What is the best course of treatment for a patient with bleeding per rectum, considering their age, medical history, and presence of abdominal pain or other symptoms?

Management of Bleeding Per Rectum

All patients presenting with rectal bleeding require risk stratification using the Oakland score, followed by appropriate resuscitation if indicated, digital rectal examination, and endoscopic evaluation—with colonoscopy being the preferred diagnostic modality for most patients, performed urgently (next available list) for major bleeds or within 2 weeks for minor bleeds in patients over 50 years old. 1

Initial Assessment and Risk Stratification

Immediate Evaluation

• Assess hemodynamic status by checking pulse, blood pressure, and orthostatic vital signs to determine bleeding severity 1
• Obtain complete blood count, coagulation studies (INR), platelet count, serum creatinine, and inflammatory markers (C-reactive protein, lactates) 1
• Perform digital rectal examination to confirm stool appearance, exclude anorectal pathology, and detect palpable rectal masses (40% of rectal cancers are palpable) 1

Oakland Score for Risk Stratification

Use the Oakland score to determine disposition 1:

• Score ≤8 points: Safe for immediate discharge with outpatient investigation
• Score >8 points: Major bleed requiring hospital admission

The score incorporates age, gender, previous lower GI bleeding, digital rectal exam findings, heart rate, systolic blood pressure, and hemoglobin level 1

Resuscitation Protocol

For Hemodynamically Unstable Patients

• Establish two large-bore IV cannulae in anticubital fossae 1
• Infuse normal saline 1-2 liters initially to restore blood pressure and urine output >30 mL/hour 1
• Transfuse packed red blood cells when hemoglobin <100 g/L or with active hematemesis and shock 1
• Correct coagulopathy with fresh frozen plasma if INR >1.5 1
• Correct thrombocytopenia with platelet transfusion if count <50,000/µL 1
• Insert urinary catheter and monitor hourly urine output for severe bleeding 1

Special Considerations

• For patients with portal hypertension and anorectal varices, maintain hemoglobin >7 g/dL and mean arterial pressure >65 mmHg while avoiding fluid overload 1
• Temporarily suspend beta-blockers in acute variceal bleeding 1
• Administer short course of prophylactic antibiotics for bleeding anorectal varices 1

Diagnostic Approach

Endoscopic Evaluation

Minor Self-Terminating Bleeds (Oakland ≤8)

• Discharge for urgent outpatient colonoscopy 1
• Perform colonoscopy within 2 weeks for patients over 50 years old, as 6% have underlying bowel cancer 1
• Include assessment of anal canal and rectum using rigid sigmoidoscopy, proctoscopy, or flexible endoscopy with retroflexion to identify hemorrhoids, vascular abnormalities, and Dieulafoy ulcers 1

Major Bleeds (Oakland >8)

• Admit to hospital for colonoscopy on next available list 1
• Colonoscopy has diagnostic yield of 42-90% and allows therapeutic intervention 1
• For patients over 70 years old, diverticulosis and angiodysplasia are most likely causes 1

Upper Endoscopy Consideration

• Perform upper endoscopy if melaena is present or if upper GI source is suspected, as up to 10% of rectal bleeding originates from upper GI tract 2

Alternative Diagnostic Modalities

For severe ongoing bleeding when colonoscopy is not diagnostic 1:

• Technetium-99m red blood cell scan: Useful for intermittent severe bleeding before angiography
• CT angiography or catheter angiography: For continual active bleeding with hemodynamic instability
• Surgery: Reserved for persistent bleeding despite medical, endoscopic, and radiological interventions

Specific Etiologies and Management

Hemorrhoidal Disease

Critical Pitfall: Never attribute anemia to hemorrhoids without full colonic evaluation, as anemia from hemorrhoids is extremely rare (0.5 per 100,000 population) 3, 4

• Hemorrhoids cause minor intermittent bleeding without significant anemia 3
• Complete colonoscopy is mandatory when anemia is present, regardless of visible hemorrhoids 3
• First-line treatment: Dietary fiber (25-30 g daily), increased water intake, avoid straining 4
• For persistent grade I-III hemorrhoids: Rubber band ligation (70-89% success rate) 4
• For grade III-IV hemorrhoids with anemia or failed conservative therapy: Surgical hemorrhoidectomy (2-10% recurrence rate) 4

Thrombosed External Hemorrhoids

• Within 72 hours: Complete excision under local anesthesia provides faster resolution and lower recurrence 4
• After 72 hours: Conservative management with topical 0.3% nifedipine + 1.5% lidocaine ointment every 12 hours for 2 weeks (92% resolution rate) 4
• Never perform simple incision and drainage—this causes persistent bleeding and higher recurrence 4

Radiation-Induced Bleeding

For patients with history of pelvic radiotherapy (prostate, cervical, endometrial cancer) 1:

• Bleeding typically peaks within 3 years but can persist 10+ years 1
• Do not biopsy radiation-induced telangiectasia due to fistula/necrosis risk 1
• Treatment only needed if bleeding interferes with daily life or causes transfusion-dependent anemia 1
• First-line: Sucralfate enemas 2g in 30-50 mL water twice daily 1
• Consider hyperbaric oxygen therapy for refractory cases 1

Anorectal Varices

• Use vasoactive drugs (terlipressin or octreotide) to reduce portal pressure 1
• Endorectal compression tube as bridging maneuver for severe bleeding 1
• Step-up approach: Medical → local procedures → angiography/embolization → TIPS → surgery 1

Common Pitfalls to Avoid

1. Never assume hemorrhoids are the cause when anemia, positive fecal occult blood, or atypical bleeding patterns are present—full colonoscopy is mandatory 3, 4

2. Do not delay colonoscopy in patients over 50 with rectal bleeding, as colorectal cancer risk ranges from 2.4-11% 3

3. Avoid operating on hemorrhoids without excluding proximal colonic pathology, which could delay cancer diagnosis 3

4. Do not attribute abdominal pain to hemorrhoids—uncomplicated hemorrhoids are painless, and pain suggests anal fissure, abscess, or other pathology 4

5. Correct anticoagulation cautiously—for warfarin patients, reverse with fresh frozen plasma and vitamin K, but anticoagulation does not preclude endoscopic intervention 1

6. Recognize inflammatory bowel disease as a leading cause in younger patients, particularly ulcerative colitis 5

Age-Specific Considerations

Patients <40 years old

• Lower risk profile (Oakland score 0 points for age) 1
• Inflammatory bowel disease more common than malignancy 5
• Consider infectious colitis, sexually transmitted proctitis 6

Patients 40-69 years old

• Intermediate risk (Oakland score 1 point) 1
• Full colonoscopy indicated for any concerning features 1

Patients ≥70 years old

• High risk (Oakland score 2 points) 1
• Diverticulosis and angiodysplasia most common causes 1
• Ischemic colitis consideration with abdominal pain 1
• Higher mortality risk requiring closer monitoring 1

Disposition Based on Clinical Presentation

75-90% of patients: Minor bleeding resolving with conservative therapy—outpatient colonoscopy within 2 weeks 1

Chronic intermittent bleeding: Elective colonoscopy preferred over angiography due to slow, sporadic nature 1

Severe intermittent bleeding with hemodynamic stability between episodes: Urgent colonoscopy or technetium-99m scan before angiography 1

Continual active bleeding with hypotension: Urgent angiography or surgery 1