Brbpr

[bio-psy]

Question:

32 y/o M c/o several episodes of BRBPR which he associates with consumption of either steak or corn chips. He has had a couple of rectal exams which were normal and did not reveal any cause of bleeding. He has no history of hemorrhoids or fissures and no family history of colon cancer. Patient has no other GI complaints such as diarrhea, constipation, or rectal or abdominal pain. He is relatively unconcerned and does not want any further testing. I think a sigmoidoscopy or barium enema should be done at the very least to look for a source of bleeding. I am not sure if it is really related to the steak and corn chips or if the patient is just looking for something to blame. Can either of these foods irritate the GI mucosa or cause constipation that might cause hemorrhoids to bleed? Am I overreacting?

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[mellow yellow]

Question:

32 y/o M c/o several episodes of BRBPR which he associates with consumption of either steak or corn chips. He has had a couple of rectal exams which were normal and did not reveal any cause of bleeding. He has no history of hemorrhoids or fissures and no family history of colon cancer. Patient has no other GI complaints such as diarrhea, constipation, or rectal or abdominal pain. He is relatively unconcerned and does not want any further testing. I think a sigmoidoscopy or barium enema should be done at the very least to look for a source of bleeding. I am not sure if it is really related to the steak and corn chips or if the patient is just looking for something to blame. Can either of these foods irritate the GI mucosa or cause constipation that might cause hemorrhoids to bleed? Am I overreacting?

the food association has nothing to do with the BRBPR. BRBPR can only occur if the site of the bleed is very distal (prox-transverse colon or later). By the time food reaches the colon, it is pretty much completely digested and therefore the food association is not relevant. I agree that a study should be performed, and a colonoscopy would be best to visualize the entire colon. BRBPR can be caused by AVMs, diverticulosis, and hemorrhoids to name a few. Rarely would BRBPR be caused by a tumor and it would be highly unusual in a 32 year old. Other sexy diagnoses to consider include UC, anal fissure.

 

[souljah1]

This man has painless BRBPR. The top three in this differential is internal hemorroids, diverticulosis, and vascular ectasias. Given his age, I think the most likely cause is probably in the order of those three I mentioned above. BRBPR can occur with ulcerating neoplasms, but this would be really uncommon in a man his age. The food really has no causitive role, unless he has issues with constipation - which increases the risk of diverticula formation and internal hemorroids. Rare causes that I have seen cause painless large volume BRBPR have been things like appendiceal carcinoid (in a young man) and an aortic-enteric fistula that occurred s/p endovascular triple A repair.

If his BRBPR was painful, then you'd have to think more about IBD (UC>>>Crohn's), infections (C. jejuni, Salmonella, E. coli, Shigella, Entamoeba histolytica, etc), radiation proctitis, etc.

This dude probably has internal hemorroids >> diverticula >> ectasias > rarer causes.

Lower GI bleeding can be really difficult to visualize b/c by the time you have an adequate bowel prep the bleeding has usually ceased. If a sigmoidoscopy or colonoscopy showed evidence of internal hemorroids - boom...diagnosis is most likely that. If he has a bunch of diverticula, then boom...diagnosis is most likely that. Did he have big Hct drops? Was this streaked stool with blood or large volume blood? If it is large volume and you expedite the work up, tagged RBC scans and/or angiography can be really helpful.