Rectum Bleeding

Rectal bleeding, or bleeding from the anus, is a common problem that causes much embarrassment to the person. Bleeding through the anus is noticed as red spot/s on the toilet tissue paper or as red colored water in the toilet bowl.

It is usually assumed that blood comes from the rectum, the part just above the anus, and hence the name rectal bleeding. The color of blood in rectal bleeding may range from bright red to maroon or tarry color.

The severity of bleeding may vary from person to person. Mild rectal bleeding is characterized by few drops or spots on the toilet tissue. This may resolve on its own without any specific treatment. In moderate rectal bleeding, the frequency and amount of blood loss are more when compared to mild rectal bleeding.

The blood may be darker in color and is often mixed with stool. In severe form of rectal bleeding large quantities of blood is lost in bleeding. The frequency of bowel movement also increases, and each time the quantity of blood loss is more.

Loss of blood associated with moderate to severe form of rectal bleeding leads to other symptoms like weakness, dizziness, fainting, and low blood pressure.

It may lead to orthostatic hypotension, a condition characterized by a sudden drop in blood pressure when a person changes position from sitting to lying. Severe loss of blood due to rectal bleeding may require hospitalization for treatment. 

Blood lost through anus may originate from any part of the gastrointestinal system, and the color of blood indicates the origin of bleeding. The color of blood is bright red when the bleeding occurs from rectum or anus. The blood may or may not be mixed with stools.

The red spots may be noticed in the toilet paper after the passing of stools. When bleeding starts from the colon, it is mixed with the stool and is dark red in color. In some rare cases, blood may not be mixed with the feces.

When the origin of blood is from small intestine or stomach, the blood is dark in color. It changes the color of feces to black or dark maroon color. This is a serious condition and requires immediate medical attention.

Rectal bleeding is caused by multiple factors, this includes: 

• Anal fissures
• Hemorrhoids
• Diverticula
• Crohn’s disease
• Ulcerative colitis
• Polyps
• Cancer
• Angiodysplasia
• Stomach ulcers
• Infections of gut

Other abnormalities in the gut may also lead to bleeding through the anus. Diagnosis of the underlying cause of bleeding is based on the suspected condition. Review of medical history is done before the physical examination to evaluate the possible causes of bleeding.

Commonly suggested techniques are sigmoidoscopy, colonoscopy, and CT colonography. In some rare cases, bleeding may not be visible to naked eye. A fecal occult blood test is done to determine the amount of blood loss in stool. This is indicated when the person has other symptoms that suggest abnormalities in the gastrointestinal system.

Treatment is also based on the suspected cause of rectal bleeding. In people with hemorrhoids, stool softeners help to ease the movement of stools without causing bleeding. Pain and bleeding can be reduced by using Sitz bath. Acid-reducing medications are suggested to treat ulcers in the gut, while antibiotics are recommended for treating inflammatory bowel disease and infections.

There are multiple etiologic factors for rectal bleeding, some of the common causes of the condition are:

Hemorrhoids – also known as piles, the hemorrhoid is characterized by swelling in anus and rectum. Bleeding due to hemorrhoids occurs after the passing of stool and is a common symptom of the condition. Other symptoms associated with piles are a discharge of mucus, pain, irritation, and itching in the anal region.

Anal fissure – anal fissure refers to a tear in the anal skin. The tear may be very small but may cause considerable pain. Bleeding due to anal fissures are usually mild and is noted after the passage of feces. Blood is bright red in color and fresh, and bleeding stops soon enough.

Diverticula – these are small pouches or projections from the walls of the gut that protrude into the cavity. It may be formed in different parts of the gastrointestinal system, but is more common in the colon. Some of these diverticula may lead to abrupt rectal bleeding. Bleeding from diverticula is usually painless, but blood loss may be severe. Another symptom of rectal bleeding due to diverticula is the change in bowel movements.

Crohn’s disease – Crohn’s disease is characterized by inflammation of the gut that leads to rectal bleeding and abdominal bleeding. The intensity of rectal bleeding is dependent on the location and severity of inflammation in the gut.

