Some people might feel embarrassed or hesitant to discuss topics related to stool. For some, this issue is seen as private and should not be shared. In fact, some individuals keep the ‘secret’ of their unusual stool until it results in serious harm to themselves. There are also patients who frequently purchase medication from the pharmacy, assuming that bloody stool is just haemorrhoids and that this is normal. Unfortunately, patients ’ perceptions are often wrong; further examination by a doctor is recommended to avoid complications. A population study conducted in Australia showed that 47% of patients believed that bloody stool was nothing to worry about. Moreover, 37% of the study population had never even looked at the colour of their own stool, and 43% self-medicated before seeking advice from a doctor.
I Found Blood in My Stool. Why?
There are many reasons why there might be blood in your stool. What doctors typically do is start by taking a detailed history concerning the patient’s bowel habits.
- Haemorrhoids – Generally, haemorrhoids are caused by tears in the blood vessels that cushion the anus (anal opening). Bleeding often occurs in patients with a history of constipation or difficulty in passing stool. Blood from haemorrhoids is usually bright red and may drip after bowel movements. The blood will not be mixed with the stool. Sometimes, the patient may feel the presence of smooth lumps (swelling) around the anal opening. Patients may also experience itching and pain in the anal area.
- Diverticula – These are small pouches found throughout the large intestine. The bleeding is usually fresh and sometimes clotted, similar to menstrual bleeding in women. Patients may report going to the toilet to pass stool, but only fresh blood comes out, with no stool. Occasionally, patients may complain of frequent constipation.
- Cancer – Bowel cancer is the third most common cancer among patients in Malaysia. Early signs include bloody stool without any pain during bowel movements. The blood will be mixed with the stool. Patients may sometimes experience a change in bowel habits – prolonged constipation, diarrhoea with blood, or frequent urges to defecate without passing stool (tenesmus).
- Anal Fissure – Patients with constipation issues can develop tears in the anal area. The bleeding from these tears is often bright red, accompanied by pain in the anus, and usually stops on its own. Patients often notice this bleeding when cleaning the anus with tissue at the end of a bowel movement.
- Polyps – These are growths that can occur along the intestine. The bleeding depends on the location of the polyp. The closer it is to the anus, the brighter red the bleeding. Some polyps have the potential to become cancerous (depending on biopsy results).
- Angiodysplasia – This refers to abnormal small blood vessels that can be found throughout the intestine. These blood vessels can rupture, causing bloody stool. The type of bleeding can vary from bright red to blackish, depending on the location of the blood vessels.
- Inflammation of the Intestine (Proctitis/Colitis) – Generally, inflammation can be caused by infections. Patients will complain of diarrhoea mixed with blood or soft stool coated with blood.
- Medications – Some types of medications can cause bleeding, such as blood thinners like warfarin and aspirin.
What Will the Doctor Do Next?
After taking a detailed history of the patient’s problem, the doctor will carry out an examination in the clinic.
- Abdomen – The doctor will examine the patient’s abdomen to feel for any lumps or swellings.
- Rectal Examination – The doctor will inspect the area around the anus to check for any growths (such as haemorrhoids or cancer) or tears (anal fissures). The doctor will then insert a finger into the anus to feel for any growths (limited to the first 7 cm from the anal opening). After the examination, the doctor will observe the colour of the stool on the glove, which will help in making a diagnosis.
- Proctoscopy – A tool approximately 2 cm in diameter will be used to examine the inside of the anus, limited to 8 cm from the anal opening. A gel will be applied to the instrument to minimise discomfort for the patient.
Is an Examination in the Clinic Sufficient, or Do I Need Further Tests?
If the history provided by the patient and the examination conducted by the doctor clearly identify the cause of the bloody stool, such as haemorrhoids or a tear (fissure), treatment can be given immediately. However, if the problem recurs, or if you are at high risk of cancer, or if the cause of the bleeding cannot be identified, it is advised that you consult a specialist surgeon.
Further investigations that allow the specialist to view the inside of the large intestine include endoscopy—specifically, a colonoscopy or sigmoidoscopy. These are tube-shaped instruments with a diameter of 1.5 cm, equipped with a camera at the end, enabling the specialist to see inside the large intestine. This test allows the source of bleeding to be identified all the way up to the terminal ileum (the junction between the large and small intestines) in the case of a colonoscopy, and up to the sigmoid colon in the case of a sigmoidoscopy. Follow-up treatment will depend on the findings from the colonoscopy or sigmoidoscopy.
In addition to endoscopic tests, the patient’s blood will also be examined to assist in follow-up treatment and diagnosis.
I Found Blood When Passing Stool. What Should I Do?
You can visit your local GP if the bleeding is minor. The doctor will conduct an examination as outlined above. Depending on the diagnosis made by the doctor, they will determine whether you need specialist treatment or a referral to a nearby hospital. However, if the bleeding is severe enough to make you feel dizzy, fatigued, or if you have other concerning symptoms such as persistent difficulty in passing stool or prolonged diarrhoea, you are advised to seek a referral to a hospital for further treatment.
Dr. Ruhi Fadzlyana is a surgeon based at a hospital in Kuala Lumpur and lectures in a local university. This article is translated from the original version https://www.mmgazette.com/berak-berdarah-apa-patut-saya-buat-dr-ruhi-fadzlyana/