Seeing blood in the toilet bowl after defecating can be a perturbing experience, especially if it is a first-time occurrence. Rectal bleeding, also known as hematochezia, is used to describe the presence of fresh blood in the stool. The primary causes of this symptom are issues that are related to the gastrointestinal intact (GI), especially conditions that affect the lower GI. Hematochezia can be an indicator of various conditions, ranging from benign to more serious conditions that require immediate medical attention. Therefore, it is important that a patient who has experienced rectal bleeding is thoroughly evaluated so that an accurate diagnosis and an effective management plan can be put in place.1
Causes of hematochezia
There are many possible causes that can account for the presence of fresh blood in faeces. A few of the common causes are:2
- Piles (Haemorrhoids): These appear as swellings in the lower rectum. They are a result of dilations of the small veins in the lower GI tract
- Anal fissures: A small tear in the skin of the anus that leads to a small bleed. Anal fissures can be very painful as the skin in this region is very sensitive
- Diverticula: These are outpouchings that can develop in the membrane of the gut with age. There is a risk that the membrane that makes up these bulges weakens and becomes damaged, resulting in bleeding
- Crohn’s disease & ulcerative colitis (Inflammatory Bowel Diseases): These are inflammatory conditions that affect the mucosal lining of the gut. Patients suffering from these conditions present with abdominal pain and diarrhoea, as well as hematochezia
- Polyps: Small stalk-like growths that develop inside the lining of the gut. Polyps tend to occur in older people and can be susceptible to tears as the surrounding membrane of the outgrowth weakens with time, potentially resulting in rectal bleeding
- Colon cancer: A severe disease that may not necessarily present with hematochezia as bleeding often occurs deep in the GI tract, leading to symptoms like weight loss and fatigue due to anaemia
- Ulcers: Ulcers are erosions in the mucosa lining of the gut. Ulcers can develop in response to smoking, alcohol consumption and the use of certain medications
Signs and symptoms of hematochezia
Rectal bleeding when passing stool can vary in intensity. It can go from being mild to severe. Yet, in most cases, bleeding is mild and intermittent. The principal sign of hematochezia is the presence of bright red blood in your stool, in the toilet bowel after you have passed stool or on the toilet paper that you have used for wiping after defecating. Depending on the underlying cause of hematochezia, going to the bathroom or applying pressure to the rectum upon wiping can be painful. In cases when hematochezia is not caused by a superficial anal fissure or haemorrhoids, other symptoms can be observed:
- Pain in the abdominal region
- Shortness of breath
- Weight loss
- Hypovolemic shock (as a consequence of severe bleeding)
In cases of chronic, untreated hematochezia, affected individuals can appear pale, experience fatigue and have difficulties breathing as a result of anaemia, which can develop from continuous blood loss.1,2
Diagnosis of hematochezia
Diagnosing rectal bleeding is quite straightforward. A diagnosis is made based on the patient’s medical history and a physical examination. It is imperative that the cause of bleeding is identified for an accurate diagnosis to be made. This might involve a stool examination, for which a faecal sample is taken. Further investigations, including a camera scan of your gut (endoscopy) or a radiological scan (such as a CT scan), may also be done to identify the site of bleeding.4,5
In mild cases, one is referred to a specialist for a routine appointment. If your doctor has concerns, they can refer you for a more urgent appointment. Similarly, in severe cases, one might be directly referred to the emergency department or immediately taken there in an ambulance.
Irrespective of the severity of the bleeding, hematochezia warrants a visit to the doctor. Your doctor may ask you specific questions about your experience of rectal bleeding. For example, they may inquire about the colour of the blood, the presence of mucous, the frequency of rectal bleeding and the approximate volume of blood that you observe when passing stool. To allow doctors to narrow down the cause of the bleeding, they may also ask if you have observed any other signs and symptoms.
