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WIKIPEDIA https://en.wikipedia.org/wiki/Hematochezia

Haematochezia (or hematochezia, from Greek ("blood") and ("to defaecate")) is the
passage of fresh blood through the anus, usually in or with stools (contrast with melena).[1]
Haematochezia is commonly associated with lower gastrointestinal bleeding, but may also occur
from a brisk upper gastrointestinal bleed. The difference between hematochezia and rectorrhagia is
that, in the latter, rectal bleeding is not associated with defecation; instead, it is associated with
expulsion of fresh bright red blood without stools.[2] The phrase bright red blood per rectum
(BRBPR) is associated with hematochezia and rectorrhagia.

In adults, most common causes are hemorrhoids and diverticulosis, both of which are
relatively benign; however, it can also be caused by colorectal cancer, which is potentially
fatal. In a newborn infant, haematochezia may be the result of swallowed maternal blood at
the time of delivery, but can also be an initial symptom of necrotizing enterocolitis, a serious
condition affecting premature infants. In babies, haematochezia in conjunction with
abdominal pain is associated with intussusception. In adolescents and young adults,
inflammatory bowel disease, particularly ulcerative colitis, is a serious cause of
haematochezia that must be considered and excluded.

Haematochezia can be due to upper gastrointestinal bleeding. However, as the blood from
such a bleed is usually chemically modified by action of acid and enzymes, it presents more
commonly as black "tarry" feces known as melena. Haematochezia from an upper
gastrointestinal source is an ominous sign, as it suggests a very significant bleed which is
more likely to be life-threatening.

Beeturia can cause red colored feces after eating beets because of insufficient metabolism of
a red pigment, and is a differential sign that may be mistaken as haematochezia.

Consumption of dragon fruit or pitaya may also cause red discoloration of the stool and
sometimes the urine (pseudohematuria). This too, is a differential sign that is sometimes
mistaken for hematochezia.

Reddish stool in toilet bowl water due to dragon fruit consumption

In infants, the Apt test can be used to distinguish fetal hemoglobin from maternal blood.

Other common causes of blood in the stool include:

Colorectal cancer[3][4][5][6][7]
Crohns disease[8]
Ulcerative colitis[9]
Other types of inflammatory bowel disease, inflammatory bowel syndrome, or ulceration
Rectal or anal hemorrhoids or anal fissures, particularly if they rupture or are otherwise
irritated[10][citation needed]
Shigella [11] or shiga toxin producing [12] E. coli food poisoning[13]
Necrotizing enterocolitis[14][citation needed]
Upper gastrointestinal bleeding[17]
Peptic ulcer disease[18]
Esophageal varices[19]
Gastric cancer[20]
Intense exercise, especially a high-impact activity like running in hot weather.[21]

A Prospective Characterization of Upper Gastrointestinal Hemorrhage

Presenting with Hematochezia.

Source: American Journal of Gastroenterology . Feb1997, Vol. 92 Issue 2, p231-235. 5p. 3

Author(s): Wilcox, C. Mel; Alexander, Lorraine N.; Cotsonis, George

Abstract: Background: Although hematochezia is well recognized to occur in patients with

