- Differentials
- Internal haemorrhoids – often bright red, separate from faeces
- Fissure
- Anal cancer – may bleed between bowel motions
- Pruritis
- Anal warts
- Prolapsed rectum/mucosa – often associated mucus
- Colorectal cancer
- Proctitis
- Colitis/ulcerative colitis/ ischaemic colitis
- Angiodysplasia – may haemorrhage
- Diverticular – may haemorrhage
- Rectal endometriosis – bleeding with menstruation
- Upper GI bleeding – melena
- Red flags
- Age > 50
- Change in bowel habit
- Weight loss
- Weakness, fatigue
- Brisk bleeding
- Constipation
- Family history of cancer
- Approach
- Quantify type/pattern/ nature of bleeding
- Associated symptoms – pain, diarrhoea, constiptaion
- lumps, urgency, tenesmus – more likely a rectal cause
- Change of bowel habit – suspect cancer of rectum or left colon
- R colon cancer more likely occult – anaemia
- Examination
- Anal inspect
- DRE
- Proctosigmoidoscopy
- If there is a benign lesion and patient <40- manage – arrange review at 6 – 8 weeks – must consider to exclude a proximal lesion with sigmoidoscopy. Do a colonoscopy if there are any bowel symptoms or if the patient is > 40
- Type of bleeding
- If bright red blood after a bowel motion or on paper – consider outlet pattern suggestive of a lesion near or in the anal canal – e.g. Haemorrhoids, fissure
- Blood is coating or mixed with the stool – consider source high in colon e.g. Polyps, IBD, cancer
- Melena – consider upper GI or proximal colon bleeding – e.g. Peptic ulcer, esophageal varices, upper GI malignancy
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