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 also result from a coagulation disorder, exposure to toxins, or certain diagnostic tests. Always a significant sign, hematochezia may precipitate life-threatening hypovolemia.
Act Now: 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 an NG tube. Iced lavage may be indicated to control bleeding. Endoscopy may be necessary to detect the source of the bleeding.
Assessment
History
If the hematochezia isn’t immediately life-threatening, ask the patient to fully describe the amount, color, and consistency of the 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 use of GI irritants, such as alcohol, aspirin, and other NSAIDs.
Physical examination
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 any rectal masses or hemorrhoids.
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.
Medical causes
Amyloidosis
Hematochezia occasionally occurs when amyloidosis 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 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.
Angiodysplastic lesions
Most common in elderly patients, angiodysplastic lesions of the ascending colon typically cause chronic, bright red rectal bleeding. Occasionally, this painless hematochezia 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 anorectal fistula. Other effects include rectal pain and pruritus.
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 bloody diarrhea, 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 bloody diarrhea 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. Abdominal pain or cramps, tenesmus, fever, and nausea may also occur.
Esophageal varices (ruptured)
Ruptured esophageal varices is a life-threatening disorder, in which 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 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 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.
Leptospirosis
The severe form of leptospirosis — 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 and severe thigh and lumbar myalgia that may be accompanied by cutaneous hyperesthesia. Conjunctival suffusion is indicative. 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 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 NSAIDs.
Rectal melanoma (malignant)
Rectal melanoma is a rare form of rectal cancer that typically causes recurrent rectal bleeding that arises from a painless, asymptomatic mass.
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.
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 mental dullness, marked abdominal distention, diarrhea, significant weight loss, and profound fatigue. Among earlier signs and symptoms are pathognomonic rose spots, headache, chills, fever, constipation, dry cough, conjunctivitis, and epistaxis.
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.
Nursing 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 sample to the laboratory to check for parasites.
Patient teaching
Provide information to the patient on signs and symptoms to report immediately. Teach the patient about ostomy self-care and consult the ostomy nurse or a home health care nurse to provide support to the patient upon discharge from the facility, as appropriate. Discuss proper bowel elimination habits. Explain dietary recommendations and restrictions.
Book Source Details
- Book Title: Alarming Signs and Symptoms: Lippincott Manual of Nursing Practice Series
- Author(s): Springhouse
- Year of Publication: 2007
- Copyright Details: Alarming Signs and Symptoms: Lippincott Manual of Nursing Practice Series, Copyright © 2007 Lippincott Williams & Wilkins.
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Copyright Details: Alarming Signs and Symptoms: Lippincott Manual of Nursing Practice Series, Copyright © 2008 Williams & Wilkins.
More About Causes of Stool color
» Next page: Melena (Alarming Signs and Symptoms: Lippincott Manual of Nursing Practice Series)
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