upper GI hemorrhage (UGIH), its prevalence, clinical presentation, causes, and outcome in
these patients are not well defined. Methods: Consecutive patients evaluated for UGIH by
the gastroenterology service at a large inner city hospital from August 1,1990, through
September 31, 1994, were prospectively identified. Vital signs and stool color were recorded
on admission to the emergency department. Endoscopy was performed in all patients,
usually within 48 h of admission. The cause of bleeding was determined by endoscopy,
surgery, or autopsy. Results: Over the 50-month study period, 727 patients with UGIH
meeting the inclusion criteria were evaluated, with 104 (14%) presenting with hematochezia
(18 with bright red blood and 86 with maroon blood). The most common causes of bleeding
were duodenal ulcer (44%) and gastric ulcer (20%). In comparison with patients with melena
(N = 441), patients with hematochezia were older (55 vs 50 yr, p < 0.01) and more likely to
present with duodenal ulcer bleeding (43 vs 25%, p < 0.01); no differences in vital signs,
including prevalence of shock, or admission Hb concentration were found. However,
transfusion requirements (5.4 vs 4.0 units, p = 0.01), need for surgery (11.7 vs 5.7%, p =
0.03), and mortality (13.6 vs 7.5%, p = 0.05) were significantly higher in patients with
hematochezia than in those with melena, suggesting more severe bleeding and a worse
outcome. Conclusions: Hematochezia is common in patients with UGIH, and the presenting
features are similar to those of patients with melena. Duodenal ulcer is the most common
cause of bleeding associated with hematochezia. Patients with UGIH and hematochezia
seem to have a worse prognosis.
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Colonoscopic evaluation of severe hematochezia in an Oriental




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BACKGROUND AND STUDY AIMS: Hematochezia is a common clinical problem. When the bleeding is
brisk and continuous it requires prompt hospital admission and careful diagnostic evaluation and
management. Colonoscopy has become the first-line investigative modality in patients presenting
with severe hematochezia in many centers, including ours. A retrospective review was carried out to
evaluate the effectiveness of colonoscopy in determining the cause of severe hematochezia in our
Oriental population. PATIENTS AND METHODS: One hundred and ninety patients with severe
hematochezia underwent colonoscopy at the National University Hospital, Singapore, from 1 January
1988 to 31 December 1994. Their records were retrieved and the data analyzed for sex, age,
presentation, concomitant medical conditions, prevalence of recent non-steroidal anti-inflammatory
drugs ingestion, past history of hematochezia, investigations, subsequent interventions and

RESULTS: Colonoscopy as the fist-line investigative modality identified the site and cause of
hematochezia in 78% (148/190) of cases. The site of bleeding remained "obscure" even after
additional investigations in 15% (29/190) of cases. The commonest cause of severe hematochezia in
our Oriental population was diverticular disease (30%, 57/190) with right-sided diverticular bleeding
constituting 44% (25/57) of these cases. Overall, bleeding stopped spontaneously in 81% (154/190)
of cases. Surgery was performed in 16% (30/190) of cases. The mortality related to severe
hematochezia in this series was 5% (9/190).

CONCLUSIONS: The diagnostic efficiency of colonoscopy in defining the site and cause of severe
hematochezia in the Oriental population is comparable to most Western series. The commonest
cause of severe hematochezia in our population was diverticular disease.
American Journal of Gastroenterology (1998) 93, 179182; doi:10.1111/j.1572-

The Outpatient Evaluation of Hematochezia


William N Segal MD, Paul D Greenberg MD, Don C Rockey MD, John P Cello MD and
Kenneth R McQuaid MD

San Francisco Veterans Affairs Hospital and San Francisco General Hospital, University of
California San Francisco, San Francisco, California

Correspondence: William N Segal, MD, 281 Witherspoon Street, Suite 230, Princeton, NJ

Received 16 June 1997; Accepted 7 October 1997.



The objective of this study was to determine whether specific clinical symptoms associated
with hematochezia are predictive of important GI pathology and whether full colonoscopic
examination is necessary.


A total of 103 outpatients ( 45 yr) with hematochezia, defined as the passage of bright red
blood per rectum, underwent anoscopy and colonoscopy. Before endoscopy, patients
completed a detailed interview, quantitating the amount and frequency of bleeding, weight
loss, use of aspirin/NSAIDs, change in bowel habits, family history, and prior GI illnesses.
Based on this information, physicians were asked to predict whether the bleeding was from a
perianal or more proximal site. At colonoscopy, pathology was stratified as either proximal or
distal to the sigmoid/descending junction. Substantial pathology was defined as one or more
adenomas > 8 mm, carcinoma, or colitis.


