Fresh Blood on Digital Rectal Examination

CLINICAL DIAGNOSTIC MANUAL

The presence of fresh blood on digital rectal examination, also known as hematochezia, is an important clinical sign indicating active bleeding in the lower gastrointestinal tract, generally below the ligament of Treitz.

This finding can be alarming for the patient and requires a rapid and thorough evaluation to identify the underlying cause. Causes can range from benign to potentially life-threatening conditions, and appropriate evaluation includes a detailed physical examination, imaging studies, and laboratory tests.

Pathology	Symptoms and Clinical Signs	Suspicion Diagnosis	Confirmatory Diagnosis
Hemorrhoids	Bright red blood during defecation, itching, pain, anal lumps	Clinical history, physical examination	Anoscopy, sigmoidoscopy
Rectal Carcinoma	Rectal bleeding, changes in bowel habits, weight loss, abdominal pain	Clinical history, physical examination, digital rectal exam	Colonoscopy with biopsy, abdominal and pelvic CT scan, MRI
Colon Carcinoma	Rectal bleeding, anemia, weight loss, abdominal pain	Clinical history, physical examination, CBC	Colonoscopy with biopsy, abdominal and pelvic CT scan, MRI
Ulcerative Colitis	Bloody diarrhea, abdominal pain, fever, weight loss	Clinical history, physical examination	Colonoscopy with biopsy, blood tests
Angiodysplasia	Intermittent bleeding, anemia	Clinical history, physical examination	Colonoscopy, angiography, technetium-99m scan
Diverticulitis	Abdominal pain, fever, changes in bowel habits, rectal bleeding	Clinical history, physical examination, CBC	Abdominal and pelvic CT scan, colonoscopy
Ischemic Colitis	Postprandial abdominal pain, rectal bleeding, diarrhea, fever	Clinical history, physical examination	Colonoscopy, abdominal and pelvic CT scan, angiography
Meckel’s Diverticulum	Massive bleeding, abdominal pain, signs of obstruction	Clinical history, physical examination	Technetium-99m scan, laparoscopy
Intussusception	Colicky abdominal pain, palpable abdominal mass, vomiting, rectal bleeding (currant jelly stools)	Clinical history, physical examination	Abdominal ultrasound, abdominal and pelvic CT scan
Mesenteric Infarction	Severe abdominal pain, rectal bleeding, nausea, vomiting, signs of shock	Clinical history, physical examination	Mesenteric angiography, abdominal and pelvic CT scan
Massive Upper Gastrointestinal Hemorrhage	Hematemesis, melena, fresh blood in stool if rapid transit, signs of shock	Clinical history, physical examination, vital signs	Upper gastrointestinal endoscopy, CBC, coagulation tests
Crohn’s Disease	Abdominal pain, diarrhea, fever, weight loss, rectal bleeding	Clinical history, physical examination	Colonoscopy with biopsy, blood tests
Trauma	History of injury, anal pain, rectal bleeding	Clinical history, physical examination	Detailed physical examination, possible endoscopy or CT scan depending on extent of trauma