You are on page 1of 8

Terms related to Rectal Bleeding

• • •

Blood In Stool Hematochezia Stool, Bloody

Blood in the stool can be bright red, maroon in color, black and tarry, or occult (not visible to the naked eye). Causes of blood in stool range from harmless, annoying conditions of the gastrointestinal tract such as hemorrhoids to serious conditions such as cancer. Blood in the stool should be evaluated by a healthcare professional. Rectal bleeding (known medically as hematochezia) refers to passage of bright red blood from the anus, often mixed with stool and/or blood clots. Most rectal bleeding comes from the colon, rectum, or anus. The color of the blood during rectal bleeding often depends on the location of the bleeding in the gastrointestinal tract. Generally, the closer the bleeding site is to the anus, the blood will be a brighter red. Thus, bleeding from the anus, rectum, and the sigmoid colon tend to be bright red, whereas bleeding from the transverse colon and the right colon (transverse and right colon are several feet away from the anus) tend to be dark red or maroon colored. In some patients bleeding can be black and "tarry" (sticky) and foul smelling. The black, smelly and tarry stool is called melena. Melena occurs when the blood is in the colon long enough for the bacteria in the colon to break it down into chemicals (hematin) that are black. Therefore, melena usually signifies bleeding is from the upper gastrointestinal tract (for example: bleeding from ulcers in the stomach or the duodenum or from the small intestine) because the blood usually is in the gastrointestinal tract for a longer period of time before it exits the body. Sometimes melena may occur with bleeding from the right colon. On the other hand, blood from the sigmoid colon and the rectum usually does not stay in the colon long enough for the bacteria to turn it black. Rarely, massive bleeding from the right colon, from the small intestine, or from ulcers of the stomach or duodenal can cause rapid transit of the blood through the gastrointestinal tract and result in bright red rectal bleeding. In these situations, the blood is moving through the colon so rapidly that there is not enough time for the bacteria to turn the blood black. Sometimes, bleeding from the gastrointestinal tract can be too slow to cause either rectal bleeding or melena. In these patients bleeding is occult (not visible to the naked eyes). The blood is found only by testing the stool for blood (fecal occult blood testing) in the laboratory. Occult bleeding has many of the same causes as rectal bleeding and may result in the same symptoms as rectal bleeding. It is often associated with anemia that is due to loss of iron along with the blood (iron deficiency anemia). For more information, please see the colon cancer screeningand fecal occult blood test articles.

and to treat the cause of the bleeding as definitively as possible. (3) identifying the source and potential specific causes. Technique The History in Gastrointestinal Bleeding Hematemesis. In the patient who may be bleeding profusely and need immediate treatment. tarry stools.1). Melena is the passage of black. melena. indicating the probable presence of blood. A bloody appearance is readily . melena. (2) estimating its amount and rapidity. or hematochezia. or because of symptoms of hypovolemia such as fainting or lightheadedness. like coffee grounds. and if the vomitus looked brown. usually in or with stools.Hematemesis. Confirming the Presence of Bleeding The patient having an acute gastrointestinal hemorrhage seeks a physician's help because of hematemesis. and (4) eliciting the presence of serious associated diseases that might adversely affect the outcome (Table 85. Melena. The information obtained is especially helpful in identifying situations that require aggressive management. if blood or clots were present in the emesis. Bleeding that brings the patient to the physician is a potential emergency and must be considered as such until its seriousness can be evaluated. The examiner should ask the patient if vomiting occurred. directed rather than open-ended questions are appropriate. Hematochezia is the passage of fresh blood per anus. to make a diagnosis of the bleeding site and its underlying cause. The goals in managing a major acute gastrointestinal hemorrhage are to treat hypovolemia by restoring the blood volume to normal. which may be obviously red or have an appearance similar to coffee grounds. The history should be directed toward (1) confirming the presence of bleeding. and hematochezia are symptoms of acute gastrointestinal bleeding. and Hematochezia Definition Hematemesis is the vomiting of blood.

