Jay W. Marks, MD, is a board-certified internist and gastroenterologist. He graduated from Yale University School of Medicine and trained in internal medicine and gastroenterology at UCLA/Cedars-Sinai Medical Center in Los Angeles.
Blood tests such as a
complete blood count (CBC) and
iron levels in the blood play no role in locating the site of gastrointestinal
bleeding; however, the CBC and blood iron levels may help to determine whether
bleeding is acute or chronic, since an anemia (low red blood cell count)
associated with iron deficiency suggests chronic bleeding over many weeks or
months. Gastrointestinal conditions commonly causing iron deficiency anemia
include colon polyps, colon cancers, colon angiodysplasias, and chronic colitis.
When a patient looses a large amount of blood suddenly, as with moderate or severe acute rectal bleeding, the lost blood is replaced by fluid from the body's tissues. This influx of fluid dilutes the blood and leads to anemia
(a reduced concentration of red blood cells). It takes time, however, for the
tissue fluid to replace the lost blood within the blood vessels. Therefore,
soon after a sudden large episode of bleeding, there may be no anemia. It
takes many hours and even a day or more for the anemia to develop as tissue
fluid slowly dilutes the blood. For this reason, a red blood cell count early
after bleeding is not reliable for estimating the severity of the bleeding.
How
is rectal bleeding treated?
Treatments for rectal bleeding include 1) correcting
the low blood volume and anemia, 2) diagnosing the cause and the location of the
bleeding, and 3) stopping active bleeding and preventing rebleeding.
Correcting low blood volume and anemia
Moderate to severe rectal bleeding can cause the
loss of enough blood to result in weakness,
low blood pressure,
dizziness, or
fainting, and even shock. Patients with these symptoms usually are hospitalized.
They need to be quickly treated with intravenous fluids and/or blood
transfusions to replace the blood that has been lost so that diagnostic tests
such as colonoscopies and angiograms can be performed safely to determine the
cause and location of the bleeding.
Patients with severe iron deficiency anemia
may need hospitalization for blood transfusions followed by prolonged treatment
with oral iron supplements (tablets). Patients with iron deficiency anemia as a result of chronic
gastrointestinal blood loss should undergo tests (such as colonoscopy) to
determine the cause of the chronic blood loss.
Unless anemia is severe,
patients with mild rectal bleeding from colon polyps, colon cancers, anal
fissures, and hemorrhoids usually do not need hospitalization. Mild anemia can
be treated with oral iron supplements while tests are performed to diagnose the
cause of bleeding.
Determining the cause and location of bleeding
Colonoscopy is
the most widely used procedure for the diagnosis and treatment of rectal
bleeding. Most colonoscopies are performed after administration of oral
laxatives to cleanse the bowel of stool, blood, and blood clots. However, in
emergency situations such as when the bleeding is severe and continuous,
a doctor may choose to perform an emergency colonoscopy without first cleansing the
large bowel. In trained and experienced hands, the risk of either elective
(delayed) or urgent colonoscopy is small. (Colon perforation, the most common
complication, is rare). The benefits usually far outweigh the potential risks.
Colonoscopy is useful for both diagnosing the cause and determining the location
of the bleeding. Locating the site of bleeding is especially important in
diverticular bleeding. Even though most diverticular bleeding stops
spontaneously without the need for surgery, patients with severe, recurrent, or
continuous diverticular bleeding may need surgery to remove the bleeding
diverticulum. Since a patient typically has numerous diverticula scattered
throughout the colon, and colonoscopy may be able to determine which diverticulum is
bleeding prior to surgery. Without an accurate knowledge of the location of the
bleeding diverticulum, the surgeon may have to perform an extensive colon
resection (which is not as desirable as removing a small section of the colon)
in order to make sure that the bleeding diverticulum is removed.
Nevertheless,
colonoscopy has limitations. During colonoscopy doctors may not find active
bleeding from a specific diverticulum. He/she may only find a colon filled with
blood along with scattered diverticula. In such situations, the diagnosis of
diverticular bleeding is assumed if no other cause for the bleeding
such as colitis or colon cancer
is found. In these situations, there is always some
uncertainty about the location of the bleeding. Small, bleeding angiodysplasias
also may be difficult to see and may be missed in a colon filled with blood.
This is when radionuclide scans and visceral angiograms may be helpful. If the
patient starts bleeding again, an urgent, tagged RBC scan followed by a visceral
angiogram may demonstrate the location of the bleeding.
