Nigel A Scott
13
Rectal bleeding in the outpatient department 167
Box 13.1 Higher-risk symptom combinations
■ Rectal bleeding and a change in bowel habit have a three to five times greater risk of colorectal cancer compared with patients presenting with either symptom alone.
■ Rectal bleeding and no anal symptoms have a three to four times greater risk than anal symptoms alone.
■ Dark-red bleeding has only a slightly higher predictive value (9–13%) when compared with bright red rectal bleeding.
It is the possible diagnosis of colorectal cancer, however, that dominates the initial consul- tation for most patients. In practice all patients referred for hospital evaluation of rectal bleed- ing require an endoscopic examination of the rectum, but certain symptom combinations make a diagnosis of colorectal cancer more likely (Box 13.1) (Thompson, 2002).
Examination
Examination includes general clinical inspection for signs of anaemia, abdominal palpation for masses and a digital rectal examination. In many clinics this is followed by rigid sigmoidoscopy of the unprepared rectum (Box 13.2).
In the large majority of patients, at the end of this sequence a positive diagnosis of haemor- rhoids, anal fissure, rectal neoplasm or proctitis can be made. Patients with anal fissure may require a short period of topical glyceryl trinitrate (GTN) therapy before tolerating sigmoi- doscopy. A few patients with rectal bleeding and a painful anus may require examination under anaesthetic in order to complete their assessment.
Box 13.2 Outpatient anorectal examination Setting
■ Always obtain consent
■ Privacy – keep patient covered
■ Use a chaperone
■ Left lateral position. Rectal examination
1 Separate buttocks – inspect perineum and perianal skin.
2 Separate anal margin to visualise fissure if relevant.
3 Insert lubricated finger – systematic 360 degree palpation; note prostate and sacral hollow.
4 Withdraw finger and observe for blood and mucus. Rigid sigmoidoscopy
1 Insert with obturator tip directed towards umbilicus.
2 Withdraw obturator – attach lens and insufflator.
3 Warn patient that rectum will feel full as air insufflated.
4 Observe mucosa – biopsy abnormality (having checked patient not anticoagulated).
5 Document extent of examination and any pathology in centimetres from anal verge.
6 Wipe perineum clean at end of examination. Communication
LOWER GASTROINTESTINAL BLEEDING 168
Flexible sigmoidoscopy for everybody?
In many UK colorectal departments, all patients with rectal bleeding are evaluated by flexible sigmoidoscopy, after suitable bowel preparation. However, although this policy may be justi- fied in the older patient (Table 13.2), the diagnostic yield in younger patients has led some authors to question this policy on the basis of cost (Mathew et al., 2004) – approximately £330 per examination – versus the low yield of colorectal neoplasia in patients under the age of 45 years.
On the other hand, at least one health economics analysis of the endoscopic evaluation of the colon in young patients (age 25–45 years) with symptomatic rectal bleeding, found an increased life expectancy in these patients – at a cost comparable with colon cancer screening (Lewis et al., 2002). Furthermore, the majority of patients who attend with the symptom of rectal bleeding seek and expect the reassurance of a normal lower gastrointestinal endoscopy.
■ KEY POINT
The majority of patients who attend with rectal bleeding seek the reassurance of a normal lower gastrointestinal endoscopy.
Haemorrhoids
Haemorrhoids are a specialised ring of vascular ‘cushions’ containing a venous plexus with arteriovenous communications. A key point to emphasise to all patients before any haemor- rhoid therapy is that this ring of vascular tissue is not a disease but part of the normal anal canal. It is only when these normal vascular cushions produce symptoms – bleeding or prolapse – that they earn the sobriquet ‘haemorrhoid’ or ‘pile’.
Haemorrhoids are classified as follows: First degree: bleeding only
Second degree: prolapse, reduce spontaneously Third degree: prolapse, need to be pushed back Fourth degree: permanently prolapsed.
