Patients present with any degree of bleeding from a smear on the toilet tissue to severe haemorrhage. Various causes are presented in 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.
Table R1 Rectal bleeding: diagnostic strategy model
Excoriated skin (anal pruritus)
Serious disorders not to be missed
Pitfalls (often missed)
Anal trauma (accidental/non-accidental)
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
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, 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 https://immunisationhandbook.health.gov.au/catch-up-vaccination).
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 https://refugeehealthguide.org.au...