Colonoscopy also cannot
positively diagnose bleeding from a Meckel's diverticulum because the
colonoscope usually cannot reach the part of the small intestine in which the
Meckel's diverticulum is located. But colonoscopy still can be helpful in
establishing the diagnosis of a bleeding Meckel's diverticulum. Thus, in a young
patient with rectal bleeding, a colonoscopy showing a blood filled colon without
another source of bleeding, particularly if accompanied by an abnormal Meckel's
scan, makes the diagnosis of Meckel's diverticulum bleeding highly likely.
Surgical resection of the Meckel's diverticulum should result in permanent cure
with no recurrence of bleeding.
Stopping bleeding and preventing rebleeding
Colonoscopy is more than just a diagnostic tool; it can also be used to stop
bleeding by removing (snaring) bleeding polyps, by cauterizing (sealing with
electrical current) bleeding angiodysplasias or postpolypectomy ulcers and,
occasionally, by cauterizing actively bleeding blood vessels inside diverticula.
Cauterization during colonoscopy is usually accomplished by inserting a long
cauterizing probe through the colonoscope. Colonoscopy
with cauterization has been used to stop bleeding in many patients with bleeding
from diverticula or angiodysplasias, thereby decreasing their need for
blood
transfusions, shortening their hospital stays, and avoiding surgery.
When
colonoscopy cannot identify the site of bleeding or is unable to stop recurrent
or continuous bleeding, visceral angiograms may be helpful. When a bleeding site
is identified by an angiogram, medications can be infused through the angiographic
catheter to constrict the bleeding blood vessel and stop the bleeding,
Microscopic coils also can be infused through the catheter to plug (embolize)
the bleeding blood vessel, thereby stopping the bleeding.
If colonoscopy and
visceral angiogram cannot stop continuous bleeding or prevent rebleeding, then
surgery becomes necessary. Ideally, the site of bleeding has been identified by
colonoscopy,
nuclear scans, or visceral angiogram, so that the surgeon can target the site of
bleeding for exploration and excision. For example, a surgeon can usually resect
a colon cancer, a bleeding polyp, or a Meckel's diverticulum with precision.
Sometimes, the exact site of bleeding cannot be established, and the surgeon
will have to perform an extensive colon resection under the presumption that a
diverticulum or angiodysplasia is the cause of the bleeding.
Mild rectal bleeding from anal fissures and hemorrhoids usually can be
treated with local measures such as sitz baths, hemorrhoidal creams, and stool
softeners. If these measures fail, several nonsurgical and surgical
treatments are available.
Abdominal pain is pain in the belly and can be acute or chronic. Causes include inflammation, distention of an organ, and loss of the blood supply to an organ. Abdominal pain can reflect a major problem with one of the organs in the abdomen such as the appendix, gallbladder, large and small intestine, pancreas, liver, colon, duodenum, and spleen.
Hemorrhoid is an enlarged vein in the walls of the anus and sometimes around the
rectum, usually caused by untreated constipation, but occasionally associated
with chronic diarrhea. If untreated, hemorrhoids can
worsen, protruding from the anus. Also known as piles.
Constipation is defined medically as fewer than three stools per week and severe constipation as less than one stool per week. Constipation usually is caused by the slow movement of stool through the colon. There are many causes of constipation including medications, poor bowel habits, low fiber diets, abuse of laxatives, hormonal disorders, and diseases primarily of other parts of the body that also affect the colon.
Diverticulitis is a condition in which diverticuli in the colon rupture. The rupture results in infection in the tissues that surround the colon. Diverticulitis symptoms include: abdominal pain, abdominal cramps, diarrhea, constipation, and bloating. Treatment methods include prescription medications, and in some cases, diverticulitis surgery.
Crohn's disease is a chronic inflammatory disease,
primarily involving the small and large intestine, but which can
affect other parts of the digestive system as well. Abdominal pain, diarrhea, vomiting, fever, and weight loss are
common symptoms.
Anemia is the condition of having less than the normal number of red blood cells or less than the normal quantity of hemoglobin in the blood. The oxygen-carrying capacity of the blood is, therefore, decreased.
Blood clots can occur in the venous and arterial vascular system. Blood clots can form in the heart, legs, arteries, veins, bladder, urinary tract and uterus. Risk factors for blood clots include high blood pressure and cholesterol, diabetes, smoking, and family history. Symptoms of a blood clot depend on the location of the clot. Some blood clots are a medical emergency. Blood clots are treated depending upon the cause of the clot. Blood clots can be prevented by lowering the risk factors for developing blood clots.
Colon cancer is a malignancy that arises from the inner lining of the colon. Most, if not all, of these cancers develop from colonic polyps. Removal of these precancerous polyps can prevent colon cancer.
Anal itching is the irritation of the skin at the exit of the rectum, known as the anus, accompanied by the desire to scratch. Causes include everything from irritating foods we eat, to certain disease and infections. Treatment options include local anesthetics, vasoconstrictors, protectants, astringents, antiseptics, keratolytics, analgesics, and corticosteroids. If condition persists, a doctor examination may be needed to identify an underlying cause.
