What is the cause of rectal (PR) bleeding in a young patient?

From the Guidelines

For a young patient with PR bleeding, I strongly recommend a thorough initial assessment including a digital rectal examination and anoscopy to rule out other causes of lower gastrointestinal bleeding, as suggested by the 2021 guidelines from the World Journal of Emergency Surgery 1. This approach is crucial in identifying the underlying cause of bleeding, which could be hemorrhoids, anal fissures, inflammatory bowel disease, or infectious colitis. The initial management should focus on assessing the severity of bleeding and associated symptoms, with a complete medical history and physical examination being mandatory to drive the diagnostic process 1. Key components of the initial assessment include:

• Checking vital signs
• Determining hemoglobin and hematocrit
• Assessing coagulation to evaluate the severity of the bleeding
• Blood typing and cross-matching in case of severe bleeding 1 For mild hemorrhoidal bleeding, conservative measures such as increased fiber intake, adequate hydration, warm sitz baths, and topical treatments like hydrocortisone 1% cream or suppositories can be initiated 1. However, persistent or severe bleeding, especially with symptoms like weight loss, abdominal pain, or change in bowel habits, requires urgent referral for colonoscopy to rule out inflammatory bowel disease or malignancy, as emphasized by the American Gastroenterological Association technical review on the diagnosis and treatment of hemorrhoids 1. The timing of intervention is crucial, and young patients with concerning symptoms may have underlying conditions requiring prompt diagnosis and treatment despite their age making certain diagnoses less likely.

From the Research

Presentation and Diagnosis of PR Bleeding in Young Patients

• PR bleeding, or haematochezia, is a common presentation of lower gastrointestinal bleeding, as noted in the study by 2.
• The initial assessment of patients presenting with acute lower gastrointestinal bleeding should include a history of co-morbidities and medications that promote bleeding, hemodynamic parameters, physical examination, and laboratory markers, as recommended by 3.
• A risk score can be used to aid in the assessment, but should not replace clinician judgment, according to 3.

Management and Treatment of PR Bleeding

• The management of patients with PR bleeding is resource intensive, with one in five patients requiring blood transfusion, as reported by 2.
• A restrictive red blood cell transfusion strategy is recommended for hemodynamically stable patients with acute lower gastrointestinal bleeding and no history of cardiovascular disease, with a hemoglobin threshold of ≤ 7 g/dL prompting red blood cell transfusion, as suggested by 3.
• Colonoscopy should be performed sometime during the hospital stay for patients with major acute lower gastrointestinal bleeding, as recommended by 3.
• Therapeutic options for lower gastrointestinal bleeding include injection, coagulation, and mechanical devices, as noted by 4.

Approach to the Patient with Bleeding

• The approach to the patient with bleeding begins with a thorough bleeding, medical, and family history to determine the nature of bleeding and severity of bleeding symptoms, as described by 5.
• A Bleeding Assessment Tool can be used to obtain a comprehensive bleeding history and determine the individual bleeding score, according to 5.
• Laboratory investigation can proceed through first-line, second-line, and third-line testing in the absence of significant findings within patient history or presenting symptoms, as outlined by 5.