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 Evaluation

• A focused medical history should be collected to determine the severity of the bleeding and to correctly stratify the risk for the patient 1
• Vital signs should be checked, and hemoglobin and hematocrit levels should be determined to evaluate the severity of the bleeding 1
• A complete physical examination, including a digital rectal examination, should be performed to rule out other causes of lower gastrointestinal bleeding 1

Diagnostic Tests

• Anoscopy is essential for visualizing hemorrhoids and determining the source of bleeding 1
• Flexible 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 should be performed to evaluate the proximal colon if 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

Special Considerations

• Patients with suspected bleeding hemorrhoids should be evaluated for other causes of lower gastrointestinal bleeding, such as diverticulosis, angiodysplasia, and colorectal cancer 1
• The individual patient's risk factors for colorectal cancer, such as age, family history, or personal history of polyps, should be considered when deciding on the extent of colonic evaluation 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, 5, 6.
• Physical examination: A physical examination is performed to check for any signs of bleeding, such as blood in the stool or rectal bleeding 2, 3, 4, 5, 6.
• Diagnostic tests: Diagnostic tests such as colonoscopy, flexible sigmoidoscopy, or rigid sigmoidoscopy may be performed to visualize the inside of the colon and rectum and identify any abnormalities 2, 3, 4, 5, 6.

Diagnostic Yield of Colonoscopy

The diagnostic yield of colonoscopy in patients with BRBPR is significant, with studies showing that:

• 22-84% of patients with BRBPR have abnormal findings on colonoscopy, including hemorrhoids, anal fissures, ulcerative colitis, and colorectal carcinoma 2, 3, 4, 5, 6.
• The diagnostic yield of colonoscopy is higher in patients with BRBPR than in those without BRBPR 6.
• Younger patients with BRBPR have a lower diagnostic yield on colonoscopy, with only 1.6% having adenomas >1 cm and no invasive cancers detected in patients under 50 years old 5.

Recommendations for Workup

Based on the available evidence, the following recommendations can be made for the workup of BRBPR:

• Colonoscopy is the examination of choice for diagnosis and treatment of BRBPR, especially in patients with significant bleeding or other alarm signs 2, 3, 4.
• Flexible sigmoidoscopy may be sufficient for the evaluation of average-risk patients with minimal BRBPR, especially in younger patients or those with no family history of colorectal neoplasia 3, 5.
• The decision to perform colonoscopy or flexible sigmoidoscopy should be individualized based on the patient's risk factors, symptoms, and medical history 3, 5, 6.