Haematochezia
Overview
Haematochezia refers to the symptom of right red per-rectal blood. This is often a distressing symptom that may herald a lower GI bleed or a massive upper GI bleed.
Aetiology
Causes of Haematochezia
Lower GI Bleed
- Inflammation - inflammatory bowel disease, diverticular disease, infectious colitis, ischaemic colitis
- Mass - carcinoma, polyp
- Anorectal disorders - haemorrhoids, fissure in ano, fistula in ano, perianal ulcer, anal SCC
- Arteriovenous malformation
- Trauma
Massive Upper GI Bleed
- Variceal bleed
- Peptic ulceration
History of Presenting Complaint
Blood
Whether the blood is in the stool, in the toilet bowl or on toilet paper; whether it is frank red blood or clots.- Blood on toilet paper onlyMore likely to be anorectal e.g. haemorrhoids, fissure
- Blood in the stoolMore likely to represent colorectal disease
- Blood in the toilet bowlSuggestive of high volume bleed
- Heavy bleedingSuggestive of diverticular bleed or AV malformation
- Minor bleedingSuggestive of haemorrhoids, polyp or cancer
Onset
- Under what circumstances the bleeding began.
Timing
- How long the patient has noticed the blood for.
Associated Symptoms
Whether the PR blood is associated with any other symptoms.- Lower Abdominal PainSuggestive of colitis of any cause
- Weight lossSuggestive of colorectal cancer
- FeversSuggestive of infectious or inflammatory cause
- DiarrhoeaSuggestive of inflammatory cause, e.g. infection, inflammation, ischaemia or tumour
- Presyncope or syncopeRed flag for hypovolaemia
- HaematemesisSuggestive of massive upper GI bleed
- Perianal massPotential haemorrhoids, abscess or anal SCC
- Sharp anorectal pain on passing stoolsSuggestive of anal fissure
Severity
- Number of bloody stools or amount of blood passed.
Extra Credit
Rare Causes of Gastrointestinal Bleeding
- Cameron lesions: linear erosions / ulcerations found at the subdiaphragmatic end of a hiatus hernia
- Dieulafoy leisons: congenitally superficial arteries within the mucosa / submucosa that erode and bleed with minor trauma
- Cancer of the small intestine
- Varices - small intestine, colon, rectum, peristomal, gallbladder, bile duct, pancreasPortal hypertension
- Haemosuccus pancreaticus: bleeding from the pancreas into the ampulla of VaterPancreatitis, malignancy, trauma, arteriovenous malformation
- Haemobilia: bleeding from the biliary systemIatrogenic, trauma, malignancy, hepatic abscess / cyst, arteriovenous malformation
- Aortoenteric fistula
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