Hemoptysis is associated with coughing and is bright. or did it look like coffee grounds?" Direct questions are the best approach to hematochezia. "What are your bowel movements like?" or "Have you experienced a change in your bowel movements?" are preferable. Very rapid upper gastrointestinal hemorrhage. to the extent allowed by the efficient use of time. melenic stools may be due to bleeding from sites as distal as the cecum. The direct question. The patient with profuse epistaxis is almost invariably aware that a nosebleed has occurred. In this situation. stomach. Make the patient understand that you mean jet black by comparing the stool color to a black object.identified as hematemesis. Melenic stools also have a stickiness that the patient often remembers. should impede the immediate treatment of hypovolemia. may cause hematochezia. "Have you observed blood in or on your stools or on the toilet paper?" and then. "Have you ever had a black or bloody stool?" A similar sequence to elicit hematemesis might be: "Have you vomited during the past year?" If the answer is yes. If this brief history suggests acute bleeding. whereas hematochezia usually has a colonic source. such as. "Are your stools black or bloody?" should be used when active bleeding may be occurring. usually from the esophagus. The usual patient seeks a physician's help for reasons other than gastrointestinal bleeding. can turn the stool black. often from an arterial site in a peptic ulcer. ask. Other substances. A melenic stool usually means upper gastrointestinal hemorrhage. After asking about bowel habits. It is important to follow with the direct question. If slow intestinal transit occurs. foamy red in color. openended questions. Nothing. or proximal duodenum. "What did it look like?" "Was it bloody?" "Was it brown. "Do you sometimes bleed from the rectum without passing stool?" Amount and Rapidity of Bleeding . such as iron or bismuth. ask. Occasionally hemoptysis or vomiting of swallowed blood from epistaxis can be confused with hematemesis. however. confirm the presence of bleeding through the testing of stool or gastric contents. but the coffee-ground appearance will not be recognized without direct questioning. Hematemesis indicates that the bleeding is from the upper gastrointestinal tract. A careful history usually resolves this confusion.

The combination of hematemesis with melena. . and duration of hematochezia should allow the examiner to determine whether the patient is having a major life-threatening hemorrhage or only acute or chronic minor bleeding. and many other serious illnesses predispose to hemorrhage gastritis. Ask about known varices or cirrhosis. resuscitation of the patient is proceeding. and the amount of blood passed with each. a source of bleeding. that bleeding is of upper gastrointestinal origin. although similar symptoms can be found in patients with peptic ulcer. the frequency. Symptoms of hypovolemia indicate that a major hemorrhage has already occurred. usually presents as minor bleeding that is important because it may have come from a rectal or colonic neoplasm. extensive central nervous system injuries. seek historical evidence for common causes such as peptic ulcer. should be pursued through questions about epigastric distress. tablespoon. and previous hepatitis. the history should be continued to determine the source and potential causes. while possibly reassuring. the relationship of symptoms to food intake. if necessary. or cup. Hematochezia. esophagitis. although it may be massive. Patients bleeding from esophagitis or esophageal ulcers usually have a long history of heartburn. Mallory–Weiss tears. Peptic ulcer. Ask the patient about the number of bloody stools passed or the times vomited. Melena strongly suggests. gastritis. Encourage an estimate in terms of common measures such as teaspoon. severe burns. also suggests a major hemorrhage. do not predict the amount or rapidity of hemorrhage yet to occur. Heavy alcohol intake. The Mallory–Weiss tear usually occurs after retching or vomiting. and is often associated with heavy alcohol ingestion. Aspirin and the nonsteroidal anti-inflammatory agents can also cause gastric mucosal injury and predipose to bleeding through their effect on platelet function. Patients with liver disease may have varices. or red hematemesis alone.While confirmation of bleeding and. and hematemesis confirms. These drugs should be removed from the patient's treatment regimen to enhance healing and prevent future episodes of gastrointestinal hemorrhage. In this situation. The physician must understand that the answers to these questions. the most common cause of gastrointestinal hemorrhage. cirrhosis with esophageal or gastric varices. and a past history of peptic ulcer disease. Direct questions regarding the frequency. Source and Potential Causes While the patient is being treated. Weight loss and anorexia suggest gastric cancer when associated with upper gastrointestinal hemorrhage. the examiner should estimate the amount and rapidity of bleeding. and malignancy. alcoholism. amount.

