The value of colonoscopy to assess rectal bleeding in patients referred from Primary Care Units

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Abstract

Objectives: rectal bleeding is very common in the general population. It is produced mainly because of benign disease originating in the anus and the rectum. Our aim was to evaluate the need for colonoscopy in patients presenting with rectal bleeding. Patients and methods: patients referred from Primary Care Units and complaining of rectal bleeding were included prospectively in a three-month study. All patients underwent a careful medical history along with physical examination, laboratory tests, and colonoscopy. Results: 126 patients with a mean age of 49.2 years (range: 19-80) were studied. Rectal digital examination was abnormal in 75 cases (59.5%). Severe disease was encountered in 22 patients (neoplasm, angiodysplasia, and inflammatory bowel disease); 10 patients had polyps, 6 had colorectal cancer, and 6 had inflammatory bowel disease. Out of 63 patients younger than 50 years, 5 had severe disease, all of them in the form of inflammatory bowel disease. Conclusions: a neoplasm of the rectum and colon in patients younger than 50 years is a rare event. A colonoscopy must be performed in this group of patients to rule out inflammatory bowel disease.

Translated abstract

Objetivos: la rectorragia es frecuente en la población general. En la mayoría de las ocasiones está producida por patología anorrectal benigna. Nuestro objetivo era determinar la necesidad de realizar pruebas endoscópicas en pacientes con rectorragia. Pacientes y métodos: se incluyeron de forma prospectiva durante tres meses todos los pacientes que eran derivados desde la Atención Primaria por rectorragia. En todos los pacientes se realizó historia clínica y exploración física que incluía tacto rectal, analítica básica y una colonoscopia. Resultados: se incluyeron 126 pacientes con una edad media de 49,2 años (19-80). El tacto rectal fue anormal en 75 (59,5%). En 22 pacientes se encontró patología severa o positiva (lesiones neoplásicas, angiodisplasias y enfermedad inflamatoria intestinal); 10 pacientes pólipos, en 6 cáncer colorrectal y en 6 enfermedad inflamatoria intestinal. De los 63 pacientes menores de 50 años, 5 presentaron patología severa todos ellos con enfermedad inflamatoria intestinal. Conclusiones: la patología neoplásica en menores de 50 años con rectorragia es rara. Se debe realizar una rectoscopia en este grupo de edad para descartar una enfermedad inflamatoria intestinal.

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Most cited references 26

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Self-reported rectal bleeding in a United States community: prevalence, risk factors, and health care seeking.

G Jones, Nicholas J. Talley (1998)

Little data on rectal bleeding in the U.S. population are available. We therefore sought to assess the prevalence of different types of rectal bleeding, their association with potential risk factors including other colonic symptoms, and predictors of health care seeking in a U.S. community. We used a crossectional survey by mail, applying a previously validated self-report symptom questionnaire. Our population comprised an age- and gender-stratified random sample of Olmsted County, Minnesota residents aged 20-64 yr. In total, 1643 responded (77%). Rectal bleeding was reported by 235 subjects (age- and gender-adjusted prevalence, 15.5 per 100; 95% confidence interval [CI], 13.6-17.4); 218 found blood on wiping, 74 noted blood coating the stools, and 46 reported dark blood mixed in the stools. The prevalence of rectal bleeding was significantly higher in younger persons (18.9%, 20-40 yr vs 11.3% > 40 yr; p < 0.001). By stepwise logistic regression analysis, constipation (odds ratio [OR] = 3.03; 95% CI, 2.09-4.41) and diarrhea (OR = 1.90; 95% CI, 1.25-2.84) were independent predictors of rectal bleeding. Among those with rectal bleeding, 13.9% (95% CI, 9.6-19.1%) had visited a physician for bowel problems in the prior yr; only a history of abdominal surgery was an independent predictor of physician visits but this explained just 15.9% of the deviance. In otherwise healthy young and middle-aged persons, approximately one in seven have a history of rectal bleeding and this is more frequent in younger people; only a minority seek health care and this is not related to symptom status.

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Occurrence and clinical significance of overt blood loss per rectum in the general population and in medical practice.

Andre J A Knottnerus, G H Blijham, H. P. D. Fijten (1994)

While the occurrence of blood loss per rectum in general practice is common and usually not serious, it may be the first symptom of a colorectal malignant disorder. To determine the occurrence and clinical significance of overt blood loss per rectum a Medline literature search was undertaken. The incidence of this symptom in the general population was reported to be approximately 20 per 100 people per year, the 'consultation incidence' in general practice approximately six per 1000 and the incidence of referral to a medical specialist was estimated to be about seven per 10,000 per year. The clinical significance of the symptom varied within different populations: the predictive value of overt rectal blood loss for colorectal malignancy was estimated to be less than one in 1000 in the general population, approximately two in 100 in general practice and up to 36 in 100 in referred patients. How the manifestation of the bleeding (and other signs and symptoms) contributes to the selection of patients at each of these stages, leading to increasing prior probabilities, is unknown.

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Rectal bleeding. Do other symptoms aid in diagnosis?

O Dent, S Koorey, M Killingback … (1989)

It has been shown previously that it is difficult for a general practitioner to predict anal vs. colorectal sources of bleeding in patients presenting with rectal bleeding. The aim of the present study was to determine whether there are any aspects of such a patient's history or clinical features that strongly indicate bleeding from a colorectal cancer or polyp. One hundred forty-five consecutive patients, aged 40 years and older, who had complained of rectal bleeding to a general practitioner, were referred to a specialist for full colonic investigation. Among 15 symptoms and clinical features examined, few had any statistically significant association with the source of bleeding. There was an elevated probability of colorectal cancer (21 percent) in patients who had seen blood mixed with feces. Most bowel symptoms and clinical features are not helpful in deciding whether to proceed with full colorectal assessment in patients aged 40 and older who have rectal bleeding of recent onset.