Patients present with any degree of bleeding from a smear on the toilet tissue to severe haemorrhage. Various causes are presented in Fig. R1.
Various causes of rectal bleeding
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.
Table R1Rectal bleeding: diagnostic strategy model ||Download (.pdf) Table R1 Rectal bleeding: diagnostic strategy model
Excoriated skin (anal pruritus)
Serious disorders not to be missed
inflammatory bowel disease (colitis/proctitis)
Pitfalls (often missed)
Anal trauma (accidental/non-accidental)
solitary ulcer of rectum
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).
Red flag pointers:
Age > 50 yrs
change of bowel habit
General inspection (evidence of anaemia) and vital signs
Abdominal examination, anal inspection, digital rectal examination, proctosigmoidoscopy
FBE and ESR
Faecal occult blood
Consider abdominal X-ray, CT colonography, angiography, small bowel enema (depending on clinical findings)
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 yrs), ...