Rectal Bleeding

Rectal bleeding is one of the most common symptoms patients have when they come to visit our office. Most patients believe that their only problem is hemorrhoids, and in many instances they, in fact, are correct. However, there are many causes of rectal bleeding, and in our practice it is important not to overlook more serious causes. Any rectal bleeding is not normal and should be evaluated. The following is a list of frequent, but not necessarily all causes of rectal bleeding:

• Internal hemorrhoids- usually associated with painless bleeding and always bright red; may drip into the bowl or be streaky on the toilet tissue; may at times be associated with mucus leakage or leakage of stool. Can be seen in any age group.

• External hemorrhoids- usually present as a painful lump just outside the anus. These are filled with clots, which can at times ulcerate through the skin leading to ongoing bleeding. This blood is typically bright red but can be somewhat darker. This can occur in any age group.
• Anal fissure- this is a cut just inside the anus. It typically is associated with bright red blood, pain with bowel movement along with itching and/or burning. This can occur in any age group. (see our discussion on anal fissures)
• Proctitis- This is an inflammation of the rectum that may have a number of causes, some of them include: radiation proctitis (especially in men who have had prostate irradiation or seed implant), inflammatory bowel disease (Ulcerative Colitis or Crohn's disease) or other causes. Blood is usually bright red and may be associated with mucus, feelings of incomplete bowel movement, diarrhea or discomfort.
• Diverticular disease- this problem is typically seen after 50 years of age, and in most cases does not cause symptoms. When this presents as a problem with rectal bleeding, the blood may be bright red, but more often is burgundy in color and associated with clots. Symptoms may include crampy abdominal pain, and diarrhea that is more blood and clots. In this type of situation, you should call the office and let us know. If after regular office hours you should get to the emergency room as soon as possible.
• Polyps- these are growths in the colon or rectum. They can be any size, but as they grow in size, bleeding may become more obvious. If the polyp is in the rectum, there is a higher likelihood, that blood could become dectected. This is typically bright red the closer is lies to the anus, but blood could also be darker in color, could be mixed in with the stool and could be associated with mucus.
• Tumors- arise from polyps. They too can be any size and can cause blood per rectum especially if the tumor grows close to the ano-rectal junction. Again as above, the blood may be bright red to dark red, may be associated with mucus, a change in the size of the stool (thinner) or a change in bowel habits, constipation or diarrhea. It must be remembered that it is possible that there are no symptoms depending upon the size and location of the tumor.
  

Management

When someone comes to our office we first take a history and then perform a physical exam to see if we can easily determine the source of the bleeding. While the source of the bleeding may be obvious, it is important to make sure that there is no other cause for the bleeding. In a patient in their 20's or early 30's with no other symptoms we would consider a flexible fiberoptic sigmoidoscopy (see Having a Flexible Sigmoidoscopy for additional information) which will allow us to see the lower third of the colon and entire rectum. For those patients of any age with additional symptoms outside of bright red blood at bowel movement, patients greater than 50, or any patient with a first degree relative with colon or rectal cancer of polyps, we may recommend a colonoscopy to evaluate the entire colon (see Having a Colonoscopy for additional information). For those patients 35-49 years of age a sigmoidoscopy or colonoscopy may be recommended depending upon your symptoms and exam.