Hematochezia: Description, Causes and Risk Factors:Hematochezia refers to the passing of blood from the anus mixed with stools or sometimes blood clots. Bloody stools are often signs of any injury or disorder present in the GI tract.Causes:Rectal hemorrhoids & anal fissures are the most common causes of hematochezia. Bleeding from ulceration on a segment of prolapsed rectal mucosa is more likely to provoke medical consultation.
Anorectal conditions account for about 8% in series of patients presenting with hematochezia. It is axiomatic that finding one of these obvious lesions does not preclude the presence of a coexisting, more proximal & more serious lesion.
Diverticulosis is the most common lower GI cause of hematochezia in adults & is progressively more likely with age. Although melena may occasionally occur it is not characteristic, nor is occult bleeding.
Neoplasia: Benign & malignant colon polyps as well as sessile & "apple-core" malignancies are increasingly prevalent in elderly patients but also occur as early as the 3rd or 4th decade in genetically predisposed patients. Although they are usually discovered by screening colonoscopy or present with mild intermittent or occult bleeding, they occasionally present with gross hemorrhage.
Angiodysplasia is probably the next most frequently seen lower GI cause of hematochezia. Two thirds of these patients are over 70 years of age, are more male than female & associated with the presence of aortic valvular stenosis (AVS).
Inflammatory Bowel Disease (IBD): The peak incidence of IBD is bimodal, the 1st peak occurring in the early 20's & the 2nd around age 70. Ulcerative colitis (UC) is much more likely to present with hematochezia than is Crohn's disease (CD). Fifteen percent present with UC catastrophic onset; 1% with massive hematochezia.
Ischemic colitis is a very common cause of hematochezia in the elderly. It is not caused by large artery occlusion but by impaired mucosal perfusion in "watershed areas" between the distributions of major vascular territories. Hence, the most frequent bleeding sites are the splenic flexure, the descending or sigmoid colon. Presentation is usually with cramping left-sided abdominal pain followed within 24 hours by hematochezia. Flat plate of the abdomen may show a classical "thumbprints" in the image of the colonic mucosa at the site of the involved segment.
Infectious colitis caused by Campylobacter jejuni, Shigella or Salmonella species, pathogenic E. coli, Clostridium difficile or E. coli 0157:H7 may cause bloody diarrhea. Blood loss is rarely significant.
Fecal Impaction has been reported as a cause of clinically significant hematochezia, usually occurring as a result of manual disimpaction.
Rectal or colonic varices, usually caused by portal hypertension (termed "portal colonopathy") may occasionally cause recurrent hematochezia.
Intussusception of the small bowel or colon is an infrequent cause of hematochezia. Aortoenteric fistula has been described as a cause of hematochezia in adults.
A total of 103 outpatients (? 45 yr) with hematochezia underwent anoscopy and colonoscopy. Before endoscopy, patients completed a detailed interview, quantitating the amount and frequency of bleeding, weight loss, use of any drugs, change in bowel habits, family history, and prior GI illnesses. Based on this information, physicians were asked to predict whether the bleeding was from a perianal or more proximal site. At colonoscopy, pathology was stratified as either proximal or distal to the sigmoid/descending junction. Substantial pathology was defined as one or more adenomas > 8 mm, carcinoma, or colitis. Anoscopy demonstrated internal and external hemorrhoids in 78 and 29 patients, respectively. On colonoscopy, 36 patients had 43 substantial lesions. Thirty-seven of these lesions were distal to the junction of the descending and sigmoid colons and 6 were proximal lesions. Four patients had cancer; all were distal lesions. Patients with substantial lesions were more likely to give a history of blood mixed within their stool (p = 0.03), to have more episodes of hematochezia per month (p = 0.008), and to have a significantly shorter duration of bleeding before medical evaluation (p = 0.02) than did patients without such lesions. However, the physician's clinical assessment did not predict reliably which patients were likely to have substantial pathology. Conclusions: In patients with hematochezia, clinicians were unable to distinguish between those patients with and those without significant colonic lesions by history alone. Flexible sigmoidoscopy would have demonstrated most (95%) substantial lesions. The lesions that flexible sigmoidoscopy missed were an unlikely cause of bleeding in this small group of patients.Symptoms:General symptoms may include:Abdominal cramping.
Diagnosis:If hematochezia is not immediately life-threatening, ask the patient to fully describe the amount, color, and consistency of his bloody stool. How long have the stools been bloody? Does the amount of blood seem to vary? Ask about other signs and symptoms. Next, explore the patient's medical history, focusing on GI and coagulation disorder. Ask about the use of GI irritants such as alcohol, smoking, or any drug use. Begin physical examination by checking for orthostatic hypotension an early sign of shock. Take the patient's blood pressure and pulse while he/she is lying down, sitting, and standing. Examine the skin for petechiae or spider angiomas. Then perform a GI assessment, checking for abdominal tenderness, pain, or masses. While palpating the patient's abdomen, check for lymphadenopathy. Finally, a digital examination must be done to rule out rectal masses or hemorrhoids. Having a sigmoidoscopy or colonoscopy would also help them to further see abnormalities like polyps in the colon and sigmoid area which can be indicative of cancer.Laboratory Tests: Blood samples will be taken and a small piece of the stool specimen should also be submitted for evaluation. An example of stool test is the fecal occult blood. According to experts, submitting for a fecal occult blood test every 1 or 2 years should be done to decrease the incidence of colorectal cancer.Treatment:The treatment is based on the cause. If the hematochezia is caused by hemorrhoids, there are home remedies that can be done like doing a hot sitz bath and some dietary changes. Patients with hemorrhoids should increase their fluid intake and take foods high in fiber to avoid constipation and much straining which can cause pain. They should also refrain from sitting too long in the comfort room because it adds pressure on the site. Doctors would also recommend some over-the-counter creams, ointment and suppositories which will relieve the pain and discomfort caused by hemorrhoids.For patients with diverticulitis, medications to alleviate the abdominal spasm like hyoscyamine, diclomine as well as antibiotics like ciprofloxacin, metonidazole, cephalexin and others. But for further treatment, surgery is needed especially when medications would not work. The bleeding diverticula will be removed to stop the bleeding.For patients diagnosed with colorectal cancer, the treatment would depend on the staging on the cancer. If the detection is early and there is no metastasis, prognosis is good. But if the condition is worse, then palliative treatment would be given. Chemotherapy is still done to reduce the likelihood of metastasis of the cancer cells. Sometimes, surgery is done but it is only for palliative treatment to remove the polyps in the colon or in the rectal area. This can be done through colonoscopy or by the abdominoperineal excision. Cancer patients would also need to modify their lifestyle. They need to modify their diet and avoid high caloric foods and meaty products. Also, they need to stop smoking, avoid alcoholic beverages and instead take the recommended amount of fiber.NOTE: The above information is educational purpose. The information provided herein should not be used during any medical emergency or for the diagnosis or treatment of any medical condition.DISCLAIMER: This information should not substitute for seeking responsible, professional medical care.
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