Do you have rectal bleeding? Has a doctor told you it’s from hemorrhoids? Has that doctor given you a Digital Rectal Exam or DRE? No, it not “digital” like digital vs analog. In this case a digital rectal exam means using a digit or finger to physically examine the rectum to find the cause of the bleeding. It may seem awkward or embarrassing to get a DRE, but it could save your life. I will keep saying this until young patients with rectal cancer stop showing up at my practice months or years into a delayed diagnosis.
The Different Forms of Bleeding
Intestinal bleeding can manifest in several forms. Tarry or black stool may be result of blood further up in the GI tract. Dark stools may also be caused by medication or supplements. Maroon colored stools may be due to a source in the colon, such as a polyp, inflammation, or cancer. It may also be caused by red foods, such as beets!
Bright red blood in the toilet bowl or seen on toilet paper after wiping usually means that the source is closer to the rectum. This can be caused by anything from aggressive use of toilet paper or frequent wiping from diarrhea to hemorrhoids or rectal cancer.
The bottom line is that bleeding should always be examined – it is not normal.
The Progression of Diagnosing Rectal Bleeding
I generally start with an external exam of the anus to look for any external hemorrhoids, tears also known as anal fissures, or a mass. I then perform a DRE with my finger. An experienced finger can tell a lot, but it doesn’t always stop there. Sometimes patients need further testing depending on the type of bleeding and findings on that initial exam. An anoscopy may be done in the office to evaluate the lowest part of the anus close to the exit. A slightly deeper look into the rectum can also be done using a special proctoscope. If these office tests are inconclusive, I may recommend a Colonoscopy or radiological imaging to confirm a diagnosis.
Remember, rectal bleeding is never normal. It must always be evaluated. All too often I see patients coming into my office – usually young – who have been told that what they have is not serious, or “just hemorrhoids.” Sometimes this advice is given by another health care provider who never performed a DRE. Many assumptions are based on age, sex, or character of bleeding – but there are always exceptions. Patients may also assume that if they were told, once upon a time, that their rectal bleeding was a hemorrhoid, and it’s now bleeding years later, that it’s still a hemorrhoid. Not always true!
Rectal bleeding and its causal conditions happen in both women and men. While less common, these conditions can manifest in young people as well. In fact, statistics are showing an alarming increase in colorectal cancers in young patients over the last few decades. Cancer can share all the same symptoms as hemorrhoids. It can bleed only with wiping. It can bleed bright red in the toilet bowl. It can hurt or be painless. It can look like an anal fissure to inexperienced eyes. It can even look like a rash.
The Bottom Line
The key is, if your symptoms don’t resolve with your current treatments, it is up to you to advocate for your own health. Go back. Ask for an exam. Ask for a referral to a specialist. Please do not assume it’s nothing. Your age has nothing to do with it. Your gender has nothing to do with it. Your family history or absence thereof has nothing to do with it. The type of bleeding has little relevance.
Fortunately, most of the time you’ll be right - it’s nothing serious. But don’t assume without testing. Colorectal cancers are some of the most successfully treatable cancers. Don’t be a statistic.
Karen Zaghiyan, MD, FACS, FASCRS, is a double board-certified colorectal surgeon in Los Angeles, California. To see Dr. Z as a patient and get to the bottom of your symptoms, make an appointment today by phone or online. Don't put off your health!