Gastrointestinal Bleeding Guidelines

Diagnostic Evaluation

• The American Gastroenterological Association recommends that patients with black tarry stools should be evaluated for upper gastrointestinal bleeding, including assessment of vital signs, hemoglobin, and hematocrit 1, 2
• The presence of bright red blood in the stool usually indicates lower gastrointestinal bleeding, and patients should undergo a digital rectal examination, anoscopy, and flexible sigmoidoscopy 1
• A full colonoscopy is mandatory if the bleeding is atypical for hemorrhoids, the source is not identified on anorectal examination, or the patient has significant risk factors for colorectal neoplasia 1, 2

Clinical Errors to Avoid

• The American College of Gastroenterology advises against attributing a positive Hemoccult test to hemorrhoids without further evaluation 1
• Hemorrhoidal bleeding typically presents as visible bright red blood, not occult blood 1
• A complete colonoscopic evaluation is obligatory in patients with a positive test for occult blood, even in the presence of hemorrhoids 1

Red Flag Symptoms

• The presence of blood in the stool is a "red flag" that requires exclusion of structural pathology 2, 3, 4, 5
• Other alarming symptoms that require evaluation include fever, weight loss, anemia, and abnormal physical findings 2, 3, 4, 5