Rectal Bleeding
Rectal bleeding is a sign that something is wrong. It is usually something minor that can be easily diagnosed, but not always. It is, therefore, important that the specific cause of rectal bleeding be identified so appropriate treatment can be started and the problem corrected. Even though rectal bleeding may not be serious, an individual should never assume this to be the case. Most importantly, rectal bleeding may be a sign of rectal cancer.
The Causes of Rectal Bleeding
Hemorrhoids - These common problems are actually widened blood vessels or veins. They can occur on the outside where they are felt as small bumps when wiping. Or they may be on the inside where they are usually painless. They quite commonly develop with chronic constipation and especially with pregnancy. Hemorrhoids are usually treated with stool bulking agents to soften the feces and reduce straining.
Fistula - A fistula is an abnormal, burrowing channel that usually runs from the rectum to the skin around the anus. It often will drain a whitish discharge, but it can also bleed. While it is usually just a local problem, a fistula can be associated with chronic swelling in other parts of the intestinal tract. This inflammatory disorder is called Crohn's disease. Fistulas are treated with antibiotics and hot baths. If they persist, surgery is usually required.
Fissure - The passage of a hard stool or severe diarrhea may tear the lining tissue of the anus. This problem is similar to having cracked lips in cold weather. Nerve endings and blood vessels are exposed so that pain and bleeding occur with bowel movements. Frequent warm baths and bulking agents to keep stools soft usually correct this problem. Sometimes surgery is needed.
Diverticulosis - Diverticula are pockets or sacs that project from the bowel wall. They balloon out over the years due to recurrent, high pressure spasm of the colon. Occasionally they can bleed. They usually produce a lot of blood, and it comes all at one time. It does not persist in small amounts with bowel movements over days or weeks. Serious, persistent diverticular bleeding usually requires hospitalization and, at times, surgery.
Proctitis and Colitis - Either the rectum, colon, or both, can become swollen and ulcerated. There are a number of disorders which cause the inside surface of the bowel to become ulcerated and bleed painlessly. There may be rectal urgency, cramps or diarrhea associated with the bleeding. When the swelling is restricted to the rectum, the condition is called proctitis. When the colon above it is involved, it is called colitis. It is important to identify the specific cause of the inflammation so that appropriate treatment can be started.
Polyps and Cancer - Of course, the greatest concern about rectal bleeding is cancer. Polyps are benign growths in the colon. When polyps reach a large size, they can bleed. And certain types of polyps turn into cancer. Colon cancer is usually curable when discovered early. It most often occurs in people over the age of 50, but it is not unheard of in younger individuals, even in their 30's. Because colon cancer is such a common cancer, it is always considered as a possible diagnosis.
Protrusion of the Rectum - Some older individuals will have weakened rectal support tissues caused by frequent straining to have a bowel movement and/or diarrhea. Part of the rectum then can project from the anus and bleed. This condition is called a rectal prolapse. It can be felt as an abnormal bulging from the rectum when wiping. Surgery is the only effective treatment.
The Diagnosis
The Medical History - What is the patient's age? Older people tend to have polyps and cancer more often. Is there anal pain and a hard, large stool associated with bleeding? A tear of the anus may be the answer. Does blood drip into the toilet after a bowel movement? Bleeding hemorrhoids may be the problem. The color and frequency of the bleeding are additional considerations. In most cases, the medical history provides clues, but never the final answer.
The Visual and Digital Exam - The physician will inspect the anal area looking for tears and hemorrhoids. A finger exam can provide information when there is tenderness or a tumor inside. In men, the prostate is also examined.
The Scopes - There are several types of viewing scopes. In the office, the physician may use a rigid or, more commonly, a flexible viewing sigmoidoscope. This exam is called flexible sigmoidoscopy and is performed in 5 to 10 minutes. A more thorough exam is accomplished with a colonoscope, allowing the physician to view the entire 5 to 6 foot long colon. Not infrequently a bleeding lesion will be present beyond the reach of the sigmoidoscope. So frequently colonoscopy is the best initial exam. Both are usually done on an outpatient basis and require intravenous sedation.
Barium Enema X-ray - This is a complementary exam that uses liquid barium inserted by enema through the rectum. X-rays highlight abnormal shadows, such as tumors, diverticuli and colitis. By itself, however, it does not identify an actual bleeding point.
In Summary
Rectal bleeding always means that there is a problem. It is usually not a serious problem, but it should always be assumed to be serious until proven otherwise. Fortunately, the diagnosis is easy to make and effective treatment is almost always available.
