Differentials
Common
Diverticular disease
History
Exam
vital signs may indicate severe bleeding (e.g., systolic BP <115 mmHg, heart rate >100 bpm); abdominal exam is usually normal; rectal exam may reveal bright red blood or blood clots, may be indistinguishable from colonic angiodysplasia but bleeding is usually more profuse and more likely to cause hemodynamic instability
1st investigation
Colonic angiodysplasia
History
typically over 60 years; intermittent, mild or severe episodes of painless hematochezia (bright red rectal bleeding), may be history of end-stage renal disease, von Willebrand disease, aortic stenosis, or anticoagulant therapy
Exam
vital signs may indicate severe bleeding (e.g., systolic BP <115 mmHg, heart rate >100 bpm); signs and symptoms of anemia may be present; abdominal exam is usually unremarkable, rectal bleeding may be indistinguishable from diverticular disease but bleeding usually less severe and less likely to cause hemodynamic instability
1st investigation
- CBC:
hemoglobin normal or low
- platelets:
normal or rarely thrombocytopenia in severe bleeding
- clotting studies:
usually normal
- colonoscopy:
angiomas may be visualized: 5 to 10 mm cherry red, ectatic blood vessels radiating from a central vessel
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Ischemic colitis
History
age typically is over 60 years, sudden-onset lower abdominal cramping, diarrhea, and self-limited hematochezia (bright red rectal bleeding); may be history of hemodialysis, hypertension, hypoalbuminemia, diabetes mellitus, constipation-inducing drugs
Exam
lower abdominal tenderness; presence of peritoneal signs/absence of bowel sounds may suggest transmural infarction or perforation
1st investigation
Other investigations
- colonoscopy:
petechial hemorrhages, edema, ulceration of colonic mucosa
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Crohn disease
History
age at diagnosis is usually under 50 years, chronic diarrhea (usually nonbloody); symptoms can be intermittent; tenesmus; gradual onset of symptoms; weight loss[53]
Exam
may appear pale, malnourished; right lower quadrant abdominal tenderness; may be abdominal mass, oral ulceration, perianal skin tags, fistulae, abscess or sinus tract; life-threatening bleeding rare
1st investigation
Other investigations
Ulcerative colitis
History
age at diagnosis is usually under 50 years, hematochezia (bright red rectal bleeding); chronic diarrhea; lower abdominal pain; fecal urgency; tenesmus; episodes of constipation; weight loss; acute arthropathy; symptoms can be intermittent; history of primary sclerosing cholangitis
Exam
pallor, may appear malnourished, abdominal tenderness, erythema nodosum or pyoderma gangrenosum, uveitis or episcleritis, fever may be present, life-threatening bleeding rare
1st investigation
- CBC:
variable degree of anemia, leukocytosis
More - platelets:
usually normal; may be elevated
- clotting studies:
normal; or coagulopathy present
- colonoscopy:
rectal involvement, continuous uniform involvement, loss of vascular marking, diffuse erythema, mucosal granularity, fistulas (rarely seen), normal terminal ileum (or mild "backwash" ileitis in pancolitis). Biopsies are diagnostic.
More - CRP:
elevated
More - erythrocyte sedimentation rate:
elevated
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Other investigations
Infectious colitis
History
acute diarrhea, abdominal pain, may be a history of travel to regions with higher risk of infectious diarrhea
Exam
abdominal tenderness may be present, fever
1st investigation
- stool studies:
stool culture: may reveal the specific pathogen; stool white blood cell count: may be elevated; tests for ova and parasites may be positive
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Other investigations
Colorectal cancer
History
typically age is over 40 years; rectal bleeding; weight loss; change in bowel movements; tenesmus, abdominal pain
Exam
palpable mass may be present in the abdomen; rectal mass may be felt on digital rectal exam
1st investigation
- colonoscopy:
friable mass in the colon may be seen and biopsy is diagnostic.
