Rectal Bleeding

What does blood in the Stool look like?

Blood in the stool can be bright red, maroon in color, black and tarry, or occult (meaning not visible to the naked eye).

Definitions

  1. Bright red blood is seen in the stool, on toilet paper after wiping, or in the toilet bowl is referred to as hematochezia.
  2. Melana refers to stool that appears black or "tarry" (or sticky).
  3. Occult blood is blood not visible to the naked eye. In this case, the stool may look completely normal. Occult blood is typically identified during specific stool studies used to screen for colorectal cancer and to assess for gastrointestinal causes of blood loss or anemia.

What tests can be used to identify occult blood in my stool?

  1. The fecal immunochemical test (or FIT) uses antibodies to detect hidden blood in the stool that could be potentially coming from cancer or tumor. It only detects human blood from the lower intestines making it is a more specific screening tool for colorectal cancer compared with the stool guiac test that many people may be more familiar with.
  2. The stool guiac test picks up blood arising from anywhere in the GI tract, making it less specific for colorectal cancer. For example, it might pick up blood arising from a bleeding stomach ulcer.

Why doesn’t all blood look the same in stool?
 

Generally, the closer the bleeding site is to the anus, the brighter red the blood will appear. Bleeding from the anus, rectum, and sigmoid colon (found on the left-hand side of the abdomen) tends to be bright red, whereas bleeding from the transverse colon and ascending colon on the right-hand side of the abdomen, located several feet away from the anus, tends to be darker red or maroon in color.

Melena occurs when blood is present in the colon for a long enough period of time that bacteria naturally present in the gut are able to break it down into chemicals that are black. Melena usually signifies bleeding from the upper gastrointestinal tract (for example, bleeding from ulcers in the stomach or small intestines).

Blood from the sigmoid colon and rectum usually does not stay in the colon long enough for bacteria to turn it black. As such, bleeding from these sites will tend to be a brighter red. Rarely, massive bleeding from the right side of the colon, small intestine, or upper GI tract can cause a rapid loss of blood resulting in bright red rectal bleeding also, usually associated with other symptoms such as acute lightheadedness, dizziness, and weakness.

Sometimes, bleeding from the gastrointestinal tract can be too slow to cause either bright red rectal bleeding or melena. In these cases bleeding is occult and the blood is only identified through laboratory testing. Occult bleeding is often associated with iron deficiency anemia.

What causes rectal bleeding?
 

Rectal bleeding can occur for many reasons.

Common causes include:

  1. Hemorrhoids
  2. Constipation
  3. Anal fissure (or tears)
  4. Proctitis, and
  5. Solitary rectal ulcer syndrome.

Less common causes include:

  1. Anal or rectal cancer
  2. Angiodysplasia
  3. Colon cancer
  4. Polyps
  5. Inflammatory Bowel Disease (such as Crohn’s Disease, or Ulcerative Colitis)
  6. Diarrhea
  7. Diverticulosis
  8. Pseudomembranous colitis (inflammation of the colon caused by an infection with a specific type of bacteria known as C. diff)
  9. Ischemic colitis
  10. Rectal trauma, and
  11. Proctitis from radiation.

***Any rectal bleeding should prompt a complete evaluation by a trained medical provider. Rectal bleeding, whether perceived to be minor or not, can be a symptom of colorectal cancer, a type of cancer that if caught early can be treated effectively.

To schedule an appointment for a comprehensive medical evaluation with Dr. Sinha and our team at Hunterdon Digestive Health Specialists, please call our office at 908-788-8200 or go to your nearest emergency department for immediate care.

Common Causes of Rectal Bleeding

1. Hemorrhoids

Also known as piles, hemorrhoids are swollen blood vessels in the anus and rectum that become engorged due to increased pressure, similar to what occurs in varicose veins in the legs.

Are there different types of hemorrhoids?
 

