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].
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- 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