Rectal Bleeding

Blood discharge through the anus generally alarms the patient greatly. It is caused by many pathological conditions, both benign and malignant, so it is important to know how to recognize the bleeding and associate it with the rest of the symptoms presented at the time of evaluation. First of all, I will clarify some concepts; it is not necessary to learn the names but the differences between them, since the presumptive diagnosis will depend on this: • Hematochezia: Red bleeding, fluid, no clots, mixed with stool • Melena: Black stools with a very bad smell and no visible blood. It is indicative of bleeding from the upper digestive tract because the blood has passed the digestion process. • Rectorrhagia: Bright red blood, with or without clots • Fecal occult blood: Refers to a type of bleeding that is not visible but causes symptoms of anemia. It can only be diagnosed by a stool test.

TYPE OF BLEEDING CHARACTERISTICS PROBABLE CAUSES

Hematochezia

Melena

• Stools mixed with blood • It may be abundant or just traces, but it is always mixed with feces. • Chron’s Disease • Ulcerative Colitis • Gastroenteritis • Amoebiasis • Diverticulosis

• Black stools with a very bad smell • Bleeding Peptic Ulcer • Gastric Cancer

Rectorrhagia

• Bright red blood that may contain clots. • It can be very abundant or only leave traces when wiped off. • Hemorrhoids • Anal Fissure • Anal Cancer • Colon Cancer

Fecal Occult Blood

• There is no blood evidence, only symptoms of weakness, and the blood test shows decreased hemoglobin. • Colon Cancer (85% of cases)

As you can see from the table, each of these types of bleeding offers a range of diagnoses that we should keep in mind when evaluating a patient with rectal bleeding. We will discuss below the most common cause of rectal bleeding.

a) Hemorrhoids

Hemorrhoidal bundles are veins found in the rectum. These veins are actually a normal anatomical feature that can become pathological. When blood does not flow properly through those veins, they become inflamed, and the disease begins. There are veins inside the rectum that cause internal hemorrhoids and others near the anus that form external hemorrhoids.

Hemorrhoids are not associated with cancer. It’s a completely benign condition. Internal hemorrhoids are not a big problem unless they come out through the anus, which is called hemorrhoidal prolapse. In these cases, it can become very annoying and bleed frequently. Hemorrhoidal prolapse begins inside the rectum and eventually progresses to become visible through the anus. In the next images, you can see the stages of hemorrhoidal prolapse.

WikipedianProlific and Mikael Häggström, CC BY-SA 3.0

GRADE 1

GRADE 2

Dr. Joachim Guntau, CC BY-SA 3.0

GRADE 3

GRADE 4

Dr. Joachim Guntau, CC BY-SA 3.0

Prof. Dr. A. Herold, CC BY 3.0

Dr. K.-H. Günther, CC BY 3.0

On the other hand, external hemorrhoids do cause a lot of pain and discomfort. The pain becomes intolerable for the patient, with a lot of hypersensitivity in the area where the hemorrhoid is located.

The treatment for each type of hemorrhoids is very different. While external ones can be solved with a simple outpatient procedure, internal ones eventually become surgical and must be taken care of in the operating room.

External Hemorrhoid Drainage

The problem with external hemorrhoids is that a clot is trapped inside the vein in the anal region, causing very strong pressure with pain and hypersensitivity. For this reason, the clot must be drained for the patient to be relieved. The improvement is immediate. Materials for the procedure: • Clean water/alcohol/ hydrogen peroxide • Disposable gloves • Lidocaine gel/spray • Scalpel blade #11 • Curved locking clamp (not absolutely necessary) • Gauze Technique Step 1 Prepare all the materials and an area where you will perform the procedure. Place an absorbent bedding pad or towel under the patient. The patient should lie in the fetal position (i.e., on his side with his knees toward his chest). Ideally, the hemorrhoid should be within comfortable reach.

CC BY 2.0

Step 2 Apply lidocaine gel or spray over the hemorrhoid and surrounding skin. This type of analgesia may not be as effective as the injected kind. However, if you are not experienced in injecting, I do not recommend that this be your first practice. This is a quick technique, and the patient will feel relief shortly after the procedure. Step 3 Take a good look at the area where the hemorrhoid looks most swollen, as if it were about to break. This is where you’re going to make the incision with the scalpel. For example, in the figure below, the incision would be in the area where a small black patch is visible. I would cut a little deeper until the entire tip of the blade is inserted, about 2 inches, and advance by about 1 centimeter.

The size of the incision will depend on the size of the hemorrhoid; it should be a single precise cut that covers it almost completely. Warn the person to take a deep breath. This step can be very painful. Step 4 As soon as you open the hemorrhoid, a dark purple to black material will start coming out, which is the clot inside. If you have forceps, finish pulling it out with that instrument. If not, you can finish draining it between your fingers with the gauze. Make sure all the dark content comes out. When red blood starts flowing, the clot is out. Step 5 Clean well with water, alcohol, or hydrogen peroxide, and leave gauze between the patient’s buttocks. After the procedure, the patient may bleed for a few days; this is completely normal. In my practice, I recommend using sanitary pads to avoid soiling the underwear. In addition to this, I recommend taking sitz baths with warm water and a squirt of iodopovidone at least twice a day for three days.

