Family Practice 2010; 27:260–262 Ó The Author 2010. Published by Oxford University Press. All rights reserved.

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Advance Access published on 5 March 2010

Rectal bleeding in patients with haemorrhoids.

Coincidental findings in colon and rectum
MV Koning and RJLF Loffeld*
Department of Internal Medicine, Zaans Medisch Centrum, Zaandam, The Netherlands.
*Correspondence to RJLF Loffeld, Department of Internal Medicine, Zaans Medisch Centrum, PO BOX 210, 1500
EE Zaandam, The Netherlands; Email: loffeld.r@zaansmc.nl
Received 21 September 2009; Revised 6 January 2010; Accepted 16 February 2010.

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Introduction. Rectal bleeding is a very common clinical sign. It is often caused by haemorrhoids.
However, it can be a symptom of other pathology in the rectum or colon. There are little data
coincidental pathology in patients with haemorrhoids and rectal bleeding.
Objective. To examine coincidental pathology in patients with rectal bleeding and haemor-
rhoids, especially with respect to age.
Methods. Prospectively, 290 consecutive patients presenting with bleeding and haemorrhoids
were analysed. All patients had an endoscopic examination. All significant endoscopic findings
(diverticuli, polyps, cancer, angiodysplasia and varices or colitis) were recorded.
Results. The patients were divided into two groups. Group 1 consisted of patients with only
haemorrhoids (n = 129, % male: 41.1, mean age: 53.6 ± 12.7 years). Group 2 consisted of patients
with haemorrhoids and coincidental pathology (n = 161, % male: 46.6, mean age: 67.3 ±
13.7 years). There was no difference in gender or in the type of endoscopy. However, patients
in Group 2 were significantly older.
Conclusion. It can be concluded that in cases of rectal bleeding and haemorrhoids, coincidental
pathology occurs in a large proportion of patients, especially the elderly. Omitting endoscopy in
these patients can lead to major doctors delay.
Keywords. Cancer, gastroenterology, epidemiology, diagnostic tests.

Introduction patients presenting with haemorrhoids and rectal

Rectal bleeding is a common complaint in the general
population. The exact epidemiology is not known. It is
also not known that how many individuals visit a doctor
because of this problem. The actual number of persons
seeking health care might be the top of the iceberg.1
Rectal bleeding can be a symptom of benign pathology
but also a sign for colorectal cancer.2 Haemorrhoids
are a very common cause.3–5 This observation makes it
difficult for the GP to decide when to accept haemor-
rhoids as the cause of rectal bleeding and when further
investigations are needed.6 While rectal bleeding oc-
curs more often at younger age, colorectal cancer
presents itself usually at ages >50 years.1,7 Therefore,
age is an important and commonly used discriminant
in guidelines for colorectal cancer screening. However,
haemorrhoids are also present at older age.3
Guidelines on this topic are present, although clini-
cal data are rather sparse.8 The relationship between
rectal bleeding and colorectal cancer has been
studied.7 However, the relationship between rectal
bleeding, haemorrhoids and other pathology is not
clear. For this reason, a prospective study was done in
bleeding in order to study the prevalence of other
abnormalities in the colon and rectum.
Methods
Prospectively, all consecutive patients with haemor-
rhoids and rectal bleeding, seen in a period of 5 years
at the endoscopy department of the Zaans Medisch
Centrum, the community hospital of the Zaanstreek
region in the Netherlands, were studied.
The main presenting complaint had to be overt rec-
tal bleeding or the patients own observation of blood
loss. Furthermore, the patients had to have haemor-
rhoids by own observation or detection by the GP.
After standard colon cleaning with polyethylene gly-
col solution (Klean prepÒ or MoviprepÒ), patients un-
derwent endoscopy of the colon and rectum using
Olympus Exera 160 and 180 endoscopes. The endoscopy
report was made with a customized version of the Endo-
baseä system of Olympus. All findings were recorded.
Clinical significant findings were defined as diverticuli,
colorectal cancer, polyps (adenomas, hyperplastic and

260
 Rectal bleeding in patients with haemorrhoids 261

inflammatory), inflammatory bowel disease (IBD) and
angiodysplasia.
For the sake of the study, patients were divided into
two groups; Group 1 consisted of patients with rectal
bleeding and only haemorrhoids (this is a colon and
rectum without abnormalities). Group 2 consisted of
patients with rectal bleeding, haemorrhoids and coin-
cidental findings in colon and rectum.
Statistical analysis was done with SPSS version 16.0.
All testing was two tailed and P-values of <0.05 were
considered significant. The Fisher’s exact or chi-square
testing was used to test frequencies between categori-
endoscopy of the colon and rectum (M. V. Koning and
R. J. L. F. Loffeld, submitted),12 there are no data on
the key complaint of haemorrhoids, namely bleeding.
In the present study, it was seen that with increasing
age, more coincidental pathology besides haemor-
rhoids was found. Most common coincidental pathol-
ogy is diverticuli in the colon, which occur in almost
100% of the oldest patients. IBD occurs more often in
younger patients with haemorrhoids. Colorectal
cancer was only found in patients >50 years. These
findings are in accordance with epidemiological
surveys of a general population (M. V. Koning and