An anal fissure is a small tear or cut in the skin lining of the anus. Pain and/or rectal bleeding during bowel movements are common symptoms of anal fissures. Treatment involves increasing liquid intake, using stool softeners and avoiding foods that may not be well-digested.
Ulcerative colitis is a chronic inflammation of the colon. Symptoms include abdominal pain, diarrhea, and rectal bleeding. Ulcerative colitis is closely related to Crohn's disease, and together they are referred to as inflammatory bowel disease. Treatment depends upon the type of ulcerative colitis diagnosed.
Stool color is generally brown. When stool color changes, often, an individual becomes concerned. The presence of the bilirubin in bile is generally responsible for stool color. Bilirubin concentration can vary bile color from light yellow to almost black in color. Changes in bilirubin can cause stool to turn green, gray, or clay-like in color. Intestinal bleeding may turn stool black, tarry, red, maroon, or smelly stool. Medication and food may also affect stool color.
Inflammation of the inner lining of the colon is referred to as colitis. Symptoms of the inflammation of the colon lining include diarrhea, pain, and blood in the stool. There are several causes of colitis including infection, ischemia of the colon, inflammatory bowel disease (Crohn's disease, Ulcerative colitis, or microscopic colitis). Treatment depends on the cause of the colitis.
A colon polyp is a benign tumor of the large intestine. Benign polyps do not invade nearby tissue or spread to other parts of the body. Benign polyps can easily be removed during colonoscopy and are not life threatening. If benign polyps are not removed from the large intestine, they can become malignant over time.
Anal cancer, cancer located at the end of the large intestine, has symptoms that include anal or rectal bleeding, anal pain or pressure, anal discharge or itching, a change in bowel movements, and/or a lump in the anal region. Treatment for anal cancer may involve radiation, chemotherapy, or surgery and depends upon the stage of the cancer, its location, whether cancer is eradicated after the first treatment, and whether the patient has HIV.
Intussusception is the telescoping (prolapse) of a portion of the intestine within another immediately adjacent portion of intestine. Intussusception affects children between the ages of 3 months and 6 years of age. The causes of intussusception is not clearly understood. Symptoms of intussusception include bilious vomiting, "currant jelly stool," and colicky abdominal pain. Intussusception is an emergency requires immediate attention.
Shigellosis is a disease caused by the Shigella bacteria. Bloody diarrhea, stomach cramps and fever are common symptoms. Mild infections usually resolve on their own. Antibiotics are used to treat more severe cases.
Nonsteroidal antiinflammatory drugs (NSAIDs) are prescribed medications for the treatment of inflammatory conditions. Examples of NSAIDs include aspirin, ibuprofen, naproxen, and more. One common side effect of NSAIDs is peptic ulcer (ulcers of the esophagus, stomach, or duodenum). Side effects, drug interactions, warnings and precautions, and patient safety information should be reviewed prior to taking NSAIDs.
Schistosomiasis (snail fever), a disease caused by parasites, causes a variety of symptoms and signs, such as cough, rash and bloody diarrhea. Praziquantel is used in the treatment of schistosomiasis.
Idiopathic means that the cause of the condition isn't known. Thrombocytopenic means there's a lower than normal number of platelets in the blood. Purpura refers to purple bruises caused by bleeding under the skin. Idiopathic thrombocytopenic purpura (ITP) is a bleeding condition in which the blood doesn't clot as it should. This is due to a low number of blood cell fragments called platelets.
Yellow fever is an infectious disease transmitted by infected mosquitoes. Side effects are rare with the yellow fever vaccine. Symptoms include fever, chills, back pain, nausea, vomiting, and headache. Treatment is aimed at relieving symptoms.
Irritable bowel syndrome (IBS) in children is a functional gastrointestinal disorder with symptoms of abdominal pain, bloating, diarrhea or constipation. The cause of IBS is unknown, however, certain foods, stress, anxiety, and depression may contribute to the symptoms of IBS. There is no cure for IBS in children; however, medications, dietary changes, and stress management may relieve symptoms.
Enterovirulent Escherichia coli (E. coli) are strains of related bacteria that have a strong propensity to cause gastrointestinal tract infections. Examples of strains include: EHEC (enterohemorrhagic E. coli), ETEC (enterotoxigenic E. coli), EPEC (enteropathogenic E. coli), EIEC (enteroinvasive E. coli), EAEC (enteroadherent E. coli), and EAggEC (enteroaggregative E. coli). Symptoms may vary depending on the strain the individual contracts. Infection is spread generally through contaminated food or drink.
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