What history should be taken in a patient presenting with hematochezia (passage of fresh blood per rectum)?

History to Elicit in Patients with Hematochezia

Begin with immediate hemodynamic assessment including vital signs (pulse, blood pressure, signs of shock) and calculate the shock index (heart rate/systolic BP), as a shock index >1 indicates hemodynamic instability requiring urgent intervention. 1

Focused Medical History

Bleeding Characteristics

• Document the volume, frequency, and duration of bleeding to assess severity and guide management urgency 1
• Inquire about previous episodes of rectal bleeding to distinguish acute from chronic presentations 1
• Ask about the color and consistency of blood (bright red vs. maroon vs. melena), as this helps localize the bleeding source 2

Medication History

• Obtain detailed medication history, particularly anticoagulants, antiplatelet agents, and NSAIDs, as these significantly increase bleeding risk and may indicate NSAID-induced ulcerations throughout the GI tract 1, 3
• Document dosages and timing of anticoagulation therapy to assess coagulopathy risk 1

Risk Factors for Upper GI Source

• Ask about history of peptic ulcer disease, as 10-15% of patients with severe hematochezia and hypovolemia have an upper GI source 4, 5
• Inquire about portal hypertension or chronic liver disease, as anorectal varices occur in up to 89% of patients with portal pressure >10 mmHg 4, 1
• Document history of angiodysplasia, which warrants early endoscopy or push enteroscopy 4

Surgical and Medical History

• Obtain history of prior abdominal surgery, as it has 85% sensitivity for adhesive bowel obstruction if presenting with obstruction symptoms 1
• Ask about radiation therapy history, as radiation proctitis can cause severe recurrent hemorrhage from vascular telangiectasia 4

Associated Symptoms

• Inquire about abdominal pain, cramping, or distension to assess for obstruction or peritoneal signs 1
• Ask about unexplained weight loss, which raises concern for colorectal cancer and mandates complete colonic evaluation 1, 3
• Document chronic constipation or straining, which predisposes to hemorrhoids and anal fissures 1
• Ask about recent trauma, including mechanical trauma from anal intercourse or douching, which can cause anal fissures 1

Family and Personal Cancer History

• Obtain personal and family history of colorectal cancer or inflammatory bowel disease, as rectal bleeding should not be attributed to hemorrhoids without complete colonic evaluation when risk factors are present 3
• Document age, as patients presenting with hematochezia and upper GI source tend to be older (mean age 55 vs 50 years for melena) 2

Physical Examination Components

Hemodynamic Assessment

• Check vital signs immediately including pulse rate, blood pressure, and signs of shock to determine bleeding severity 4, 1
• Assess for signs of dehydration (skin turgor, mucous membranes, capillary refill) 5

Abdominal Examination

• Examine for abdominal tenderness, distension, or peritoneal signs to identify complications 1
• Assess for signs of chronic liver disease (jaundice, ascites, spider angiomata) if portal hypertension is suspected 1

Digital Rectal Examination

• Perform digital rectal examination to rule out other causes of lower gastrointestinal bleeding and assess for masses, hemorrhoids, fissures, or blood 4, 1, 3
• Confirm blood presence in stool during DRE to verify hematochezia 3

Critical Pitfalls to Avoid

• Do not rely on initial hemoglobin values alone, as they may appear falsely normal in the first 30-60 minutes after acute bleeding; serial measurements are essential 1
• Never assume hemorrhoids without proper evaluation, as symptoms attributed to hemorrhoids frequently represent other pathology and colorectal cancer must be excluded 5, 3
• Do not overlook upper GI sources in patients with severe hematochezia and hypovolemia, as 10-15% will have an upper GI bleeding source requiring different management 4, 5