Management of New Per Rectal Bleeding
Initial assessment and management of new per rectal bleeding should include vital sign monitoring, hemoglobin/hematocrit determination, and digital rectal examination, followed by appropriate endoscopic evaluation based on hemodynamic stability. 1
Initial Assessment
Immediate Evaluation
- Check vital signs (blood pressure, heart rate, respiratory rate)
- Determine hemoglobin and hematocrit levels
- Assess coagulation parameters
- Perform digital rectal examination to rule out anorectal causes
- Blood typing and cross-matching if severe bleeding is present 1
Hemodynamic Stabilization
- For severe bleeding: maintain hemoglobin >7 g/dL (4.5 mmol/L) and mean arterial pressure >65 mmHg 1
- Administer intravenous fluids for volume resuscitation
- Avoid fluid overload which can worsen bleeding 1
- Transfuse blood products as needed using a restrictive strategy (Hb trigger <70 g/L for most patients, <80 g/L for those with cardiovascular disease) 2
- Correct any coagulopathy with appropriate blood products 2
Diagnostic Approach
First-Line Diagnostic Tools
- Ano-proctoscopy or flexible sigmoidoscopy is recommended as the initial diagnostic procedure 1
- For patients with high-risk features or ongoing bleeding, perform urgent colonoscopy within 24 hours 1
- Complete colonoscopy is indicated when:
Second-Line Diagnostic Tools
- If endoscopic evaluation fails to identify bleeding source:
- CT Angiography (CTA) for hemodynamically stable patients 1, 2
- Endoscopic ultrasound (EUS) with color Doppler for suspected anorectal varices 1
- Contrast-enhanced CT scan if EUS unavailable or fails to detect bleeding site 1
- Nuclear medicine labeled red cell scan for detection of slow bleeding (0.05-0.1 mL/min) 2
Management Based on Etiology
Anorectal Varices
- For mild bleeding:
- Intravenous fluid replacement
- Blood transfusion if necessary
- Correction of coagulopathy
- Optimal medication for portal hypertension 1
- Local procedures for active bleeding:
- Endoscopic variceal ligation
- Endoscopic band ligation
- Sclerotherapy
- EUS-guided glue injection 1
- Consider vasoactive drugs (terlipressin or octreotide) to reduce splanchnic blood flow 1
- Short course of prophylactic antibiotics is recommended 1
Non-Variceal Bleeding
- Endoscopic intervention for active bleeding:
- Clipping
- Thermal therapy
- Injection therapy
- Band ligation 2
- If endoscopic treatment fails or is unavailable:
Escalation of Care
Step-Up Approach for Persistent Bleeding
- Initial endoscopic management
- Radiological intervention if endoscopic treatment fails:
- Surgical management as last resort when other methods fail 1, 2
Common Pitfalls and Caveats
- Delayed diagnosis: Failure to perform timely endoscopic evaluation can lead to increased morbidity and mortality 2
- Inadequate resuscitation: Underestimating blood loss can result in hemodynamic instability 1
- Overlooking upper GI sources: Up to 11% of apparent lower GI bleeding may originate from upper GI tract 3
- Resource utilization: Management of PR bleeding is resource-intensive; appropriate allocation of resources is essential 4
- Medication considerations: For patients on anticoagulants, careful consideration of reversal agents and timing of anticoagulant resumption is necessary 5
- Regional variations in etiology: Frequencies of different causes vary by region; in some areas, ulcerative colitis is the leading cause, while in others, hemorrhoids and diverticular disease predominate 3, 6
By following this structured approach to the management of new per rectal bleeding, clinicians can effectively diagnose the cause, stabilize patients, and implement appropriate therapeutic interventions to reduce morbidity and mortality.