Colitis – colitis refers to inflammation of the colon that results in rectal bleeding. Both colon and rectum may become inflamed in colitis. The ulcers present in the inner wall of the colon may lead to rectal bleeding which is usually indicated by a color change in the stools.

Polyps – polyps are small growths from the inner wall of colon or rectum. It is more common among elderly people and is benign. These polyps may bleed in some cases leading to bloody stools.

Cancer – colon and rectal cancer are characterized by rectal bleeding, one of the most common symptoms of the condition. Bleeding due to cancer may not be easily visible but is associated with other symptoms. Unexplained weight loss, anemia, diarrhea, or constipation may indicate chances of cancer in colon or rectum.

Angiodysplasia – enlargement of the blood vessels in the inner lining of the colon is referred to as angiodysplasia. It often leads to rectal bleeding, and the color of feces may range from bright red to dark maroon.

Ulcers – ulcers in stomach and duodenum may lead to rectal bleeding, causing dark-colored stools.

Infections of gut – Infections in different parts of the gut lead to inflammation and bleeding through the anus.

Abnormalities of gut – twisting or volvulus and other abnormalities of the gut may lead to bleeding through the anus. Some other abnormalities that lead to rectal bleeding include:

• Intussusception – this is a condition in which one part of the gut is sucked into another.
• Meckel’s diverticulum – this is a congenital condition characterized by an extra bulge in the small intestine.
• Hirschsprung's disease – Hirschsprung's disease is characterized by inability of the bowel muscles to move feces
• Abnormal development of blood vessels – unusual development of the blood vessels may also lead to rectal bleeding.

Diagnosis of the underlying cause is aided by a review of medical history, presenting symptoms, and physical examination. Physical examination includes examination of rectum and anus. A proctoscope is a device used to evaluate the inner tissue deep inside the gut.

This method helps in the identification of hemorrhoids and anal fissures. Other tests are recommended on the basis of the probable cause of bleeding after evaluation of medical history and physical examination. Confirmatory diagnosis may be done using three common tests including sigmoidoscopy, colonoscopy, virtual colonoscopy or CT colonography.

Colonoscopy – in this procedure, a device called colonoscope is inserted into the rectum and passed to the colon. Colonoscope contains fiber optic channels that help to visualize the internal parts of colon till the meeting point of small intestine with the large intestine. The colonoscopy can also be used to collect a small sample of tissue of colon for biopsy.

Sigmoidoscopy – Sigmoidoscope is a shorter version of the colonoscope and contains a light source attached to the end. This device is used in the diagnosis of causes when the involvement of lower parts of the large intestine is suspected.

It is particularly useful in identifying the cause when rectal issues are the probable cause of the condition. The device is inserted through the anus and moved up the gut to view the inner parts of colon and rectum.

Virtual colonoscopy – in this procedure, a tube is inserted through the anus and moved up into the rectum. The tube is used to push gas into the rectum to open it up for better visualization. A CT scan of the region is then taken for analyzing the structure and function of rectum and colon.

A fecal occult blood test is used when bleeding is very less and not visible with naked eye, but other symptoms suggest a loss of blood from the gut. It detects the presence of blood cells in feces, but may not be useful in locating the origin of bleeding in the gastrointestinal system.

Imaging techniques like x-ray, CT scan, and MRI are used to visualize the inner parts and also to locate the origin of bleeding. The recommendation for a particular imaging study depends on the suspected cause of the condition.

Treatment also varies with the underlying cause of rectal bleeding. Stool softeners are used to make the movement of stool easier in people with hemorrhoids. Pain and bleeding can be reduced using Sitz bath.

Acid-reducing drugs are used in stomach ulcers that lead to bleeding through the anus. Infections are treated with antibiotics, while immunosuppressant medications are indicated in inflammatory bowel disease.

Abnormalities in vein and blockages in blood vessels are treated by surgical repair. Surgery is suggested only when the bleeding does not resolve with conventional treatment. Severe blood loss may lead to anemia, requiring a blood transfusion.

Transfusion replaces lost blood cells in the body. For benign polyps, periodic monitoring is suggested. Cancerous conditions are treated with chemotherapy, radiotherapy, or surgery.