- quantitative fecal immunochemical tests:
positive
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Other investigations
- CT abdomen:
extent of disease, metastatic lesions
Internal hemorrhoids
History
self-limited, intermittent, painless bright red rectal bleeding that may be chronic or intermittent; constipation may also be present; blood may be covering the stool
Exam
general exam is usually normal
1st investigation
- anoscopy:
internal hemorrhoids visualized
Other investigations
Anal fissure
History
rectal bleeding (usually seen on wiping) and severe perianal pain on defecation
Exam
fissure may be visible when parting buttocks, most commonly in the posterior midline
1st investigation
- none:
usually a clinical diagnosis in younger people
- exam under anesthetic:
fissure present
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Other investigations
Colonic polyps
History
typically age is over 40 years; may be a family history of colonic polyps, colon cancer, or familial adenomatous polyposis or Gardner syndrome; rectal bleeding, may be otherwise asymptomatic, change in bowel movements, abdominal pain
Exam
normal abdominal exam
1st investigation
- colonoscopy:
polyps visible
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Other investigations
Uncommon
Meckel diverticulum
History
occurs in children or young adults; painless melena or bright red blood per rectum (described as "currant jelly") is the major symptom
Exam
abdominal tenderness and an abdominal mass may be present
1st investigation
- CBC:
hemoglobin normal or low
- platelets:
usually normal
- clotting studies:
usually normal
- radionuclide imaging:
shows an uptake due to technetium binding to the ectopic gastric parietal cells
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Other investigations
- mesenteric angiography:
extravasation of the dye at the bleeding site in the terminal ileum
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Radiation-induced telangiectasia
History
history of radiation therapy for abdominal cancers; diarrhea, rectal pain or urgency, fecal incontinence, and obstructed defecation may also occur; symptoms typically 9 weeks to 4 months after radiation injury; bleeding may be persistent or severe
Exam
abdominal exam is noncontributory; rectal exam may reveal bright red blood per rectum
1st investigation
- CBC:
hemoglobin usually normal
- platelets:
usually normal
- clotting studies:
normal; or coagulopathy present
- colonoscopy:
mucosal pallor with friability and telangiectasias; telangiectasias may be large and multiple
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Other investigations
Dieulafoy lesion
History
painless hematochezia (bright red rectal bleeding); bleeding may be severe
Exam
vital signs may indicate severe bleeding (e.g., systolic BP <115 mmHg, heart rate >100 bpm); abdominal exam is normal; rectal exam may reveal bright red blood or blood clots
1st investigation
- CBC:
hemoglobin usually low
- platelets:
usually normal
- clotting studies:
normal; or coagulopathy present
- colonoscopy:
a superficial blood vessel (either actively bleeding or nonbleeding with stigmata of recent bleed), may be seen in the colon at the site of bleeding
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Other investigations
Aortoenteric fistula
History
herald bleed may occur; history of aortic graft, melena, and hematemesis; fever may be present
Exam
vital signs may indicate severe bleeding (e.g., systolic BP <115 mmHg, heart rate >100 bpm); abdominal tenderness, bleeding more likely to be profuse with hemodynamic instability
1st investigation
- CBC:
hemoglobin usually low
- platelets:
usually normal, may be low
- clotting studies:
usually normal, may be coagulopathy with severe bleeding
- esophagogastroduodenoscopy (EGD):
bleeding from the second or third part of duodenum may be visualized
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Other investigations
- CT scan of abdomen:
typical findings: perigraft fluid, soft tissue attenuation, ectopic gas, pseudoaneurysm or focal ischemic bowel
Vasculitis
History
history of vasculitis (e.g., systemic lupus erythematosus [SLE], polyarteritis nodosa) abdominal pain, GI bleeding, nausea, vomiting, and hematemesis
Exam
abdominal tenderness may be present, stigmata of the underlying vasculitic condition may be present (e.g., malar butterfly rash in patients with SLE)
1st investigation
- CBC:
hemoglobin may be normal; blood film may be consistent with an iron deficiency anemia, may be leukopenia
- platelets:
usually normal; may be thrombocytopenia
- clotting studies:
normal; or coagulopathy present
- serologic markers (e.g., antinuclear antibodies [ANA], antineutrophil cytoplasmic antibodies [ANCA]):
