What is the appropriate management for a 71-year-old female patient with rectal bleeding, not on aspirin (acetylsalicylic acid) therapy, and having undergone therapy for 12 months, presenting with bright red blood per rectum?

From the Guidelines

For a 71-year-old female patient with bright red rectal bleeding, I recommend performing an in-office evaluation including digital rectal examination and anoscopy to assess for common causes like hemorrhoids or anal fissures, as suggested by the most recent guidelines 1. This approach is crucial in identifying the source of bleeding and ruling out other causes of lower gastrointestinal bleeding.

• The patient's medical history and physical examination, including vital signs, should be thoroughly assessed to determine the severity of the bleeding and identify any potential risk factors.
• A complete blood count (CBC) should be performed to check for anemia and assess hemodynamic stability, as recommended by the guidelines 1.
• If the bleeding is minimal and a benign source is identified, topical treatments such as hydrocortisone cream for hemorrhoids or stool softeners to prevent constipation may be considered.
• For persistent bleeding, significant blood loss, or if no clear source is identified during office evaluation, GI referral is necessary while coordinating with the patient's primary care physician regarding further management. The guidelines suggest that patients with suspected bleeding hemorrhoids should undergo a thorough physical examination, including a digital rectal examination, to rule out other causes of lower gastrointestinal bleeding 1. Additionally, the guidelines recommend checking vital signs, determining hemoglobin and hematocrit, and assessing coagulation to evaluate the severity of the bleeding 1. It is essential to note that the decision to temporarily discontinue any medication, including aspirin, requires balancing the risk of thrombotic events against the severity of bleeding, with shorter interruptions generally considered safer. However, in this case, since the patient is not on aspirin therapy, this consideration is not applicable. The most recent and highest-quality study 1 provides the best guidance for managing this patient's condition, and its recommendations should be prioritized.

From the Research

Patient Assessment

• The patient is a 71-year-old female with recent rectal bleeding, which is a common symptom that can be alarming due to its association with bowel cancer 2.
• The patient is not on aspirin therapy and has not received therapy for 12 months, which may be relevant in assessing her risk factors for colorectal cancer.

Risk Factors and Diagnostic Evaluation

• Rectal bleeding can have various causes, ranging from benign to life-threatening, and its evaluation requires consideration of anatomic, age-related, and comorbid factors 3.
• Patients over 40 years old presenting with rectal bleeding often require colonoscopy to screen for and treat premalignant polyps and colorectal cancer 2.
• A study found that risk factors for colorectal cancer were documented in patients' charts between 9% and 66% of the time, and most patients (89%) with rectal bleeding needed a colonoscopy according to a clinical guideline 4.
• The presence of severe anaemia has the highest diagnostic value in patients with rectal bleeding, with a pooled positive likelihood ratio of 3.67, but still only generates a post-test probability of 21.6% 5.

Diagnostic Approach

• A systematic approach to diagnosis, including history, examination, and investigation, is essential in evaluating rectal bleeding 2.
• A study evaluated the operation of a central access and triage system for patients with rectal bleeding, which uses a "high-risk"/ "low-risk" designation based on the referring doctor's subjective designation and a 10-item symptom checklist 6.
• The study found that patients in the high-risk group had a higher incidence of cancer and shorter waits to endoscopy, and identified two variables (weight loss and anemia) that can be added to the referral symptom checklist to improve the triage system 6.

Next Steps

• Consider the patient's age, symptoms, and medical history in determining the best course of action for diagnostic evaluation and potential referral to a specialist 2, 3, 4.
• Evaluate the patient's risk factors for colorectal cancer and consider ordering a colonoscopy if indicated by clinical guidelines 2, 4.