RECTAL BLEEDING
RECTAL BLEEDING: Excerpt from Differential Diagnosis in Primary Care
This discussion considers the causes of bright red or maroon stools. (The causes of melena or black stools are the same as the causes of hematemesis; the differential diagnosis is given on page 261.) Bright-red blood may occasionally result from an upper GI lesion if there is associated diarrhea.
RECTAL BLEEDING
A list of the causes of rectal bleeding of fresh blood is best developed with the use of the mnemonic VINDICATE.
- V—Vascular prompts the recall of hemorrhoids, but one cannot forget mesenteric infarctions.
- I—Inflammation suggests perirectal abscess, anal fissure or ulcer, amebic colitis, or condyloma latum and acuminatum.
- N—Neoplasms call to mind polyps and carcinomas of the rectum and anus.
- D—Degenerative does not suggest anything in particular.
- I—Intoxication suggests pseudomembranous colitis complicating gentamicin, clindamycin, and other antibiotic therapy. Jejunal ulcers from potassium chloride tablets should be considered here.
- C—Congenital and acquired anomalies suggest fistula in ano, bleeding Meckel diverticulum, and bleeding colonic diverticula, among other congenital conditions. Intussusception would fall in this category also.
- A—Autoimmune recalls granulomatous colitis and ulcerative colitis.
- T—Trauma suggests the bleeding from any foreign body inserted into the rectum, including the male organ.
- E—Endocrine does not suggest anything other than the Zollinger–Ellison syndrome, which, because it causes ulceration of the jejunum, may be associated with maroon stools.
In disorders of the upper colon and small intestines, the blood is older and thus a maroon color is likely. In addition, the blood is mixed with the stool and may indeed be so well mixed that it will not be discovered without a test for occult blood. Other features are more prominent in bacillary dysentery and salmonellosis.
Approach to the Diagnosis
Armed with a more comprehensive list of causes of rectal bleeding, the clinician is ready to eliminate some of them as he or she asks appropriate questions during the history and performs the examination with all the causes in mind. The diagnosis may be pinned down by the presence or absence of other symptoms and signs. The principal diagnostic procedures are stool cultures, stool examination for ova and parasites, proctoscopy, barium enema, and colonoscopy.
Other Useful Tests
- CBC (infection)
- Urinalysis (systemic disease)
- Sedimentation rate (infection, granulomatous, or ulcerative colitis)
- Chemistry panel (liver disease)
- Frei test (lymphogranuloma venereum)
- Rectal biopsy (colitis, neoplasm)
- Small-bowel series (neoplasm)
- Angiogram (mesenteric thrombosis)
Book Source Details
- Book Title: Differential Diagnosis in Primary Care
- Author(s): R. Douglas Collins
- Year of Publication: 2007
- Copyright Details: Differential Diagnosis in Primary Care, Copyright © 2007 Lippincott Williams & Wilkins.
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Copyright notice for book excerpts: Copyright © 2008 Lippincott Williams & Wilkins. All rights reserved.
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