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Hematochezia [Rectal bleeding]

The passage of bloody stools, also known as hematochezia, usually indicates—and may be the first sign of—GI bleeding below the ligament of Treitz. However, this sign—usually preceded by hematemesis—may also accompany rapid hemorrhage of 1 L or more from the upper GI tract.

Hematochezia ranges from formed, blood-streaked stools to liquid, bloody stools that may be bright red, dark mahogany, or maroon in color. This sign usually develops abruptly and is heralded by abdominal pain.

Although hematochezia is commonly associated with GI disorders, it may also result from a coagulation disorder, exposure to toxins, or certain diagnostic tests. Always a significant sign, hematochezia may precipitate life-threatening hypovolemia.

Emergency interventions

If the patient has severe hematochezia, check his vital signs. If you detect signs of shock, such as hypotension and tachycardia, place the patient in a supine position and elevate his feet 20 to 30 degrees. Prepare to administer oxygen, and start a large-bore I.V. line for emergency fluid replacement. Next, obtain a blood sample for typing and crossmatching, hemoglobin level, and hematocrit. Insert a nasogastric tube. Iced lavage may be indicated to control bleeding. Endoscopy may be necessary to detect the source of the bleeding.

History and physical examination

If the hematochezia isn’t immediately life-threatening, ask the patient to fully describe the amount, color, and consistency of his bloody stools. (If possible, also inspect and characterize the stools yourself.) How long have the stools been bloody? Do they always look the same, or does the amount of blood seem to vary? Ask about associated signs and symptoms.

Next, explore the patient’s medical history, focusing on GI and coagulation disorders. Ask about the use of GI irritants, such as alcohol, aspirin, and other nonsteroidal anti-inflammatory drugs.

Begin the physical examination by checking for orthostatic hypotension, an early sign of shock. Take the patient’s blood pressure and pulse while he’s lying down, sitting, and standing. If systolic pressure decreases by 10 mm Hg or more, or pulse rate increases by 10 beats/minute or more when he changes position, suspect volume depletion and impending shock.

Examine the skin for petechiae or spider angiomas. Palpate the abdomen for tenderness, pain, or masses. Also, note lymphadenopathy. Finally, a digital rectal examination must be done to rule out rectal masses or hemorrhoids.

Medical causes

Amyloidosis

Hematochezia occasionally occurs when this disorder affects the GI tract. Massive, rapid hematochezia may precipitate signs of shock, such as hypotension and tachycardia. Associated signs and symptoms include hypoactive or absent bowel sounds, abdominal pain, malabsorption, diarrhea, and renal disease. The patient may also have a stiff, enlarged tongue, resulting in dysarthria.

Anal fissure

Slight hematochezia characterizes this disorder; blood may streak the stools or appear on toilet tissue. Accompanying hematochezia is severe rectal pain that may make the patient reluctant to defecate, thereby causing constipation.

Angiodysplastic lesions

Most common in elderly patients, these arteriovenous lesions of the ascending colon typically cause chronic, bright red rectal bleeding. Occasionally, they may result in life-threatening blood loss and signs of shock, such as tachycardia and hypotension.

Anorectal fistula

Blood, pus, mucus, and occasionally stools may drain from this type of fistula. Other effects include rectal pain and pruritus.

Coagulation disorders

Patients with a coagulation disorder (such as thrombocytopenia or disseminated intravascular coagulation) may experience GI bleeding marked by moderate to severe hematochezia. Bleeding may also occur in other body systems, producing such signs as epistaxis and purpura. Associated findings vary with the specific coagulation disorder.

Colitis

Ischemic colitis commonly causes bloody diarrhea, especially in elderly patients. Rectal bleeding may be slight or massive and is usually accompanied by severe, cramping lower abdominal pain and hypotension. Other effects include abdominal tenderness, distention, and absent bowel sounds. Severe colitis may cause life-threatening hypovolemic shock and peritonitis.

Ulcerative colitis typically causes bloody diarrhea that may also contain mucus. Blood loss may be slight or massive and is preceded by mild to severe abdominal cramps. Associated signs and symptoms include fever, tenesmus, anorexia, nausea, vomiting, hyperactive bowel sounds and, occasionally, tachycardia. Weight loss and weakness occur late.

Colon cancer

Bright red rectal bleeding with or without pain is a telling sign, especially in cancer of the left colon. This type of tumor usually causes early signs of obstruction, such as rectal pressure, bleeding, and intermittent fullness or cramping. As the disease progresses, the patient also develops obstipation, diarrhea or ribbon-shaped stools, and pain that’s typically relieved by passage of stools or flatus. Stools are grossly bloody.

Cancer of the right colon may initially cause melena and abdominal aching, pressure, and dull cramps. As the disease progresses, the patient may also experience diarrhea, anorexia, weight loss, anemia, weakness and fatigue, vomiting, an abdominal mass, and signs of obstruction, such as abdominal distention and abnormal bowel sounds.

Colorectal polyps

These polyps are the most common cause of intermittent hematochezia in adults younger than age 60, but they don’t always produce symptoms. When located high in the colon, polyps may cause blood-streaked stools that yield a positive response when tested with guaiac. If the polyps are located closer to the rectum, they may bleed freely.

Crohn’s disease

Hematochezia is not a common sign of this disorder unless the perineum is involved. If rectal bleeding does occur, it’s likely to be massive. The chief clinical features of Crohn’s disease include fever, abdominal distention and pain with guarding, diarrhea, hyperactive bowel sounds, anorexia, nausea, and fatigue. Palpation may reveal a mass in the colon.

