Diagnostic Approach to Hematochezia

Initial Assessment

The American Gastroenterological Association recommends determining if blood is truly from the rectum versus other sources, such as hemorrhoids, to distinguish true hematochezia from other causes 1
Normal-appearing stools with streaks of blood on toilet paper may represent bleeding hemorrhoids rather than true dysentery, according to the American Society of Colon and Rectal Surgeons 2
Bright red blood on toilet paper is typical of hemorrhoidal bleeding, as noted by the American Gastroenterological Association 1, 3
Darker blood or blood mixed within stool suggests a more proximal source, as indicated by the American Gastroenterological Association 3

The American Gastroenterological Association recommends performing external anal examination to identify external hemorrhoids, anal fissures, skin tags, thrombosed external hemorrhoids, or rectal mucosal prolapse 3
Anoscopy is essential for visualizing internal hemorrhoids, which are the most common cause of bright red bleeding on toilet paper, according to the American Gastroenterological Association 1, 4
Flexible sigmoidoscopy should be performed in all patients reporting rectal bleeding, even if hemorrhoids are identified, as recommended by the American Gastroenterological Association 1, 3

The American Gastroenterological Association recommends considering full colonoscopy based on risk factors, such as family history of colorectal cancer, personal history of polyps, presence of anemia, guaiac-positive stools, and bleeding characteristics inconsistent with hemorrhoids 1, 3
First-degree hemorrhoids respond best to medical therapy, which includes adequate intake of fiber and water, as noted by the American Gastroenterological Association 1
Nonoperative techniques, such as injection sclerotherapy and rubber band ligation, may be considered for second and third-degree hemorrhoids that do not respond to medical therapy, according to the American Gastroenterological Association 1