The first thing when called is to identify whether the bleeding is truly a lower GI bleed or whether it is an Upper GI Bleed as the management differs. Both can quickly become emergencies so seek senior advice.
When the nurse first calls you
- Check the observations & their trend (urgent review for haemodynamic instability)
- If unwell, apply your A to E assessment (otherwise you can take a history as usual)
- If well with minimal PR bleeding, the focus is identifying who needs further testing & managing the underlying condition (see at the bottom)
- Take bloods including a group & save (2 samples are needed if there’s no historic sample)
- A venous/arterial blood gas can give you an instant haemoglobin
- Ideally 2 large cannulas, but a small cannula in a vein is better than a large one in the bin
- Consider a major haemorrhage call as it is better to resuscitate with blood (& you might not have time to wait for properly matched blood)
- Consider tranexamic acid (can cause clots)
- Keep nil by mouth
- Infectious (recent travel, gastroenteritis symptoms, very acute, exposure to antibiotics for c-difficile)
- Inflammatory (chronic history of multiple episodes, family history, extra-intestinal associated features, nutritionally deplete)
- Ischaemic (vascular risk factors)
- Diverticulitis (known diverticular disease, constipation, associated pain, older)
- Perforation (peritonism)
- Blood thinners may exacerbate bleeding (and may need reversal e.g. warfarin)
- Painless bleeding associated with bowel movement. Bright red blood coats stool. Blood may be seen in the toilet or on a tissue
- Anal fissures
- Tearing pain with the passage of stool, a small amount of bright rectal on tissue or stool surface. Itch or perianal skin irritation
- Usually asymptomatic. Bleeding more likely with distal polyps
- Intermittent rectal bleeding, mucus, and mild diarrhoea present in <4 small loose motions per day
- Rectal cancers
- bleeding, mucus, straining, sense of incomplete evacuation
- Haematochezia, abdominal pain, change in bowel habit, family history, weight loss, change in bowel habit. Likely lesion on left
- If on examination (including a rectal examination) doesn’t reveal the cause or there are red flags or they are older (especially above 50y) then colonoscopy should be considered
- In the intermediate population, a sigmoidoscopy could be offered first with a colonoscopy only if the cause was not identified.
- Beware though as there could be multiple pathologies – haemorrhoids are very common and the patient could have cancer also.
- Fibre, water & laxatives as necessary aiming for soft stools
- Regular exercise
- Any emollients/anaesthetic/anti-inflammatory agents you have at your hospital which can be used in the very short term (less than a week) for relief
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