massive lower intestinal hemorrhage is frequently caused by a bleeding diverticulum or an arteriovenous malformation. A history suggestive of inflammatory bowel disease should be sought in all patients. Serious causes of hematochezia in the neonate include necrotizing enterocolitis and midgut volvulus. being arterial. The diagnostic accuracy of the history in gastrointestinal bleeding is sufficiently low to make appropriate tests indicated.Hematochezia usually comes from a colonic site. direct the questions at causes such as cancer. often smaller hemorrhages is more typical of an arteriovenous malformation. The maternal source of blood can be determined by checking for fetal hemoglobin. inflammatory conditions. abdominal pain. A spurious cause of bleeding during the first several days of life is vomiting of blood swallowed at birth. suggesting hemorrhoids or a rectal lesion. Diverticular bleeding. In neonates. It is helpful to know whether the blood is mixed into the stool. A history of chronic inflammatory bowel disease should also be sought. bleeding usually subsides spontaneously. With minor rectal bleeding. and hemorrhoids. or whether it merely covers the stool or is on the toilet paper. The risk of missing a serious. tends to be brisk. and systemic symptoms such as fever and weight loss. and juvenile polyps. whereas a history of repeated. although blood rapidly transported from the upper gastrointestinal tract can be red when passed. The increasing availability of nonoperative interventions such as sclerosis of varices and coagulation of bleeding lesions makes accurate diagnosis more important in management of acute massive gastrointestinal hemorrhage. Children with gastrointestinal hemorrhage merit special consideration. not present in maternal blood. Less common causes of massive colonic hemorrhage include cancer and ischemic colitis. In older patients. neoplastic polyps. Presence of Serious Associated Diseases . treatable lesion is too high to warrant dependence on the history and physical examination for diagnosis. a change in bowel habits. A wide variety of causes of hemorrhage occur as children grow older. Other symptoms that may be helpful include diarrhea. Exsanguinating hemorrhage is uncommon in children. Meckel's diverticulum. suggesting a colonic lesion. Causes relatively unique to children are intussusception.

One to two liters of blood administered orally will cause bloody or tarry stools for up to 5 days.Ask the patient about advanced malignancies and diseases of the heart. Although melena usually means upper gastrointestinal hemorrhage. hematemesis. Previous or present myocardial infarction. and their presence can alter the decision regarding early operation when bleeding continues. In one small study. a melenic stool is indicative of recent hemorrhage but does not indicate the presence or rapidity of bleeding at the time of passage. Melena. The most important complication of hemorrhage is circulatory impairment with tissue hypoxemia. Hematemesis confirms an upper gastrointestinal location of the bleeding and suggests that the hemorrhage is large. kidneys. congestive heart failure. liver. A 15% loss of blood volume is usually readily tolerated . cirrhosis. The size of the hematemesis gives a further indication of the extent of the hemorrhage. This makes the hypothesis untenable that melena is caused by the effect of gastric acid and pepsin on blood. or lungs because their presence can substantially alter therapy and affect the outcome of the patient who is bleeding rapidly. Basic Science Melena is the most common presenting symptom of major gastrointestinal hemorrhage. It takes 50 ml or more of blood in the stomach to turn stools black. A bleeding tendency may be an unappreciated adverse factor in patients with gastrointestinal hemorrhage. or duodenum. or hematochezia indicates that a potentially lethal situation may be developing. or renal failure each markedly increase the risk of a major gastrointestinal hemorrhage. Age also is an important consideration because most deaths occur in patients over 60. the small intestine and cecum should be studied if no cause for bleeding is found in the esophagus. vomiting of red blood is more ominous. chronic obstructive lung disease. An underlying defect in the blood coagulation system should also be sought. Patients must be asked about anticoagulant use. all six patients with hematemesis had lost more than a quarter of their red cell volume. the first such stool usually appearing within 4 to 20 hours after ingestion. Administration of blood into the small intestine or cecum can cause melena if the blood remains in the intestine long enough. In general. stomach. Thus. Melena usually means bleeding from this location. Correction of a clotting disorder may be important to stopping the hemorrhage. About 90% of quantitatively important gastrointestinal bleeding episodes occur from sites above the ligament of Treitz.