Management and treatment for hematochezia
The treatment of hematochezia depends on an individual’s specific situation.3
- In cases when hematochezia is treated as an emergency, the patient is first stabilised by replenishing the lost volume of blood. This is done in order to avoid hypovolemic shock
- For a patient who is in a stable condition and for whom the cause of bleeding has been identified, management involves termination of the bleeding. This can be achieved through the use of medications that allow blood to clot more quickly
- Surgical procedures can be performed to seal bleeding blood vessels with the use of a heated metal rod (cauterisation)
- Rectal bleeding caused by haemorrhoids can be managed by applying topical agents, such as hydrocortisone creams
- Patients suffering from Inflammatory Bowel Disease (IBD) who experience hematochezia can benefit from taking non-steroidal anti-inflammatory drugs (NSAIDs)
How common is hematochezia?
Hematochezia is a relatively common symptom that presents in around 10% of Britain’s every year.1
How can I prevent hematochezia?
The best way to prevent rectal bleeding is to adopt lifestyle changes and health practices that will help you avoid developing the underlying conditions that are associated with this symptom. This can include:
- Incorporating lots of fluids and fibres into your diet and having a proper bowel emptying schedule to avoid haemorrhoids
- Adopting proper hygiene techniques to avoid the formation of anal fissures
- Timely screening and lifestyle changes to prevent bowel cancer, especially if you are at a higher risk than others
Who is at risk of hematochezia?
People who are older, along with those who lead an unhealthy lifestyle, tend to be at a higher risk of experiencing hematochezia. Certain habits and lifestyle choices, such as consuming excessive alcohol, smoking and eating excessive amounts of red meat, can make you more susceptible to rectal bleeding. A sedentary lifestyle also puts one at a higher risk. Finally, having a family history of gastrointestinal problems, such as colon cancer and IBD, may cause you to have a higher chance of presenting with hematochezia.
When should I see a doctor?
If you experience rectal bleeding, it is important to see a doctor immediately. People may ignore incidences of hematochezia, especially if the bleeding is mild. However, attributing your experience of rectal bleeding to benign causes, without first consulting a doctor, may aggravate your condition as a more severe underlying cause can be left undetected.
Hematochezia, more commonly referred to as rectal bleeding, is a symptom that can present in individuals who have conditions that affect the gastrointestinal tract. It is a common presentation amongst the general population. It is a symptom that should be addressed immediately because it can be linked to both benign and malignant causes. A diagnosis can be made by evaluating your medical history and performing a physical examination. Diagnostic blood and imaging tests can be used to identify the site of bleeding and confirm a diagnosis. Receiving a diagnosis will allow you to manage the condition with medications, surgical interventions and lifestyle changes. Hematochezia can often be prevented by adjusting your diet and avoiding unhealthy habits, like smoking and alcohol consumption. Please visit your GP if you notice rectal bleeding.
- Walsh CJ, Delaney S, Rowlands A. Rectal bleeding in general practice: new guidance on commissioning. Br J Gen Pract [Internet]. 2018 Nov [cited 2023 May 19];68(676):514–5. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6193784/
- Amin SK, Antunes C. Lower gastrointestinal bleeding. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2023 [cited 2023 May 19]. Available from: http://www.ncbi.nlm.nih.gov/books/NBK448126/
- Oakland K, Chadwick G, East JE, Guy R, Humphries A, Jairath V, et al. Diagnosis and management of acute lower gastrointestinal bleeding: guidelines from the British Society of Gastroenterology. Gut. 2019 May;68(5):776–89. Available from: https://gut.bmj.com/content/gutjnl/68/5/776.full.pdf
- Burling D, East JE, Taylor SA. Investigating rectal bleeding. BMJ. 2007 Dec 15;335(7632):1260–2. Available from: https://pubmed.ncbi.nlm.nih.gov/18079550/
- Percac-Lima S, Pace LE, Nguyen KH, Crofton CN, Normandin KA, Singer SJ, et al. Diagnostic evaluation of patients presenting to primary care with rectal bleeding. J Gen Intern Med. 2018 Apr;33(4):415–22 Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5880768/