Table 13.2 Flexible sigmoidoscopy and common diagnoses by age
Diagnosis Patients aged ≥ 45 years Patients aged < 45 years
(n = 1033) (n = 242)
Nothing abnormal detected 214 (20.7) 108 (44.6)
Haemorrhoids 301 (29.1) 89 (36.8)
Diverticular disease 218 (21.1) 9 (3.7)
Colitis 49 (4.7) 6 (2.5)
Polyps 171 (16.6) 19 (7.9)
Carcinoma (confirmed on histology) 36 (3.5) 0
Other (melanosis coli, anal polyp, radiation 44 (4.3) 10 (4.1) proctitis, submucous lipoma, solitary rectal
ulcer, anal fissure)
Rectal bleeding in the outpatient department 169 Outpatient therapy
First-degree piles are defined by bleeding alone and are usually managed on an outpatient basis as follows:
● Fibre supplementation can reduce episodes of haemorrhoidal bleeding (Nisar and Scholefield, 2003).
● Sclerotherapy with 5% phenol in oil carries the principal hazard of accidental prostatic injection. Among 189 patients managed by single-session large-dose oily phenol injection (3 × 5 mL), and followed for 4 years, only 53 (28%) considered themselves cured (Santos et al., 1993). Infrared coagulation has been described as achieving better symptom relief than injection sclerotherapy at 3 months, but with no difference between the two techniques at 1 year’s and 4 years’ follow-up (Walker et al., 1990).
● Rubber-band ligation (RBL) is the dominant outpatient intervention for bleeding haemorrhoids. Meta-analyses of randomised controlled trials have demonstrated superior outcomes for RBL compared with both injection sclerotherapy and infrared coagulation (MacRae and McLeod, 1995). Potential banding problems include discomfort, vasovagal episodes and urinary symptoms, all of which are worsened by multiple banding (Nisar and Scholefield, 2003).
It is unlikely that haemorrhoidal bleeding can be cured by these techniques in all patients. ‘Cure’ depends on the definition of success, but when defined as permanent relief of symptoms or a marked improvement in symptomatology with rare manifestation of bleeding (< 1/month), the proportion of patients free from haemorrhoid symptoms after RBL decreases as a function of time (Figure 13.1). Thus, living with rectal bleeding is an everyday reality for many people, with or without haemorrhoid therapy.
■ KEY POINT
It is unlikely that haemorrhoidal bleeding can be cured in all patients. Surgical therapy
Surgical therapy for haemorrhoids is directed largely at the symptom of prolapse – that is, second-, third- and fourth-degree piles. Surgical techniques for haemorrhoids include the fol- lowing: 0 200 400 600 800 1000 1200 1400 0 0.2 0.4 0.6 0.8 1
Figure 13.1 ● Success of rubber band ligation (RBL) diminishes with time. Kaplan–Meier curves of patients who are symptom- free after RBL of haemorrhoids. The x-axis represents time (days) and the y-axis represents the percentage of patients who are symptom-free.
Reproduced, with kind permission of Springer Science and Business Media, from Iyer VS, Shrier I, Gordon PH (2004). Long-Term Outcome of Rubber Band Ligation for Symptomatic Primary and Recurrent Internal Hemorrhoids. DCR 47(8):1364–1370.
䡬, first RBL; ●, second RBL; 䡺, third RBL;■, fourth RBL.
LOWER GASTROINTESTINAL BLEEDING 170
● Open (Milligan–Morgan) haemorrhoidectomy
● Closed haemorrhoidectomy
● Stapled haemorrhoidopexy (procedure for prolapse and haemorrhoids, PPH)
● Ligasure haemorrhoidectomy
● Doppler-guided haemorrhoidal artery ligation (DG-HAL).
Excision of haemorrhoids (open technique – UK; closed technique – USA) is designed to remove swollen haemorrhoidal tissue from within the canal and out on to the perianal skin, while preserving sufficient mucosa and anoderm in order to maintain anal canal function.
Ligasure haemorrhoidectomy is an excisional technique that is thought to be associated with less postoperative pain and reduced operative time when compared with conventional techniques. Stapled haemorrhoidopexy aims to return normal but prolapsed haemorrhoidal tissue to the anal canal by correction of the weakened suspensory ligament. This procedure should be less painful than excisional techniques, as it does not involve the skin of the anal canal.
Doppler-guided haemorrhoidal artery ligation also avoids haemorrhoid excision. A modified proctoscope housing a miniature Doppler transducer locates terminal branches of the superior rectal artery supplying the haemorrhoids. A small window in the device allows a suture to be placed around the artery, thus cutting off the blood supply to the haemorrhoid.