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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_3113_Библиотеки_им_академика_М_И_Перельмана
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58
RECTAL BLEEDING
IN ADULTS
The GP overview
is is a very common presenting complaint and creates a lot of anxiety in the patient. By far the
likeliest causes are haemorrhoids or a ssure, but more sinister pathologies should be considered
according to the clinical picture, especially in older patients.
NOTE: Rectal bleeding in children is covered in a separate section.
Differential diagnosis
COMMON
haemorrhoids
anal ssure
gastroenteritis
rectal carcinoma
diverticular disease
OCCASIONAL
villous adenoma
trauma
anticoagulant therapy
inammatory bowel disease
colonic carcinoma
RARE
blood clotting disorders (including anticoagulants)
bowel ischaemia
angiodysplasia
intussusception
https://t.me/med1917
RECTAL BLEEDING IN ADULTS 59
Ready reckoner
Piles Fissure Gastroenteritis Cancer of rectum Diverticulosis
Blood and stool
mixed
No No Ye s No Possible
Abdominal pain No No Ye s No Possible
Diarrhoea No No Ye s No Ye s
Mass felt PR Possible No No Ye s Possible
Sentinel anal skin tag No Ye s No No No
Possible investigations
LI KE LY: Proctoscopy.
POSSIBLE: FBC, ESR/CRP, LFTs, bone biochemistry, U&E, stool for microbiology and faecal
calprotectin, hospital-based lower GI investigations.
SMALL PRINT: Clotting screen.
FBC: Check for anaemia from acute or chronic bleeding; low platelets may cause or aggravate
bleeding.
ESR/CRP raised in active inammatory bowel disease and malignancy.
If malig nancy is suspected, L FT, U&E and bone biochemistry are usef ul early on as a baseli ne.
Clotting screen: If clotting disorder a possibility; INR if on warfarin.
Stool specimen: Helpful in the presence of diarrhoea. May show evidence of infective cause
(especially Campylobacter) or white cells in inammatory bowel disease. Faecal calprotectin
may be useful in diagnosing IBD.
Proctoscopy: Helpful in primary care in visualising haemorrhoids and proctitis to conrm
a clinical diagnosis.
Hospital-based lower GI investigations: Necessary if signicant pathology is suspected.
TOP TIPS
Eighty percent of rectal tumours are within ngertip range. Always do a PR examination
unless the diagnosis is manifestly obvious from the history.
If blood is on the toilet paper and surface of the motions, the cause is likely to be palpable
PR or visible on proctoscopy; if mixed in with the motions, referral for further investigation
will be required to make a denite diagnosis.
In young adults, the diagnosis is u sually clear from the histor y and is likely to be haemorrhoids
or a ssure. In such cases, if and when you refer, to allay anxiety, emphasise that this is for
treatment rather than investigation.
e presence of diarrhoea with rectal bleeding in young adults suggests gastroenteritis
(especially Campylobacter) or colitis.
https://t.me/med1917
60 SYMPTOM SORTER
Change of bowel habit and weight loss with rectal bleeding are ominous symptoms which
should prompt urgent referral.
Any patient aged 50 or over with unexplained rectal bleeding merits urgent referral to rule
out cancer.
e presence of haemorrhoids does not necessarily clinch the diagnosis – another lesion may
be present, especially in the elderly.
A brisk, painless haemorrhage in an elderly patient is likely to be caused by diverticular
disease. Signicant amounts of blood can be lost, so assess urgently with a view to admission.
NOTES:
https://t.me/med1917
61
RECTAL BLEEDING
IN CHILDREN
The GP overview
Bleeding from anywhere tends to generate a great deal of anxiety. If that bleeding is from the
rectum, and the patient is a child, then the stress levels inevitably multiply. So while this is a
relatively unusual presentation, it will oen present as an ‘urgent’ and typically require much
reassurance. GPs have to deal with their own anxiety too – of overlooking the rare serious cause.
Differential diagnosis
COMMON
swallowed maternal blood (from cracked nipples)
anal ssure
gastroenteritis
cow’s milk protein intolerance (CMPI)
rectal polyp
OCCASIONAL
trauma (including non-accidental injury)
inammatory bowel disease (IBD)
Meckel’s diverticulum
intussusception
haemorrhoids (in older children)
RARE
Henoch–Schönlein purpura
solitary rectal ulcer syndrome
volvulus
necrotising enterocolitis (in neonates)
vascular lesion/bleeding tendency
https://t.me/med1917
62 SYMPTOM SORTER
Ready reckoner
Swallowed maternal blood Anal ssure Gastroenteritis CMPI Rectal polyp
Constipated No Ye s No Possible No
Anal pain No Yes No No No
Diarrhoea No No Ye s Possible No
Repeated
episodes
No Possible No Ye s Yes
Vomiting No No Possible Possible No
Possible investigations
In most cases, primary care investigations will be unnecessary – the diagnosis will either be
obvious and harmless (e.g. anal ssure) or will require admission or referral and investigation in
secondary care. So the following are the only investigations likely to be performed in primary
care:
Stool: M, C and S for gastroenteritis.