Yes. Hemorrhoids can either be internal (found inside the anus above an anatomical line known as the dentate line in insensitive anal mucosa, making them generally painless unless complicated or thrombosed) or external (found under the skin around the anus, below the dentate line on sensitive skin making them painful).

What symptoms do hemorrhoids causes?

  1. Pain in the anus and/or rectum
  2. Itching around the anus
  3. Burning
  4. Throbbing
  5. A bulge felt around the anus
  6. Rectal bleeding or blood noticed on toilet paper with wiping

What does hemorrhoidal bleeding look like?
 

Hemorrhoidal bleeding is typically associated with bowel movements and is most often noticed as bright red blood on toilet paper after wiping. Hemorrhoids are the most common cause of minor rectal bleeding.

How are hemorrhoids diagnosed and evaluated?
 

To evaluate minor rectal bleeding and assess whether your bleeding is due to hemorrhoids or another cause, a trained medical provider, like Dr. Sinha, will perform a digital rectal examination where she’ll insert a lubricated, gloved, finger into your anus to evaluate for any irregularities in the tissue, to assess for hemorrhoids, and feel for any obvious masses. Endoscopic procedures such as anoscopy, flexible sigmoidoscopy, and/or colonoscopy may also be recommended.

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Anoscopy is a procedure that can be performed in the office without sedation or anesthesia. During this simple inner office procedure, Dr. Sinha will insert a small, clear, plastic speculum, called an anoscope, into your anus to evaluate for problems of the anal canal including hemorrhoids, fissures, and some anal-rectal cancers. You’ll be asked to remove your underwear, and lay on your side on the exam table with your knees bent up towards your chest. Dr. Sinha will coat the anoscope with a lubricant and then gently push it into your anus. She may ask you to "bear down" or push as if you were going to have a bowel movement, and then relax. This will allow her to insert the anoscope more easily and help her to identify any bulges along the lining of your rectum. She’ll use a light to help her see more clearly. You may feel some pressure during the exam, and the anoscope may make you feel as if you’re going to have a bowel movement; this is completely normal. Generally speaking though, the procedure is well tolerated. Typically it takes less than a few minutes to perform and patients are able to return to normal work immediately thereafter. We advise that you get up slowly after the procedure because some individuals can feel faint or dizzy afterward.

What are the risk factors for hemorrhoids?
 

Hemorrhoids are made worse with increased pressure in the lower abdomen, anus, and rectum. Therefore, risk factors for hemorrhoids include:

  1. Chronic constipation
  2. Diarrhea
  3. Heavy lifting
  4. Prolonged sitting or standing
  5. Cycling
  6. Obesity, and
  7. Pregnancy

Symptoms are often made worse with age and there does seem to be some sort of familial pattern. The condition can run in families. Fortunately, there is no correlation between hemorrhoids and colorectal cancer.

How are hemorrhoids treated?

  1. Medical management is often the first approach to treatment and includes treating any underlying conditions such as chronic constipation or diarrhea, using a stool softener if appropriate, increasing the fiber in your diet (if appropriate) to help bulk stools and make bowel movements easier to pass, taking warm Sitz baths 3-4 times daily, and applying OTC creams or suppositories containing steroids (like hydrocortisone) or numbing agents (like lidocaine) for inflammation and pain relief.
  2. If medical management fails to alleviate symptoms, other inner office procedures may be recommended including rubber band ligation and infrared coagulation or IRC.
    1. Rubber band ligation is highly effective and involves placing a rubber band around the base of each internal hemorrhoid (we each have three) to cut off their blood supply. This causes the hemorrhoids to shrink and eventually fall off during a bowel movement a few days following the procedure. Possible complications include pain, bleeding, and infection, although most patients do very well and only notice minimal discomfort during the procedure. If you are allergic to Latex, please be sure to notify our staff and latex free bands are available.

2. Anal fissures

These are tears that occur in the lining of the anus, most commonly as a result of constipation and the passage of very hard stools. Other causes include diarrhea and inflammation of the anal tissue.

