Per Rectal Bleeding

(Hematochezia)

Nkechi Nweke
Anatomy
The colon extends from the cecum to the anal canal. It has an average length of 135-150 cm. Its function is to receive
digested food from the small bowel from which it absorbs water and other substances to form fecal matter.

Anatomically it is divided into the ascending, transverse, descending and sigmoid colon. The ascending and
descending segments of the colon are fixed to the retroperitoneum while the transverse and sigmoid colon are
supported by a mesentery.

Branches of the SMA supply blood to the colon (cecum, ascending and proximal transverse colon). SMV drains right
side of colon.

IMA supplies the distal transverse, descending and sigmoid colon. IMV drains the left side of the colon.

The rectosigmoid junction and rectum are supplied by a rich network of vessels from the superior, middle and inferior
hemorrhoidal vessels.

Innervation is via pelvic splanchnic nerves (parasympathetic) and lumbar splanchnic nerves (sympathetic).

Ascending and transverse colon drain lymph into the superior mesenteric nodes; descending and sigmoid drain into
the inferior mesenteric nodes. Most of the lymph from superior and inferior mesenteric nodes go into the intestinal
lymph trunks and then the cisterna chyli from where it empties into the thoracic duct.
Epidemiology
Prevalence of rectal bleeding has been estimated to be between 13 to 34% in community based studies. No significant incidence
difference was found between males and females.
Women in 18 to 39 age groups and men in 40 to 49 age group appear to have higher rates. Less than 50% of patients with rectal bleeding
seek medical treatment, mostly because they thought the bleeding would go away on its own. This group of patients are majorly above 60
years of age.

Etiology
GI bleeding is divided into upper and lower GI bleeding depending on if it originates from above of below the suspensory ligament of
the duodenum (ligament of Treitz).

Rectal bleeding is mainly due to pathology from the lower GI tract i.e small bowel beyond the duodenum, colon, rectum or anal canal.
Hematochezia can result from upper GI bleeding if the hemorrhage is so large that intestinal and gastric secretions are insufficient to
convert hemoglobin to hematin ( resulting in black tarry stool).

Other contributory factors to an acute presentation includes bleeding diatheses such as hemophilia, thrombocytopenia, vitamin K
deficiency or anticoagulant toxicity.
Pathophysiology
Anal fissures : tears in the epithelial lining of the anal canl from constipation or childbirth.

Hemorrhoids : anal cushions deteriorate or disintegrate, causing venous dilatation and prone to rupture /bleeding.

Colonic ca: mutations, genetics . Bruising of lesions.

Irritable bowel syndrome: changes in bowel movement.

Diverticulosis: outpouchings within the colon at points of weakness. Erosion and bleeding can result from trauma to vasa recta along the
luminal aspect or contraction/relaxation of surrounding muscularis propria which thins out the media.

Colonic angiodysplasia are arteriovenous malformations which are acquired and can result in bleeding.

Others…

Presentation
Presentation varies with source and etiology of bleeding.

- Fever, abdo cramps, dehydration and hematochezia may be due to infectious or idiopathic colitis in a young patient.
- Painless bleeding with minimal symptoms may se due to angiodysplasia or diverticular bleeding in an older person.
- Perianal pain, stools streaked with blood, blood drops in toilet bowl or paper may be associated with anal fissure or
hemorrhoids.
- Painless bleeding can be due to hemorrhoids.
- Colon ca may present with bleeding, iron deficiency anemia and syncope.
Physical exam
- Start with vital signs to assess hemodynamic status. Tachycardia, low BP and/or high respiratory rate may indicate hemodynamic
instability.
- Examine abdomen for pain, distension, masses, cirrhosis (hint towards rectal varices).
- Inspect perineum with pt in left lateral decubitus position for hemorrhoids, fissures, thrombosis, old blood, protruding masses.
- Inspect anus for fissures, skin tags, hemorrhoids or any other cause of bleeding.
- Do a digital rectal exam for internal hemorrhoids and masses. Check for blood on withdrawing finger.

Differentials
- Hemorrhoids
- Anal fissures
- Colon ca
- Diverticular disease
- Colon angiodysplasia
- Inflammatory bowel disease
- Endometriosis
- Colitis
- Anorectal abscess
Investigations
- Bloods: CBC, INR & PTT (to assess for bleeding tendencies). Cross match test in case transfusion
is needed.
- Endoscopy especially in patients older than 40 years of age.
- Anoscopy or rigid proctosigmoidoscope for distal bleeding.
- Colonoscopy if there is concern for proximal lower GI pathology.
- CT angio may be considered if there is large volume bleeding or if patient is not a candidate for
anesthesia (for endoscopy).
- Tagged RBC scintigraphy to localize bleeding vessels.
Treatment
3 main components of management : Initial assessment and resuscitation, localization of bleeding site and therapeutic intervention to
stop bleeding.

- High fibre diet, sitz baths, steroids, glyceryl trinitrate rectal ointment, topical LA, anti
inflammatories, rubber ligation, infrared coagulation, sclerotherapy or surgery for
hemorrhoids.
- Hemostatic resuscitation with IV fluids and vasopressors in severe cases.
- Pt in shock, continuous bleeding or high risk (requiring multiple transfusions) should be
transferred to ICU.
- Therapeutic colonoscopy.
- Endoscopic therapies.
- Surgery for - persistent and recurrent bleeding , active bleeding with persistent
hemodynamic instability, transfusion of more than 4 units of packed RBC in 24 hours with
recurrent or active bleeding.
Complications
- Pain and discomfort from thrombosed external hemorrhoids
- Ongoing bleeding may result in anemia with symptoms such as chest pain, fatigue, shortness of breath.
- Acute anal fissures may become chronic and resistant to conservative management thereby necessitating
surgery.
- Metastases from malignancies if treatment is delayed.
Prognosis
Lower GI bleeding ranges from simple hematochezia to severe hemorrhage which can
result in shock. It is associated with morbidity and mortality of about 10 - 20%.

Elderly patients and those with other significant comorbidities are at the greatest risk.
Once the bleeding site is localized, treatment options are normally straightforward and
curative.
References
1. Lower Gastrointestinal Bleeding: Practice Essentials, Background, Anatomy. (2019, August 12). Medscape.com.
https://emedicine.medscape.com/article/188478-overview
2. Oakland, K., Chadwick, G., East, J. E., Guy, R., Humphries, A., Jairath, V., McPherson, S., Metzner, M., Morris, A. J.,
Murphy, M. F., Tham, T., Uberoi, R., Veitch, A. M., Wheeler, J., Regan, C., & Hoare, J. (2019). Diagnosis and
management of acute lower gastrointestinal bleeding: guidelines from the British Society of Gastroenterology.
Gut, 68(5), 776–789. https://doi.org/10.1136/gutjnl-2018-317807
3. Rodriguez-Franco, G., Rabell-Bernal, A., Roman-Colon, D., Rodriguez-Ramos, R., & Martinez-Souss, J. (2021).
S2333 An Unusual Case of Rectal Bleeding. Official Journal of the American College of Gastroenterology | ACG,
116, S992. https://doi.org/10.14309/01.ajg.0000782864.78576.9e
4. Sabry, A. O., & Sood, T. (2021). Rectal Bleeding. PubMed; StatPearls Publishing.
https://www.ncbi.nlm.nih.gov/books/NBK563143/
5. Walsh, C. J., Delaney, S., & Rowlands, A. (2018). Rectal bleeding in general practice: new guidance on
commissioning. British Journal of General Practice, 68(676), 514–515. https://doi.org/10.3399/bjgp18x699485