Diagnostic Approach to Green-Tinted Skin, Nausea, Headache, Elbow Joint Pain, and Rectal Bleeding

Primary Considerations

The American Gastroenterological Association suggests that rectal bleeding should not be attributed to hemorrhoids without complete colonic evaluation, as other conditions such as NSAID-induced gastrointestinal bleeding can cause ulcerations throughout the GI tract 1, 2
The World Journal of Emergency Surgery recommends that anorectal varices be distinguished from hemorrhoids and not treated with standard hemorrhoidal therapies, as they can cause rectal bleeding in patients with portal hypertension 1, 3

The American Gastroenterological Association recommends that rectal bleeding in any patient requires exclusion of colorectal cancer, particularly if atypical for hemorrhoids, and that complete colonic evaluation by colonoscopy is mandatory when bleeding is atypical or a positive fecal occult blood test is present 1, 2, 4
The World Journal of Emergency Surgery suggests that systemic symptoms such as nausea and headache may reflect underlying liver disease in patients with portal hypertension 3
The American College of Gastroenterology recommends that joint pain and systemic symptoms such as nausea and headache may indicate metastatic disease or paraneoplastic syndrome in patients with colorectal neoplasia 4

The American College of Emergency Physicians recommends that digital rectal examination be performed to confirm blood in stool and exclude obvious anorectal pathology, and that vital signs and shock index be calculated to assess hemodynamic stability 4, 5
The World Journal of Emergency Surgery suggests that complete blood count, serum electrolytes, BUN, creatinine, coagulation assessment, liver function tests, and iron studies be obtained in patients with rectal bleeding 3, 5
The American Gastroenterological Association recommends that endoscopic evaluation, including anoscopy and flexible sigmoidoscopy, be performed in patients with bright-red rectal bleeding, and that complete colonoscopy be indicated when bleeding is atypical for hemorrhoids or patient has risk factors for colonic neoplasia 1, 2, 4

The American College of Emergency Physicians recommends that the Oakland score be applied for bleeding severity, and that patients with a score >8 be admitted to the hospital 4, 5
The World Journal of Emergency Surgery suggests that CT angiography be performed first in hemodynamically unstable patients, rather than routine endoscopy 4, 5
The American Gastroenterological Association recommends that anemia from hemorrhoidal disease alone is rare, and that other causes of anemia be investigated 1, 2