Fresh rectal bleeding — model surgical clerking

Patient details

Name: Mr N.T.
Age / sex: 59-year-old man
Occupation: Taxi driver
Marital status: Married
Seen: Surgical clinic, 11:00
Clerked: Surgical clinic, 11:20
Source: Patient himself, reliable
Referred by: Pharmacist, then family doctor

Presenting complaint

“I have been passing fresh blood with my stool for three months.”

History of presenting complaint

Mr N.T. was well until three months ago, when he first noticed bright red blood when opening his bowels. The blood is mixed with the stool and also coats its surface, and there is often slimy mucus with it. The amount is small each time, without clots, but it now happens on most days and is increasing. Passing stool is not painful. Over the same three months his bowel habit has changed: he used to pass one formed stool each morning and now goes three or four times a day, with looser and narrower stools, an urgent need to go in the morning, and a feeling that the bowel has not emptied afterwards. He has lost 6 kg in three months without trying, and his appetite is reduced. For the last month he has felt tired and becomes breathless climbing stairs. He thought the bleeding was from piles and used a cream from the pharmacy for six weeks without benefit. He has no pain at the anus, no lump coming down and no itching. He has no abdominal pain, swelling or vomiting. He has passed no black stools and has not vomited blood. He has had no fever, no diarrhoea at night, no mouth ulcers or joint pains, and no similar episodes in earlier years. He has not travelled recently or taken antibiotics. He has no urinary symptoms, no bone pain and no jaundice. He has never had a colonoscopy.

One continuous storyA single passage in time order, with no sub-headings and no bullet points.

Describe the blood exactlyColour, whether it is mixed in, on the surface, or separate from the stool, the amount, clots, mucus, and pain. Blood mixed with stool comes from above the anus. Blood that drips after the stool comes from the anal canal.

Bowel habit: before and nowFrequency, consistency, calibre, urgency and the feeling of incomplete emptying. That last feeling, called tenesmus, means something is occupying the rectum.

Weight and anaemiaKilograms lost, and the symptoms of anaemia: tiredness and breathlessness on effort.

Record the delayHe treated himself for piles. This is the commonest reason rectal cancer is found late, and it teaches why bleeding is never called piles without an examination.

End with the negativesIn this order: piles and fissure · obstruction · bleeding from the upper gut · colitis · infection · spread to bladder, bone and liver.

Past medical history

No chronic illness. No previous bowel disease or polyps.

Past surgical history

No previous operations.

Drugs and allergies

No regular medication. No aspirin, anti-inflammatory drugs or anticoagulants. No iron tablets.

No known drug allergies.

Family history

His father had cancer of the colon at 64. No other relatives with bowel cancer or polyps.

Social history

Smokes 20 cigarettes a day for 25 years (25 pack-years). No alcohol. Eats red meat most days and few vegetables. Sits for most of the day.

Systems review

No cough or chest pain. No headache.

General examination

A thin man, comfortable at rest. Alert and orientated. Conjunctivae pale. Not jaundiced. Weight 76 kg.

Temperature36.9 °C

Pulse92 /min, regular

Blood pressure126/78 mmHg

Respiratory rate16 /min

Oxygen saturation98% on air

Nails normal. No enlarged lymph node in the left supraclavicular fossa. No ankle swelling.

Abdominal examination

Abdomen not distended. No scars. Soft and not tender. No mass felt, including in the right iliac fossa. Liver not palpable, span 11 cm. Spleen not palpable. No shifting dullness. Bowel sounds normal. No enlarged inguinal lymph nodes.

Anorectal examination

Performed with consent and a chaperone, in the left lateral position with the knees drawn up.

Inspection

Perianal skin normal. No skin tags, no fissure, no external piles, no fistula opening, nothing coming down on straining.

Digital examination

Anal tone normal and the examination is not painful. A hard, irregular, ulcerated mass is felt on the posterior wall of the rectum. Its lower edge is about 6 cm from the anal verge and its upper limit cannot be reached. It occupies about half of the circumference and moves on the tissues beneath it. The prostate is felt separately in front and is normal. Blood and mucus on the glove.

Other systems

Chest: clear.

Heart: first and second heart sounds normal, soft flow murmur.

Legs: no swelling.

Summary

Say this to the examinerMr N.T. is a 59-year-old smoker whose father had colon cancer, who presents with three months of fresh rectal bleeding mixed with stool and mucus, with increased frequency, narrow stools, tenesmus, 6 kg of weight loss and symptoms of anaemia. On examination he is pale with stable vital signs, has no abdominal mass or enlarged liver, and has a hard, ulcerated, mobile mass on the posterior rectal wall 6 cm from the anal verge, with blood and mucus on the glove.

Provisional diagnosis

Carcinoma of the rectum, with probable iron deficiency anaemia.

Plan

Bloods: full blood count, ferritin, urea and electrolytes, liver function tests, CEA as a baseline.
Colonoscopy with biopsy of the mass and inspection of the whole colon.
Staging: CT of the chest, abdomen and pelvis, and MRI of the pelvis.
Discussion at the multidisciplinary meeting.
Results and diagnosis to be explained by the consultant.

Differential diagnosis of fresh rectal bleeding

Group the causes by site: anus, rectum and colon. Use the pattern of the blood and the presence of pain to separate them.