What symptoms might I notice?
 

Anal fissures can cause significant pain during and after bowel movements. Bright red blood with wiping is common.

How are anal fissures treated?
 

Treatment involves treating the underlying cause, taking stool softeners when appropriate, soaking in warm Sitz baths 3-4 times daily, increasing dietary fiber, and using creams to alleviate discomfort.

Medications such as externally applied nitroglycerin are sometimes used to increase blood flow to the fissure to promote healing and to help relax the anal sphincter. The anal sphincter is the muscle that controls the release of stool from your body. When this muscle contracts too much, stool can be hard to pass. On the other hand, when it contracts too little incontinence can result.

Nitroglycerin is generally considered the medical treatment of choice when other conservative measures fail. It is very important if prescribed NOT to touch the cream with your bare hands. Instead, use a q-tip. Touching the nitroglycerine can result in a significant drop in your blood pressure and subsequent fainting.

Surgery may be required to fix the fissure if all else fails.

How can I avoid anal fissures?
 

Avoid constipation. Increase the fiber in your diet to help bulk your stools and make them easier to pass. Drink plenty of fluids. Avoid inserting anything into your anus.

3. Proctitis

Proctitis is an inflammation of the lining of the rectum.

What causes proctitis?
 

Causes include prior radiation therapy for various cancers, such as prostate cancer, medications, bacterial or viral infections, sexually transmitted diseases (STDs) like Herpes Simplex, trauma, and Inflammatory Bowel Disease (IBD).

What are the symptoms of proctitis?
 

Symptoms include:

  1. Incomplete emptying
  2. The sensation that you can’t completely empty your bowels
  3. Increased urgency to have a bowel movement
  4. Spasms in the rectum
  5. Increased frequency of bowel movements
  6. Mucous in your stool
  7. Rectal bleeding, and
  8. Rectal pain.

What is the treatment for proctitis?
 

Treatment options are dependent on the cause.

If an infection is a cause, antibiotics like doxycycline or antiviral medications like acyclovir may be used.

When radiation is the cause, medications like sucralfate (Carafate), mesalamine (Asacol, Canasa), sulfasalazine, and metronidazole may be used to help control inflammation and reduce bleeding.

When IBD is the cause, mesalamine (Asacol, Canasa), steroids, and immunomodulators may be used. Medications can be prescribed by mouth or in the form of a suppository or enema to help control inflammation more directly.

Stool softeners, if recommended, will help to soften your stools making them easier and more comfortable to pass.

Dilation procedures may be used to open up obstructed areas, and ablation procedures may be recommended for select patients. If drug therapy isn’t effective, surgery may be necessary to remove the affected tissue.

4. Colon and Rectal Polyps
 

What are colon and rectal polyps?
 

Colon and rectal polyps are benign or noncancerous growths found inside the colon (or large intestine) and rectum, the last two parts of the digestive tract before digested food waste exits the body. Some polyps grow on a “stalk” and expand out, resembling a mushroom. Others are flat. Most are asymptomatic except for minor bleeding, which is typically unnoticed.

What are the symptoms of colon and rectal polyps?
 

Most often they do not cause any symptoms except for maybe some minor bleeding. Rarely, individuals may notice abdominal pain, iron deficiency anemia, or a change in the color of the stool as a result of minor bleeding.

If the colon and rectal polyps are benign and don’t typically cause any symptoms, why do we care so much about them?
 

Colorectal cancer often begins as a polyp, so screening for and removing polyps significantly reduces your risk for developing colorectal cancer in the future.

Will all polyps turn into cancer?
 

No. There are two main types of polyps: hyperplastic polyps and tubular adenomas.

