Little Johnny was overheard by his teacher, describing to his classmates, how to insert a firework in a frog, saying, “You slip it up its ass.” The teacher immediately said, “Rectum, Johnny, rectum.” “Wrecked ‘em? Blew ‘em to bits, more likely!” replied Johnny!
So after that irreverent (but not totally irrelevant) beginning let’s look at rectal bleeding, without using a mirror. The rectum is the last portion of the large bowel that ends just before the anus. Bleeding from this area can be a herald sign of a mild or life-threatening matter, which is why all episodes of rectal bleeding must be investigated.
Depending upon how high up in the gastro-intestinal tract is the cause of the bleeding, it may be seen as black, tarry stools, maroon stools; bright red blood on or in the stool, blood on the toilet tissue, or blood staining the water in the toilet bowl bright red. Treatment can range from relief of symptoms and let Mother Nature do the rest, to antibiotics, blood transfusion, or even surgery. It all depends on the cause.
There are many potential causes, including Hemorrhoids (piles) which are swollen rectal veins in the anal and rectal area. They can cause burning, painful discomfort, as well as bleeding. External hemorrhoids are small swellings that are easy to see (with the mirror) and quite painful; however, internal hemorrhoids are usually painless. A feeling of incomplete emptying may be noted with bowel movements. Treatment focuses on relieving these symptoms with the use of stool bulking agents and softeners, and if necessary, ligation of the bleeding piles.
Rectal fissure is another. This is a tear in the lining of the rectum caused by the passage of hard stools, which can lead to mild rectal bleeding of bright red blood. Exposed nerves and vessels result in moderate to severe pain.
Diverticulosis, I dealt with before in a previous issue, and these little pockets on the bowel wall can also bleed. The stools are dark red or maroon. Pain is usually absent but surgery is required in up to 25 percent of these patients.
Bloody diarrhea is often seen in Bacterial dysentery, which we have all had to a greater or lesser degree. Responsible organisms include Campylobacter jejuni, Salmonella, Shigella, Escherichia coli, and Clostridium difficile. A most unsavory bunch! The treatment depends upon the organism, but generally intravenous fluid replacement and an anti-spasmodic and broad spectrum antibiotic will bring this under control.
Another common cause of rectal bleeding is Inflammatory bowel disease especially in young adults — typically those younger than 50 years of age. Bleeding occurs in small to moderate amounts of bright red blood in the rectum, usually mixed in with stool and mucus. Associated symptoms include fever and abdominal cramps. This condition generally settles with steroids.
The list does not stop there, as there are also conditions like Angiodysplasia, which is a vascular problem that involves enlarged veins and capillaries in the wall of the right colon. In the elderly, these areas become fragile and can bleed.
Of course, the one that everyone worries about is bowel cancer. We lump these together under the general heading of Tumors and polyps. Polyps bulge out from the lining of the colon. Bleeding occurs when large polyps develop. They can be hereditary, and are usually harmless, but some types can be precancerous.
Both benign and malignant tumors are frequently found in the colon and rectum. Those people older than 50 years are most affected; however, tumors can be found in younger people. It should also be noted that less than 20 percent of people with tumor or polyps will have rectal bleeding. However, when bleeding does occur, it is usually slow, chronic, and minimal. Diagnosis requires careful evaluation with colonoscopy.
Rectal bleeding from a traumatic cause is always a critical concern. Rectal damage from a gunshot wound or foreign body insertion can result in extensive infection or rapid and fatal blood loss.
And yes, there’s more! A common source of bleeding is hemorrhage from the stomach or duodenum. This can occur after someone has swallowed a foreign body that causes injury to the stomach lining or bleeding stomach ulcers.
The list does go on, but these conditions are rare. The message is that rectal bleeding must always be investigated, unless Little Johnny is the culprit.