Rectal Bleeding
Gastroenterology
Introduction
Author: Sarosh Ibrahim
Taking a thorough rectal bleeding history is crucial for diagnosing the underlying cause of the symptom, which can range from benign conditions like haemorrhoids to more serious issues such as colorectal cancer. A comprehensive history helps to identify key characteristics, including the onset, duration, and nature of the bleeding, as well as associated symptoms such as pain, changes in bowel habits, or weight loss. Understanding risk factors, such as age, family history, and lifestyle, is also essential for guiding the clinical approach. A detailed history not only aids in narrowing down potential causes but also assists in determining the urgency of further investigation and treatment.
WIPER
W – Wash/sanitise hands
I – Introduce yourself (name and title)
P – Permission, take consent
E – Expose the patient (if necessary)
R – Reposition the patient (if needed)
Presenting Complaint
1. Onset:
When did the bleeding start?
Was it sudden or gradual?
2. Nature of the Bleeding:
Colour: Bright red (fresh), maroon, or dark/black (melaena)?
Amount: Minimal streaks, moderate, or heavy?
Timing: Associated with bowel movements, constant, or intermittent?
3. Triggers:
Recent constipation, diarrhoea, or straining?
Recent trauma (e.g., rectal examination, anal intercourse)?
4. Progression:
Has it been worsening, improving, or stable over time?
5. Associated Symptoms:
Gastrointestinal:
Abdominal pain, change in bowel habits, bloating, or tenesmus.
Mucus in stools or urgency.
Systemic:
Weight loss, fatigue, fever, or dizziness (suggesting anaemia).
6. Trigger/exacerbating Factors:
Recent constipation, diarrhoea, or straining?
Recent trauma (e.g., rectal examination, anal intercourse)?
7. Relieving Factors:
Any treatments tried (e.g., creams, stool softeners)?
8. Impact:
How does it affect daily activities, work, or sleep?
9. Severity:
Use a scale (e.g., mild, moderate, severe)
ICE: Ideas, Concerns, Expectations
Ideas: What do they think is causing the bleeding?
Concerns: Are they worried about anything specific? (e.g., cancer).
Expectations: What are they hoping for in terms of diagnosis or treatment?
Past Medical History
W – Wash/sanitise hands
I – Introduce yourself (name and title)
P – Permission, take consent
E – Expose the patient (if necessary)
R – Reposition the patient (if needed)
Medications
Current medications and recent changes including over the counter drugs.
Anticoagulants, antiplatelet, NSAIDs, or corticosteroids.
Family History
Family history of colorectal cancer, polyps, or inflammatory bowel disease.
Social History
Smoking History: Calculate pack-years history
Alcohol Consumption: How many units per week?
Dietary Habits: Low fibre diet or excessive processed foods?
Occupation and Stress: Any recent changes?
Explore risk factors for rectal bleeding including:
Age >50 years, family history of colorectal cancer, inflammatory bowel disease, or recent use of anticoagulants/NSAIDs.
Differential Diagnosis
Rectal bleeding may arise from the following causes:
Benign Causes
Haemorrhoids, anal fissures or rectal prolapse
Inflammatory Causes
Inflammatory bowel disease
Malignancy
Colorectal cancer or anal cancer
Diverticular disease
Infective causes
Infective colitis (bacterial, viral or parasitic)
Vascular causes
Ischaemic colitis
Systemic causes
coagulopathies or thrombocytopenia
Management
Bedside:
Physical examination to check for
Abdominal Examination:
Inspect, palpate, percuss, and auscultate for tenderness, masses, or organomegaly.
Per Rectum Examination
Assess for haemorrhoids, fissures, masses, or fresh blood.
Laboratory:
Blood Tests:
Full blood count (FBC) – anaemia or infection
Coagulation profile (PT/INR, aPTT): if anticoagulated or coagulopathy suspected.
Liver function tests (LFTs): for liver disease or portal hypertension.
Stool Tests
Faecal occult blood test (FOBT): screening for occult bleeding.
Stool culture: if infective colitis suspected.
Imaging and Special Tests:
Sigmoidoscopy or Colonoscopy: Gold standard for identifying source of bleeding.
CT Abdomen and Pelvis: If malignancy or diverticulitis suspected.
Management Plan
Tailor based on underlying cause:
Address modifiable risk factors
If there are haemorrhoids/anal fissure you may consider laxatives, anusol gel or referral to surgery.
Red flag features for colorectal cancer require an immediate referral.
Consider referral to gastroenterology medicine for further investigation or treatment if required.
Provide reassurance and advice