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Malignant Sources of Lower Gastrointestinal Hemorrhage

Malignant Sources of Lower Gastrointestinal Hemorrhage. Robert D. Madoff, MD University of Minnesota. 17-20% of individuals in the community have rectal bleeding each year. “It’s my hemorrhoids, doc”. = “Is it cancer, doc?”. LGI bleeding sources. causes of LGI bleeding. diverticula

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Malignant Sources of Lower Gastrointestinal Hemorrhage

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  1. Malignant Sources of Lower Gastrointestinal Hemorrhage Robert D. Madoff, MD University of Minnesota

  2. 17-20% of individuals in the community have rectal bleeding each year

  3. “It’s my hemorrhoids, doc” = “Is it cancer, doc?”

  4. LGI bleedingsources

  5. causes of LGI bleeding • diverticula • polyps • cancer • angiodysplasia • inflammatory bowel disease • hemorrhoids • ischemia • radiation • Meckel’s diverticulum • rectal ulcer • anal varices

  6. LGI bleedingthe classical view

  7. diagnostic value of dark red rectal bleeding

  8. disadvantages of colonic investigation • anxiety • risks • bleeding • perforation • death • cost • inconvenience • consumption of limited resources

  9. Bayes theorem The likelihood of a true positive examination depends upon the “prior probability” of the condition in question in the population being studied.

  10. predictive value of rectal bleeding for cancer community 1:700 primary care clinic 1:30 surgical clinic 1:17

  11. Sutton’s law “go where the money is”

  12. colorectal cancerpresenting signs and symptoms signs rectal mass abdominal mass hepatomegaly abdominal distension microcytic anemia CEA cachexia symptoms hematochezia melena altered bowel habits stool caliber abdominal pain nausea/vomiting obstipation tenesmus anorexia fatigue, weakness

  13. family historylife-time risk of colorectal cancer no family history of CRC……………………….6% one 30 relative with CRC…...……...…….....…..8% one 20 relative with CRC………………………..9% one 10 relative with CRC over 50y…………..12% one 10 relative with CRC under 50y…………25% two 10 relatives with CRC under 50y………..35% Giardello 2000

  14. Bayes again… investigation of a low-risk population will result in a high rate of false positive examinations

  15. sudden, large-volume, fresh red rectal bleeding low risk of large bowel cancer

  16. Incidence Increases with Age (93% > 50 yrs)

  17. peak incidence of rectal bleeding is age 20-40; fewer than 1% of large bowel cancers occur in this age group

  18. “Is it cancer, Doc?” 75% of cancer patients who present with rectal bleeding have an associated change in bowel habits

  19. *especially loose or frequent stools Figten 1995 Ellis 1999

  20. cancer risk by symptom profile Thompson

  21. “It’s my hemorrhoids, doc” = “Is it cancer, doc?”

  22. malignant sources of lower GI hemorrhage • most LGI bleeding is from a benign source • use some judgment: let risk profile be your guide

  23. “increased risk” population age family history history of polyps history of cancer underlying IBD symptom complex

  24. “If there is any doubt, there should be no doubt” Richard C. Varco, MD

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