AREAS OF EXPERTISE

INTRODUCTION —  PR bleeding is defined as Rectal passage of minimal bright red blood most commonly occurs in a chronic intermittent pattern with or without pain. The term  bright red (fresh) blood per rectum  is used  to indicate small amounts of red blood on toilet paper after wiping or a few drops of blood in the toilet bowl after defecation.

 

Benign causes  are common and  account for 90 percent or more of all episodes of fresh PR bleeding. The true proportion of benign etiologies may be even higher, since many young people with minimal PR bleeding never present for care. However, scant rectal bleeding is also a common presenting symptom of serious diagnoses, such as colorectal cancer

 

DIFFERENTIAL DIAGNOSIS — The causes of  bright red blood per rectum are  different and depends on different factor like age, medication diet, lifestyle. Only when a lesion is witnessed to be actively bleeding can it be definitively considered the cause of bleeding.

Common causes and presentations of PR Bleeding include:

Haemorrhoids

Anal fissures

Polyps

Proctitis

Rectal ulcers

Cancer

Diverticulosis is a common finding on endoscopy in older adults but is generally an incidental finding in the workup of chronic  PR bleeding, since diverticular bleeding is usually more acute and of greater volume.

 

OPC and CLINICAL ASSESSMENT:
 

History: directed at confirming the diagnosis of Fresh rectal bleeding and at identifying potentially worrisome symptoms and risk factors

Physical examination : A detailed physical examination must include external inspection of the anus and a digital rectal examination. An Out Patient Clinic anoscopy or proctoscopy should be carried out in patients who present with acute minimal bleeding because these are simple maneuvers that do not require bowel preparation and with high sensitivity

Laboratory testing: A complete blood count (FBC) and ferritin are reasonable preliminary tests in patients over age 40, or those with other risk factors for colonic neoplasia, such as family history

Sigmoidoscopy versus colonoscopy — Flexible sigmoidoscopy investigates 60 cm of the colon It has the advantages over colonoscopy that it can be done without sedation (although sedation is sometimes used for the procedure) The main disadvantage of sigmoidoscopy is the potential need for a colonoscopy if a source of bleeding is not found or if a distal adenomatous polyp is found, thus exposing the patient to two endoscopic procedures.

Colonoscopy is the definitive tool for evaluating the entire colon for neoplastic lesions and is also a sensitive tool for the detection of all other bleeding lesions in the lower gastrointestinal tract Colonoscopy requires full bowel preparation and a facility where the test is available. It is often performed under conscious sedation.

 

Treatment: (also see One Stop Clinic).

Treatment depends on diagnosis and severe of symptoms and need to be discussed with your Colorectal Consultant once diagnosis confirmed. Majority of treatment can be performed in Out patient clinic or under ambulatory regime.

 

Red flags:  Patients with minimal PR bleeding in the following categories should undergo additional testing regardless of age:

 

• Patients with a history of melena, dark red blood per rectum, or vital abnormalities should be evaluated for upper gastrointestinal tract pathology first.
• Patients with symptoms suggestive of malignancy such as constitutional symptoms, anemia, or change in frequency, caliber, or consistency of stools, should undergo colonoscopy.
• Patients with fecal occult blood positive stools are known to derive mortality benefit from investigation with colonoscopy.
• Patients with family histories suggestive of familial polyposis or hereditary nonpolyposis colon cancer syndromes who present with bleeding per rectum should be investigated with colonoscopy.
• Patients with minimal PR bleeding who were felt not to require initial colonoscopy or sigmoidoscopy who then develop new constitutional symptoms or a change in bowel habits should undergo colonoscopy.