Emergency Department Management of Patients With Rectal Bleeding

Table of Contents

 

About This Issue

Rectal bleeding can be anxiety-provoking for both patients and emergency clinicians, and providing reassurance and a swift diagnosis will help manage what has the potential to be a life-threatening bleed. By focusing on assessment of patient risk factors, laboratory testing, and imaging studies, rectal bleeding can be treated expeditiously in the ED. In this issue, you will learn:

How to differentiate upper GI bleeding from lower GI bleeding, and when the usual signs may be misleading.

The life-threatening and non-life-threatening causes – and mimics – of rectal bleeding in children and adults.

Why the location of an anal fissure can be important.

The highest-value laboratory studies that can point to etiology of the bleed.

CT angiography or ultrasound: which study is best for each type of bleed?

The latest recommendations on blood transfusion thresholds.

Coagulation reversal, platelet transfusion, antibiotics, tranexamic acid, immunosuppression: is there value in these treatments?

The most effective treatments for hemorrhoids and anal fissures.

Special considerations for pediatric, pregnant, and elderly patients with rectal bleeding.

How to use scoring systems, such as Glasgow-Blatchford and Oakland, in determining disposition.

1. About This Issue
2. Abstract
3. Case Presentations
4. Introduction
5. Critical Appraisal of the Literature
6. Etiology and Pathophysiology
7. Differential Diagnosis
8. Prehospital Care
9. Emergency Department Evaluation
   1. History
   2. Physical Examination
      1. Abdominal Examination
      2. Perineal and Rectal Examination
10. Diagnostic Studies
    1. Laboratory Testing
       1. Fecal Occult Blood Testing
    2. Imaging Studies
       1. Computed Tomography
       2. Ultrasound
    3. Red Blood Cell Scintigraphy
    4. Anoscopy
    5. Nasogastric Tubes
    6. Colonoscopy
11. Treatment
    1. Treatments for Bleeding Control
       1. Blood Transfusion
       2. Coagulation Reversal
       3. Platelet Transfusion
       4. Embolization
       5. Antibiotics
       6. Tranexamic Acid
       7. Immunosuppression
    2. Treatment of Hemorrhoids and Anal Fissures
       1. Sitz Baths
       2. Topical Medications
       3. Fiber and Laxatives
       4. Surgical Excision
       5. Subspecialty Referral
12. Special Populations
    1. Pediatric Patients
    2. Pregnant Patients
    3. Elderly Patients
13. Controversies and Cutting Edge
14. Disposition
    1. Glasgow-Blatchford Score
    2. Oakland Score
    3. Other Risk Scoring Systems
15. Risk Management Pitfalls for Rectal Bleeding in the Emergency Department
16. 5 Things That Will Change Your Practice
17. Summary
18. Time- and Cost-Effective Strategies
19. Case Conclusions
20. Clinical Pathway for Management of Rectal Bleeding in the Emergency Department
21. Tables and Figures
22. References

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…

How would you manage these patients? Subscribe for evidence-based best practices and to discover the outcomes.

Clinical Pathway for Management of Rectal Bleeding in the Emergency Department

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Tables and Figures

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Key References

Following are the most informative references cited in this paper, as determined by the authors.

4. * Kocaoğlu S, Çetinkaya HB. Use of age shock index in determining severity of illness in patients presenting to the emergency department with gastrointestinal bleeding. Am J Emerg Med. 2021;47:274-278. (Retrospective; 151 patients) DOI: 10.1016/j.ajem.2021.05.008

18. * Harewood GC, McConnell JP, Harrington JJ, et al. Detection of occult upper gastrointestinal tract bleeding: performance differences in fecal occult blood tests. Mayo Clin Proc. 2002;77(1):23-28. (Prospective; 42 patients) DOI: 10.4065/77.1.23

24. * Sengupta N, Feuerstein JD, Jairath V, et al. Management of patients with acute lower gastrointestinal bleeding: an updated ACG guideline. Am J Gastroenterol. 2023;118(2):208-231. (Guidelines) DOI: 10.14309/ajg.0000000000002130

29. * Triantafyllou K, Gkolfakis P, Gralnek IM, et al. Diagnosis and management of acute lower gastrointestinal bleeding: European Society of Gastrointestinal Endoscopy (ESGE) guideline. Endoscopy. 2021;53(8):850-868. (Society guidelines) DOI: 10.1055/a-1496-8969

30. * Abraham NS, Barkun AN, Sauer BG, et al. American College of Gastroenterology-Canadian Association of Gastroenterology clinical practice guideline: management of anticoagulants and antiplatelets during acute gastrointestinal bleeding and the periendoscopic period. Am J Gastroenterol. 2022;117(4):542-558. (Society guidelines) DOI: 10.14309/ajg.0000000000001627

54. * Oakland K, Jairath V, Uberoid R, et al. Derivation and validation of a novel risk score for safe discharge after acute lower gastrointestinal bleeding: a modelling study. Lancet Gastroenterol Hepatol. 2017 Sep;2(9):635-643. (Prospective; 2336 patients) DOI: 10.1016/S2468-1253(17)30150-4

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Keywords: gastrointestinal, lower, hemorrhoids, hematochezia, LGIB, anticoagulant, diverticulitis, fissure, transfusion, hemoglobin, nifedipine, elderly, pregnant, Glasgow-Blatchford, Oakland