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hematochezia; bloody stool, maroon stool

Passage of bloody stools or maroon stools. Etiology: 1) colorectal cancer (generally melana, NOT BRBPR) 2) colonic polyps (generally melana, NOT BRBPR) 3) diverticula* (diverticulosis, diverticulitis) 4) ulcerative colitis - primary sclerosing cholangitis 5) infectious dysentery 6) ischemic colitis 7) vascular malformations (angiodysplasia, angioectasia)* 8) pharmaceutical agents a) NSAIDs - consider upper GI bleed in taking NSAIDS b) warfarin 9) hemorrhoids 10) anal fissure 11) proctitis in homosexual men 12) reddish, but not bloody stool may be secondary to ingestion of beets (pink urine generally precedes reddish stool) * most common causes in the elderly Pathology: 1) red blood in the stool generally originates in the colon, rectum or anus 2) less frequently brisk bleeding from the small intestine may result in red blood in the stool. Clinical manifestations: - stools may be described as maroon in color Laboratory: - complete blood count (CBC) - leukocytosis may be observed (case description) [1] - basic metbolic panel - serum glucose - serum creatinine - serum bicarbonate - INR - stool studies for Clostridium difficile (GRS9) [4]* - presumably Clostridium difficile enterotoxin A+B in stool or Clostridium difficile toxin genes in stool with fast turnaround * priority over colonoscopy due to concern for toxic megacolon (GRS9) [3] Special laboratory: 1) see lower gastrointestinal hemorrhage 2) anoscopy (hemmorhoids) 3) gastric lavage to rule out brisk upper GI hemorrhage 3) flexible sigmoidoscopy in patients < 30 years if anoscopy negative [3] 4) colonoscopy* in patients > 30 years if anoscopy negative [3] - within 48 hours 5) ref [2] suggests upper GI endoscopy first in patient taking NSAID with anemia & an episode of syncope suggesting brisk bleeding from small intestine 6) capsule endsocopy to identify jejunal &/or ileal sources of GI bleed [3] * in older patients with painless, large volume hematochezia most likely due to diverticular bleeding [6] * flexible sigmoidoscopy plus air contrast barium enema may be substituted colonoscopy Radiology: - CT angiography [2] - initial diagnostic test after upper GI endoscopy in hemodynamically unstable patients [2] - angiography (arteriography)* - identification of bleeding lesion with CT angiography - infusion of vasoconstrictors to stop bleeding [3] - transcatheter embolization to stop bleeding [5] - see lower gastrointestinal hemorrhage * in older patients with painless, large volume hematochezia most likely due to diverticular bleeding, thus colonoscopy [6] Management: - see lower gastrointestinal hemorrhage

Related

fecal occult blood; fecal immunochemical testing; fecal immunofluorescence testing, multitarget stool DNA (mt-sDNA, FOB, FIT, iFOBT, ColonCARE, Hemoccult, ICT, InSure) melena

Specific

bright red blood per rectum (BRBPR)

General

sign/symptom lower gastrointestinal hemorrhage

References

  1. Stedman's Medical Dictionary 26th ed, Williams & Wilkins, Baltimore, 1995
  2. Medical Knowledge Self Assessment Program (MKSAP) 16, 19 American College of Physicians, Philadelphia 2012, 2021
  3. Brock AS et al A Not-So-Obscure Cause of Gastrointestinal Bleeding N Engl J Med 2015; 372:556-561. February 5, 2015 PMID: 25651250 http://www.nejm.org/doi/full/10.1056/NEJMcps1302223
  4. Geriatric Review Syllabus, 9th edition (GRS9) Medinal-Walpole A, Pacala JT, Porter JF (eds) American Geriatrics Society, 2016
  5. Sengupta N, Feuerstein JD, Jairath V et al Management of patients with acute lower gastrointestinal bleeding: An updated ACG guideline. Am J Gastroenterol 2023 Feb 1; 118:208. PMID: 36735555 https://journals.lww.com/ajg/Fulltext/2023/02000/Management_of_Patients_With_Acute_Lower.14.aspx
  6. NEJM Knowledge+