Management of Bleeding Per Rectum
Immediate Assessment and Risk Stratification
All patients presenting with bleeding per rectum require immediate hemodynamic assessment including pulse, blood pressure, and orthostatic vital signs to determine bleeding severity, with laboratory evaluation including complete blood count, coagulation studies, and serum creatinine. 1
Apply the Oakland score to determine disposition: Score ≤8 points indicates safe discharge, while >8 points indicates major bleed requiring hospital admission, incorporating age, gender, previous lower GI bleeding, digital rectal exam findings, heart rate, systolic blood pressure, and hemoglobin level. 1
Perform digital rectal examination in all patients to confirm stool appearance, exclude anorectal pathology, and detect palpable rectal masses—40% of rectal cancers are palpable on digital exam. 1
Check inflammatory markers (C-reactive protein, procalcitonin, lactate) in patients with suspected complicated presentations such as rectal prolapse with ischemia, as these correlate with tissue necrosis and mortality. 2
Resuscitation for Hemodynamically Unstable Patients
For hemodynamically unstable patients, establish two large-bore IV cannulae in anticubital fossae and infuse 1-2 liters normal saline 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 bleeding and shock. 1
Correct coagulopathy with fresh frozen plasma if INR >1.5. 1
Diagnostic Approach Based on Bleeding Severity
Colonoscopy is the preferred diagnostic modality for most patients, performed urgently for major bleeds or within 2 weeks for minor bleeds in patients over 50 years old, with diagnostic yield of 42-90% and allowing therapeutic intervention. 1
For Severe Ongoing Bleeding When Colonoscopy Non-Diagnostic:
Consider technetium-99m red blood cell scan, CT angiography, or catheter angiography for severe ongoing bleeding when colonoscopy fails to identify the source. 1
In hemodynamically stable patients with irreducible or strangulated rectal prolapse, perform urgent contrast-enhanced abdomino-pelvic CT scan without delaying appropriate treatment to detect complications. 2
Age-Specific Diagnostic Considerations
Full colonoscopy is mandatory for patients over 50 years old with rectal bleeding, as colorectal cancer risk ranges from 2.4-11%. 1
Older Patients (≥70 years):
Consider diverticulosis and angiodysplasia as common causes—these account for 30-50% of colonic bleeding in this age group. 1, 3
Recognize higher mortality risk requiring closer monitoring. 1
Younger Patients:
- Consider inflammatory bowel disease (particularly ulcerative colitis) as a leading cause—ulcerative colitis was the most common diagnosis (46%) in one large series. 1, 4
Management of Specific Etiologies
Hemorrhoidal Disease (Most Common Benign Cause):
First-line treatment includes dietary fiber (25-30 grams daily), increased water intake, and avoidance of straining. 1, 5
For persistent grade I-III hemorrhoids after conservative management fails, rubber band ligation is the most effective office-based procedure with success rates of 70-89%. 5
For thrombosed external hemorrhoids presenting within 72 hours, complete excision under local anesthesia provides faster symptom resolution and lower recurrence rates compared to conservative management. 5
Never perform simple incision and drainage of thrombosed hemorrhoids—this leads to persistent bleeding and higher recurrence rates. 5
Anorectal Varices (Portal Hypertension):
Use a step-up approach starting with local endoscopic maneuvers, progressing to embolization via interventional radiology, then TIPS for portal decompression, and finally liver transplantation in selected cases. 2
Administer prophylactic antibiotics to all patients with cirrhosis and gastrointestinal bleeding to decrease risk of spontaneous bacterial peritonitis and improve survival. 2
Consider vasoactive drugs to reduce portal pressure, though beta-blockers should be temporarily suspended if systolic blood pressure <90 mmHg. 2
TIPS is recommended for severe portal hypertension to decompress the portal venous system and reduce rebleeding risk, though it carries 20-30% risk of encephalopathy. 2
Rectal Prolapse with Complications:
Request complete blood count, serum creatinine, and inflammatory markers (CRP, procalcitonin, lactate) to assess for ischemia or strangulation. 2
Leukocytosis and elevated lactate are potential predictors of transmural bowel necrosis and mortality in acute mesenteric ischemia. 2
Critical Pitfalls to Avoid
Never attribute anemia or positive fecal occult blood to hemorrhoids alone until the colon is adequately evaluated—hemorrhoids do not cause positive stool guaiac tests. 5
Anemia from hemorrhoidal disease is rare (0.5 per 100,000 population), and alternative sources must be excluded. 5
Anal pain is generally not associated with uncomplicated hemorrhoids—its presence suggests other pathology such as anal fissure (occurs in 20% of hemorrhoid patients), abscess, or thrombosis. 5
Colonoscopy complications can present with delayed massive bleeding even months after the procedure, as illustrated by fatal cases of rectal perforation with secondary hemorrhage. 6
Consider rare causes like Dieulafoy's ulcer in cases of massive rectal bleeding without obvious source—rigid sigmoidoscopy can diagnose rectal lesions, and widely oversewing the vessel is the primary treatment. 7
Abdominal Pain as a Red Flag
When rectal bleeding is accompanied by abdominal pain, this suggests more serious pathology requiring urgent evaluation:
Consider inflammatory bowel disease, ischemic colitis (accounts for 5-15% of colonic bleeding), or complicated rectal prolapse with strangulation. 2, 3
Perform urgent imaging (CT scan) in hemodynamically stable patients to exclude perforation, ischemia, or obstruction. 2
Proctitis (inflammatory, radiogenic, ischemic, infectious, or sexually transmitted) requires interdisciplinary diagnostics and management. 8