Bloody Stool

Exciting I know. But it’s all different when you’re the one hovering over the reddened bowl.
I’ll start with the take home points:

  • Chances that I diagnose your colon cancer in the ER are next to nil. Pre-R can help with a few outpatient studies, but you really want to find a GI doc.
  • Unless you are one click from dead, the chances you’ll meet an excited GI doctor in the ER with colonoscope in hand are sub-nil.
  • Chances are considerably higher that the source of bright red bleeding are from a hemorrhoid or fissure.
  • Bright red means lower source with active bleeding. Dark red or “coffee grounds” suggest a higher source (often stomach) with slower bleed.
  • A single drop of blood explodes in water. So focus on red flags instead of bowl appearance.

Red Flags:

• Lightheaded
• Syncope
• Abdominal pain
• Concurrent bloody vomit
• Taking blood thinners like Warfarin or Plavix
• Underlying anemia
• Hemophilia
• Liver failure
• Dialysis
• Elderly
• Prior need for transfusions
• Known intestinal cancer
• Alcoholism / cirrhosis / hepatitis
• Esophageal varices
• Chronic NSAID use (ibuprofen, naproxen, aspirin)
• Associated fevers and diarrhea
• Community outbreak of infectious diarrhea
• “Colon cancer runs in my family.”

Happy Words

• “I’ve had anal fissures ever since my surgeon gave me Norco after my hernia repair without any Colace.”
• “I’ve had hemorrhoids for years.”
• “I’m constipated and have been straining for a week.”
• “This seems like my diverticulosis.”
• “I had a clean colonoscopy two weeks ago.”
• “I ate Pepe’s homemade green chile last night, and it hurt more going than coming.”

Bleeding from the bottom scares a lot of people, and rightly so. Patients of all ages land in ERs wide-eyed at all hours following any amount of blood in the bowl, with cancer probably their biggest fear. Unfortunately, however, the ER is a terrible place for a workup. Sometimes the source is obvious with a glance. Rarely an anoscope proves helpful. However, more often than not the source remains a mystery. We’ll keep you alive. Maybe you’ll be admitted for stabilization and inpatient colonoscopy. Maybe you’ll get some saline rehydration or rarely a transfusion.

If your blood counts are ok, if you aren’t vomiting blood, if you don’t have a bleeding disorder that needs to be addressed, or signs of an infectious cause, then you’ll very likely be sent home with instructions to:

  1. Return if light headed, fevers, pain, worse bleeding, etc.
  2. Follow up with GI for possible colonoscopy/endoscopy.
  3. Limit use of ibuprofen.
  4. Avoid spicy foods.

Before you head to an ER, I’d recommend you first buy a hand held mirror for a closer DIY look. For a hemorrhoid or fissure, with no other red flags, stay put. Call your doctor. Call a GI doc. Call Pre-R.

If you do choose to head to an ER, just realize that diagnosing the source of your bleeding is about as hard as understanding the inner workings of a kaleidoscope with a glance at the lens. Without a deeper look inside, it’s a tough nut to crack.

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