Rectal bleeding

Rectal bleeding, also known as hematochezia, is a common presentation in the emergency department (ED) and can range from benign to serious conditions. As a junior doctor in emergency medicine, understanding the potential causes, assessment, and management strategies for rectal bleeding is crucial for effective patient care.

Understanding Rectal Bleeding

Rectal bleeding refers to the passage of bright red blood from the anus, often mixed with stool or on toilet paper. It typically indicates bleeding from the lower gastrointestinal (GI) tract, but can also result from brisk upper GI bleeding.

Common Causes of Rectal Bleeding

Anorectal Causes

• Hemorrhoids: Swollen veins in the rectum or anus that can cause painless bright red bleeding during bowel movements.

• Anal Fissures: Small tears in the lining of the anus, often associated with pain during defecation and bright red blood.

Colorectal Causes

• Diverticular Disease: Diverticula are small pouches that can form in the colon wall and bleed.

• Colorectal Polyps or Cancer: Polyps can bleed intermittently; colorectal cancer may present with rectal bleeding, changes in bowel habits, and weight loss.

• Inflammatory Bowel Disease (IBD): Conditions like ulcerative colitis and Crohn's disease can cause inflammation and ulceration leading to bleeding.

Other Causes

• Infectious Colitis: Infections of the colon due to bacteria such as Campylobacter, Salmonella, or Shigella can cause bloody diarrhea.

• Ischemic Colitis: Reduced blood flow to the colon leading to inflammation and bleeding.

• Angiodysplasia: Abnormal blood vessels in the colon that can bleed.

Initial Assessment and Management

History Taking

A thorough history is essential to guide further evaluation:

• Onset, duration, and amount of bleeding

• Associated symptoms such as abdominal pain, diarrhea, weight loss, or changes in bowel habits

• History of hemorrhoids, IBD, or colorectal cancer

• Medication use including anticoagulants or NSAIDs

Physical Examination

The physical examination should focus on identifying signs that may indicate specific causes:

• Abdominal examination: Assess for tenderness or masses.

• Digital rectal examination: Evaluate for hemorrhoids, fissures, or masses.

• Inspection for signs of anemia such as pallor or fatigue.

Diagnostic Workup

Depending on clinical suspicion from history and examination, the following tests may be considered:

• Complete Blood Count (CBC): To assess for anemia.

• Coagulation Profile: If coagulopathy is suspected.

• Stool Tests: To check for infectious causes if diarrhea is present.

• Colonoscopy: For direct visualization of the colon and rectum to identify sources of bleeding.

Management Strategies

Management of rectal bleeding in the ED focuses on stabilization and addressing the underlying cause:

1. Stabilization:

   • Ensure hemodynamic stability with intravenous fluids if significant blood loss is suspected.

   • Blood transfusion if there is severe anemia or hemodynamic instability.

2. Specific Interventions:

   • Topical treatments or banding for hemorrhoids.

   • Antibiotics for infectious colitis if indicated.

   • Surgical consultation for severe cases such as large polyps or suspected malignancy.

3. Monitoring and Follow-up:

   • Continuous monitoring for ongoing bleeding or deterioration in clinical status.

   • Referral to gastroenterology for further evaluation if needed.

Challenges and Considerations

Rectal bleeding can be challenging due to its broad differential diagnosis. It is important to differentiate between minor causes like hemorrhoids and more serious conditions like colorectal cancer. Rapid identification and intervention are crucial in cases where rectal bleeding indicates a potentially life-threatening condition such as massive diverticular hemorrhage.

By taking a systematic approach to the assessment and management of rectal bleeding, you can effectively address this condition in the emergency setting while ensuring appropriate follow-up care.