Editors

MattiV.Kairaluoma

Examining a Patient with Rectal Bleeding

Rectal bleeding is defined as fresh or clotted blood in the faeces or in association with defecation.
The colour of the faeces may be otherwise normal, in contrast to melena Haematemesis and Melaena, which is defined as black, tar-like stools or the maroon stool often seen with caecal bleeding.
The site and cause of the bleeding must be identified, most importantly separating bleeding from the anal canal versus the proximal colon.
Patients in whome the bleeding is caused by a tumour, inflammatory bowel disease or other severe condition requiring specific treatment must be identified, examined and treated.
In patients with haemorrhoids, anal fissure, abrasions from scratching, or other mild condition, the treatment is symptomatic.

Does the bleeding occur only in association with defecation or also at other times?
Is the blood fresh (bright red), clotted or old (maroon)?
Is the blood seen
- during cleansing (anal fissure or excoriation, external or prolapsed haemorrhoids)
- dripping in the toilet bowl (internal haemorrhoids)
What is the colour and consistency of the stools?

Ask about the duration, frequency, and eventual exacerbation of the symptoms.
Bowel habits and changes in them
Other symptoms (abdominal or systemic symptoms, weight loss)
Does the patient use ASA or other NSAIDs Safe Use of Non-Steroidal Anti-Inflammatory Drugs (Nsaids) or anticoagulants?
Has there been colorectal cancer Colorectal Cancer or inflammatory bowel disease Ulcerative Colitis Crohn's Disease in close relatives?
Earlier investigations or surgeries, diagnosed liver or bowel diseases
Are there other symptoms associated with the bleeding?
- Anal pain (fissure)
- Abdominal pain or tenesmus (tumour, inflammation of the bowel)

Palpation and auscultation of the abdomen (tenderness?)
Inspection by spreading the anal margins: fissure, sentinel fold, rhagades, fistular orifices
Diagnose eventual mucosal or rectal prolapse by spreading the anal margins and asking the patient to bear down.
Digital rectal examination (DRE): tonus and strength of the anal sphincter, fissure, anal crypts, ampullar mucosa, prostate, colour of the stools
Proctoscopy: examination of the size, prolapse tendency and surface character of haemorrhoids by applying gentle compression on them while the patient is bearing down, and then pulling the proctoscope slowly outwards

Always identify the origin of rectal bleeding.
Indiciations for colonoscopy, see Colonoscopy and Sigmoidoscopy
- Rectal bleeding is the most commonly missed opportunity to diagnose colorectal cancer.
- Inflammatory bowel diseases have become more common especially in young people.