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Approach to minimal bright red bleeding per rectum in adults

Robert M Penner, BSc, MD, FRCPC, MSc
Sumit R Majumdar, MD, MPH
Section Editor
Mark D Aronson, MD
Deputy Editor
H Nancy Sokol, MD


Rectal passage of minimal bright red blood most commonly occurs in a chronic intermittent pattern and has also been referred to as "intermittent scant hematochezia" [1]. Although we are unaware of any standardized definition, in this review we use the term minimal bright red bleeding per rectum (BRBPR) to indicate such patient complaints as small amounts of red blood on toilet paper after wiping or a few drops of blood in the toilet bowl after defecation. Small amounts of blood on the surface of the stool is also considered minimal BRBPR, but red blood intermixed with stool is not.

Benign etiologies are common, and there are few recommendations on the appropriate evaluation of patients with minimal BRBPR. This topic reviews the evidence for evaluating such patients and makes recommendations for evaluation based on age and other risk factors for more serious etiologies of minimal BRBPR. The approach to patients who pass larger amounts of blood or blood intermixed with stool is discussed elsewhere. (See "Approach to acute lower gastrointestinal bleeding in adults".)


By self-report, minimal BRBPR occurs in approximately 15 percent of people [2-4]. The problem may be even more common in younger adults because of under-reporting to physicians [2,4,5]. This latter point was illustrated by the following:

A study of 202 community-dwelling adults ages 30 and older in Australia found that 14 percent reported seeing blood on the toilet paper and two percent reported seeing blood in the toilet bowl [2]. However, 43 percent of the people seldom or never looked at either their stool or the toilet paper, suggesting that the true frequencies are higher.

A community-based study of 1643 adults ages 20 to 64 found that 13 percent reported blood on wiping [3]. The prevalence of any rectal bleeding was significantly higher in younger people. Only 14 percent of those with any rectal bleeding had seen a physician for bowel problems in the prior year.


