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Rectal bleeding


Rectal bleeding is a common symptom. The majority of patients with rectal bleeding have a simple condition such as haemorrhoids, but the symptoms should always be taken seriously and investigated. Rectal bleeding with a change in bowel habit or weight loss should be regarded as due to colorectal cancer until proved otherwise.

Causes

Anus

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    Haemorrhoids

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    Fissure-in-ano

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    Carcinoma

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    Trauma

Colon and rectum

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    Carcinoma ( Fig. 51 )

    Figure 51, Carcinoma of the rectum .

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    Polyps

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    Diverticular disease

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    Inflammatory bowel disease

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      Ulcerative colitis

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      Crohn’s disease

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    Ischaemic colitis

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    Rectal prolapse

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    Angiodysplasia

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    Irradiation colitis or proctitis

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    Solitary rectal ulcer

Small bowel

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    Meckel’s diverticulum

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    Intussusception

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    Mesenteric infarction

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    Aortoenteric fistula

Upper gastrointestinal tract

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    Massive haemorrhage, e.g. duodenal ulcer

Others

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    Anticoagulants

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    Bleeding diatheses

History

Anus

Haemorrhoids

Piles occur at any age. Bleeding from piles is noted either on the toilet paper or as splashes in the toilet after defecation. Uncomplicated piles are not painful.

Fissure-in-ano

Fissure-in-ano is most common under the age of 40 years. It is quite common in children. The patient experiences pain on defecation, which may persist for minutes or hours afterwards. Constipation is usually a precipitating cause, the constipation being made worse by the fissure as the patient avoids defecation because of pain. Blood is noticed on the toilet paper or streaked on the stool.

Carcinoma of the anal canal

Carcinoma of the anal canal usually occurs in the elderly. It presents with pain on defecation and streaking of blood on the stools and blood on the toilet paper. Initially, in the early stages, it may be mistaken for a fissure-in-ano.

Trauma

There may be a history of a penetrating injury to the anal canal. Sexual abuse or homosexual practices may be relevant.

Colorectal

Carcinoma

With colonic carcinoma, the blood may be mixed with the stool. There is usually a history of accompanying change in bowel habit and colicky abdominal pain. With rectal cancer, the blood is usually streaked on the stool and there may be a history of tenesmus, i.e. a sense of incomplete evacuation of the rectum.

Polyps

The history may be similar to that of carcinoma.

Diverticular disease

Bleeding associated with diverticular disease is typically acute, massive and fresh. There may be a past history of diverticular disease.

Inflammatory bowel disease

With ulcerative colitis and Crohn’s disease, there is often sudden onset of diarrhoea with watery, brown motions containing mucus and fresh blood. There is usually colicky abdominal pain. With ulcerative proctitis, the patient may complain of tenesmus.

Ischaemic colitis

This usually occurs in the elderly. There is colicky abdominal pain associated with the passage of dark-red venous blood PR.

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