Diagnosis	Points to it in the history	Points to it on examination	In this patient
Anus
Haemorrhoids	Bright blood after the stool, dripping into the pan or on the paper; painless; lump that comes down	Often nothing outside; seen on proctoscopy	Blood is mixed in; there is a mass
Anal fissure	Sharp pain on passing stool lasting minutes to hours, streak of blood on the paper, constipation	Tear at the back of the anal margin with a skin tag; examination too painful	No pain
Anal cancer	Pain, bleeding, lump at the anus	Hard ulcer at the anal margin, groin nodes	Anus normal
Rectum
Carcinoma of the rectum	Blood and mucus mixed with stool, tenesmus, change in bowel habit, weight loss	Hard irregular mass on rectal examination	Most likely
Rectal polyp	Painless bleeding, sometimes mucus; no weight loss	Soft mobile lump on a stalk	Mass is hard and ulcerated
Proctitis	Urgency, blood and mucus, frequent small stools; ulcerative colitis or past radiotherapy	Tender, granular rectal wall	Discrete mass
Colon
Cancer of the left colon	Change in bowel habit, blood mixed with stool, colicky pain	Sometimes a mass in the left abdomen	Possible second tumour; colonoscopy
Cancer of the right colon	Tiredness and anaemia with little visible blood, weight loss	Mass in the right iliac fossa, pallor	No mass
Diverticular bleeding	Older patient, sudden large painless bleed that stops by itself	Normal examination	Small daily bleeds for months
Angiodysplasia	Elderly, repeated painless bleeds, anaemia	Normal examination	Does not explain the mass
Ulcerative colitis or Crohn's disease	Young adult, bloody diarrhoea for weeks, night stools, mouth ulcers, joint pains	Thin, tender abdomen	Wrong age, no such symptoms
Infective colitis	Sudden bloody diarrhoea with fever; travel, contacts	Fever, tender abdomen	Three months, no fever
Ischaemic colitis	Elderly with vascular disease, sudden pain then bloody diarrhoea	Left-sided tenderness	No pain
Upper gut
Fast bleeding from stomach or duodenum	Ulcer history, vomiting blood, black stools, collapse	Fast pulse, low blood pressure	Stable, no black stools

Model OSCE answer“My diagnosis is carcinoma of the rectum. He has three months of fresh bleeding mixed with stool and mucus, a change in bowel habit with tenesmus, weight loss and symptoms of anaemia, and his father had colon cancer. On rectal examination I felt a hard, ulcerated, mobile mass on the posterior wall 6 cm from the anal verge. Haemorrhoids and fissure are excluded by the absence of pain and the normal anus. I would confirm with colonoscopy and biopsy, examine the rest of the colon, and stage him with CT and MRI of the pelvis.”

Clinical signs related to this case

The signs you should look for in any patient with rectal bleeding. For each one, know how to elicit it and what a positive result means.

Sign	How to elicit it, or what you see	What it means
General signs
Pallor	Pale conjunctivae and palm creases	Chronic blood loss
Spoon-shaped nails	Nails flat or curved upwards	Long-standing iron deficiency
Fast pulse with low blood pressure	Check lying and sitting if safe	Acute significant bleed: resuscitate first
Virchow's node	Hard node in the left supraclavicular fossa	Spread from an abdominal cancer
Signs in the abdomen
Mass in the right iliac fossa	Firm mass that does not move with breathing	Cancer of the caecum, or Crohn's disease
Hard irregular liver	Knobbly edge below the costal margin	Liver deposits
Shifting dullness	Flank dullness that moves when the patient turns	Fluid from spread of cancer
Distension with a drum-like note	Swollen resonant abdomen	The tumour is obstructing
Signs at the anus
Sentinel skin tag	Small tag at the back of the anal margin with a tear above it	Chronic anal fissure
Prolapsing haemorrhoids	Bluish cushions at 3, 7 and 11 o'clock that come down on straining	Haemorrhoids. Their presence does not explain a change in bowel habit.
Fistula opening or abscess	Small opening or tender swelling beside the anus	Perianal sepsis; consider Crohn's disease if multiple
Signs on rectal examination
Hard, irregular mass	Describe wall, distance, circumference, surface, upper limit, mobility	Rectal cancer
Soft mobile lump on a stalk	Slips away from the finger	Polyp
Blood and mucus on the glove	Look every time and record the colour	Bright red: lower bowel. Dark or black: higher up.
Hard nodules felt in front of the rectum	A firm shelf above the prostate or cervix	Deposits in the pelvis from a cancer in the abdomen
Enlarged inguinal nodes	Hard nodes in the groin	Anal cancer below the dentate line drains to the groin; rectal cancer does not

Key: piles do not exclude cancerHaemorrhoids are common, so many patients with cancer also have them. Finding piles never ends the investigation in a patient over 50 or with a change in bowel habit.

“If you do not put your finger in, you put your foot in it”The old surgical saying. Never accept a history of piles without a rectal examination.

Key: fixed or mobileA mobile tumour is confined to the bowel wall. A fixed tumour has grown into the tissues around it. Write which, because it changes the treatment.

Key: right side and left sideRight colon cancers bleed silently and present with anaemia. Left colon and rectal cancers present with visible blood and a change in bowel habit.

Key: in this patientPallor, normal anus, a hard ulcerated mobile mass at 6 cm, blood and mucus on the glove, no liver enlargement and no nodes. Rectal cancer without clinical evidence of spread.

Teaching case. The patient is fictional and written to illustrate format and reasoning. Local protocols decide investigation and treatment.