Faecal calprotectin: If IBD suspected.
FBC, CRP, ESR: If IBD suspected.
TOP TIPS
Remember that red stools do not necessarily imply blood – discolouration can be caused by
food, drink and medication.
Rectal bleeding caused by an anal ssure should be obvious through the history – it should
not be necessary to traumatise the child further via a digital examination.
As in adults, the nature of the bleeding will help locate its origin, with bright blood usually
from distal, and altered blood from more proximal, sites.
If gastroenteritis is suspected, then Campylobacter or Shigella are likely.
https://t.me/med1917
RECTAL BLEEDING IN CHILDREN 63
Always be alert to the rare possibility that rectal bleeding might be the result of non-
accidental injury.
e classic redcurrant jelly stool is a fairly late feature of intussusception. Consider this
especially in young children (usually under two) with episodes of severe distress/abdominal
pain associated with pallor.
Many symptoms are attributed to possible CMPI. It certainly can cause rectal bleeding, but
remember other possible causes if a trial of cow’s milk protein-free feeds does not resolve the
problem, and ensure investigation.
NOTES:
https://t.me/med1917
https://t.me/med1917
65
BREAST
Breast enlargement in men 66
Breast lumps in women 69
Breast pain 72
Nipple discharge 75
https://t.me/med1917
66
BREAST ENLARGEMENT
IN MEN
The GP overview
Swelling of the breast tissue in a male is an embarrassing symptom, oen presented behind the
facade of a ‘calling card’. e following dierential diagnosis does not include other causes of
breast swelling, which are referred to in the Top Tips at the end of this section. In true breast
swelling, glandular tissue is palpable behind the areola and is usually bilateral.
Differential diagnosis
COMMON
puberty
drugs (spironolactone, cimetidine, digoxin, cyproterone, nasteride, marijuana)
chronic liver disease (especially alcohol)
lung carcinoma
hyperthyroidism
OCCASIONAL
hypothyroidism
hyperprolactinaemia
haemodialysis and chronic renal failure
testicular carcinoma
adrenal carcinoma
cryptorchidism and other causes of hypogonadism
RARE
Klinefelter’s syndrome
true hermaphroditism and male pseudohermaphroditism
acromegaly
McCune–Albright syndrome
hypernephroma
carcinoma
https://t.me/med1917
BREAST ENLARGEMENT IN MEN 67
Ready reckoner
Puberty Drugs Liver disease Lung cancer Hyperthyroidism
Often unilateral Ye s No No No No
Cough No No No Ye s No
Weight loss No No Possible Ye s Ye s
Generally unwell No Possible Ye s Ye s Ye s
Other physical signs No Possible Ye s Yes Possible
Possible investigations
LIKELY (except for obvious pubertal cause): FBC, U&E, LFT, TFT.
POSSIBLE: Testosterone, CXR, tests of pituitary function.
SMALL PRINT: Tumour markers, chromosome analysis, CT scan, biopsy.
FBC: Many chronic systemic illnesses can cause g ynaecomastia. ere may be an associated
normochromic, normocytic anaemia. MCV may be raised in hypothyroidism and chronic
liver disease.
U&E and LFT: Will reveal chronic renal and liver disease.
TFT: To diagnose thyroid abnormality.
Testosterone: Reduced in hypogonadism and chronic illness including liver disease.
CXR: If lung carcinoma a possibility.
Tests of pituitary function (e.g. FSH, LH, prolactin and other more complex, hospital-based
tests): To check for pituitary hormone abnormalities.
Tumour markers (usually hospital-based): AFP and HCG act as tumour markers for
testicular carcinoma.
Chromosome analysis: For Klinefelter’s syndrome.
CT scan (secondary care): May be necessary for testicular tumour staging and diagnosis of
adrenal and renal tumours.
Biopsy: If carcinoma suspected.
TOP TIPS
Many male breast swellings are not true breast enlargement – possibilities include simple
obesity, abscess, sebaceous cyst and lipoma.
Pubertal boys will be very self-conscious about gynaecomastia. Reassure them that the
problem is common and will resolve, and that they are not changing sex.
Iatrogenic causes are common – check the drug history (including over-the-counter and
illicit drugs).
https://t.me/med1917
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