hematochezia; bloody stool, maroon stool
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Introduction
Passage of bloody stools or maroon stools.
Etiology
- colorectal cancer (generally melana, NOT BRBPR)
- colonic polyps (generally melana, NOT BRBPR)
- diverticula* (diverticulosis, diverticulitis)
- ulcerative colitis
- infectious dysentery
- ischemic colitis
- vascular malformations (angiodysplasia, angioectasia)*
- pharmaceutical agents
- NSAIDs
- consider upper GI bleed in taking NSAIDS
- warfarin
- NSAIDs
- hemorrhoids
- anal fissure
- proctitis in homosexual men
- reddish, but not bloody stool may be secondary to ingestion of beets (pink urine generally precedes reddish stool)
* most common causes in the elderly
Pathology
- red blood in the stool generally originates in the colon, rectum or anus
- less frequently brisk bleeding from the small intestine may result in red blood in the stool.
Clinical manifestations
- stools may be described as maroon in color
Laboratory
- complete blood count (CBC)
- leukocytosis may be observed (case description)[1]
- basic metbolic panel
- INR
- stool studies for Clostridium difficile (GRS9)[4]*
- presumably Clostridium difficile enterotoxin A+B in stool or Clostridium difficile toxin genes in stool with fast turnaround
* priority over colonoscopy due to concern for toxic megacolon (GRS9)[3]
Diagnostic procedures
- see lower gastrointestinal hemorrhage
- anoscopy (hemmorhoids)
- gastric lavage to rule out brisk upper GI hemorrhage
- flexible sigmoidoscopy in patients < 30 years if anoscopy negative[3]
- colonoscopy* in patients > 30 years if anoscopy negative[3]
- within 48 hours
- ref[2] suggests upper GI endoscopy first in patient taking NSAID with anemia & an episode of syncope suggesting brisk bleeding from small intestine
- capsule endsocopy to identify jejunal &/or ileal sources of GI bleed[3]
* in older patients with painless, large volume hematochezia most likely due to diverticular bleeding[6]
* flexible sigmoidoscopy plus air contrast barium enema may be substituted colonoscopy
Radiology
- CT angiography[2]
- initial diagnostic test after upper GI endoscopy in hemodynamically unstable patients[2]
- angiography (arteriography)*
- identification of bleeding lesion with CT angiography
- infusion of vasoconstrictors to stop bleeding[3]
- transcatheter embolization to stop bleeding[5]
- see lower gastrointestinal hemorrhage
* in older patients with painless, large volume hematochezia most likely due to diverticular bleeding, thus colonoscopy[6]
Management
More general terms
More specific terms
Additional terms
- fecal occult blood; fecal immunochemical testing; fecal immunofluorescence testing, multitarget stool DNA (mt-sDNA, FOB, FIT, iFOBT, ColonCARE, Hemoccult, ICT, InSure)
- melena
References
- ↑ 1.0 1.1 Stedman's Medical Dictionary 26th ed, Williams & Wilkins, Baltimore, 1995
- ↑ 2.0 2.1 2.2 2.3 Medical Knowledge Self Assessment Program (MKSAP) 16, 19 American College of Physicians, Philadelphia 2012, 2021
- ↑ 3.0 3.1 3.2 3.3 3.4 3.5 Brock AS et al A Not-So-Obscure Cause of Gastrointestinal Bleeding N Engl J Med 2015; 372:556-561. February 5, 2015 <PubMed> PMID: https://www.ncbi.nlm.nih.gov/pubmed/25651250 <Internet> http://www.nejm.org/doi/full/10.1056/NEJMcps1302223
- ↑ 4.0 4.1 Geriatric Review Syllabus, 9th edition (GRS9) Medinal-Walpole A, Pacala JT, Porter JF (eds) American Geriatrics Society, 2016
- ↑ 5.0 5.1 Sengupta N, Feuerstein JD, Jairath V et al Management of patients with acute lower gastrointestinal bleeding: An updated ACG guideline. Am J Gastroenterol 2023 Feb 1; 118:208. PMID: https://www.ncbi.nlm.nih.gov/pubmed/36735555 https://journals.lww.com/ajg/Fulltext/2023/02000/Management_of_Patients_With_Acute_Lower.14.aspx
- ↑ 6.0 6.1 6.2 NEJM Knowledge+