a treatment regimen should be planned. restore and maintain normal blood volume. embolization of bleeding vessels using angiography. As the volume depletion becomes greater. congestive heart failure. This regimen might include pharmacologic therapy to reduce gastric acidity. This is becoming increasingly important as methods using interventional endoscopy or radiology are developed to stop hemorrhage. The regimen must also provide for long-term management of the underlying disease. A history suggesting an active gastrointestinal hemorrhage should alert the physician to the immediate need for treatment of hypovolemia and shock. but varies widely with age and with the presence or absence of serious associated diseases such as renal failure. tachycardia. or cirrhosis. Rapid correction of blood volume is essential. The description of acute hemorrhage should trigger three management steps. . shunting of cardiac output from nonvital areas such as skin and bone. the site and cause of the bleeding should be established. Next. or operation. Mortality from acute upper gastrointestinal hemorrhage is between 8 and 10%. tissue hypoxemia. malignancy. Clinical Significance A convincing description of hematemesis.and compensated by contraction of large veins and recruitment of fluid from extravascular sites. and orthostatic hypotension occur. or substantial amounts of hematochezia indicates bleeding that is a potential emergency and should be handled as such until the situation can be assessed. decreasing cardiac output. constriction of arterioles. melena. lactic acidosis. First. Finally. based on diagnosis and the condition of the patient. complete loss of the ability to compensate occurs with shock. This is the most important inference to be made from the history in gastrointestinal hemorrhage. and ultimately. death. impaired flow of blood to vital organs. Older patients are less able to withstand massive hemorrhage and surgical intervention. The majority of deaths occur in patients over age 60. After 40 to 50% depletion of blood volume. The patient is likely to be thirsty and feel faint when standing. endoscopic coagulation of bleeding ulcers or sclerosis of varices.

such as analgesic use. At this point. The patient must be educated about bleeding so that early therapeutic intervention is possible during a recurrence. Passage of a nasogastric tube is a simple but often neglected method of demonstrating that bleeding is upper gastrointestinal. Optimal care requires development of a long-term treatment plan that maximizes wellness and minimizes the morbidity of the underlying disease. diagnostic tests are required to confirm the clinical impression. will stop or can be stopped in the majority of patients. Colonoscopy should be used if bleeding ceases. it becomes important to manage the underlying disease aggressively. Shunt procedures are rarely needed. but these techniques have limitations. intermittent bleeding will allow a positive test. and ulcerative colitis. Although each may be suggested by details obtained during the history. Proctoscopy will demonstrate bleeding from hemorrhoids. If the bleeding does not stop. an aggressive stance favoring early endoscopy for diagnosis in all patients makes sense.Causes of Hematochezia The causes of gastrointestinal hemorrhage are numerous. With the radioisotopic study. . Bleeding. should be avoided. Either an isotopic study. operation is usually indicated. or angiography may be helpful during active colonic hemorrhage. Active colonic bleeding is frequently from above the reach of the proctoscope and makes colonoscopy difficult by impeding the view. Acid-peptic disease should be treated to prevent recurrences by use of prolonged pharmacologic therapy. but precise localization of the site is difficult. Angiography requires active and substantial bleeding to be diagnostic. using labeled erythrocytes. although modern methods of bowel preparation have partially overcome this problem. rectal lesions. Until further controlled studies become available. esophageal varices should be obliterated by endoscopic sclerosis and the underlying liver disease treated to lower portal pressure. With the development of therapeutic endoscopic techniques. Barium studies make subsequent angiography or endoscopy difficult and should be avoided. Esophagogastroduodenoscopy is the preferred method for diagnosis of upper gastrointestinal hemorrhage. however. Precipitating causes. A negative gastric aspirate does not exclude an upper gastrointestinal source because the bleeding may have stopped or because blood from the duodenum may not be entering the stomach. Patients who have bled need attention to their long-term management as well as to the medical emergency that the hemorrhage constitutes.