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Literature review current through: Apr 2016. | This topic last updated: May 30, 2014.
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  1. ASGE Standards of Practice Committee, Pasha SF, Shergill A, et al. The role of endoscopy in the patient with lower GI bleeding. Gastrointest Endosc 2014; 79:875.
  2. Dent OF, Goulston KJ, Zubrzycki J, Chapuis PH. Bowel symptoms in an apparently well population. Dis Colon Rectum 1986; 29:243.
  3. Talley NJ, Jones M. Self-reported rectal bleeding in a United States community: prevalence, risk factors, and health care seeking. Am J Gastroenterol 1998; 93:2179.
  4. Eslick GD, Kalantar JS, Talley NJ. Rectal bleeding: epidemiology, associated risk factors, and health care seeking behaviour: a population-based study. Colorectal Dis 2009; 11:921.
  5. Goulston K, Chapuis P, Dent O, Bokey L. Significance of bowel symptoms. Med J Aust 1987; 146:631.
  6. Helfand M, Marton KI, Zimmer-Gembeck MJ, Sox HC Jr. History of visible rectal bleeding in a primary care population. Initial assessment and 10-year follow-up. JAMA 1997; 277:44.
  7. Goulston KJ, Cook I, Dent OF. How important is rectal bleeding in the diagnosis of bowel cancer and polyps? Lancet 1986; 2:261.
  8. Segal WN, Greenberg PD, Rockey DC, et al. The outpatient evaluation of hematochezia. Am J Gastroenterol 1998; 93:179.
  9. Korkis AM, McDougall CJ. Rectal bleeding in patients less than 50 years of age. Dig Dis Sci 1995; 40:1520.
  10. Simmang CL, Shires GT. Diverticular disease of the colon. In: Sleisenger and Fordtran's Gastrointestinal and liver disease: pathophysiology, diagnosis, management, 7th ed, Feldman M, Friedman LS, Sleisenger MH (Eds), Saunders, Philadelphia 2002. p.2100.
  11. Speights VO, Johnson MW, Stoltenberg PH, et al. Colorectal cancer: current trends in initial clinical manifestations. South Med J 1991; 84:575.
  12. Majumdar SR, Fletcher RH, Evans AT. How does colorectal cancer present? Symptoms, duration, and clues to location. Am J Gastroenterol 1999; 94:3039.
  13. Bat L, Pines A, Rabau M, et al. Colonoscopic findings in patients with hemorrhoids, rectal bleeding and normal rectoscopy. Isr J Med Sci 1985; 21:139.
  14. Mant A, Bokey EL, Chapuis PH, et al. Rectal bleeding. Do other symptoms aid in diagnosis? Dis Colon Rectum 1989; 32:191.
  15. Graham DJ, Pritchard TJ, Bloom AD. Colonoscopy for intermittent rectal bleeding: impact on patient management. J Surg Res 1993; 54:136.
  16. Wong RF, Khosla R, Moore JH, Kuwada SK. Consider colonoscopy for young patients with hematochezia. J Fam Pract 2004; 53:879.
  17. Alonso-Coello P, Wong RF, Kuwada SK. Other strategies for evaluating rectal bleeding in younger patients. J Fam Pract 2005; 54:688.
  18. du Toit J, Hamilton W, Barraclough K. Risk in primary care of colorectal cancer from new onset rectal bleeding: 10 year prospective study. BMJ 2006; 333:69.
  19. Winawer S, Fletcher R, Rex D, et al. Colorectal cancer screening and surveillance: clinical guidelines and rationale-Update based on new evidence. Gastroenterology 2003; 124:544.
  20. Mitka M. Colon cancer screening guidelines stress initial test's importance. JAMA 2003; 289:1089.
  21. Fine KD, Nelson AC, Ellington RT, Mossburg A. Comparison of the color of fecal blood with the anatomical location of gastrointestinal bleeding lesions: potential misdiagnosis using only flexible sigmoidoscopy for bright red blood per rectum. Am J Gastroenterol 1999; 94:3202.
  22. Zuckerman GR, Trellis DR, Sherman TM, Clouse RE. An objective measure of stool color for differentiating upper from lower gastrointestinal bleeding. Dig Dis Sci 1995; 40:1614.
  23. Church JM. Analysis of the colonoscopic findings in patients with rectal bleeding according to the pattern of their presenting symptoms. Dis Colon Rectum 1991; 34:391.
  24. Kinney TP, Kozarek RA, Ylvisaker JT, et al. Endoscopic evaluation and treatment of rectal hemorrhage after prostate biopsy. Gastrointest Endosc 2001; 53:117.
  25. Van Rosendaal GM, Sutherland LR, Verhoef MJ, et al. Defining the role of fiberoptic sigmoidoscopy in the investigation of patients presenting with bright red rectal bleeding. Am J Gastroenterol 2000; 95:1184.
  26. Teshima T, Hanks GE, Hanlon AL, et al. Rectal bleeding after conformal 3D treatment of prostate cancer: time to occurrence, response to treatment and duration of morbidity. Int J Radiat Oncol Biol Phys 1997; 39:77.
  27. Swarbrick ET, Fevre DI, Hunt RH, et al. Colonoscopy for unexplained rectal bleeding. Br Med J 1978; 2:1685.
  28. Acosta JA, Fournier TK, Knutson CO, Ragland JJ. Colonoscopic evaluation of rectal bleeding in young adults. Am Surg 1994; 60:903.
  29. Eckardt VF, Schmitt T, Kanzler G, et al. Does scant hematochezia necessitate the performance of total colonoscopy? Endoscopy 2002; 34:599.
  30. Richter JM, Christensen MR, Kaplan LM, Nishioka NS. Effectiveness of current technology in the diagnosis and management of lower gastrointestinal hemorrhage. Gastrointest Endosc 1995; 41:93.
  31. Gonvers JJ, De Bosset V, Froehlich F, et al. 8. Appropriateness of colonoscopy: hematochezia. Endoscopy 1999; 31:631.
  32. Imperiale TF, Wagner DR, Lin CY, et al. Results of screening colonoscopy among persons 40 to 49 years of age. N Engl J Med 2002; 346:1781.
  33. Mandel JS, Bond JH, Church TR, et al. Reducing mortality from colorectal cancer by screening for fecal occult blood. Minnesota Colon Cancer Control Study. N Engl J Med 1993; 328:1365.
  34. Hardcastle JD, Chamberlain JO, Robinson MH, et al. Randomised controlled trial of faecal-occult-blood screening for colorectal cancer. Lancet 1996; 348:1472.
  35. Kronborg O, Fenger C, Olsen J, et al. Randomised study of screening for colorectal cancer with faecal-occult-blood test. Lancet 1996; 348:1467.