Diverticulitis

Most common in elderly patients, this disorder can suddenly cause mild to moderate rectal bleeding after the patient feels the urge to defecate. The bleeding may end abruptly or may progress to life-threatening blood loss with signs of shock. Associated signs and symptoms may include left-lower-quadrant pain that’s relieved by defecation, alternating episodes of constipation and diarrhea, anorexia, nausea and vomiting, rebound tenderness, and a distended tympanic abdomen.

Dysentery

Bloody diarrhea is common in infection with Shigella, Amoeba, and Campylobacter, but rare with Salmonella. Abdominal pain or cramps, tenesmus, fever, and nausea may also occur.

Esophageal varices (ruptured)

In this life-threatening disorder, hematochezia may range from slight rectal oozing to grossly bloody stools and may be accompanied by mild to severe hematemesis or melena. Signs of shock, such as tachycardia and hypotension, may follow or occasionally precede overt signs of bleeding. Typically, the patient has a history of chronic liver disease.

Food poisoning (staphylococcal)

The patient may have bloody diarrhea 1 to 6 hours after ingesting food toxins. Accompanying signs and symptoms, which last a few hours, include severe, cramping abdominal pain, nausea and vomiting, and prostration.

Hemorrhoids

Hematochezia may accompany external hemorrhoids, which typically cause painful defecation, resulting in constipation. Less painful internal hemorrhoids usually produce more chronic bleeding with bowel movements, which may eventually lead to signs of anemia, such as weakness and fatigue.

Leptospirosis

The severe form of this infection—Weil’s syndrome—produces hematochezia or melena along with other signs of bleeding, such as epistaxis and hemoptysis. The bleeding is typically preceded by a sudden frontal headache, severe thigh and lumbar myalgia, cutaneous hyperesthesia, and conjunctival suffusion. Bleeding is followed by chills, a rapidly rising fever, and perhaps nausea and vomiting. Fever, headache, and myalgia usually intensify and persist for weeks. Other findings may include right-upper-quadrant tenderness, hepatomegaly, and jaundice.

Peptic ulcer

Upper GI bleeding is a common complication in this disorder. The patient may display hematochezia, hematemesis, or melena, depending on the intensity and amount of bleeding. If the peptic ulcer penetrates an artery or vein, massive bleeding may precipitate signs of shock, such as hypotension and tachycardia. Other findings may include chills, fever, nausea and vomiting, and signs of dehydration, such as dry mucous membranes, poor skin turgor, and thirst. Most patients have a history of epigastric pain that’s relieved by foods or antacids; some also have a history of habitual use of tobacco, alcohol, or nonsteroidal anti-inflammatory drugs.

Rectal melanoma (malignant)

This rare form of rectal cancer typically causes recurrent rectal bleeding that arises from a painless, asymptomatic mass.

Small-intestine cancer

This disorder occasionally produces slight hematochezia or blood-streaked stools. Its characteristic features include colicky pain and postprandial vomiting. Other common signs and symptoms include anorexia, weight loss, and fever. Palpation may reveal abdominal masses.

Typhoid fever

About 10% of patients with typhoid fever develop hematochezia, which is occasionally massive. However, melena is more common. Both signs of bleeding occur late and may be accompanied by marked abdominal distention, diarrhea, significant weight loss, mental dullness, and profound fatigue. Earlier signs and symptoms are pathognomonic rose spots, headache, chills, fever, constipation, dry cough, conjunctivitis, and epistaxis.

Ulcerative proctitis

In this disorder, the patient typically has an intense urge to defecate but passes only bright red blood, pus, or mucus. Other common findings include acute constipation and tenesmus.

Other causes

Heavy metal poisoning

Bloody diarrhea is accompanied by cramping abdominal pain, nausea, and vomiting. Other signs may include tachycardia, hypotension, seizures, paresthesia, depressed or absent deep tendon reflexes, and an altered level of consciousness.

Tests

Certain procedures, especially colonoscopy, polypectomy, and proctosigmoidoscopy, may cause rectal bleeding. Bowel perforation is rare.

Special considerations

Place the patient on bed rest and check his vital signs frequently, watching for signs of shock, such as hypotension, tachycardia, weak pulse, and tachypnea. Monitor the patient’s intake and output hourly. Remember to provide emotional support because hematochezia may frighten the patient.

Prepare the patient for blood tests and GI procedures, such as endoscopy and GI X-rays. Visually examine the patient’s stools and test them for occult blood. If necessary, send a stool specimen to the laboratory to check for parasites.

Pediatric pointers

Hematochezia is much less common in children than in adults. It may result from structural disorders, such as intussusception and Meckel’s diverticulum, and from inflammatory disorders, such as peptic ulcer disease and ulcerative colitis.

In children, ulcerative colitis typically produces chronic, rather than acute, signs and symptoms and may also cause slow growth and maturation related to malnutrition. Suspect sexual abuse in all cases of rectal bleeding in children.

Geriatric pointers

Because older people have an increased risk of colon cancer, hematochezia should be evaluated with colonoscopy after perirectal lesions have been ruled out as the cause of bleeding.

Book Source Details

• Book Title: Professional Guide to Signs & Symptoms (Fifth Edition)
• Author(s): Springhouse
• Year of Publication: 2006
• Copyright Details: Professional Guide to Signs & Symptoms (Fifth Edition), Copyright © 2006 Lippincott Williams & Wilkins.

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Copyright Details: Professional Guide to Signs & Symptoms (Fifth Edition), Copyright © 2008 Williams & Wilkins.

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• Back to symptom: Bloody stool: Introduction (review 352 causes)
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More About This Book: Title: Professional Guide to Signs & Symptoms (Fifth Edition) Authors: Springhouse Publisher: Lippincott Williams & Wilkins Copyright: 2006 ISBN: 1-58255-510-9

 » Next page: Diarrhea (The 10-Minute Diagnosis Manual: Symptoms and Signs in the Time-Limited Encounter)

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