small pedunculated / sessile lesions
-retain a tubular form similar to normal colonic
mucosa
-least potential for malignant transformation
2. Villous adenomas
-sessile and frond like lesions
-secrete mucus
-more dysplastic
-greater potential for malignant change
3. Tubulo-villous adenoma
-intermediate between tubular and villous
adenoma
-pedunculated, stalk is covered with normal
epithelium

48. SIGN AND SYMPTOM
 Rectal bleeding
 Iron deficiency anaemia
 Mucus
 Hypokalaemia
 Tenesmus
 Prolapse
 Obstructive symptoms

49. INVESTIGATION
 Sigmoidoscopy
 Colonoscopy -gold standard
-visualize, biopsy, remove
 CT pneumo-colon
 Double contrast barium enema

50. Inflammatory Bowel Disease
Signs
 Abdominal Mass
 Ulcerative Colitis: No abdominal mass
 Crohn's Disease: Mass often at Right lower quadrant
 Gastrointestinal Tract Affected
 Ulcerative Colitis
 Affects only colon
 Continuous from rectum
 Crohn's Disease
 Mouth to anus potentially affected
 Discontinuous, "Skip" lesions
 Bowel Tissue affected
 Ulcerative Colitis: Mucosal disease (no granuloma)
 Crohn's Disease: Trans-mural disease (granulomas)

51. Inflammatory Bowel Disease
Symptoms
 Pain
 Ulcerative Colitis
 Lower abdominal cramps
 Relieved with Bowel Movement
 Crohn's Disease
 Constant pain often in right lower quadrant
 Not relieved with Bowel Movement
 Stool Blood
 Grossly bloody stool in Ulcerative Colitis

52. Investigation
Fecal Occult Blood Testing
• Normally lose 0.5-1.5mL blood/day from GIT
• Three types of test
(a)Guaiac-based (Haemoccult II, Haemoccult II Sensa)
• Good for detecting large, more distal lesions
• Inconsistent
– Need >10mL daily blood loss for +ve test 50% of the time
– Can detect as little as 1mL of blood in stool
• Affected by dietary factors
– Foods which darken stool make it harder to read
– False positives from dietary iron
(b)Immunochemical
• Do not detect bleeding from upper GIT - localizes to the colon
• Can detect as little as 0.3mL of blood in stool
• Lab processing required

53. Fecal Occult Blood Testing
(c)Haemo-porphyrin test
• Very sensitive
• High false positive rate
• Lab processing required
• Sensitivity 60-80%
• False positive rate 5-13%
• If test is positive patients require a colonoscopy or double-contrast
Barium Enema + sigmoidoscopy
• If test is positive and the colon has been “cleared”
unless iron deficiency is present no further Ix is
necessary

54. Investigation
Colonoscopy
• Diagnostic and therapeutic capabilities
• Can be used even with ongoing massive bleeding
– Active bleeding - focal adherent clots
– Non-bleeding visible vessels
- Timing ideally 6-24 hours post presentation
– Patient must be in stable condition
– Allows bowel prep
– This is the time when recurrent bleeding usually occurs

55. DIVERTICULAR DISEASE
This disease may present in one of the following manners:
1-chronic left sided abdominal pain + change in bowel habits
2-acute abdominal symptoms
3- Rectal bleeding: acute, massive and fresh blood
 Elderly pt. with this disease present with a little faint,
lower abdominal pain, and a desire to defecate that when
emptied pass large volume of fresh blood and clots.
 The patients are rarely shocked and don’t require
transfusion.
 It is diagnosed via barium enema or colonoscopy

57. DIVERTICULAR DISEASE
Causes of bleeding are:
 Eroded artery in the mouth of the diverticulum
 The disease is incidental and the bleeding is due to
angiodysplasia of the chronic mucosa .