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cal data. Mann–Whitney U-test was used to check for
significant differences in continuous data.
The study was approved by the local ethical com-
mittee of the Zaans Medical Centre.
R. J. L. F. Loffeld, submitted).12–16
This study shows that patients with haemorrhoids
can have other causes of bleeding. Especially, the GP
should be aware of this. Haemorrhoids can easily be
identified and thus blamed for rectal bleeding. This

Results
TABLE 1 All important coincidental findings in patients with rectal
A total of 290 patients [128 men (44.1%), 162 women bleeding and haemorrhoids per age cohort. More than one endoscopic
diagnosis can be present
(55.9%)] were seen because of rectal bleeding and hae-
morrhoids. Group 1 consisted of 129 patients [53 men
Age N Diverticuli Polyp IBD Cancer Angiody
(41.1%), 76 women (58.9%)]. Group 2 consisted of 161 (years) splasia
patients [75 men (46.6%), 86 women (53.4%)]. There was
no significant difference in gender between both groups. Total 126 50 8 5 6
Patients of Group 1 were statistical significant youn- (43.4%) (17.2%) (2.8%) (1.7%) (2.1%)
ger than patients in Group 2, 53.6 ± 12.7 versus 67.3 ± 30–39 3 2 1 1 — —
13.7 years, P < 0.001. 40–49 16 9 8 — — —
50–59 29 18 11 1 1 —
Patients in both groups underwent the same number 60–69 39 28 17 3 2 1
of colonoscopies (94.6% versus 98.8%, P = 0.08). 70–79 41 36 9 3 — 3
However, the percentage of successful caecal intuba- 80–89 28 28 3 — 1 2
tion was significantly higher in Group 2 (78.7% versus >90 5 5 1 — 1 —
<50 19 11 9 1 — —
91.8%, P < 0.001). >50 142 115 41 7 5 6
Table 1 shows all findings at endoscopy in the different
age cohorts. Figure 1 presents both groups in different Other coincidental findings were anastomosis [n = 1(0.3%)], pseu-
age categories. With increasing age, more coincidental domelanosis [3(1.0%)], lipoma [2(0.7%)] and solitary rectal ulcer
syndrome [2(0.7%)].
diagnoses were seen. Figure 2 shows this graphically.
These diagnoses are presented per age cohort.

Discussion
In recent guidelines on rectal bleeding, age is an im-
portant discriminant in diagnostic tactics.9,10 In these
guidelines, it is stated that patients over the age of
50 years are more likely to have an increases risk of
colorectal cancer. Only the Spanish guideline men-
tions that in case of haemorrhoids, these should be
treated first before performing any other investiga-
tions.11 Postponing endoscopy will cause a delay of
2 weeks, which is considered as acceptable.11
With regard to the patients with known haemor-
rhoids, the guideline is based on an expert’s opinion be-
cause there are few data on when to suspect other
pathology in a patient with haemorrhoids. Although
there are data on the presence of coincidental colorec-
tal pathology in patients with haemorrhoids undergoing FIGURE 1 Age cohorts of patients in both groups
262 Family Practice—an international journal
FIGURE 2 Coincidental findings in the different age cohorts of Group 2. (the y-axis depicts the percentage)
shortcut can lead to a doctors delay, which can be lon-
ger than the earlier mentioned 2 weeks.9
The present study has several limitations. Although
it is prospectively, all patients were sent because of
bleeding to the internist or gastroenterologist. Hence,
selection bias is present since many patients with
haemorrhoids are primarily treated by surgeons. Fur-
thermore, patients had bleeding as their primary and
most important complaint, other symptoms were not
recorded. Clinical suspicion on causes other than hae-
morrhoids could not be objectified.
From the present study, it can be concluded that in
cases of rectal bleeding in patients with haemorrhoids,
coincidental pathology occurs in a large proportion of
patients, especially the elderly. Omitting colonoscopy
in these cases can lead to a significant delay. Hence, it
is recommended to do colonoscopy in the elderly
before starting treatment of haemorrhoids.
Declaration
Funding: none.
Ethical approval: ethical committee of the Zaans
Medical Centre.
Conflict of interest: none.
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