SJ is a 45 year old man who lost his job a year ago. He had been unable to feed well due to lack of fund hence resorting to eating road-side snacks like roasted corn, roasted plantain, groundnut, et cetera. He recently noticed some blood in his stool, after straining to pass stool. He had been having difficulty passing stool for about 2 weeks now, going to toilet once in 2 or 3 days, instead of his usual daily habit. SJ was alarmed, confused, and very anxious.
The presence of blood in stool is quite common (affecting up to 15% of a population). It is usually noticed as blood staining the stool, toilet paper used to clean up, or the toilet bowl.
The quantity of blood may be small. In some cases, it may be so much to require blood transfusion. Sometimes, however, blood in stool may not be observed with the naked eye and is only discovered on microscopic examination of stool during routine health screening.
For most people, the sight of blood in their stool is quite frightening, especially if it is the first time. Instinctively they begin to wonder what the cause is, and how to treat it. The common opinions and fears include- ‘pile’ or haemorrhoids; anal tears or fissures; dysentery; ‘poison’; ‘spiritual attack’ or cancer. In the Nigerian environment, many people who notice blood in their stool first use herbal medications before visiting the hospital.
Blood in stool may be due to a number of causes including most of those documented above. Common causes include, but not limited to the following.
- Haemorrhoids – The vessels in the anus become abnormally enlarged or distended. Bleeding from hemorrhoids is bright red, coating the stool. It is painless and usually associated with defecation.
- Anal fissures – Tear in the lower half of the anus. There is associated pain with bleeding while passing stool.
- Rectal ulcers
- Diverticulosis – These are out-pouchings of the lining of the large intestine. Usually these present with sudden and more profuse bleeding.
- Massive bleeding gastric ulcers – may present as passage of blood in the stool.
- Inflammatory bowel disease – for example Tuberculosis of the gastrointestinal system.
- Drug-induced- Use of medications like ibuprofen, piroxicam, and herbal concoctions.
- Infective causes – amoebic dysentery
- Bleeding disorders – Certain conditions predispose the individual to uncontrolled bleeding.
- Cancer – People do not like to say or hear this! Cancer of the colon and rectum is a common cause.
Management of Patient Who Passes Blood in Stool: A detailed physical evaluation is carried out, including a rectal examination- digital and where possible an anoscopy (video inspection of the anus for abnormalities). Focused laboratory tests are done to identify amount of blood left following bleeding, markers of tumor, et cetera.
Very important is the need for colonoscopy or sigmoidoscopy. These are video imaging of the entire colon (large intestine) or the latter part of the colon respectively. They help in visualization of the sources of bleeding.
Treatment depends on the severity of blood loss and the cause. Some would require medications, surgery, or both. Blood transfusion may be necessary if blood loss is severe enough to threaten life.
SJ, the case in point, most likely had bleeding haemorrhoids as a result of constipation aggravated by his poor diet. He would however need to visit the hospital for evaluation and at least a sigmoidoscopy, to rule out a more worrisome cause of the bleeding.
Opeyemi O. Owoseni is a Gastroenterologist and Hepatologist. She is a Fellow of the Medical College of Physicians, Nigeria. She is a member of the Society for Gastroenterology and Hepatology in Nigeria (SOGHIN) and that of the American Society for Gastrointestinal Endoscopy (ASGE). She currently consults for several hospitals and performs liver biopsies, fibroscans, diagnostic and therapeutic endoscopies. She can be reached on firstname.lastname@example.org