How should I manage a patient with rectal bleeding and a history of inflammatory bowel disease?

In managing a patient presenting with rectal bleeding who has a history of inflammatory bowel disease (IBD), the initial approach should focus on assessing the severity and cause of bleeding, considering both disease activity and potential complications such as colorectal cancer.

Immediate assessment should include a detailed history and physical examination to evaluate the extent of bleeding, associated symptoms (e.g., abdominal pain, weight loss, change in bowel habits), and signs of active inflammation or complications NICE CKS. Blood tests including full blood count and inflammatory markers (CRP) are important to assess for anaemia and disease activity NICE CKS.

Referral criteria for urgent specialist assessment or suspected cancer pathway referral should be applied, especially if the patient is aged 50 or over with unexplained rectal bleeding, or if there are additional alarm features such as iron deficiency anaemia or weight loss NICE CKS.

Endoscopic evaluation is essential to differentiate between active IBD flare, dysplasia, or malignancy. Patients with longstanding IBD (symptoms >10 years) require colonoscopic surveillance with chromoscopy and targeted biopsies to assess for dysplasia or colorectal cancer risk NICE CG118. The risk stratification guides surveillance intervals and management NICE CG118.

Medical management depends on the underlying cause. If rectal bleeding is due to active ulcerative colitis or Crohn's colitis flare, optimize maintenance therapy with aminosalicylates, corticosteroids, or immunosuppressants as appropriate, ideally in consultation with a gastroenterologist NICE CKS,NICE CKS,NICE NG130. Avoid NSAIDs as they may exacerbate IBD symptoms NICE CKS,NICE CKS.

Complications such as fistulae, strictures, or perianal sepsis in Crohn's disease require specialist referral and may necessitate antibiotics, immunosuppressive therapy, or surgical intervention NICE CKS. Persistent or severe bleeding with suspected complications warrants hospital admission and multidisciplinary management NICE CKS.

Supportive care includes managing anaemia and fatigue, which are common in IBD patients with bleeding, through iron supplementation and addressing nutritional status NICE CKS.

In summary, management integrates prompt assessment, exclusion of malignancy, optimization of IBD therapy, and specialist referral for complications or suspected cancer, following UK guidelines and supported by current literature emphasizing the importance of surveillance and multidisciplinary care M'Koma 2022 NICE CKS,NICE CKS,NICE CKS,NICE NG130,NICE CG118 M'Koma 2022.