A 34-year-old gentleman with good past health presents to the emergency department with on and off rectal bleeding for 2 weeks. He has had no vomiting or haematemesis. He has no abdominal pain, fever or anaemic symptoms. He denies the use of pain killers and he is not on aspirin.
•Temperature 37°C, pulse 80 bpm, BP 123/63mmHg, SaO2 98-100% on RA.
•Examination of the hands reveals no clubbing and normal-appearing palmar creases.
•Head and neck examination is unremarkable.
•Cardiovascular: HS dual, no murmur.
•His chest is clear on auscultation.
•Abdominal examination reveals a soft, non-tender abdomen.
•PR old blood.
•No signs of oedema.
–WBC 8 x 109/L;
–platelets 234 x 109/L.
What is the differential diagnosis of per rectal bleeding?
•Inflammatory bowel disease.
An OGD is performed and shows a clean stomach with normal mucosa down to D2.
What should be done next?
A colonoscopy is performed with good bowel preparation and complete colonic examination. The terminal ileum is intubated and is normal up to 20cm from the ileocecal valve. Some old blood is seen passing from above.