From the Guidelines
The evaluation of microscopic hematochezia in adults should begin with a thorough history and physical examination, followed by targeted diagnostic testing, with colonoscopy being the gold standard diagnostic procedure, as recommended by the most recent guidelines 1. The initial assessment should focus on identifying potential causes such as hemorrhoids, anal fissures, inflammatory bowel disease, diverticular disease, or colorectal cancer.
- Laboratory tests should include complete blood count, coagulation studies, and fecal occult blood testing to confirm the presence of blood.
- For adults with suspected bleeding hemorrhoids, a complete medical history and physical examination, including a digital rectal examination, should be performed to rule out other causes of lower gastrointestinal bleeding 1.
- In patients with suspected bleeding anorectal varices, ano-proctoscopy or flexible sigmoidoscopy is suggested as the first-line diagnostic tool, with urgent colonoscopy recommended for those with high-risk features or evidence of ongoing bleeding 1.
- For patients with inflammatory bowel disease, fecal calprotectin or lactoferrin may help prioritize patients for endoscopic evaluation, with colonoscopy recommended for those with intermediate to high suspicion for underlying IBD, microscopic colitis, or colorectal neoplasia 1.
- Treatment depends on the underlying cause, with hemorrhoids managed with increased fiber intake, adequate hydration, and topical treatments, while anal fissures respond to stool softeners, sitz baths, and topical nitroglycerin or diltiazem ointment.
- Inflammatory conditions require specific treatments, and diverticular bleeding often resolves spontaneously but may require endoscopic intervention or surgery for persistent bleeding.
- Regular follow-up is essential, particularly for patients with risk factors for colorectal cancer, as the prognosis is generally good for benign causes, but colonoscopy is recommended for adults with unexplained hematochezia, particularly those over 40 years old or with concerning symptoms like weight loss or change in bowel habits 1.
From the Research
Evaluation Approach for Microscopic Hematochezia in Adults
- The evaluation of microscopic hematochezia in adults typically involves a thorough medical history, physical examination, and diagnostic tests such as colonoscopy 2, 3, 4.
- Colonoscopy is a crucial diagnostic tool for evaluating hematochezia, as it allows for the visualization of the entire colon and the detection of lesions, polyps, and other abnormalities 2, 4, 5.
- The decision to perform a colonoscopy should be based on the patient's age, medical history, and risk factors for colorectal cancer 2, 5.
Treatment Approach for Microscopic Hematochezia in Adults
- The treatment of microscopic hematochezia depends on the underlying cause, which may include hemorrhoids, diverticulosis, polyps, or inflammatory bowel disease 3, 4, 6.
- For patients with microscopic colitis, treatment may involve the elimination of offending medications, antidiarrheals, and budesonide for induction of clinical remission 6.
- In some cases, immunomodulators may be required for patients with recurrent or severe symptoms 6.
Considerations for Patient Age and Risk Factors
- Younger patients with scant hematochezia and no risk factors for neoplasia may not require a total colonoscopy, whereas older patients should undergo a total colonoscopy even in the presence of anal pathology 5.
- Patients with a family history of colorectal cancer, previous colon surgery, or other risk factors should be evaluated on a case-by-case basis 2, 5.
- The presence of comorbidities, such as autoimmune diseases, and the use of certain medications, such as proton pump inhibitors, may also influence the evaluation and treatment approach 6.