Which specialist treats patients with rectal bleeding?

Which Specialist Treats Rectal Bleeding

Patients with rectal bleeding should be evaluated by a gastroenterologist, who can perform the necessary endoscopic procedures (colonoscopy, flexible sigmoidoscopy, or anoscopy) to diagnose and treat the underlying cause. 1

Initial Evaluation and Specialist Referral

The management of rectal bleeding requires endoscopic evaluation, which is performed by gastroenterologists who have the expertise in both diagnostic and therapeutic endoscopy. 1

When to Refer to Gastroenterology

All patients over age 40 with rectal bleeding should be referred for colonoscopy or flexible sigmoidoscopy, regardless of symptoms or findings on rectal examination. 1, 2 This is critical because:

• Approximately 6% of patients presenting with lower GI bleeding have underlying colorectal cancer 1
• Serious pathology (cancer, polyps ≥5mm, inflammatory bowel disease) is detected in up to 44% of patients over 40 with rectal bleeding 2
• Symptoms are unreliable for distinguishing benign from serious causes 3

Urgency of Referral

The timing depends on risk stratification using the Oakland score 1:

• Oakland score >8 points: Admit to hospital for urgent colonoscopy within 24 hours by gastroenterology 1, 4, 5
• Oakland score ≤8 points: Discharge for outpatient colonoscopy within 2 weeks 1, 4, 5

Role of Colorectal Surgeons

Colorectal surgeons should be involved when:

• Anorectal pathology (hemorrhoids, fissures, fistulas) is identified and requires surgical intervention 1
• Endoscopic therapy fails and surgical hemostasis is needed 1
• There is suspicion of colorectal malignancy requiring resection 1

Ideally, gastroenterologists (medical or surgical) should collaborate, with patients admitted under the responsibility of a gastroenterology service. 1

Special Circumstances Requiring Multidisciplinary Care

Portal Hypertension and Anorectal Varices

If portal hypertension is suspected (history of cirrhosis, varices), early involvement of hepatology is essential in addition to gastroenterology. 1, 6 This requires:

• Gastroenterology for endoscopic diagnosis and treatment (band ligation, sclerotherapy) 1, 6
• Hepatology for medical management of portal hypertension 1, 6
• Interventional radiology if TIPS procedure is needed 6, 4

Radiation-Induced Bleeding

Patients with prior pelvic radiotherapy for cancer require gastroenterology evaluation, but may also need:

• Hyperbaric oxygen therapy specialists 1
• Oncology consultation for overall cancer management 1

Common Pitfalls to Avoid

• Do not assume hemorrhoids are the cause without endoscopic evaluation. Even when hemorrhoids are present on examination, up to 48% of patients have additional pathology requiring different management. 7
• Do not rely on symptoms alone to determine who needs investigation. Symptoms are unhelpful in predicting serious disease, and all patients over 40 require full colonic evaluation. 2, 3
• Do not perform only anoscopy or rigid sigmoidoscopy. Full colonoscopy is necessary because 16-31% of significant lesions are found proximal to the reach of sigmoidoscopy. 1, 8
• Do not delay referral in patients with "typical hemorrhoid symptoms." Colorectal cancer can coexist with hemorrhoids, and hemorrhoids alone do not cause positive fecal occult blood tests. 1

Summary Algorithm

1. All patients with rectal bleeding → Calculate Oakland score 1, 4
2. Score >8 → Admit under gastroenterology for urgent colonoscopy within 24 hours 1, 4
3. Score ≤8 → Refer to gastroenterology for outpatient colonoscopy within 2 weeks 1, 4
4. If portal hypertension suspected → Add hepatology consultation 1, 6
5. If surgical pathology identified → Involve colorectal surgery 1