58. Crohn’s Disease
 Inflammatory disease of the intestines that may
affect any part of the gastrointestinal
tract from mouth to anus

59. Symptoms
 Abdominal pain
 Diarrhea (which may be bloody)
 Vomiting
 Weight loss
 Skin rashes
 Arthritis
 Inflammation of the eye
 Rectal bleeding

60. Causes
 genetics (mutations in CARD15)
 environmental factors
 immune system
 microbes (Mycobacterium avium
subspecies paratuberculosis)

61. Diagnosis
 endoscopy
 radiologic tests
 blood tests
 comparison with ulcerative colitis

62. Solitary rectal ulcer
syndrome
Young adults with a history of constipation,
self-medication, ano-rectal prolapse.
Fibrous obliteration of the lamina propria
with disorientation of muscle fiber.

63. Inflammatory bowel disease-cause swelling in the intestines.
symptoms similar to other intestinal disorders, such as IBS and
ulcerative colitis it can be difficult to diagnose.
Ulcerative colitis Inflammation occurs uniformly throughout an
affected area.
Crohn's disease can develop in several places simultaneously,
with healthy tissue in between.
Blood test
 anemia-could indicate bleeding in the intestines.
 high white blood cell count, which is a sign of inflammation
somewhere in the body
Colonoscopy-inflammation, bleeding large intestine
upper gastrointestinal (GI) series view small intestine
 Patient drinks barium, chalky solution that coats the lining of the
small intestine, before x-rays are taken.
 The barium shows up white on x-ray film, revealing inflammation
or other abnormalities in the intestine.

64. Discussion
Enquire about the amount of bleeding,the colour of the blood
lost-
Bright red- coming from the rectum or anal canal
Dark red-coming from the ascending, transverse, descending or
sigmoid colon
Black(i.e melaena)-from the small intestine or higher.
Its relation with the faeces-unchanged blood may appear in four
ways-
(i)Blood mixed with faeces means that the blood has come from
bowel higher than sigmoid colon where the softness of the
stool remains giving chance to the blood to mix with the
faeces.

65. (ii)Blood on the surface of the faeces usually come
from the rectum or anal canal.
(iii)Blood separate from the faeces may occur when
bleeding occur at some other time than defaecation
e.g bleeding carcinoma of the rectum when blood
accumulates in the rectum and gives rise to desire to
defaecate and only blood and mucus come out.Such
bleeding may also occur in diverticulosis, diverticulitis,
ulcerative colitis, polyp,prolapsed piles etc.
(iv)Blood in the toilet paper is only seen in case of
minor bleeding from the anal skin either due to fissure-
in-ano or external haemorrhoids.
When a child comes with bleeding per anum,a diagnosis
of rectal polyp should be made until this is excluded by
rectal examination.

66.  Bleeding per rectum with pain:-
Fissure-in-ano,Fistula-in-ano,Carcinoma of the anal canal,
Ruptured perineal haematoma, Ruptured-anorectal abscess,
endometriosis, Injury etc.
 Bleeding per rectum without pain:-
(i)Blood alone-Polyp,villous adenoma and diverticular disease
(ii)Blood after defaecation-Haemorrhoid
(iii)Blood with mucus-Ulcerative colitis,Crohn’s
disease,intussusception,ischaemic colon etc.
(iv)Blood streaked on stool-Carcinoma of the rectum.

67. Conclusion
 Bleeding per rectum is very common symptom
 It is often attributed by patient to hemorrhoids and they are a
common cause of this symptom and it is important to know
what the possible causes are and when and how to investigate
this symptom further.
 The type and amount of the bleeding as well as the age of the
patient are important in initial assessment of the bleeding.
 The majority of cases of rectal bleeding are due to benign
causes, particularly haemorrhoids and anal fissure. However
there are many other possible causes which are explained
earlier.
 The age of the patient gives a clue to aetiology and as a result
,under the age of 30 to have haemorrhoids ,an anal fissure or
inflammatory bowel disease. Over the age of 50,there should
be a higher suspicion of colorectal cancer.

68. THANK YOU