Diarrhea
Everyone has diarrhea at one time or another. We all have our own idea of exactly what diarrhea is. Is it one liquid stool each day? Is it several soft, semiformed stools each day? Or is it frequent, watery stools throughout the day and even the night? Stool is made up mostly of water. For the average person in the Western World, the maximum daily amount of water in stool is generally no more than 7 oz. or 200 ml (8 oz. = 1 cup). When it is consistently more, then medically it is called diarrhea.
Causes of Diarrhea
There are many causes of diarrhea. Fortunately, in most instances, the change in bowel habits is short lived and clears up on its own. In these cases, we assume it is a virus infection or even "something I ate." Whenever diarrhea lasts more than two or three weeks, medical advice is generally recommended. Among the many known causes are:
- Food - Most people have certain foods that may cause diarrhea. For hot pepper lovers (the chemical in it is called capaiscin), diarrhea often occurs the morning after. Many people are intolerant to milk and milk products so that even small amounts of the milk sugar lactose can cause diarrhea. Large amounts of fatty foods cause the same problem in other people. The obvious solution in all these instances is to avoid the offending agent.
- Chemical Laxatives - Many people become dependent on laxatives early in life and use them on a daily basis. The names for the usual chemical stimulants: Milk of Magnesia, magnesium (Epsom salt), cascara (Nature's Remedy), phenolphthalein (Exlax, Correctol, Feen-A-Mint). Magnesium can be inadvertently ingested in various over the counter preparations such as Maalox or Mylanta. Check labels! Sorbitol is an artificial sweetener that is used in sugar free gum and prepared foods such as jams and jellies. Sorbitol, too, is a laxative.
- Prescription Drugs - if a change in bowel habit occurs after taking a new drug, the physician should be contacted. In particular, antibiotics are known to cause diarrhea, at times quite severe. Diarrhea can develop up to one month after taking antibiotics.
- Infection - There are over 400 different bacteria that normally live quietly and beneficially in the large intestine. There are also many viruses and other infectious agents that find their way into our bodies. Some of these can infect the intestinal tract and cause diarrhea.
Fortunately, most of the time these infections come and go on their own. Some bacterial infections, such as salmonella, are nasty and require medical evaluation. Salmonella commonly comes from contaminated poultry. There are parasites, such as amoeba and Giardia, that attack the Magnesium containing antacids intestines. Giardia is often found in wild animals and in contaminated streams and well water. For people infected with the AIDS virus, there are a number of infections that can occur in the intestinal tract. Close medical follow up is always required in these instances. Virus infection is probably the most common cause of transient diarrhea and, fortunately it usually clears up on its own. - Traveler's Diarrhea - The cause of traveler's diarrhea is a toxic bacteria called E. Coli. It most often occurs in developing countries where sanitation is not good. This infection can often be prevented by avoiding fresh, uncooked produce and fruits. Fruits, such as oranges, that have protective skins are safe. In particular, tap water in any form and especially ice should be avoided. Bottled beverages are recommended. The physician should be contacted prior to travel to Third World countries to obtain more information on prevention and treatment.
- Diseases - There are certain intestinal disorders that can cause chronic diarrhea. These include colitis, Crohn's disease, diverticulosis, and even colon cancer. These are all serious diseases that require careful medical attention and treatment. It is a major reason why the cause of chronic diarrhea should always be known.
- Stress and Irritable Bowel Syndrome (IBS) - IBS is a problem that occurs when the colon does not contract in a smooth, rhythmic manner. The contractions can be exaggerated in which case diarrhea occurs or they may be sluggish and result in constipation. Sometimes there is alternating constipation and diarrhea. Emotional stress often aggravates these symptoms.
Diagnosis
The discovery of the cause of diarrhea may be very simple, such as discontinuing magnesium containing antacids. Or it may be more difficult. Testing of blood and stool may be needed. X-rays and ultrasound may also be necessary. In some cases, sigmoidoscopy or colonoscopy are required to visually inspect the colon with a lighted, flexible tube. Testing depends on how severe and prolonged the condition is, and how the physician evaluates each case.
Treatment
There are simple things that can be done at the beginning of a diarrheal episode which may help reduce symptoms. Taking only liquids by mouth and avoiding solid food and milk may be helpful. Over-the-counter constipating agents, such as Pepto-Bismol, Kaopectate, or Imodium can also be tried. For explosive or persistent diarrhea, treatment will obviously depend on the cause. Fortunately, the source of diarrhea can almost always be found and effective treatment is then usually available.
In Summary
Diarrhea is a common problem which is usually not serious. If it is severe or persistent, a specific diagnosis should be sought. By working closely with the physician, effective treatment is almost always available.
