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

Figure 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.

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Table R1 Rectal bleeding: diagnostic strategy model

Probability diagnosis

Haemorrhoids/perianal haematoma

Anal fissure

Colorectal polyp


Excoriated skin (anal pruritus)

Serious disorders not to be missed


  • ischaemic colitis

  • angiodysplasia (vascular ectasia)

  • anticoagulant therapy


  • enteritis (e.g. Campylobacter, Salmonella)


  • 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).

Red flag pointers

  • Age >50 yrs

  • Change of bowel habit

  • Weight loss

  • Brisk bleeding

  • Constipation

  • FH cancer

  • Haemorrhoids

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)


Common presenting problems Psychological and behavioural disorders, anaemia esp. iron deficiency, oro-dental disease, tropical diseases (e.g. helminths, malaria, schistosomiasis), Helicobacter pylori infection, vitamin deficiencies esp. vitamin D, disorder of special senses—skin, ears, eyes, chronic disease (e.g. diabetes).

Important diseases that ‘must not be missed’ include malaria, tuberculosis, schistosomiasis, HIV, typhoid fever, Hepatitis B and C, haemoglobinopathies, e.g. sickle cell, G6PD deficiency, meningoencephalitis and severe pyschological illness such as psychosis, major depression esp. suicide risk, and separation anxiety.

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. Catch-up immunisation is important (see

Basic screening investigations: FBE, CXR, antibodies for Hep. B and Hep. C, strongyloides, HIV, TB (Mantoux or IGRA). Others based on age, risk or country of origin. For general refugee information, see

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