Chapter 20 RECTAL BLEEDING AND HAEMORRHOIDS
RECTAL BLEEDING
Causes
Bleeding per rectum can originate from the stomach, duodenum, small intestine, colon or anorectum (Table 20.1). The diagnosis of colorectal neoplasia should be entertained in most cases: 1 in 20 patients over the age of 45 years of age who present with new onset rectal bleeding have colon cancer. The colour of the blood may indicate the source of the bleeding but the rate of bleeding needs to be taken into account. Haematochezia is the passage of bright red blood per rectum and usually indicates bleeding from the distal colon, rectum or anal canal. Dark red blood mixed in with bowel motions usually originates from the small intestine or proximal colon. Melaena, the passage of black tarry stools with characteristic odour, occurs with bleeding proximal to the ligament of Treitz.
Region | Causes |
---|---|
Anorectum | |
Colonic | |
Other (stomach, small intestine) | • Upper gastrointestinal sources (peptic ulcer, erosions, Mallory-Weiss tear, oesophagitis, varices, neoplasia) |
Other symptoms are useful to help localise the site of bleeding. Epigastric pain, heartburn and haematemesis or melaena are symptoms associated with bleeding from the upper gastrointestinal tract. Significant weight loss is associated with malignancy and inflammatory bowel disease. Change in bowel habit, tenesmus (feeling of incomplete evacuation) and blood mixed in with faeces are consistent with colonic pathology. Bloody diarrhoea indicates the possibility of colitis. Bright red rectal bleeding not mixed with faeces, blood on the toilet paper and anal pain or discharge are symptoms more indicative of an anorectal source. Personal and family history of colonic polyps, cancer and inflammatory bowel disease are important to elicit.