Emergency Department Management of Patients With Rectal Bleeding

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Delivery Method:	Online
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Publication Date: September 2023 (Volume 25, Number 9)

CME Credits: 4 AMA PRA Category 1 Credits™, 4 ACEP Category I credits, 4 AAFP Prescribed credits, and 4 AOA Category 2-B CME credits. CME expires 09/01/2026.

Authors

Peer Reviewers

Abstract

Rectal bleeding accounts for approximately 1 out of every 1000 United States emergency department visits annually. The causes of rectal bleeding are broad, and can range from the benign to the life-threating. This review provides foundational knowledge on rectal bleeding as well as evidence-based recommendations for its evaluation and initial management in the emergency department. Anatomic considerations are discussed, and the differential diagnosis based on risk factors such as age and comorbid conditions is presented. Treatment recommendations based on the presumed diagnosis as well as the evidence associated with their use are also described. Decision-making, including disposition based on laboratory results, imaging studies, and application of risk scoring calculations is also discussed.

Case Presentations

A 24-year-old man presents with abdominal pain, weight loss, and bright-red blood per rectum…

• The patient’s temperature is 37°C; heart rate,120 beats/min; blood pressure, 90/55 mm Hg; and oxygen saturation, 100%.
• His physical examination is remarkable for mild diffuse abdominal tenderness to palpation. Hemorrhoids or fissures are absent on anal examination, and digital rectal examination demonstrates a mixture of blood, stool, and mucus.
• You wonder whether this patient requires an emergent proctosigmoidoscopy, triple-contrast abdominal CT, or whether he can simply be discharged with confirmed GI follow-up…

A 2-year-old girl with rectal bleeding presents to the ED with her parents…

• According to the parents, she had a normal birth history, no history of hospitalization, and is tolerating an oral diet.
• Her vital signs are within an appropriate range for a 2-year-old, with temperature, 37°C; heart rate,120 beats/min; blood pressure, 90/55 mm Hg; and oxygen saturation, 100%.
• What is your differential diagnosis for this patient? Will your physical examination identify the source of bleeding?

A 65-year-old man with history of alcohol dependence presents to the ED with bright-red blood per rectum and altered sensorium…

• The patient says he recently started taking apixaban for a deep vein thrombosis.
• His temperature is 36°C; heart rate,120 beats/min; blood pressure, 90/55 mm Hg; and oxygen saturation, 91%.
• Your initial evaluation reveals diffuse tenderness to palpation, and you note bright-red blood on rectal examination, without an obvious source for the bleeding.
• You begin stabilization with 2 large-bore IV lines and administer crystalloid fluids. Beyond the ABCs, you wonder whether there are other interventions that could be life-saving…

Accreditation:

EB Medicine is accredited by the Accreditation Council for Continuing Medical Education (ACCME) to provide continuing medical education for physicians.