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ULY CLINIC

11 Septemba 2025, 06:04:47

Hematochezia (Rectal bleeding)

Hematochezia is the passage of fresh or partially digested blood through the rectum, usually indicating lower gastrointestinal (GI) bleeding below the ligament of Treitz. However, it may also result from rapid, massive upper GI bleeding (>1 L), especially if preceded by hematemesis.

The appearance of stools ranges from bright red or maroon streaks to liquid, bloody stools. Hematochezia often develops abruptly and may be accompanied by abdominal pain. It is a significant clinical sign, as severe bleeding can precipitate life-threatening hypovolemia. Hematochezia may arise from GI disorders, coagulopathies, exposure to toxins, or certain medical procedures.

Emergency interventions

Assess vital signs immediately; monitor for hypotension, tachycardia, and signs of shock.
Place the patient supine and elevate feet 20–30° if hypotensive.
Administer oxygen and establish large-bore IV access for fluid resuscitation.
Obtain blood for typing, crossmatching, hemoglobin, hematocrit, and coagulation studies.
Consider nasogastric tube insertion and iced lavage if indicated.
Prepare for urgent endoscopy to localize and manage the source of bleeding.

History and Physical Examination

History

Duration, frequency, and quantity of rectal bleeding
Stool color, consistency, and presence of mucus or pus
Associated symptoms: abdominal pain, tenesmus, fever, nausea, vomiting
Past medical history: GI disorders, coagulation abnormalities, liver disease
Medication history: NSAIDs, anticoagulants, alcohol use
History of recent GI procedures (colonoscopy, polypectomy, proctosigmoidoscopy)

Physical examination

Assess orthostatic vital signs to detect volume depletion (systolic drop ≥10 mmHg or pulse increase ≥10 bpm)
Inspect skin for pallor, petechiae, or spider angiomas
Abdominal exam: tenderness, masses, distention, bowel sounds
Digital rectal exam: evaluate for hemorrhoids, anal fissures, or rectal masses
Examine stools directly and/or test for occult blood

Medical causes of Hematochezia

Cause	Clinical Features	Distinguishing Points
Anal Fissure	Bright red streaks on stool/toilet paper, severe rectal pain	Pain with defecation, constipation common
Angiodysplastic Lesions	Chronic, painless rectal bleeding, often in elderly	May cause life-threatening hemorrhage; ascending colon common
Coagulation Disorders	Moderate to severe bleeding, epistaxis, purpura	Lab evidence of thrombocytopenia, hemophilia, or DIC
Colitis	Bloody diarrhea with cramps, fever, tenesmus	Ischemic colitis: elderly, severe abdominal pain; Ulcerative colitis: chronic, mucus + blood
Colon Cancer	Left-sided: bright red bleeding, obstruction signs; Right-sided: melena, anemia	Progressive constipation/diarrhea, ribbon stools, weight loss
Colorectal Polyps	Intermittent hematochezia, usually asymptomatic	Bleeding may be detected via guaiac test; location affects severity
Diverticulitis	Mild to massive rectal bleeding, LLQ pain	Alternating constipation/diarrhea, rebound tenderness, tympanic abdomen
Dysentery (Shigella, Amoeba, Campylobacter)	Bloody diarrhea with abdominal cramps, tenesmus, fever	Infection often identifiable by stool culture
Esophageal Varices (Ruptured)	Massive rectal bleeding ± hematemesis	History of chronic liver disease; signs of shock may precede visible bleeding
Food Poisoning (Staphylococcal)	Bloody diarrhea 1–6 hrs post ingestion	Severe cramping, nausea, vomiting, prostration, short-lived
Hemorrhoids	Bright red bleeding, external hemorrhoids painful, internal usually painless	Chronic bleeding may lead to anemia
Leptospirosis (Weil’s Syndrome)	Hematochezia/melena, epistaxis, hemoptysis	Preceded by headache, myalgia, fever, conjunctival suffusion, jaundice
Peptic Ulcer	Hematochezia ± hematemesis, history of epigastric pain	Massive bleeding if artery involved; associated nausea, vomiting, dehydration
Ulcerative Proctitis	Bright red blood, pus, mucus, tenesmus	Intense urge to defecate with small stool volume

Other Causes

Diagnostic or therapeutic procedures: colonoscopy, polypectomy, proctosigmoidoscopy (rarely perforation)
Trauma or instrumentation

Special considerations

Bed rest and frequent monitoring of vital signs
Monitor intake and output hourly
Visual stool assessment and occult blood testing
Emotional support for patient, as visible blood can be distressing
Prepare for GI procedures (endoscopy, imaging)
Maintain hydration and replace blood if necessary

Patient counseling

Educate about warning signs: increased bleeding, dizziness, hypotension
Discuss bowel habits, dietary recommendations, and proper hygiene
Teach ostomy self-care if relevant
Advise avoiding NSAIDs, alcohol, and GI irritants

Pediatric considerations

Less common in children; may result from intussusception, Meckel’s diverticulum, inflammatory bowel disease, or peptic ulcer disease
Chronic rectal bleeding may cause growth delays and malnutrition
Consider sexual abuse in unexplained rectal bleeding

Geriatric considerations

Increased risk of colorectal cancer; colonoscopy is indicated after ruling out benign perirectal lesions
Age-related comorbidities (liver disease, coagulopathy) may worsen outcomes

References

Centers for Disease Control and Prevention. (2012). Prevalence of colorectal cancer screening among adults—Behavioral Risk Factor Surveillance System, United States, 2010. Morbidity and Mortality Weekly Report, 61, 51–56.
Zapka, J., Klabunde, C. N., Taplin, S., Yuan, G., Ransohoff, D., & Kobrin, S. (2012). Screening colonoscopy in the US: Attitudes and practices of primary care physicians. Journal of General Internal Medicine, 27, 1150–1158.
Laine, L., & Jensen, D. M. (2012). Management of patients with ulcer bleeding. American Journal of Gastroenterology, 107(3), 345–360.
Kornbluth, A., Sachar, D. B. (2010). Ulcerative colitis practice guidelines in adults: American College of Gastroenterology. American Journal of Gastroenterology, 105, 501–523.
Sarin, S. K., & Kumar, A. (2002). Diagnosis and management of variceal hemorrhage. New England Journal of Medicine, 347, 813–822.