Anoscopy demonstrated internal and external hemorrhoids in 78 and 29 patients,

respectively. On colonoscopy, 36 patients had 43 substantial lesions. Thirty-seven of these
lesions were distal to the junction of the descending and sigmoid colons and six were
proximal lesions. Four patients had cancer; all were distal lesions. Patients with substantial
lesions were more likely to give a history of blood mixed within their stool (p = 0.03), to
have more episodes of hematochezia per month (p = 0.008), and to have a significantly
shorter duration of bleeding before medical evaluation (p = 0.02) than did patients without
such lesions. However, the physician's clinical assessment did not predict reliably which
patients were likely to have substantial pathology.


In patients with hematochezia, clinicians were unable to distinguish between those patients
with and those without significant colonic lesions by history alone. Flexible sigmoidoscopy
would have demonstrated most (95%) substantial lesions. The lesions that flexible
sigmoidoscopy missed were an unlikely cause of bleeding in this small group of patients.

Ischemic colitis as a cause of severe hematochezia: risk factors and

outcomes compared with other colon diagnoses

Disaya Chavalitdhamrong, MD1,

Dennis M. Jensen, MD1, 2, 3, 4, ,
Thomas O.G. Kovacs, MD1, 2, 3, 4,
Rome Jutabha, MD1, 2, 3,
Gareth Dulai, MD1, 4,
Gordon Ohning, MD1, 4,
Gustavo A. Machicado, MD1, 2, 3, 4

Referred to by

George F. Longstreth
Ischemic colitis and bleeding
Gastrointestinal Endoscopy, Volume 75, Issue 3, March 2012, Page 697

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Risk factors and outcomes of severe hematochezia from ischemic colitis compared with other
colonic diagnoses have not been well studied.


Our purposes were (1) to compare demographics and outcomes of patients hospitalized with
severe hematochezia from ischemic colitis compared with other colonic diagnoses, (2) to
compare inpatient and outpatient start of bleeding from ischemic colitis, and (3) to describe
potential risk factors.


Prospective cohort study.


Tertiary referral academic centers.


Patients referred for gastroenterology consultation for severe hematochezia.


Colonoscopic therapy was provided as indicated.

Main Outcome Measurements

Rebleeding, surgery, and length of hospital stay after colonoscopy.


Of 550 patients in the past 12 years with severe hematochezia from colonic sources, the cause
in 65 patients (11.8%) was ischemia. Ischemic colitis was found more often in females, in
patients taking anticoagulant agents, in patients with severe lung disease, those with higher
creatinine levels, those with higher glucose levels, and those with more fresh frozen plasma
transfusions. Five patients with focal lesions had colonoscopic hemostasis. Major 30-day
outcomes of ischemic colitis patients were significantly worse than patients with other
colonic diagnoses. Patients with inpatient (vs outpatient) ischemic colitis had significantly
more and more severe comorbidities at baseline and significantly higher rates of rebleeding,
surgery, and more days spent in hospital and in the intensive care unit.


Two-center study.


Major 30-day outcomes in ischemic colitis patients were significantly worse than in patients
with other colonic diagnoses. Comparing outpatient and inpatient start of ischemic colitis,
inpatients had significantly worse outcomes.

CURE, Center for Ulcer Research and Education;
Hgb, hemoglobin;
ICU, intensive care unit;
OR, odds ratio;
PT, prothrombin time;
RBC, red blood cell

DISCLOSURE: All authors disclosed no financial relationships relevant to this

publication. This study was partially supported by research funds from an NIH grant
(K24 DK002650) and CURE Digestive Diseases Research Center Human Studies
Core grant (P30 DK041301).

Reprint requests: Dennis M. Jensen, MD, CURE Digestive Diseases Research Center, Building
115, Room 318, Greater Los Angeles VA Healthcare Center, 11301 Wilshire Blvd., Los
Angeles, CA 90073-1003

Copyright 2011 American Society for Gastrointestinal Endoscopy. Published by Mosby,

Inc. All rights reserved.

