What is the treatment for rectal bleeding?

Treatment of Rectal Bleeding

The treatment of rectal bleeding depends critically on identifying the underlying cause through systematic evaluation, with management ranging from conservative measures for benign anorectal conditions to urgent endoscopic or surgical intervention for severe hemorrhage.

Initial Assessment and Hemodynamic Stabilization

Immediately assess hemodynamic status and initiate resuscitation if needed. 1, 2

• Check vital signs including blood pressure, heart rate, and orthostatic changes to identify significant blood loss 1
• Obtain complete blood count with hemoglobin/hematocrit and coagulation parameters 3, 1
• For hemodynamically unstable patients or severe bleeding, maintain hemoglobin >7 g/dL and mean arterial pressure >65 mmHg while avoiding fluid overload 3, 1
• Administer intravenous fluid replacement and blood transfusion as necessary 3
• Correct coagulopathy and thrombocytopenia 1

Diagnostic Evaluation to Guide Treatment

Perform digital rectal examination and anoscopy as first-line diagnostic tools, as approximately 40% of rectal carcinomas are palpable and up to 20% of patients with hemorrhoids have concomitant anal fissures. 1

• For hemodynamically unstable patients with suspected active bleeding, perform CT angiography first to rapidly localize the bleeding site 2
• Flexible sigmoidoscopy or colonoscopy is recommended for nearly all patients with rectal bleeding, even when hemorrhoids are identified, to evaluate for colorectal neoplasia 1
• Risk stratify using the Oakland score: scores >8 indicate major bleeding requiring hospital admission 2

Treatment Based on Specific Etiology

Benign Anorectal Conditions (Anal Fissure, Hemorrhoids)

Conservative management is first-line treatment for anal fissures and uncomplicated hemorrhoids. 1

• Fiber supplementation, adequate fluid intake, sitz baths, and topical analgesics 1
• For thrombosed external hemorrhoids presenting within 48-72 hours with severe pain, excision is recommended; otherwise use conservative management with analgesics and stool softeners 1

Radiation-Induced Bleeding

For radiation-induced rectal bleeding affecting quality of life, optimize bowel function and consider stopping anticoagulants/antiplatelet agents if possible, as this often reduces bleeding to acceptable levels. 3

• Reassure patients with minor bleeding and explain the natural history; intervention is not required 3
• Sucralfate enemas (2g in 30-50 mL water, twice daily initially) can be used as temporary treatment until definitive therapy is effective or for long-term use in those unsuitable for disease-modifying therapy 3
• Treatment is only required if symptoms demand it (e.g., transfusion-dependent bleeding, recurrent anemia, or bleeding interfering with daily life) 3

Anorectal Varices from Portal Hypertension

For bleeding anorectal varices, use a step-up approach starting with medical management, followed by local endoscopic procedures, then radiological interventions, and finally surgical options if all else fails. 3

• Initiate vasoactive drugs such as terlipressin or octreotide to reduce splanchnic blood flow and portal pressure 3
• Administer short course of prophylactic antibiotics 3
• Consider endorectal placement of a compression tube as a bridging maneuver for stabilization or transfer 3
• For failure of medical treatment and local procedures, use embolization via interventional radiological techniques for short-term control 3
• Consider percutaneous TIPS to decompress the portal venous system and reduce rebleeding risk in patients with severe portal hypertension 3
• Temporarily suspend non-selective beta-adrenergic blockers during acute bleeding 3

When to Escalate Care

Urgent colonoscopy within 24 hours is indicated for high-risk features, ongoing bleeding, hemodynamic instability despite resuscitation, or inability to identify source on anorectal examination. 1

• Surgical consultation is warranted for suspected perianal abscess requiring drainage, thrombosed hemorrhoids presenting within 48-72 hours with severe pain, or failure of conservative management 1
• For bleeding anorectal varices with failure of medical, local, and radiological procedures, proceed to surgical intervention using a step-up approach 3

Critical Pitfalls to Avoid

Never assume all rectal bleeding is benign, as anemia due to hemorrhoidal disease is extremely rare and should prompt search for alternative diagnoses. 1

• Age-appropriate cancer screening is mandatory 1
• For patients over 50 years, colonoscopy should be performed within 2 weeks due to a 6% risk of underlying bowel cancer 2
• Avoid biopsying irradiated mucosa unless neoplastic or inflammatory processes seem likely, as this carries risk of fistula development or necrosis 3
• In cirrhotic patients with bleeding rectal varices, recognize that prognosis is poor even with initial hemostasis (cumulative survival rates of 63.6% and 32.7% at 6 and 12 months respectively), as mortality is related to hepatic failure 3