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 complete 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, palpable masses, or other abnormalities 1
• Check vital signs, including blood pressure, heart rate, and oxygen saturation, to evaluate the severity of bleeding 1

Laboratory Tests

• Order laboratory tests, including:
  • Complete blood count (CBC) to evaluate for anemia or thrombocytopenia 1
  • Serum electrolytes, blood urea nitrogen (BUN), and creatinine to assess for electrolyte imbalances or renal dysfunction 1
  • Coagulation studies, including prothrombin time (PT) and partial thromboplastin time (PTT), to evaluate for coagulopathy 1
  • Blood type and crossmatch for possible transfusion of blood components in cases of severe bleeding 1

Imaging Studies

• Consider imaging studies, such as:
  • Endoscopy (anoscopy or flexible sigmoidoscopy) to visualize the rectum and sigmoid colon 1
  • Endoscopic ultrasound (EUS) with color Doppler evaluation to assess for deep rectal varices or other abnormalities 1
  • Contrast-enhanced CT scan to evaluate for other sources of bleeding or underlying conditions 1

Risk Stratification

• Use risk stratification scores to evaluate the severity of bleeding and guide management decisions 1
• Consider the presence of comorbidities, such as liver disease or cardiovascular conditions, which may impact management 1

Management

• Provide multidisciplinary management, involving hepatology specialists and other experts as needed, to optimize control of comorbid conditions and manage bleeding 1
• Consider non-operative management, including intravenous fluid replacement, blood transfusion, and correction of coagulopathy, for patients with mild bleeding 1
• Use endoscopic or radiological interventions, such as endoscopic variceal ligation or balloon tamponade, to control bleeding in patients with 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.