Rectal bleeding may be manifested by bright red blood, blood mixed with stool, or black, tarry stools. Bright red blood per rectum, also known as hematochezia, can occur from colonic tumors, diverticular disease, or ulcerative colitis. Blood mixed with stool can be the result of ulcerative colitis, diverticular disease, tumors, or hemorrhoids. Ask the patient who describes rectal bleeding the following questions:
How long have you noticed bright red blood in your stools?'' Is the blood mixed with the stool?'' ' 'Are there streaks of blood on the surface of the stool?'' Have you noticed a change in your bowel habits?''
''Have you noticed a persistent sensation in your rectum that you have to move your bowels, but you cannot?''
Tenesmus is the painful, continued, and ineffective straining at stool. It is caused by inflammation or a space-occupying lesion such as a tumor at the distal rectum or anus. Hemorrhoidal bleeding is a common cause of hematochezia and streaking of stool with blood.
Melena is a black, tarry stool that results from bleeding above the first section of the duodenum, with partial digestion of the hemoglobin. Inquire about the presence of melena. A useful way of questioning is to show the patient the black tubing on the stethoscope and ask, ''Have your bowel movements ever been this color?'' If asked directly whether the bowel movements have ever been black, the patient may answer in the affirmative, equating dark (normal) stools with black stools. Ask these questions of a patient who describes melena:
Have you passed more than one black, tarry stool?'' If yes, When?'' How long have you been having black, tarry stools?'' Have you noticed feeling lightheaded?''
Have you had any nausea associated with these stools? any vomiting? diarrhea? abdominal pain? sweating?''
The answers to these questions can provide some information regarding the acuteness and the amount of the hemorrhage. Lightheadedness, nausea, and diaphoresis are seen with rapid gastrointestinal bleeding and hypotension.
The presence of silver-colored stools is rare but pathognomonic of acholic stools with melena, a condition resulting from cancer of the ampulla of Vater in the duodenum. The cancer produces biliary obstruction, and the cancerous fronds are sloughed, causing melena.
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