Please enable JavaScript.
Coggle requires JavaScript to display documents.
Scenario 1, The 50-year-old male presents with blood in stools, Few…
Scenario 1
Relevant Questions
Following are the questions related to his complaint includes bowel habits, duration, amount/quantity of blood, frequency, character of stool, along with pain, along with defecation etc
Does the blood look fresh and bright red or black
to differentiate between
Hematochezia/ Melana
Is it mixed with stool or come separate
(mucus + bleeding more common in
Proctitis)
Is it with defecation or comes at the end of defecation
Rectal etiology causes fresh bleeding
Is it with every defecation or sometimes alone?
Painless bleeding happens in hemorrhoids
Is it painful or painless?
To exclude anal fissure/ fistula
Quantity? Large/ Scanty?
acute and greater volume of
blood notice in Rectal ulcer / Ca / Diverticulosis
Any complain about tenesmus (common in proctitis)
Relevant Physical Examination
General physical examination along with vitals
Digital Rectal Examination followed by External Inspection of Anus
Proctoscopy: Look for any signs and symptoms of Extra Colonic features e.g: Arthritis, Ocular or Skin Lesions.
Management Plan
:
IBD
Step 1
: Aminosalicylates: Either Sulphasalazine or Mesalamine as an Anti Inflammatory Agent 800mg TDS or Olsalazine 500 mg BD.
Antibiotics + Folic Acid Supplements: Metronidazole 250-500 mg TDS/ Ciprofloxacine 500 mg BD/ Rifaximine 550 mg PO OD
Step 2
: Add Corticosteroids PO 40-60 MG OD/IV/Rectal/Topical
Step 3
: (Moderate to Severe) If symptoms still persist then Add Immunomodulators including Azathioprine 2.5mg/kg/day/PO /Infliximab 5mg /kg IV wkly /MTX 15-25mg wkly / 6
Mercatopurine 1-1,5mg/kg/day OD PO.
Step 4
: If medical therapy not beneficial then go for Surgery
Hemorrhoids
Internal Hemorrhoids
: Either per rectal bleeding or Prolapse mass on straining: Fiber Supplements, Sitz Bath, Topical Ointments.
External Hemorrhoids
: Surgery is the treatment of choice.
Medical: Oral analgesics, Sitz Bath, Stool Softeners, Topical Ointment
Differential Diagnoses
Hemorrhoids,
Anal Fissures,
Polyps,
Proctitis,
IBD,
Rectal Ulcer,
CA Colon,
Diverticulosis,
Pelvic Radiations
Relevant Investigations
CBC, ESR, CRP
Serum Ferritin
DRE
Stool DR/Calprotectin
Proctoscopy
Colonoscopy
Sigmoidoscopy
Serology: PANCA & ASCA
For the suspicion of Bleeding Disorder: Go for PT/APTT/Platelets count/Fibrinogen level / Blood smear.
If APTT is prolonged, then go for Factor VIII Inhibitor also.
The 50-year-old male presents with blood in stools
Few questions about
weight loss, diet, family and medical history
:
-Inquire about dietary routine,smoking habits /alcohol consumption(Smoking is one of the risk factor)
Any similar or relevant complaint in the past ? (to exclude IBD and then Colorectal Ca)
Any comorbidity ? exposure to radiation / any medication in use ? (increase risk of colorectal Ca)
Family history of similar complaints / any case of Colonic ca? (Risk factor)
Lifestyle Modifications for IBD
: Healthy diet, Exercises, Smoking Cessation, Dupplements Vit B12, Calcium, Magnesium, Vit A & D.
Contributor:
Dr. Naveed Taufiq
Algorithm made by Dr. Maheen Batool