Dr. K.-H. Günther, CC BY 3.0

b) Anal Fissures

Anal fissures are small cuts found in the anal region. These are usually very painful, especially when evacuating. They are not easy to observe with the naked eye unless you look for them specifically. Usually, the patient squeezes the anus because it is painful, so the buttocks must be separated well in order to evaluate it. About 90% of them are in the middle of the anus (hour 12 or 6).

The main cause is constipation. The patient passes very hard or large stools so that the anal sphincter becomes too wide and the skin tears. In addition to the pain, it also causes bleeding that can only be noticed on the toilet paper when wiping.

Treatment

Although many surgeons operate on anal fissures, I worked for a year with a proctologist who taught me an excellent treatment, and I have left the anal fissure surgeries for exceptional cases. This treatment consists of preparing a cream with petroleum jelly, lidocaine cream, and two crushed tablets of Tadalafil (Cialis). Preparation In a specimen cup, add Vaseline to fill one third of the cup and then lidocaine until reaching half of the container. Crush two tablets of 20mg Cialis with a mortar and add them to the cream, stirring everything together. How it Is Applied With your index finger, take some of the cream and insert it into the anus until the first phalanx or until the nail is inside the anus. Try to apply the cream with special attention to the fissure for better analgesia. If you can’t do it, it works anyway. The cream is applied three times a day and before bowel movements for 10 days. The improvement is felt from the first day, and the fissure begins to heal between the fifth and sixth day.

How Does it Work? Cialis is a product widely known for its use in erectile dysfunction; however, it works in many other treatments as well, especially cardiovascular issues, because it helps improve circulation. In the anus, it increases blood flow, which promotes sphincter relaxation. That makes the scar more relaxed in the mucosa, and it heals properly.

c) Colorectal Cancer

Colorectal malignancy is quite common in people over 50. When a person suffers from colonic conditions such as Chron’s disease or ulcerative colitis, the risk of colorectal cancer increases. A genetic component has also been seen in families that have more than two members with diagnosed colon cancer. Depending on the location of the tumor, the symptoms are different, although they all lead to weight loss and cause changes in bowel habit, alternating between periods of diarrhea and constipation.

Symptoms

Physical Findings

Diagnosis

Treatment

Prevention RIGHT SIDE

• Pain in the right hemiabdomen • abdominal discomfort • bulging • distention • Flattened stools • rectal bleeding that may be heavy with clots • periods of constipation • feeling of not being able to fully evacuate

• A mass may be found on deep palpation in a normal rectal examination. • The mass can be felt by the rectal exam if the tumor is low enough, and traces of blood can be found on the glove.

• Stool test that reveals occult blood • Colonoscopy • CT scan • Rectoscopy • Colonoscopy • CT scan

• Surgical: Radical right hemicolectomy • Surgical: Depending on the location of the tumor, it can be left radical hemicolectomy or resection of the sigmoid or lower rectum.

LEFT SIDE

• There is now strong scientific evidence that changes in lifestyle reduce the risk of colon cancer. • Be physically active at least 4 times a week for 30 minutes, kick the tobacco and alcohol habits, and reach a healthy weight according to your body mass index.

Previously, it was thought that a high-fiber diet improved the condition of the colon and decreased the risk of suffering from this type of cancer. However, data from large multi-hospital studies have not shown a relationship between diet and risk of this condition.

d) Inflammatory Bowel Disease (IBD)

Inflammatory bowel disease is a term used to cover two autoimmune diseases that cause inflammation in the intestine: ulcerative colitis and Chron’s disease. Despite being distinct entities, they have common symptoms, such as severe diarrhea, fever, weight loss, bloating and distension, abdominal pain, and fatigue. IBD patients adapt to living with this condition as it can only be treated but not cured. Although they do not have to follow a strict diet, during crises, it is recommended to eat liquid or semi-solid food and to avoid vegetables that cause bloating.

1. Ulcerative Colitis

Ulcerative colitis is a disease that is manifested by the appearance of ulcers and bleeding patches over the entire mucosal lining of the colon and rectum. Patients with ulcerative colitis may have frequent rectal bleeding and require specialized treatment. Most patients with this type of disease know how to manage their painful crises and maintain strict treatment. If you or someone close to you is suffering from this disease and has a crisis, I recommend that you contact your doctor so that they can devise a plan of action.

2. Chron’s Disease

Chron’s disease is an inflammatory condition that can spread throughout the entire digestive tract, from the mouth to the anus. It is also capable of causing disease in other organs outside the intestine such as skin ulcers and arthritis among others.

Samir, 3 October 2006 (UTC)

The most important thing when evaluating a patient with Chron’s disease who is experiencing pain is to rule out peritoneal irritation.

If any signs of peritoneal irritation are present, it is very likely that the colon or intestine has fissured in some segment and the patient will need surgery.

Samir, CC BY-SA 3.0