The vast majority of polyps are benign (or “hyperplastic”); however, tubular adenomas and other less common types of polyps have the potential to turn into cancer. The majority of colorectal cancers arise from tubular adenomas. Roughly 10% of tubular adenomas if left alone will turn into colorectal cancer. The likelihood that an adenoma will become cancerous increases with size; however, we can’t predict, or be certain, which adenomas will turn into cancer just by looking at them or analyzing their size. Therefore, all polyps are removed during the colonoscopy and sent to pathology for analysis of their cellular components.

If polyps are found in your colon or rectum during a colonoscopy, current screening guidelines recommend that you be screened for colorectal cancer more often than the general population.

How common are polyps?
 

Roughly, 1 in every 4 people over the age of 60 who are screened for colorectal cancer will have a polyp, and about 1/3rd to 1/2 of all people will develop an adenoma at some point in their life.

If you have a personal history of colorectal polyps you are at increased risk for developing more in the future.

How will I know if I have colon polyps?
 

Although most polyps do not cause symptoms, some polyps can cause minor bleeding. The only way to know for sure, though, if you have colon polyps or not is to be screened with colonoscopy.

All polyps should be removed during this procedure because most colorectal cancers most commonly begin from a polyp.

5. Colorectal Cancer
 

What is colorectal cancer?
 

Colorectal Cancer is cancer that originates in the colon (or large intestine) and rectum. Colorectal cancer affects both men and women of all ages and ethnic backgrounds. Of late, a rise in colorectal cancer and colorectal cancer deaths amongst younger populations has been recognized.

How does colorectal cancer begin?
 

Most colon cancers develop from a single colon polyp over a period of several years, although some colon cancers are more aggressive and faster-growing than others.

What are the symptoms of colorectal cancer?
 

Symptoms include:

  1. A change in bowel habits
  2. The sensation of incomplete emptying (or feeling like you still have to go after you’ve evacuated your bowels)
  3. Abdominal pain, cramping or discomfort
  4. Rectal bleeding
  5. Iron deficiency anemia (especially in any male or post-menopausal woman)
  6. Back pain (especially back pain that keeps you up at night)
  7. Unexplained weight loss
  8. Fevers, chills, sweats
  9. Night sweats
  10. Generalized fatigue and/or weakness.

How is colorectal cancer treated?
 

If caught early, colorectal cancer is highly treatable with surgery, chemotherapy, radiation, or a combination of treatments.

6. Anal Cancer
 

What is anal cancer?
 

Anal cancer is cancer arising in the anus.

Anal cancer is less common than colorectal cancer but also curable when diagnosed early. Therefore it is pertinent to have ALL rectal bleeding evaluated promptly by a trained medical professional like Dr. Sinha as both colorectal cancer and anal cancer often present with rectal bleeding.

7. Solitary rectal ulcer syndrome
 

What is solitary rectal ulcer syndrome?
 

Solitary rectal ulcer syndrome occurs when a single ulcer forms in the rectum resulting in symptoms of blood, mucus, and pain.

What are the symptoms of solitary rectal ulcer syndrome?

  1. Constipation
  2. Rectal bleeding
  3. Rectal pain
  4. Straining with bowel movements
  5. Pain or fullness in the abdomen or pelvis
  6. A feeling of incomplete emptying
  7. Mucous in your stools
  8. Anal leakage or leaking mucous, and
  9. Fecal incontinence

How common is solitary rectal ulcer syndrome?
 

It is an uncommon condition affecting both men and women.

Who is at risk?
 

Individuals with a longstanding history of constipation and prolonged straining with bowel movements.

How is solitary rectal ulcer syndrome diagnosed and treated?
 

Diagnosis is typically made based on symptoms and findings discovered during anoscopy, flexible sigmoidoscopy and/or colonoscopy.

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Treatment involves avoiding constipation, using stool softeners when appropriate, and increasing dietary fiber to help bulk and soften stools making them easier to pass. For those with significant symptoms, surgery may be required. Topical steroids, sulfasalazine enemas, Botox, and even biofeedback may be used to help ease ulcer symptoms.

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