Case Report: Aortoenteric Fistula Presenting as Repeated


Michael K. Doney, MD, MS,

Gary M. Vilke, MD

Department of Emergency Medicine, University of California, San Diego Medical

Center, San Diego, California

Received 15 July 2009, Revised 21 October 2009, Accepted 8 November 2009,

Available online 25 January 2010


Background: Aortoenteric fistula (AEF) is a rare but life-threatening condition in which
expedient diagnosis is often difficult. It arises from erosion of a segment of aorta, usually an
abdominal aortic aneurysm, into an adjacent portion of the gastrointestinal tract or between a
vascular graft of the aorta and an adjacent portion of the gastrointestinal tract. It can present
as life-threatening upper or lower gastrointestinal bleeding and is a surgical emergency that
requires rapid assessment, emergency resuscitation, and definitive treatment. Case Report: To
present the case of an 87-year-old man diagnosed with AEF in the emergency department. A
review of the literature follows the case report. Conclusions: Aortoenteric fistula is a rare
diagnosis that can cause sudden life-threatening gastrointestinal bleeding.


Reprint Address: Gary M. Vilke, MD, UCSD Medical Center, Department of

Emergency Medicine, 200 West Arbor Drive, Mail code 8676, San Diego, CA 92103
Copyright 2012 Elsevier Inc. All rights reserved.



Hematochezia, which is also called rectal bleeding, refers to the passing of blood from the
anus mixed with stools or sometimes blood clots. Bloody stools are often signs of any injury
or disorder present in the digestive tract. Once the presence of blood is noticed in stools,
medical attention should be sought so that it can be evaluated and possible cause detected.

The colour of the blood is determined by the location of the injury or disorder in the digestive
tract. It can come from anywhere along the digestive tract. The closer the location is to the
anus, the brighter the blood will be. Accordingly, bleeding from the anus, the rectum or the
sigmoid colon is usually bright red while bleeding from the transverse colon and the right
colon is darker or of a maroon colour. There is situation referred to as Melena which occurs
when blood stays in the colon so long that bacteria break it down into chemicals causing it to
be black. Melana in patients is signified by black, tarry and foul smelling stool. It is a sign
of bleeding in the upper gastrointestinal tract. In situations where the blood is bright red, it
means that the blood is moving fast so there is not enough time for bacteria to turn it black.

Sometimes bleeding is occult which means that it cannot be seen by the naked eye but can
only be detected by fecal occult blood test. This occurs when bleeding is so slow that it does
not pass through the anus.

There is a wide range of causes for blood in stool.

Causes of blood usually black stools are

1. Abnormal blood vessels

2. A tear in the esophagus caused by vomiting
3. Bleeding stomach or ulcers
4. Gastritis inflammation of the stomach lining
5. Bowie ischemia improper blood flow to the intestines
6. Trauma or the presence of a foreign body in the upper gastrointestinal tract.
7. Esophageal and stomach varices widened, overgrown blood vessels
Causes of maroon or bright red, bloody stools are

1. Anal fissures cuts or tears in the anus due to straining.

2. Bowel ischemi
3. Colon polyps (clump of cells bulging from the lining of the colon or colon cancer
4. Diverticulitis pockets of blood protruding from the bowel wall
5. Hemorrhoids swollen veins in the anus or rectal area
6. Crohns disease or ulcerative colitis inflammation of the walls of the bowe
7. Intestinal infection
8. Small bowel tumor
9. Presence of foreign body in the lower gastrointestinal tract.

Hematochezia may be accompanied by abdominal pain, vomiting blood, diarrhea, fever and
excessive gas. Treatment is dependent on the cause of the bleeding. The patient may be
admitted to hospital for observation. If bleeding is severe, a blood transfusion may be
necessary for excessive bleeding.

To prevent hematochezia

Eat plenty vegetables and fiber-rich foods

Do not smoke.
Avoid stress
Avoid alcohol
Limit your use of drugs like ibuprofen, aspirin and naproxen.

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Multiple ulcers in the small and large intestines occurred during

tocilizumab therapy for rheumatoid arthritis.

