General and Colorectal

CASE 7: per reCtal bleeDing

history

A 62-year-old businessman presents to the emergency department with significant bright red rectal bleeding for the past 6 h. He has no abdominal pain and has not vomited. There is no previous history of altered bowel habit. His appetite is normal and he reports no recent weight loss. He has recently been diagnosed with mild hypertension. He takes bendroflumethiazide 2.5 mg once daily and smokes ten cigarettes per day.

examination

He looks pale and sweaty. His blood pressure is 94/60 mmHg and his pulse is thready with a rate of 118/min. His temperature is normal. His abdomen is soft with no evidence of distension. The rest of his examination is unremarkable. Rectal examination reveals altered blood mixed with the stool and there are some blood clots on the glove. Rigid sigmoidoscopy was unsuccessful due to the presence of blood and faeces.

INVESTIGATIONS

Questions

•What is the immediate management?

•What is the differential diagnosis?

•If the bleeding does not settle, what other investigations may be necessary?

•What are the indications for surgical treatment?

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100 Cases in Surgery

ANSWER 7

The immediate management is to obtain intravenous access with two large-bore cannulae in the anterior cubital fossae. Bloods should be taken for a full blood count, coagulation screen, renal function and a crossmatch for at least four units. Intravenous fluids should be started and a urinary catheter inserted to monitor hourly urine output. The patient is best monitored closely until he becomes stable with regular observations. Central venous monitoring should be considered and transfer to a high-dependency unit (HDU) may be necessary.

!Differential diagnoses

•Diverticular disease

•inflammatory bowel disease

•angiodysplasia

•infective colitis, e.g. Campylobacter, Salmonella, E. coli, Clostridium species

•ischaemic colitis, e.g. mesenteric infarction/embolism

•radiation colitis

•haemorrhoids

•neoplasia

•meckel’s diverticulum

Often the bleeding settles with conservative management. If the bleeding continues, an oesophagogastroduodenoscopy (OGD) should be done first to rule out an upper gastrointestinal cause for the bleeding. Colonoscopy can then be performed to assess the large bowel for a cause. Unfortunately, because of the presence of blood, views are often poor. If the approximate area of affected bowel can be established, it allows better planning for surgical intervention.

If the bleeding is quite dramatic, mesenteric angiography should be considered, to delineate the anatomy and identify any bleeding vessels. Selective embolization may be employed to stop the bleeding in certain cases. With this technique, sites of bleeding can only be located if the blood loss is over 1 mL/min. If the source of bleeding is not known and other measures have failed, the patient may require a sub-total colectomy.

KEY POINT

•haemoglobin should be repeated at 12 h as anaemia may not be evident on the initial sample.

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General and Colorectal

CASE 8: SWelling in the groin

history

A 38-year-old computer engineer is referred to surgical outpatients complaining of pain in the right groin. He has noticed this over the past few months and his pain is worse on exertion. He has also noticed an intermittent swelling. He is otherwise fit and well. There is a family history of bowel cancer. He is a smoker of 25 cigarettes per day and drinks 10 units of alcohol per week.

examination

He is apyrexial with normal blood pressure and pulse. The abdomen is grossly normal but there is some tenderness in the right groin. The patient is asked to stand. In the right groin, there is a swelling, which is more pronounced when the patient coughs. The other groin and the scrotal examination are normal.

Questions

•What is the likely diagnosis?

•What are the anatomical boundaries?

•What are the complications associated with this condition?

•How should the patient be treated?

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100 Cases in Surgery

ANSWER 8

The patient is likely to have an inguinal hernia. The boundaries of the inguinal canal are:

•Anteriorly: the external oblique and internal oblique muscle in the lateral third

•Posteriorly: the transversalis fascia and the conjoint tendon (merging of the pubic attachments of the internal oblique and transverse abdominal aponeurosis into a common tendon)

•Roof: arching fibres of the internal oblique and transverse abdominus muscles

•Floor: the inguinal ligament

Inguinal herniae are more common in males and in the right groin. Indirect inguinal hernial sacs are found lateral to the inferior epigastric vessels at the deep inguinal ring. Direct hernias are found medial to the inferior epigastric vessels and are a result of a weakness in the posterior wall. This distinction between the two can only be made with certainty at the time of surgery. The key in distinguishing between femoral and inguinal herniae is their point of reduction. Femoral herniae reduce below and lateral to the pubic tubercle, and inguinal herniae above and medial to the tubercle.

!Complications of an inguinal hernia

•incarceration, i.e. irreducible

•bowel obstruction

•Strangulation

•reduction en-masse: reduction through the abdominal wall without pushing bowel contents out of the hernial sac

The patient should have a surgical repair of the hernia. This can be done by either an open or laparoscopic approach. Both involve reduction of the hernia and placement of a mesh to prevent recurrence.

KEY POINTS

•indirect and symptomatic direct herniae should be repaired to prevent the risk of future strangulation.

•irreducible inguinal herniae should be repaired promptly to avoid strangulation.

•easily reducible symptomless direct herniae, need not always be repaired, especially in elderly patients with significant comorbidities.

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