Blood in the stools or rectal bleeding is often an alarming thing to happen. It can happen at any age and is often sudden. It may be small in quantity in the form of few drops at time or it may be a large amount mixed with stools. It may be associated with pain while passing stools or can be absolutely painless. It often causes concern and scare, especially if it is large in amount.

Mark (name changed) was an otherwise healthy fifty-year-old gentleman who came to us with complaints of passing small quantity of fresh blood with stools for one week. He had no other complaints. He had similar blood in the stools 3 months ago and had shown to a doctor. He was told to have hemorrhoids (piles) and given some pills. He remained fine till the current episode of bleeding.

Blood in the stools is most commonly due to piles or hemorrhoids. The blood is usually in the form of drops of blood seen separate from the stools. Usually there is no pain. Hemorrhoids are common in those who have habitual constipation and strain a lot to pass stools. Minor bleeding from hemorrhoids can be treated with medicines. For recurrent bleeding and severe bleeding, surgery is required.

Another common cause of blood in the stools is anal fissure which is actually a sharp cut in the anal skin. This type is bleeding is usually associated with severe pain while passing stools unlike bleeding from piles which is painless. Anal fissure is usually treated with medicines and ointments.

A serious cause of bleeding in stools is inflammatory bowel disease also known as ulcerative colitis. This type of bleeding usually occurs for several days, blood is usually mixed with stools and stools itself are loose or soft. There is no pain while passing stools but there can be lower abdominal pain. The diagnosis of ulcerative colitis has to be confirmed on a biopsy from the colon. This is a chronic disease and needs treated with medications over several years.

The most alarming cause of blood in the stools is colon or rectal cancer. It can present with intermittent blood in the stools, usually painless. Person may have recent change in bowel habits especially development of constipation. Colon cancers can be effectively treated if diagnosed early.

A proper assessment of a patient with blood in the stools is essential. While hemorrhoids and anal fissure can be diagnosed by a simple rectal examination, it is often necessary to do a sigmoidoscopy to visualize the rectum and lower colon if other diseases such as colon cancer or ulcerative colitis are suspected. Flexible sigmoidoscopy is a very safe and simple procedure to perform and takes hardly 10 minutes to ascertain the exact cause of bleeding.

Mark finally underwent a sigmoidoscopy and found to have a small cancer in the lower part of the colon. He also had small hemorrhoids. Since the diagnosis was made quite early, Mark underwent a successful surgery for removal of the colon cancer.  

Some important points to remember:

• Any blood that is mixed with the stool should be investigated further
• Hemorrhoids bleeding is usually in the form of drops and blood is seen separately from stools.
• Presence of hemorrhoids does not mean that bleeding is necessarily from hemorrhoids. There can be other causes of bleeding that often go missed if proper investigations are not done.
• Any bleeding that occurs repeatedly should be investigated