From the Guidelines
Bright Red Blood Per Rectum (BRBPR) workup should start with a thorough medical history and physical examination, including a digital rectal examination, to rule out other causes of lower gastrointestinal bleeding.
Initial Evaluation
- A complete physical examination, including a digital rectal examination, is essential to evaluate the severity of the bleeding and to rule out other possible causes of acute anal pain or bleeding 1.
- Vital signs, hemoglobin, and hematocrit should be checked to assess the severity of the bleeding, and coagulation should be evaluated 1.
- A focused medical history should be collected to determine the severity of the bleeding and to correctly stratify the risk for the patient 1.
Diagnostic Tests
- Anoscopy is the optimal method for visualizing hemorrhoids 1.
- Sigmoidoscopy should be performed on all patients who report rectal bleeding 1.
- Colonoscopy or air-contrast barium enema should be used to evaluate the proximal colon in cases where the bleeding is not typical of hemorrhoids, or if the patient has significant risk factors for colonic neoplasia 1.
Laboratory Tests
- A complete blood count (CBC), serum electrolytes, blood urea nitrogen (BUN), creatinine, and coagulation assessment should be performed to determine the severity of the bleeding and to correctly stratify the risk for the patient 1.
- Blood type and crossmatch for possible transfusion of blood components should be ordered at the time of initial assessment for patients with signs of severe bleeding 1.
From the Research
Workup for Bright Red Blood Per Rectum (BRBPR)
The workup for BRBPR typically involves a combination of medical history, physical examination, and diagnostic tests. The following are some of the key steps involved in the workup:
- Medical history: A thorough medical history is taken to identify any underlying conditions that may be causing the BRBPR, such as hemorrhoids, anal fissures, or inflammatory bowel disease 2, 3, 4.
- Physical examination: A physical examination is performed to check for any signs of bleeding, such as blood in the stool or rectal vault, and to assess the patient's overall health 2, 3, 4.
- Diagnostic tests: Diagnostic tests such as colonoscopy, flexible sigmoidoscopy, or rigid sigmoidoscopy may be performed to visualize the colon and rectum and identify any lesions or abnormalities 2, 3, 5, 6.
Diagnostic Yield of Colonoscopy
The diagnostic yield of colonoscopy in patients with BRBPR is generally high, with studies showing that it can detect significant lesions such as adenomas, colorectal carcinoma, and inflammatory bowel disease in a significant proportion of patients 2, 3, 5.
- A study published in the Journal of Ayub Medical College, Abbottabad found that colonoscopy showed abnormal findings in 84% of patients with BRBPR, with the most common diagnoses being ulcerative colitis, colorectal carcinoma, and non-specific colitis 2.
- Another study published in the World Journal of Gastroenterology found that significant lesions were found in 30.1% of patients with minimal BRBPR, including adenocarcinoma and adenomatous polyps 3.
Approach to Diagnosis
The approach to diagnosis of BRBPR depends on the patient's symptoms, medical history, and physical examination findings. The following are some of the key considerations:
- Patients with classic "outlet" bleeding, defined as bright red blood after or during defecation, with no family history of colorectal neoplasia or change in bowel habits, may not require full colonoscopy to exclude significant pathology 6.
- Flexible sigmoidoscopy or rigid sigmoidoscopy may be sufficient to exclude significant pathology in patients with outlet bleeding, especially in younger patients 3, 6.
- However, full colonoscopy may be necessary in patients with suspicious bleeding, hemorrhage, or occult bleeding, or in those with a family history of colorectal neoplasia or change in bowel habits 6.