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A 52-year-old businessman presents to accident and emergency anxious and worried. He has been passing bright red blood with stools that is apparent on the toilet paper and can be seen in the toilet bowel. He denies any pain whilst passing stools but does say that he has to spend long on the toilet and strains most times to pass stool. On examination he is anxious but otherwise healthy. Cardiac examination reveals a mild tachycardia and respiratory examination shows evidence of a mild tremor with a respiratory rate of 24 breaths per minute. Abdominal examination reveals no abnormality, however, on digital rectal examination there are soft fluctuant masses felt at 11, 3 and 7 o’clock with the patient in the lithotomy position and a few spots of fresh red blood on the glove. Which of the following diagnoses is most likely in this man?

• A. Rectosigmoid carcinoma
• B. Anal fissure
• C. Angiodysplasia
• D. Inflammatory bowel disorder
• E. Haemorrhoids

Correct Answer:E

Rectal bleeding is a distressing symptom for patients and every effort should be taken to reassure the patient. An accurate history can be more useful than investigation and should always be undertaken as the difficulty in finding an occult source of bleeding should never be underestimated. Classifying rectal bleeding into fresh red and altered dark bleeding can help to differentiate between upper and lower gastrointestinal causes. The presence of melaena, i.e. altered changed blood almost exclusively locates the source of bleeding to the upper gastro-intestinal tract as blood is altered by digestive enzymes and acid found in the stomach and proximal small intestine.Fresh red blood suggests lower tract bleeding. Further classifying lower tract bleeding into painful versus painless helps to exclude conditions such as anal fissure, which causes excruciating pain on passing stool. Angiodysplasia is a cause of fresh rectal bleeding from an arteriovenous malformation often in the elderly.It can be seen at colonoscopy as a luminal vascular abnormality that may bleed on pressure over it. Rectosigmoid carcinoma typically presents with obstruction and may only bleed when advanced. Inflammatory bowel disorders tend to present with altered bowel habit and bloody diarrhoea mixed in with mucus rather than bright red blood.