What is the workup for Bright Red Blood Per Rectum (BRBPR)?

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 Assessment

• Collect a focused medical history to suspect specific diseases and guide the subsequent diagnostic process 1
• Perform a complete physical examination, including a digital rectal examination, to rule out other causes of lower gastrointestinal bleeding 1
• Check vital signs, determine hemoglobin and hematocrit, and assess coagulation to evaluate the severity of the bleeding 1
• In case of severe bleeding, suggest blood typing and cross-matching 1

Diagnostic Tools

• Anoscopy or flexible sigmoidoscopy as the first-line diagnostic tool for suspected bleeding anorectal varices 1
• Colonoscopy for patients with high-risk features, evidence of ongoing bleeding, or risk factors for colorectal cancer 1
• Endoscopic ultrasound (EUS) as a second-line diagnostic tool, especially for deep rectal varices or when in doubt 1
• Contrast-enhanced CT-scan if endoscopy and EUS fail to identify the bleeding site 1

Key Considerations

• Differential diagnosis between hemorrhoids and anorectal varices is crucial, as they require different treatments 1
• Risk stratification is essential to determine the severity of bleeding and guide further management 1
• Pregnancy test should be considered in women of childbearing age with suspected BRBPR 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 initial evaluation should include a thorough medical history to identify any underlying conditions that may be causing the bleeding, such as hemorrhoids, diverticulosis, or inflammatory bowel disease 2.
• A physical examination, including a digital rectal examination, should be performed to identify any abnormalities in the rectum or anus 3.
• Diagnostic tests, such as colonoscopy, may be necessary to visualize the entire colon and identify any lesions or other abnormalities that may be causing the bleeding 3, 4, 5.

Diagnostic Tests

• Colonoscopy is a commonly used diagnostic test for BRBPR, as it allows for visualization of the entire colon and identification of any lesions or other abnormalities 3, 4, 5.
• However, some studies suggest that flexible sigmoidoscopy may be sufficient for 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 4.
• Other diagnostic tests, such as proctosigmoidoscopy, may also be used in certain cases 5.

Special Considerations

• Patients under 40 years of age with BRBPR may not require colonoscopy, unless they have specific risk factors such as a family history of colorectal cancer or advanced adenoma polyps 6.
• The presence of other symptoms, such as changes in bowel habits or abdominal pain, may also influence the workup for BRBPR 2.
• The diagnostic yield of colonoscopy may vary depending on the patient's age, symptoms, and medical history, and should be taken into consideration when deciding on a diagnostic approach 3, 4, 5, 6.