21 year old male presented with blood mixed with stool and pr bleed with lower abdominal pain and unexplained anemia (7) . Upon examination several lymph nodes were palpable. Colonoscopy showered large internal hemorrhoids otherwise normal . Any suggestions ??

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Hello Dr Sudhir Mann, Thanks for the request. As of now, a bleeding PR could be divided into one of the four categories: 1. Anatomical - diverticulosis 2. Vascular - angiodysplasia , ischemic colitis 3. Neoplastic - Colon CA, polyp etc 4. Inflammatory- Crohns & UC (non infective) These are the commoner variants. I would suggest you to prioritise the patient based on this diagnostic algorithm and perform the following:: • ultrasound abdomen to rule out cirrhosis-portal hypertension related changes. • CECT (if required) for vascular conditions and neoplastic diseases. • Tissue diagnosis for inflammatory and neoplastic conditions. (If indicated). Specifically for this case, this much history seems a bit inadequate, but I would suggest you to start with a simple USH and go ahead according to the algorithm. Thanks.. Regards, Dr Farman Ali

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Dr. Sudhir. It is clearly not "unexplained anemia" as you have already given history of PR bleed and blood mixed with stool so cause of anemia is clear. Your barium enema pics are also normal. As the patient is patient's age is 21 yrs, a simple proctoscopy would have diagnosed the large hemarrhoids. I think it's a case of internal hemarrhoids and hemarrhoidectomy is all that is required. Only thing suspicipus is palpable lymph nodes and an opacity near splenic flexure both of which can be evaluated with CECT abdomen

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Cect abdomen triphasic Looks like a calcific vascular lesion communication near splenic flexure Anemia can be explained with bleeding haemorrhoids or the lesion In addition with Lymphadenopathy needs work up to rule out lymphoma

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Dr. Farman, you have given a very useful algorithm but please note that colonoscopy and barium enema has already ruled out almost all your D/Ds. Also you have not mentioned the common causes like hemarrhoids, fissures as the cause of PR bleed.

Hemorrhoids leading to aneamia. Exclude abd. TB in 17 year pt . Barium has not passed through ileo coeval area.

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Barium enema done or it is a follow through of barium meal study ..barium in stomach plus ...in either case , unless a barium enema is done under fluoroscopy ,it is not a valid investigation

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@Sudhir Mann I think abdominal CT scan with angiogram is recommended for this patient. If colonoscopy is not showing mass, it may be extra intestinal mass. Lymph nodes are palpable, so, I think CT scan is indicated. For large hemorrhoids, operative indication --> stapler hemorroidectomy.

Sudhir Mann I think abdominal CT scan with angiogram is recommended for this patient. If colonoscopy is not showing mass, it may be extra intestinal mass. Lymph nodes are palpable, so, I think CT scan is indicated. For large hemorrhoids, operative indication --> stapler hemorroidectomy. also get coagulation profile done

Haemorrhoid

hemorohhoids.

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