Rectal Bleeding: Causes, Symptoms, and Next Steps

Is it rectal bleeding?

Hello Doctor: I have been experiencing pain in my left lower abdomen every day for over three years.
The location of the pain changes slightly over time, and the sensation is similar to that of a skin abrasion (the pain is located about one to two centimeters from the abdominal surface).
The pain worsens when I eat too much.
There is no pain during bowel movements, but it becomes more pronounced afterward.
Initially, I thought it might be due to inflammation of the intestinal wall (as a colorectal specialist mentioned ten years ago that my anal canal is relatively narrow).
I have undergone two colonoscopies in the past three years (the most recent one was about 16 months ago), which only examined the sigmoid colon.
Both doctors concluded that I only have internal hemorrhoids, and there is no narrowing of the anal canal or any other abnormalities.
In March of this year, I also had a PET scan at a large hospital in northern Kaohsiung, which indicated that there were no tumors larger than one centimeter in the intestines.
Therefore, I wondered if the left lower abdominal pain could be due to gas or damage to my abdominal muscles (as I do not engage in much exercise aside from walking).

My daily bowel habit involves drinking unsweetened yogurt with ice after waking up in the morning (I add a sufficient amount of lactase enzyme to the unsweetened yogurt 24 hours prior).
I then perform Kegel exercises and use a squatting position to gradually push the stool to the anal opening before squatting over the toilet.
I usually have one bowel movement per day, typically producing a long, tubular stool that is sometimes about 15% thicker than my thumb, sometimes slightly thinner, and occasionally harder (unable to be broken with chopsticks), but sometimes of normal consistency.
Each time, I expel about 70g to 170g of tubular stool, and occasionally I can visually see blood-streaked mucus (about three times out of ten).
Since the amount of blood is minimal and previous examinations showed no abnormalities, I did not worry too much.

Yesterday, I experienced a hard stool that got stuck at the anal opening for half an hour and could not be expelled.
I could not remove it manually, so I had to use a glycerin suppository, which resulted in the expulsion of a very hard fecal impaction, approximately 55% larger than my thumb, which was coated with some blood-streaked mucus.
Since the subsequent fecal impaction could not be expelled, I decided to use another glycerin suppository, which only produced some mucus.
I then took Fleet saline laxative, which allowed the remaining stool to pass, but it also caused a significant amount of blood to drip from the anus (which is usually rare for me, as I only see a little blood-streaked mucus).
The first type of blood was thin and mixed with mucus (I considered this to be less concerning, likely from internal hemorrhoids), but the second type of blood appeared in patches (mixed with mucus), forming a thick, net-like pattern, which alarmed me.
When I exerted pressure (after taking Fleet, I attempted to pass gas), blood dripped from my anus, so I went out in the evening to buy three days' worth of hemostatic and anti-inflammatory medication.

I would like to ask the doctor: (1) Regarding the second type of net-like patchy blood mixed with mucus, could this be blood seepage from pressure on the rectal wall? Or could my rectum already be inflamed? (2) I have scheduled a colonoscopy for mid-May at a clinic where the doctor was previously the head of the gastroenterology department at a large hospital and has a good reputation.
However, due to the symptoms that occurred yesterday, I am somewhat concerned.
Can a physician who is not a colorectal surgeon also diagnose conditions such as rectal inflammation (cancer) or anal fissures? Thank you for your patience in reading this, and I appreciate your guidance.

Niming, 50~59 year old female. Ask Date: 2016/05/01

Dr. Ke Fangxu reply Surgery

1.
It is normal to experience mucus and bleeding after using various enema medications following constipation.
Pressure on the rectal mucosa can lead to inflammation and bleeding, and the stimulation from the enema solution can also cause rectal inflammation.

2.
The National Health Insurance Administration stipulates that only two types of physicians are authorized to perform colonoscopy: gastroenterologists and colorectal surgeons, so you can feel assured about undergoing the examination.

Reply Date: 2016/05/01

More Info

Rectal bleeding can be a concerning symptom, and understanding its causes, symptoms, and the next steps is crucial for proper management. Based on your description, it seems you have been experiencing ongoing left lower abdominal pain, occasional rectal bleeding, and difficulties with bowel movements, particularly with hard stools. Here’s a comprehensive overview of what you might be dealing with and the steps you should consider.

Causes of Rectal Bleeding
1. Hemorrhoids: Internal hemorrhoids are a common cause of rectal bleeding, especially if you notice blood mixed with mucus. They can become engorged and bleed, particularly during bowel movements.

2. Anal Fissures: These are small tears in the lining of the anus, often caused by passing hard stools. They can lead to sharp pain during and after bowel movements, and bleeding may occur.

3. Diverticular Disease: Diverticulosis can lead to diverticulitis, which may cause abdominal pain and rectal bleeding. This condition is often associated with a low-fiber diet.

4. Inflammatory Bowel Disease (IBD): Conditions like ulcerative colitis or Crohn's disease can cause inflammation in the gastrointestinal tract, leading to symptoms such as abdominal pain, diarrhea, and rectal bleeding.

5. Colorectal Polyps or Cancer: Although less common, polyps can bleed, and colorectal cancer can present with rectal bleeding, especially in older adults or those with a family history of colorectal cancer.

Symptoms to Monitor
- Type of Blood: The appearance of the blood can provide clues. Bright red blood usually indicates bleeding from the lower gastrointestinal tract (like hemorrhoids or fissures), while darker blood may suggest bleeding from higher up in the digestive tract.

- Associated Symptoms: Pay attention to any changes in bowel habits, weight loss, or changes in appetite, as these can indicate more serious conditions.

Next Steps
1. Consult a Specialist: Since you have already scheduled a colonoscopy, this is an excellent step. A gastroenterologist will be able to visualize the colon and rectum directly, allowing for a more accurate diagnosis.

2. Immediate Care: Given your recent symptoms of significant bleeding, especially the "grid-like" appearance of the blood mixed with mucus, it is advisable to seek immediate medical attention. This could indicate a more serious issue that needs prompt evaluation.

3. Dietary Adjustments: Increasing fiber intake can help soften stools and reduce straining during bowel movements, which may alleviate some of your symptoms. Consider incorporating more fruits, vegetables, and whole grains into your diet.

4. Hydration: Ensure you are drinking enough fluids, as this can help prevent constipation and the formation of hard stools.

5. Medication: If you are experiencing pain or discomfort, over-the-counter pain relievers may help. However, be cautious with medications that can affect bleeding, such as NSAIDs.

Diagnostic Considerations
Regarding your concern about whether a non-colorectal specialist can diagnose conditions like rectal inflammation or fissures, it is important to note that while gastroenterologists are well-equipped to handle these issues, other specialists, including general surgeons and primary care physicians, can also assess and manage these conditions. However, for definitive diagnosis and treatment, especially for conditions like colorectal cancer or IBD, a gastroenterologist is typically the best choice.

Conclusion
In summary, rectal bleeding can arise from various causes, and your symptoms warrant thorough investigation. The upcoming colonoscopy will be crucial in determining the underlying issue. In the meantime, monitor your symptoms closely, maintain a high-fiber diet, and seek immediate care if your bleeding worsens or if you experience new symptoms. Your health is paramount, and addressing these concerns promptly will help ensure the best outcomes.

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