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Rectal bleeding


Patients present with any degree of bleeding from a smear on the toilet tissue to severe haemorrhage. Various causes are presented in Fig. R1.


Local causes of bleeding include excoriated skin, anal fissure, a burst perianal haematoma and anal carcinoma. A characteristic pattern of bright bleeding is found with haemorrhoids. It is usually small, non-prolapsing haemorrhoids that bleed.


Black tarry (melaena) stool indicates bleeding from the upper gastrointestinal tract and is rare distal to the lower ileum.


Rectal bleeding: diagnostic strategy model

++ Probability diagnosis

  • Haemorrhoids/perianal haematoma

  • Anal fissure

  • Colorectal polyp

  • Diverticulitis

  • Excoriated skin (anal pruritus)

++ Serious disorders not to be missed

  • Vascular:

    • ischaemic colitis

    • angiodysplasia (vascular ectasia)

    • anticoagulant therapy

  • Infection:

    • enteritis (e.g. Campylobacter, Salmonella)

  • Cancer/tumours:

    • colorectal, caecum

    • lymphoma

    • villous adenoma




  • inflammatory bowel disease (colitis/proctitis)

  • intussusception

++ Pitfalls (often missed)

  • Rectal prolapse

  • Anal trauma (accidental/non-accidental)

  • Villous adenoma




  • Meckel diverticulum

  • solitary ulcer of rectum

++ Key history

Nature of the bleed, including fresh versus altered blood, mixed with faeces and/or mucus, in toilet bowl or on underwear. Quantity of bleeding: slight, moderate or torrential. Associated symptoms (e.g. weight loss, constipation, diarrhoea, pain, weakness, presence of lumps, urgency, unsatisfied defecation, recent change of bowel habit).

++ Key examination

  • General inspection (evidence of anaemia) and vital signs

  • Abdominal examination, anal inspection, digital rectal examination, proctosigmoidoscopy

++ Key investigations

  • FBE and ESR

  • Stool M&C

  • Faecal occult blood

  • Colonoscopy

  • Consider abdominal X-ray, CT colonography, angiography, small bowel enema (depending on clinical findings)


Refugee health

++ Common presenting problems

Psychological and behavioural disorders, anaemia esp. iron deficiency, orodental disease, tropical diseases (e.g. helminths, malaria, schistosomiasis), helicobacter plyori infection, vitamin deficiencies esp. vitamin D, disorder of special senses—skin, ears, eyes, chronic disease.


Important diseases that ‘must not be missed’ include malaria, tuberculosis, schistosomiasis, HIV, typhoid fever, Hepatitis B and C, haemoglobinopathies, e.g. sickle cell, G-6-DP deficiency, meningoencephalitis and severe pyschological illness such as psychosis, major depression esp. suicide risk.

++ Key recommendations (ASID)

All refugees should be offered a comprehensive health assessment, ideally within 1 mth of arrival. This should include screening for and treatment of TB, malaria, blood borne viral infections, e.g. dengue, Hepatitis B and C, schistosomiasis, helminth infections esp. strongyloides, hookworm.


Refugees should have met pre-departure screening criteria (for a permanent visa): this includes CXR (if ≥11 ...

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