Rectal Bleeding

Rectal bleeding (hematochezia) is a frightening (and embarrassing) occurrence for patients.  

The majority of cases of rectal bleeding are of benign origin.  Anatomically, there are very few sources of the bleeding:

• Anus or perianal region

• Rectum

• Colon

• Small intestine

• Stomach.  

Anal fissures and hemorrhoids are the most common cause of rectal bleeding. For a stomach hemorrhage to cause hematochezia, it must be greater than 1 liter and have less than four hours of transit time through the GI tract, thus making it a rare, but serious occurrence. Other causes include:

• Hemorrhoids

• Anal Fissures

• Diverticulosis

• Angiodysplasia

• IBD

• Cancer/Polyps

• Infectious Colitis/Enteritis

The history should focus on the time course, the amount and any prior episodes of bleeding. Was there any abdominal pain with the episodes?  Are they also having concurrent diarrhea (which might suggest an infectious colitis)?  Are there any symptoms that would suggest massive hemorrhage: dizziness, loss of consciousness. It is  important to determine if there is any history of rectal trauma.

Most important in the physical exam is to look for signs of shock. Signs suggesting immediate resuscitative measures include:

• Tachycardia

• Orthostatic hypotension

• Pallor

• Dry mucous membranes

• Weak distal pulses

If the patient is stable, the physical exam should focus on the abdomen (masses, pain, peritoneal signs) and the anus and rectum (fissures, external or internal hemorrhoids, gross or occult blood in the stool.) 

Laboratory evaluation should be guided by findings on history and physical.  If a source of the bleeding can be easily identified and the patient is stable, there may be no need for further studies.  However, a CBC may help in determining amount of blood loss if the patient reports massive bleeding or seems unstable.  But let your clinical judgment guide decisions, as the hematocrit may not fall immediately with acute bleeding.  Coagulation studies and type and cross for blood transfusion (if available) may be necessary in a hemodynamically compromised patient.

If the patient is stable, the bleeding is not continuing, and an identifiable cause is found (hemorrhoid or anal fissure), no further work up may be necessary.  For hemorrhoids and anal fissures, stool softeners can increase patient’s comfort and decrease future bleeds.  Applying a small amount of petroleum jelly or other lubricantIf an upper GI source is suspected (history of ulcer, alcohol or NSAID abuse) a nasogastric tube should be placed and lavaged to check for upper GI bleeding.  If no source of bleeding can be readily identified, the patient will need further testing to locate a source.  Most patients who are stabilized can wait 12-24 hours for endoscopy or colonoscopy at an appropriate medical facility.  If a patient continues to bleed and cannot be stabilized, emergent Medevac to the nearest medical facility with surgical capability should be arranged.  In cases where an infectious colitis is suspected, Ciprofloxacin 500 mg every 12 hours is a good choice for treatment.

This section provided by LT James B. Witkowski, MC, USNR

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*This web version is provided by The Brookside Associates, LLC.  It contains original contents from the official US Navy NAVMED P-5139, but has been reformatted for web access and includes advertising and links that were not present in the original version. The medical information presented was reviewed and felt to be accurate in 2001. Medical knowledge and practice methods may have changed since that time. Some links may no longer be active. This web version has not been approved by the Department of the Navy or the Department of Defense. The presence of any advertising on these pages does not constitute an endorsement of that product or service by either the US Department of Defense or the Brookside Associates. The Brookside Associates is a private organization, not affiliated with the United States Department of Defense.

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