Iwasa T , Nakamura K , Ogino H , Itaba S , Akiho H , Okamoto R , Iboshi Y , Aso A , Murao

H , Kanayama K , Ito T , Takayanagi R
Department of Medicine and Bioregulatory Science, Graduate School of Medical Sciences,
Kyushu University, Japan.
Endoscopy [2011, 43(1):70-72]
Type: Journal Article, Case Reports
DOI: 10.1055/s-0030-1255931


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Gene Ontology(3) Diseases(7) Genes/Proteins(1) Species(3)
Tocilizumab is a monoclonal antibody against human interleukin-6 receptor which blocks the binding
of interleukin-6 to its receptor. Tocilizumab is effective for the treatment of inflammatory disorders
including rheumatoid arthritis. We report a case of multiple ulcers in the small and large intestines,
which occurred during tocilizumab therapy. A 57-year-old woman started to use tocilizumab for
rheumatoid arthritis. Three months later, she complained of hematochezia. Double-balloon
endoscopy revealed multiple small aphthoid ulcers in the small and large intestines. One month
after the woman had recovered, she was given tocilizumab again. The woman had hematochezia
and abdominal pain again 2 weeks later. Colonoscopy revealed multiple round, discrete punched-out
ulcers in the terminal ileum, and vast deep ulcers from the cecum to the descending colon. Bioptic
histopathology and cultivation showed non-specific findings. Six weeks after discontinuation of
tocilizumab, ulcers in the small and large intestine dramatically improved, leaving ulcer scars. This
disease course and the results of examination made us strongly suspect that tocilizumab induced
multiple ulcers in the small and large intestines. Interleukin-6 is a pleiotropic cytokine and involved
in intestinal mucosal wound healing as well as in inflammatory processes. It is possible that
tocilizumab inhibited tissue repair of the intestine and caused intestinal ulcers.

Overview of GI Bleeding

By Parswa Ansari, MD


GI bleeding can originate anywhere from the mouth to the anus and can be overt or occult.
The manifestations depend on the location and rate of bleeding.

Hematemesis is vomiting of red blood and indicates upper GI bleeding, usually from a peptic
ulcer, vascular lesion, or varix. Coffee-ground emesis is vomiting of dark brown, granular
material that resembles coffee grounds. It results from upper GI bleeding that has slowed or
stopped, with conversion of red Hb to brown hematin by gastric acid.

Hematochezia is the passage of gross blood from the rectum and usually indicates lower GI
bleeding but may result from vigorous upper GI bleeding with rapid transit of blood through
the intestines.

Melena is black, tarry stool and typically indicates upper GI bleeding, but bleeding from a
source in the small bowel or right colon may also be the cause. About 100 to 200 mL of
blood in the upper GI tract is required to cause melena, which may persist for several days
after bleeding has ceased. Black stool that does not contain occult blood may result from
ingestion of iron, bismuth, or various foods and should not be mistaken for melena.

Chronic occult bleeding can occur from anywhere in the GI tract and is detectable by
chemical testing of a stool specimen. Acute, severe bleeding also
can occur from anywhere in the GI tract. Patients may present with signs of shock. Patients
with underlying ischemic heart disease may develop angina or MI because of coronary

GI bleeding may precipitate portosystemic encephalopathy or hepatorenal syndrome (kidney

failure secondary to liver failure).

There are many possible causes (see Table: Common Causes of GI Bleeding), which are
divided into upper GI (above the ligament of Treitz), lower GI, and small bowel.

Bleeding of any cause is more likely, and potentially more severe, in patients with chronic
liver disease (eg, caused by alcohol abuse or chronic hepatitis), in those with hereditary
coagulation disorders, or in those taking certain drugs. Drugs associated with GI bleeding
include anticoagulants (eg, heparin, warfarin), those affecting platelet function (eg, aspirin
and certain other NSAIDs, clopidogrel, SSRIs), and those affecting mucosal defenses (eg,