From the Guidelines
The management of bright red blood per rectum (BRBPR) begins with assessing hemodynamic stability and severity of bleeding, with initial steps including obtaining vital signs, placing two large-bore IVs, and ordering complete blood count, coagulation studies, and type and cross-match if significant bleeding is present, as recommended by the British Society of Gastroenterology guidelines 1.
Initial Assessment
The first step in managing BRBPR is to assess the patient's hemodynamic stability and severity of bleeding. This includes obtaining vital signs, such as heart rate, blood pressure, and oxygen saturation, and evaluating the patient's overall clinical condition.
- Placing two large-bore IVs to ensure adequate access for fluid resuscitation and potential blood transfusions
- Ordering laboratory tests, including complete blood count, coagulation studies, and type and cross-match, to evaluate the severity of bleeding and potential coagulopathy
Diagnostic Evaluation
After initial stabilization, diagnostic evaluation includes a focused history and physical examination, including digital rectal examination to identify potential sources like hemorrhoids or anal fissures.
- Endoscopic evaluation is the cornerstone of diagnosis, with colonoscopy being the preferred initial test for most patients, as recommended by the American College of Radiology 1
- For severe, ongoing bleeding, urgent colonoscopy within 24 hours is recommended after adequate bowel preparation
Treatment
Treatment is directed at the underlying cause, ranging from endoscopic interventions (clipping, thermal coagulation, or band ligation), angiographic embolization for arterial bleeding, or surgery for uncontrolled hemorrhage.
- Correction of coagulopathy with vitamin K, fresh frozen plasma, or platelet transfusions may be necessary for patients on anticoagulants or with underlying coagulation disorders, as suggested by the World Journal of Emergency Surgery guidelines 1
- The approach must be tailored to the individual patient based on the suspected source, severity of bleeding, and comorbidities.
From the Research
Management Approach for Bright Red Blood Per Rectum
The management approach for a patient presenting with bright red blood per rectum involves a thorough evaluation to determine the underlying cause.
- The first step is to take a detailed medical history and perform a physical examination to identify any potential risk factors or symptoms that may indicate the source of the bleeding.
- Laboratory tests, such as complete blood count and stool tests, may be ordered to rule out any underlying conditions that could be causing the bleeding.
Diagnostic Procedures
Diagnostic procedures such as colonoscopy may be recommended to visualize the inside of the colon and rectum and identify any potential sources of bleeding 2.
- Colonoscopy has been shown to be effective in detecting significant findings, including polyps, colitis, diverticular disease, and angiodysplastic lesions, in patients with rectal bleeding 2.
- Other diagnostic procedures, such as CT scans, may also be used to evaluate the extent of the disease and identify any potential complications 3.
Surveillance and Management
For patients with inflammatory bowel disease (IBD), surveillance colonoscopy is recommended to monitor for the development of colorectal cancer (CRC) 4, 5.
- Chromoendoscopy with targeted biopsies of visible lesions is a recommended approach for surveillance in patients with IBD 4.
- New technologies, such as virtual chromoendoscopy and endomicroscopy, are emerging as potential tools in CRC screening and surveillance 4, 6.
- Management of IBD-related CRCs typically involves a multidisciplinary approach, including medical therapy, endoscopic resection, and surgery 5.