Table 322 Presentation and causes of rectal bleeding

Bright red blood in toilet separate from faeces

Bright red blood on toilet paper

Blood and mucus on underwear

Blood on underwear (no mucus)

Internal haemorrhoids

Internal haemorrhoids Fissure

Anal carcinoma Pruritus

Anal warts and condylomata

3rd-degree haemorrhoids 4th-degree haemorrhoids Prolapsed rectum Mucosal prolapse Prolapsed mucosal polyp

Ulcerated perianal haematoma Anal carcinoma

Blood and mucus mixed with faeces

• Colorectal carcinoma

• Colitis, ulcerative colitis

• Large mucosal polyp

• Ischaemic colitis

Blood mixed with faeces (no mucus)

• Small colorectal polyps

• Small colorectal carcinoma

Melaena (black tarry stools)

• Gastrointestinal bleeding (usually upper) with long transit time to the anus

Torrential haemorrhage (rare)

Diverticular disease

• Angiodysplasia

Large volumes of mucus in faeces (little blood)

• Villous papilloma of rectum

• Villous papilloma of colon

Blood in faeces with menstruation (rare)

• Rectal endometriosis

Source: Orlay, G. Office Proctology, p. 11. 4 © Copyright 1987 George Orlay—reproduced with permission

Frequent passage of blood and mucus indicates a rectal tumour or proctitis, whereas more proximal tumours or extensive colitis present different patterns.

Substantial haemorrhage, which is rare, can be caused by diverticular disease, angiodysplasia or more proximal lesions such as Meckel's diverticulum and even duodenal ulcers. Angiodysplasias are 5 mm collections of dilated mucosal capillaries and thick-walled submucosal veins, found usually in the ascending colon of elderly patients who have no other bowel symptoms. The site is identified by technetium-labelled red cell scan or colonoscopy.

The history should also include an analysis of any associated symptoms such as pain, diarrhoea or constipation, presence of lumps and a sensation of urgency or unsatisfied defecation. The latter symptoms point to a rectal cause. Associated change of bowel habit suggests a diagnosis of carcinoma of the rectum or left colon. Bleeding from right colon cancer is often occult, presenting as anaemia.

The examination includes a general assessment, anal inspection, digital rectal examination and proctosigmoidoscopy. Even if there is an anal lesion, proximal bleeding must be excluded in all cases by sigmoidoscopy 2 and by colonoscopy if there are any bowel symptoms or no obvious anal cause or a doubt about a lesion causing the symptoms.

Pruritus ani, which is itching of the anus, can be a distressing symptom that is worse at night, during hot weather and during exercise. It is seen typically in adult males with considerable inner drive, often at times of stress and in hot weather when sweating is excessive. In children, threadworm infestation should be suspected. It may be part of general itching, such as with a skin disease, or localised whereby various anorectal disorders have to be excluded.

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