Hematochezia
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 result from a coagulation disorder, exposure to toxins, or certain diagnostic tests. Always a significant sign, hematochezia may precipitate life-threatening hypovolemia.
Emergency Actions
If the patient has severe hematochezia, check his vital signs. If you detect signs of shock, such as hypotension and tachycardia, place him 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
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.
Explore the patient’s medical history, focusing on GI and coagulation disorders. Ask about use of GI irritants, such as alcohol, aspirin, and other nonsteroidal anti-inflammatory drugs.
CULTURAL CUE:In the Chinese culture, discomfort isn’t usually displayed openly. Direct questioning and vigilant assessment skills are necessary to ensure that a Chinese patient’s quiet nature doesn’t mask signs and symptoms that may be life-threatening.
Physical assessment
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
Anal fissure
Slight hematochezia characterizes an anal fissure; 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.
Anorectal fistula
Blood, pus, mucus, and occasionally stools may drain from an anorectal fistula. Other effects include rectal pain and pruritus. If an abscess is present, the patient may have a fever.
Coagulation disorders
Patients with a coagulation disorder (such as thrombocytopenia and 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 hematochezia, especially in elderly patients. The hematochezia 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 hematochezia that may also contain mucus. The hematochezia is preceded by mild to severe abdominal cramps and may cause slight to massive blood loss. 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. Usually, a left colon tumor 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, which is typically relieved by passage of stools or flatus. Stools are grossly bloody.
Early tumor growth in the right colon may cause melena, abdominal aching, pressure, and dull cramps. As the disease progresses, the patient develops weakness and fatigue. Later, he may also experience diarrhea, anorexia, weight loss, anemia, vomiting, abdominal mass, and signs of obstruction, such as abdominal distention and abnormal bowel sounds.
Colorectal polyps
Colorectal polyps are the most common cause of intermittent hematochezia in adults younger than age 60; however, sometimes such polyps produce no symptoms. When located high in the colon, polyps may cause blood-streaked stools. The stools 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 isn’t a common sign of Crohn’s disease unless the perineum is involved. If rectal bleeding occurs, 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. A palpable mass in the colon area may be present.
Diverticulitis
Most common in elderly patients, diverticulitis 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. In addition, abdominal pain or cramps, tenesmus, fever, and nausea may occur. Signs and symptoms of dehydration may also be present.
Esophageal varices (ruptured)
When an esophageal varix ruptures (a life-threatening condition), hematochezia may range from slight rectal oozing to grossly bloody stools and may be accompanied by mild to severe hematemesis or melena. This painless but massive hemorrhage may precipitate signs of shock, such as tachycardia and hypotension. In fact, signs of shock occasionally precede overt signs of bleeding. Typically, the patient with esophageal varices has a history of chronic liver disease.
Food poisoning (staphylococcal)
The patient with staphylococcal food poisoning may have bloody diarrhea 1 to 6 hours after ingesting food toxins. Accompanying signs and symptoms include severe, cramping abdominal pain, nausea and vomiting, and prostration, all of which last a few hours.
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.
Peptic ulcer
Upper GI bleeding is a common complication in peptic ulcer. The patient may display hematochezia, hematemesis, or melena, depending on the rapidity 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. The patient typically has a history of epigastric pain that’s relieved by foods or antacids; he may also have a history of habitual use of tobacco, alcohol, or nonsteroidal anti-inflammatory drugs.
Small-intestine cancer
Small-intestine cancer occasionally produces slight hematochezia or blood-streaked stools. Its characteristic features include colicky pain and postprandial vomiting. Other common signs and symptoms include weight loss, anorexia, and fever. Palpation may reveal abdominal masses.
Ulcerative proctitis
Ulcerative proctitis typically causes an intense urge to defecate, but the patient passes only bright red blood, pus, or mucus. Other common signs and symptoms include acute constipation and tenesmus.
Other causes
Diagnostic tests
Certain procedures, especially colonoscopy, polypectomy, and proctosigmoidoscopy, may cause rectal bleeding. Bowel perforation is rare.
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.
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.
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 sample 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.
Patient counseling
Provide emotional support because hematochezia may frighten the patient. Tell the patient to report changes in bowel habits and blood in the stool to his health care provider. Show him how to perform ostomy self-care if indicated. Discuss proper bowel elimination habits and dietary recommendations and restrictions.
Pictures
Book Source Details
- Book Title: Signs & Symptoms: A 2-in-1 Reference for Nurses
- Author(s): Springhouse
- Year of Publication: 2007
- Copyright Details: Signs & Symptoms: A 2-in-1 Reference for Nurses, Copyright © 2007 Lippincott Williams & Wilkins.
Other Book Chapters Related to Gastrointestinal bleeding
Read excerpts from these other book chapters related to Gastrointestinal bleeding:
Medical Books Excerpts
- MELENA
- "Algorithmic Diagnosis of Symptoms and Signs" (2003)
- [ read ]
- Melena
- "Handbook of Signs & Symptoms (Third Edition)" (2006)
- [ read ]
- Hemorrhoids
- "Professional Guide to Diseases (Eighth Edition)" (2005)
- [ read ]
- Melena
- "Professional Guide to Signs & Symptoms (Fifth Edition)" (2006)
- [ read ]
- Rectal pain
- "Professional Guide to Signs & Symptoms (Fifth Edition)" (2006)
- [ read ]
- Rectal Bleeding
- "The 10-Minute Diagnosis Manual: Symptoms and Signs in the Time-Limited Encounter" (2000)
- [ read ]
- Hematochezia
- "Alarming Signs and Symptoms: Lippincott Manual of Nursing Practice Series" (2007)
- [ read ]
- Melena
- "Alarming Signs and Symptoms: Lippincott Manual of Nursing Practice Series" (2007)
- [ read ]
- Melena
- "Signs & Symptoms: A 2-in-1 Reference for Nurses" (2007)
- [ read ]
- Rectal pain
- "Signs & Symptoms: A 2-in-1 Reference for Nurses" (2007)
- [ read ]
- Melena
- "Nursing: Interpreting Signs and Symptoms" (2007)
- [ read ]
Copyright Details: Signs & Symptoms: A 2-in-1 Reference for Nurses, Copyright © 2008 Williams & Wilkins.
More About Causes of Gastrointestinal bleeding
» Next page: Melena (Signs & Symptoms: A 2-in-1 Reference for Nurses)
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