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Monday, 2 December 2013

Hemorrhaging: Hematochezia (rectal bleeding) - The Causes

Hemorrhaging is also known as bleeding or abnormal bleeding as a result of blood loss due to internal.external leaking from blood vessels or through the skin.
Hematochezia (rectal bleeding)
Hematochezia is defined as a condition of the passage of bright red, bloody stool. In most cases it is an indication of hemorrhoids (swollen veins in and around the rectum) or diverticulitis, a common digestive disease particularly found in the large intestine, as a result of infection or inflammation.
Causes
2.1. Ectopic pregnancy
There is a report of case of severe rectal bleeding due to an ectopic pregnancy in the wall of the cecum is reported. The usual preoperative studies for rectal bleeding were performed but did not yield a definitive diagnosis. At laparotomy the right side of the uterus was found to be adherent to the cecum(1).

2.2. Abdominal colic and major gastrointestinal haemorrhage
There is a report of a case of massive rectal bleeding resulting from the placental attachment of an abdominal pregnancy to the sigmoid colon is reported. Both mother and infant survived this rare complication which should be considered when abdominal colic and major gastrointestinal haemorrhage occur in a pregnant patient(2). Other researchers also report of a case of an unusual case of massive bleeding per rectum caused by erosion into the caecum of placental tissue from an ectopic pregnancy is presented. Despite its rarity, abdominal pregnancies may have to be considered in sexually active fertile women presenting with difficult torrential bleeding from the lower gastrointestinal tract(3).

2.3. Angiodysplastic lesions (vascular lesions of the gastrointestinal tract)
In the study of a single angiodysplasias demonstrated by preoperative angiography in four patients and the review of the literature on intestinal angiodysplastic lesions, found that the relative frequency of angiodysplasias in the right side of the colon is noted. Visceral angiography is an important investigation in cases where there is persistent or recurrent bleeding from the gastrointestinal tract, especially when barium studies and laparatomy have been negative(4).

2.4. Coagulation disorder 
In the study of Rectal bleeding, deep venous thrombosis, and coagulopathy in a patient with Klippel-Trénaunay syndrome, reserachers indicated that this report validates the use of endorectal resection for venous malformation of the rectum in patients with KTS and highlights the difficult balance of controlling bleeding by correction of a consumptive coagulopathy and the increased risk of thromboembolic complications(5).

2.5. Hemostatic disorders
In the report of a 79-year-old woman (weight, 69 kg) was hospitalized in a gastroenterology unit for severe rectal bleeding. She had been treated for 2 months with dabigatran etexilate 110 mg twice daily for chronic atrial fibrillation. On admission, her creatinine clearance (CrCl) was 20.7 mL/min/1.73 m(2), prothrombin time (PT) less than 10% (reference range 70-130%), and international normalized ratio (INR) 14.5 (venous blood). Eleven days after admission, hematologic and renal function were normalized and rectal bleeding stopped. An 84-year-old man (weight, 71 kg) was admitted for rectal bleeding with acute renal failure and dehydration that began while he was treated with dabigatran etexilate 110 mg twice daily for atrial fibrillation. On admission, CrCl was 33.5 mL/min/1.73 m(2), PT 13%, and INR 7.53 (venous blood). Dabigatran etexilate was stopped on admission. At the end of the hospitalization, CrCl was 66.5 mL/min/1.73 m(2), PT 54%, and INR 1.53. In both cases, an objective causality assessment revealed that those adverse reactions were probably related to dabigatran etexilate(6).

2.6. Colon cancer
It can be with or without pain. In the study of 604 patients and 22 (3.6%, 95% confidence interval [CI] = 2.0% to 5.2%) were diagnosed with colorectal cancer. Significant predictors of colorectal cancer were found to be age (<50 years: odds ratio [OR] = 1; 50-69 years: OR = 5.1, 95% CI = 1.4 to 18.6; > or = 70 years: OR = 8.2, 95% CI = 2.1 to 31.8) and blood mixed with the stool (Likelihood ratio [LR] 1.5; adjusted OR = 3.8; 95% CI = 1.4 to 10.5). Presence of haemorrhoids associated with bright red bleeding not mixed with stool reduced the likelihood of cancer (OR = 0.4, 95% CI = 0.1 to 1.2) but did not eliminate it--a cancer was present in 2% of patients with these symptoms(7).

2.7. Colorectal polyps
In the conduction of two studies, the first in 1989, the second in 1991, in which we invited Danish general practitioners to register 3-4 patients aged 40 and over presenting with rectal bleeding, researchers found that study 1 among 208 patients aged 40 and over and presenting with a first episode of rectal bleeding, colorectal cancer and polyps were present in 15.4 and 7.7%, respectively. In Study 2 among 209 patients aged 40 and over and presenting with overt rectal bleeding, 156 reported a first bleeding episode or a change in their usual bleeding pattern, and in this group colorectal cancer and polyps were diagnosed in 14.1 and 11.5%, respectively. In the group with unchanged bleeding the cancer polyp prevalence was 6.7% (P < 0.05). The patients in both studies were followed through a yearly letter to the GP for at least 32 and 22 months, respectively(8).

2.8. Hemorrhoids
There is a report of within a period of 18 months, 387 patients were referred to the Proctologic Service at the Chaim Sheba Medical Center because of recurrent rectal bleeding. Hemorrhoids were found in 194 of these patients and further investigation showed that 45 of the 194 patients (23.2%) had other coexisting colonic pathology (12 cancers, 28 polyps, 4 inflammatory bowel diseases and 1 angiodysplasia). Sixteen of 40 patients with diverticulosis and 13 of 30 patients with hemoglobin less than 11 g/dl had additional colonic pathology(9).

2.9. Etc. 
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Sources
(1) http://www.ncbi.nlm.nih.gov/pubmed/309659
(2) http://www.ncbi.nlm.nih.gov/pubmed/3875846  
(3) http://www.ncbi.nlm.nih.gov/pubmed/1295424
(4) http://www.ncbi.nlm.nih.gov/pubmed/4544790
(5) http://www.ncbi.nlm.nih.gov/pubmed/22424361
(6) http://www.ncbi.nlm.nih.gov/pubmed/22669799
(7) http://www.ncbi.nlm.nih.gov/pubmed/17007706
(8) http://www.ncbi.nlm.nih.gov/pubmed/8732328
(9) http://www.ncbi.nlm.nih.gov/pubmed/3872288