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Hematochezia: Blood in Stool – Causes & Treatment

Hematochezia refers to the passage of fresh, bright red blood through the rectum. It can indicate conditions of the lower gastrointestinal tract and should always be evaluated by a doctor.

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Things worth knowing about "Hematochezia"

Hematochezia refers to the passage of fresh, bright red blood through the rectum. It can indicate conditions of the lower gastrointestinal tract and should always be evaluated by a doctor.

What is Hematochezia?

Hematochezia is the medical term for the presence of fresh, bright red blood in the stool or at the anus. Unlike melena (black, tarry stools caused by digested blood from upper gastrointestinal bleeding), the blood in hematochezia is undigested and visibly red. This typically indicates that the source of bleeding is located in the lower gastrointestinal tract, such as the colon, rectum, or anus.

Causes

Hematochezia can result from a wide range of conditions. The most common causes include:

Hemorrhoids: Enlarged vascular cushions in the anal region are the most frequent cause of bright red rectal bleeding.
Anal fissures: Small tears in the anal mucosa that bleed during bowel movements.
Diverticular bleeding: Pouches in the colon wall (diverticula) that rupture and bleed, particularly in older adults.
Colorectal polyps and colorectal cancer: Benign or malignant growths on the inner lining of the colon or rectum.
Inflammatory bowel disease: Conditions such as Crohn's disease and ulcerative colitis are commonly associated with intestinal bleeding.
Infectious colitis: Intestinal inflammation caused by bacteria or viruses.
Angiodysplasia: Abnormal blood vessel formations within the intestinal wall.
Ischemic colitis: Reduced blood supply to parts of the colon.

Symptoms and Associated Findings

The hallmark sign is bright red blood visible in the stool, on toilet paper, or dripping into the toilet bowl. Depending on the underlying cause, additional symptoms may include:

Abdominal pain or cramping
Changes in bowel habits (diarrhea or constipation)
Pain during bowel movements
Fatigue and weakness due to chronic blood loss (anemia)
Dizziness and circulatory instability in cases of significant bleeding

Diagnosis

Diagnosis begins with a thorough medical history and physical examination, including a digital rectal examination. Further diagnostic steps may include:

Proctoscopy and rectoscopy: Direct visual inspection of the anus and lower rectum.
Colonoscopy: Examination of the entire colon using a flexible endoscope; considered the gold standard for evaluating lower gastrointestinal bleeding.
Blood tests: To assess the degree of blood loss and rule out clotting disorders.
Imaging studies: Ultrasound, CT scan, or angiography in cases of unclear findings or severe bleeding.
Stool tests: To detect blood and possible infectious agents.

Treatment

Treatment depends on the underlying cause:

Hemorrhoids: Dietary changes (high-fiber diet), sitz baths, topical ointments, and endoscopic or surgical procedures for more severe cases.
Anal fissures: Topical medications, stool regulation, and surgery if conservative treatment fails.
Diverticular bleeding: Often resolves spontaneously; endoscopic or surgical intervention for persistent bleeding.
Polyps and tumors: Endoscopic removal (polypectomy) or surgical resection; chemotherapy or radiation therapy for malignant tumors.
Inflammatory bowel disease: Medical therapy with anti-inflammatory agents, immunosuppressants, or biologics.
Acute severe bleeding: Hospitalization, hemodynamic stabilization, endoscopic hemostasis, or surgery.

When to See a Doctor

Any new episode of rectal bleeding should be evaluated by a doctor promptly, even if a benign cause such as hemorrhoids seems likely. Urgent medical attention is required in cases of heavy bleeding, dizziness, fainting, unintentional weight loss, or significant changes in bowel habits.

References

Strate, L.L. & Gralnek, I.M. - ACG Clinical Guideline: Management of Patients With Acute Lower Gastrointestinal Bleeding. American Journal of Gastroenterology, 2016.
DGVS - Deutsche Gesellschaft für Gastroenterologie, Verdauungs- und Stoffwechselkrankheiten: Guideline on Lower Gastrointestinal Bleeding (2022).
Feldman, M., Friedman, L.S., Brandt, L.J. - Sleisenger and Fordtran's Gastrointestinal and Liver Disease. 11th Edition. Elsevier, 2021.

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