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Rectal Bleeding

Checked: 23-02-2023 by Rob Adams Next Review: 23-02-2024

Overview

The passage of blood per rectum is a very common symptom. The type and amount of the bleeding as well as the age of the patient are important in initial assessment of the bleeding. There are many causes of rectal bleeding and the likely aetiology depends on the age of the patient and the frequency of the underlying diseases in a given population (1).

There is a summary in the article below:

Rectal Bleeding in Adults, Blood in Stool. Information | Patient (1)

Red Flags

See the BNSSG Lower GI Urgent Suspected Cancer - USC (2WW) guidelines for red flags for patients with rectal bleeding including advice on FIT testing and when and how to refer.

Patients with massive GI bleeding (either dark or fresh) require urgent admission to hospital.

What to do before referral

History and examination is important when assessing rectal bleeding. Unnecessary investigation should not delay referral where there is a high suspicion of malignancy (see Red Flags section above). Rectal examination and FBC are worth performing on most patients prior to referral. Further investigations will be guided by the presentation (1).

Consider the following investigations:

Bloods - FBC (and ferritin if anaemia),UE, LFT, CRP (if IBD suspected)
FIT test - if indicated.
Faecal calprotectin - if IBD suspected.

There is no evidence that tumour markers such as carcinoembryonic antigen (CEA) are useful as diagnostic tools in these situations. Sensitivity and specificity are both very low as levels as frequently normal in early disease and may be raised in many benign disease and most types of adenocarcinoma (2).

Referral

If a patient does not meet criteria for referral via a 2WW pathway, but still needs referral for further investigation then please consider checking the following pages for referral pathways:

If lower GI endoscopy outside of a 2WW pathway is indicated, please see the endoscopy page for advice on referral.

Resources

1) Rectal Bleeding in Adults, Blood in Stool. Information | Patient

(2) General Biochemistry | North Bristol NHS Trust (nbt.nhs.uk) - Guidelines for CEA requesting.

Efforts are made to ensure the accuracy and agreement of these guidelines, including any content uploaded, referred to or linked to from the system. However, BNSSG ICB cannot guarantee this. This guidance does not override the individual responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or guardian or carer, in accordance with the mental capacity act, and informed by the summary of product characteristics of any drugs they are considering. Practitioners are required to perform their duties in accordance with the law and their regulators and nothing in this guidance should be interpreted in a way that would be inconsistent with compliance with those duties.

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