may be positive
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Other investigations
- CT scan of abdomen:
may show thickening of the wall of the colon or the small intestine
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Hereditary hemorrhagic telangiectasia
History
epistaxis; family history of hereditary hemorrhagic telangiectasia
Exam
multiple telangiectasia on lips, oral cavity, fingers, nose; may have signs related to complications of arteriovenous malformations in lungs, liver, brain
1st investigation
- CBC:
hemoglobin usually normal or low
- platelets:
usually normal
- clotting studies:
normal; or coagulopathy present
- esophagogastroduodenoscopy:
telangiectasia present in the upper GI tract
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Other investigations
- colonoscopy:
telangiectasia present in the lower GI tract
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Blue rubber bleb nevus syndrome
History
multiple skin venous malformations often present at birth or diagnosed in early childhood; bleeding more likely as a young adult; melena and hematemesis; fatigue may be present
Exam
cutaneous lesions (protuberant dark blue vascular tumors) may be seen; skeletal bowing may be present if there is bone involvement
1st investigation
- CBC:
hemoglobin usually normal
- platelets:
usually normal
- clotting studies:
normal; or coagulopathy present if liver cirrhosis is present
- colonoscopy:
protuberant dark blue vascular lesions are seen in the GI tract
More - esophagogastroduodenoscopy:
protuberant dark blue vascular lesions are seen in the GI tract
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Other investigations
Anal cancer
History
rectal bleeding, rectal pain or feeling of a rectal mass may be present
Exam
inspection of the perianal area and digital rectal exam may reveal the presence of anal mass, inguinal lymphadenopathy
1st investigation
- anoscopy:
tumor visualized
Other investigations
- CT pelvis:
tumor visualized
Rectal ulcer
Rectal varices
History
painless rectal bleeding in a patient with history of portal hypertension
Exam
may reveal the stigmata of chronic liver cirrhosis such as jaundice, ascites, gynecomastia, spider nevi, palmar erythema, finger clubbing
1st investigation
- colonoscopy:
vascular structures extending proximally from the dentate line
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Other investigations
Postpolypectomy bleeding
History
painless rectal bleeding after colonoscopy.
Exam
vital signs may indicate severe bleeding (e.g., systolic BP <115 mmHg, heart rate >100 bpm); patients may be pale if anemia is present, abdominal exam is noncontributory
1st investigation
- CBC:
hemoglobin usually normal; low in patients with severe blood loss
- platelets:
usually normal; may be thrombocytopenia
- clotting studies:
normal
- colonoscopy:
bleeding or stigmata of recent bleed from the site of the polypectomy
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Other investigations
Nonsteroidal anti-inflammatory drug (NSAID) colopathy
History
painless rectal bleeding, history of use of NSAID medication
Exam
general exam is usually normal
1st investigation
- colonoscopy:
erosions and ulcerations in the colon may be seen
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Other investigations
Upper GI bleeding (rapid transport)
History
melena and rectal bleeding, upper abdominal pain also may be present
Exam
vital signs may indicate severe bleeding (e.g., systolic BP <115 mmHg, heart rate >100 bpm); epigastric tenderness, orthostatic hypotension may be present, bleeding more likely to be severe
1st investigation
- CBC:
hemoglobin normal or low
- platelets:
usually normal
- clotting screen:
usually normal
- esophagogastroduodenoscopy:
erosions, ulcerations or actively bleeding vessels may be seen
Other investigations
Prostate biopsy site bleeding
History
rectal bleeding at a few hours or days after a prostate biopsy
Exam
general exam is usually normal
1st investigation
- colonoscopy:
site of bleeding at the site of prostate biopsy
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Other investigations
Endometriosis
History
female sex, reproductive age, may be a history of dysmenorrhea, pelvic pain, dyspareunia, infertility
Exam
lower abdomen tenderness; pelvic exam may reveal pelvic mass (ovarian endometrioma), fixed and retroverted uterus or uterosacral ligament nodularity, and tenderness
1st investigation
- colonoscopy:
endometriotic lesions visualized
Other investigations
- transvaginal ultrasound:
ovarian endometrioma-homogeneous, low-level echoes; deep pelvic endometriosis such as uterosacral ligament involvement-hypoechoic linear thickening
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