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 identify potential causes of BRBPR, such as hemorrhoids, anorectal varices, or other conditions 1
• Perform a complete physical examination, including a digital rectal examination, to assess for signs of bleeding, pain, or other abnormalities 1
• Check vital signs, determine hemoglobin and hematocrit, and assess coagulation to evaluate the severity of the bleeding 1

Diagnostic Tests

• Anoscopy is essential for visualizing internal hemorrhoids and associated rectal mucosal prolapse 1
• Sigmoidoscopy is recommended as a minimum for bright-red rectal bleeding to rule out other causes of bleeding 1
• Colonoscopy or air-contrast barium enema is indicated when the bleeding is atypical for hemorrhoids, when no source is evident on anorectal examination, or when the patient has significant risk factors for colonic neoplasia 1
• Upper endoscopy may be necessary in cases where a clear diagnosis of bleeding anorectal varices is not possible or when there is suspicion of an upper gastrointestinal source of bleeding 1

Risk Stratification

• Use risk stratification scores to assess the severity of bleeding and stratify the risk for each patient, including vital signs, hemodynamic parameters, laboratory tests, and presence of comorbidities 1
• Consider blood typing and cross-matching in cases of severe bleeding 1 By following this approach, clinicians can effectively evaluate and manage patients with BRBPR, ensuring timely and appropriate treatment.

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.