Approach to minimal bright red blood per rectum in adults
- Robert M Penner, BSc, MD, FRCPC, MSc
Robert M Penner, BSc, MD, FRCPC, MSc
- Assistant Clinical Professor
- University of Alberta, Canada
- Sumit R Majumdar, MD, MPH
Sumit R Majumdar, MD, MPH
- University of Alberta Medical School, Canada
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" . The term minimal bright red blood per rectum (BRBPR) is used in this topic to indicate 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.
A history of minimal BRBPR suggests a lesion near the anal canal but must be differentiated from a history of melena (which implies upper gastrointestinal or slow proximal colonic bleeding) or maroon stool with intermixed bright red blood (which implies a proximal colonic or small intestinal source). However, patients' and clinicians' perceptions of stool color vary widely, even when assisted by a standardized color chart [2,3].
Benign etiologies of BRBPR are common and appear to account for 90 percent or more of all episodes of minimal BRBPR. The true proportion of benign etiologies may be even higher, since many young people with minimal BRBPR never present for care. However, scant rectal bleeding is also a common presenting symptom of serious diagnoses, such as colorectal cancer [4-6].
The appropriate evaluation of a patient presenting with minimal BRBPR must be guided by the risk of underlying serious pathology, and there are few available guidelines. This topic will review the evaluation of patients with BRBPR 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 bright red blood per rectum (BRBPR) occurs in approximately 15 percent of adults, and may be even more common in younger adults who may be less likely to seek medical consultation for this problem [7-9].To continue reading this article, you must log in with your personal, hospital, or group practice subscription. For more information on subscription options, click below on the option that best describes you:
- 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.
- 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.
- 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.
- 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.
- Speights VO, Johnson MW, Stoltenberg PH, et al. Colorectal cancer: current trends in initial clinical manifestations. South Med J 1991; 84:575.
- Majumdar SR, Fletcher RH, Evans AT. How does colorectal cancer present? Symptoms, duration, and clues to location. Am J Gastroenterol 1999; 94:3039.
- Dent OF, Goulston KJ, Zubrzycki J, Chapuis PH. Bowel symptoms in an apparently well population. Dis Colon Rectum 1986; 29:243.
- 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.
- Goulston K, Chapuis P, Dent O, Bokey L. Significance of bowel symptoms. Med J Aust 1987; 146:631.
- 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.
- Goulston KJ, Cook I, Dent OF. How important is rectal bleeding in the diagnosis of bowel cancer and polyps? Lancet 1986; 2:261.
- Segal WN, Greenberg PD, Rockey DC, et al. The outpatient evaluation of hematochezia. Am J Gastroenterol 1998; 93:179.
- Korkis AM, McDougall CJ. Rectal bleeding in patients less than 50 years of age. Dig Dis Sci 1995; 40:1520.
- 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.
- 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.
- Mant A, Bokey EL, Chapuis PH, et al. Rectal bleeding. Do other symptoms aid in diagnosis? Dis Colon Rectum 1989; 32:191.
- Graham DJ, Pritchard TJ, Bloom AD. Colonoscopy for intermittent rectal bleeding: impact on patient management. J Surg Res 1993; 54:136.
- 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.
- Mitka M. Colon cancer screening guidelines stress initial test's importance. JAMA 2003; 289:1089.
- Rex DK, Johnson DA, Anderson JC, et al. American College of Gastroenterology guidelines for colorectal cancer screening 2009 [corrected]. Am J Gastroenterol 2009; 104:739.
- 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.
- Kinney TP, Kozarek RA, Ylvisaker JT, et al. Endoscopic evaluation and treatment of rectal hemorrhage after prostate biopsy. Gastrointest Endosc 2001; 53:117.
- 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.
- 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.
- Swarbrick ET, Fevre DI, Hunt RH, et al. Colonoscopy for unexplained rectal bleeding. Br Med J 1978; 2:1685.
- Acosta JA, Fournier TK, Knutson CO, Ragland JJ. Colonoscopic evaluation of rectal bleeding in young adults. Am Surg 1994; 60:903.
- Eckardt VF, Schmitt T, Kanzler G, et al. Does scant hematochezia necessitate the performance of total colonoscopy? Endoscopy 2002; 34:599.
- Wong RF, Khosla R, Moore JH, Kuwada SK. Consider colonoscopy for young patients with hematochezia. J Fam Pract 2004; 53:879.
- 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.
- Gonvers JJ, De Bosset V, Froehlich F, et al. 8. Appropriateness of colonoscopy: hematochezia. Endoscopy 1999; 31:631.
- 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.
- 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.
- Hardcastle JD, Chamberlain JO, Robinson MH, et al. Randomised controlled trial of faecal-occult-blood screening for colorectal cancer. Lancet 1996; 348:1472.
- Kronborg O, Fenger C, Olsen J, et al. Randomised study of screening for colorectal cancer with faecal-occult-blood test. Lancet 1996; 348:1467.
- DIFFERENTIAL DIAGNOSIS
- CLINICAL ASSESSMENT
- Physical examination
- Laboratory testing
- Diagnostic tests
- - Sigmoidoscopy versus colonoscopy
- APPROACH TO THE PATIENT
- Red flags
- Age 50 or older
- Ages 40 to 50
- Age less than 40
- Persistent bleeding
- INFORMATION FOR PATIENTS
- SUMMARY AND RECOMMENDATIONS