Background

Bleeding from the back passage is a common problem accounting for 7 out of every 1000 general practice consultations.  Minor ailments will be responsible in 90% of cases whilst only 3 out of every 100 patients with bleeding will turn out to have bowel cancer.

Making a diagnosis

Important factors in making the diagnosis are the age of the patient, the duration of the symptoms, the colour of the bleeding, the pattern of the patient's bowel function and any family history.

Age

Children may suffer from bleeding, the common cause are anal fissure and inflammatory bowel disease.

Adults 20 - 30 years, commonly, fissure, piles, inflammatory bowel disease.

Adults 30 - 50 years, commonly piles.

Adults >50s, commonly piles, diverticular disease, malignancy.

Colour

This can be quite an unreliable sign in making a diagnosis.

Bright red bleeding suggests a local anal cause e.g. piles

Dark red bleeding suggests a colonic cause e.g. diverticular disease

Melaena is very dark stool, like tar, and suggests bleeding from the upper gastrointestinal tract, usually the stomach or small intestine e.g. a stomach ulcer.

Bowel Function

This is probably the most important symptom.  A patient who has bleeding from piles will be well with steady weight, good appetite and no change in bowel function.  Alteration in any of the above should stimulate a search for other causes.  Significant pain is NOT a symptom of piles except in the emergency situation of strangulation.

Assessment


This will depend on taking a thorough history and performing a full examination including a full internal digital rectal examination.  This will be followed by insertion of the sigmoidoscope, a plastic telescope of about 20cm length.  This is accompanied by inflation of air into the bowel, which can be quite uncomfortable.  The examination is completed by proctoscopy, a shorter telescope to look right at the anal margin.

If the cause of the bleeding has not been identified, it may be necessary to examine the bowel further by either colonoscopy or a barium enema X-ray.  It should be noted, however, that barium enema reports are NOT definitive and if symptoms persist, further investigation is required.

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