Rectal bleeding is defined as passing of blood from the back passage or anus.One of the most common problems for which patients get referred to a colorectal surgeon Irrespective of the age and no matter quantity or duration – this causes great consternation and anxiety for the average patient than almost any other problem In general patients under 30 yrs are more likely to have haemorrhoids , anal fissure or inflammatory bowel disease and patients over 50 yrs of age have a higher risk of colorectal cancer It is thought that the one year prevalence in the UK in adults is about 10 % other studies quote thatup to 15 % of adults report seeing blood in the toilet paper or in the toilet bowl in the previous 6 months One of the most common indication for colonoscopy worldwide.
Causes –Most cases are benign and self-limiting but may also reflect a serious underlying condition as colorectal cancer or inflammatory bowel disease. Other potential causes include but are not limited to diverticular disease colonic polyps radiation proctitis infectious gastroenteritis angiodysplasia ischaemic colitis solitary rectal cancer anal cancer sexually transmitted diseases anorectal trauma.
History-How long Quantity of bleeding Frequency Colour ( bright or dark red ) Bleeding associated with colonic malignancy is more often dark and mixed with stools Character of bleeding e.g blood is liquid or in clots , on the stool or mixed with it , associated with passage of pus or mucus Relation ship to stool – for e.g a small amount in the tissue versus a large quantity in the toilet Focused history to clarify if symptoms are related to haemorrhoids Abdominal pain Bowel habits ( ? CIBH ) Peri-anal symptoms Family h/o colorectal malignancy Constitutional symptoms as weight loss , symptoms of anaemia Sexual history Previous medical history Any previous abdominal surgeries ? Medications ( e.g antiplatelets , anti-coagulants , calcium channel blockers , NSAIDs )
Examination –Abdominal examination to exclude an abdominal mass External examination for visible haemarrhoids , fissures , fistula , abscess , prolapse polyps tags , ulceration also inspect the skin of the peri-anal region Consider prolapse Digital rectal examination to examine for fissures and exclude rectal cancer If low risk of CRC eg young patients or those with short duration of symptoms and / or in whom a review is planned AND a good h/o haemorrhoids – a DRE can be deferred to second presentation If forward referral is planned a DRE is desirable but may not be necessary If you plan to manage the patient in primary care good practice requires DRE prior to definetely attributing rectal bleeding symptoms to a benign cause Proctoscopy if expertise available in primary care.
FBC Us and Es LFTs Inflammatory markers like ESR or CRP Faecal calprotectin Faecal occult blood – has no role in investigating patients with frank bleeding Tumour markers like CEA have no role as a tool to aid diagnosis in patients with rectal bleeding.
NICE guideline colorectal cancer – Refer USC pathways to be seen within 2 weeks if aged 40 and over with unexplained weight loss and abdominal pain OR they are aged 50 and over with unexplained rectal bleeding OR they are aged 60 and over with iron deficiency anaemia OR changes in their bowel habit OR tests show occult blood in their faeces Consider a suspected cancer pathway referral for CRC in adults with rectal or abdominal mass Consider a suspected cancer pathway referral for CRC in adults under 50 with rectal bleeding and any of the following unexplained symptoms or findings abdominal pain change in bowel habit weight loss iron deficiency anaemia.
Management in primary care –Actively bleeding patient consider admission if blood loss considered significant or malaena Severe abdominal pain with bleeding – admit Review medications and stop NSAIDs, anti-platelets If on anticoagulants and bleeding – consider admission Low risk patients who are not anxious- it is reasonable to adopt a wait and watch policy Minimally symptomatic hemorrhoids – can be safely observed Symptomatic hemorrhoids offer treatment and advice and refer if symptoms persist / alter or are particularly bothersome Some local colorectal guidelines recommend referral for direct access flexible sigmoidoscopy if no improvement in symptoms after 4 weeks Acute anal fissure – treat with dietary advice and a bulking agent – consider referral to colorectal surgeon if no improvement after 6 weeks.
Choice of investigations –Anoscopy- limited anoscopy can detect perianal pathology such as haemorrhoids and anal fissures Colonoscopy – represents the most accurate , invasive and costly evaluation of the colon. Risk of serious complications is 0.3 %. Traditional colonoscopy allows tissue biopsy or polyp removal Barium or CT imaging – little data about accuracy of using X-ray imaging studies to evaluate patients with rectal bleeding Barium enema has relatively poor sensitivity for detecting cancer Flexible sigmoidoscopy – provides a highly accurate exam of the distal colon , in young patients less than 40 with rectal bleeding most non-serious causes can be found in the distal colon with signoidoscopy Virtual colonoscopy – used CT to examine the prepared , distended colon ( air or CO2 insufflation ) enabling a rapid examination of the whole colon with excellent completion rates of 99 %. This does not require sedation , is well tolerated by patients and is relatively safe with no reported deaths worldwide since its introduction in 1994.
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- NICE Suspected cancer : recognition and referral NICE June 2015
- Royal College of Surgeons Commissioning guide Rectal Bleeding 2013
- Office Evaluation of Rectal Bleeding Martha A Ferguson MD Clin Colon Rectal Surg . 2005 Nov ; 18 (4) : 249-254