Visual Rectal Bleeding Associated with High Risk of Serious Pathology
ABSTRACT & COMMENTARY
Synopsis: In a recent study, 24% of men with visible rectal bleeding had "serious" colon disease.
Source: Helfand M, et al. JAMA 1997;277:44-48.
Visible rectal bleeding is a common occurrence in the general population as well as a primary care complaint. There is no consensus about how aggressive one should be or if any specific signs or symptoms can guide deciding who should have a full evaluation of their colon.
Helfand and colleagues at the Palo Alto Veterans Hospital have addressed parts of these controversies in a recent report. They performed a prospective study that focused on the value of asking about visible rectal bleeding in the last three months as part of a systematic written review of systems. Since the study began in the early 1980s, evaluation included rectal exam, anoscopy, rigid sigmoidoscopy, and then double contrast barium enema. Patients had short-term follow-up at one year and medical record and death record review 8-10 years later.
Of the 201 patients completing the evaluation, more than 20% had serious pathology: nine (4.5%) had inflammatory bowel disease, 13 had (6.5%) colon cancer, and 26 had polyps. Ninety-three percent of patients having a negative evaluation were confirmed to have no serious colon pathology 10 years later. Clinical findings alone or in any logical combination were poor predictors of diagnosis. For example, blood on the toilet paper and duration of bleeding were not helpful. Only 44% of serious conditions had positive tests for occult blood.
COMMENT BY BRUCE E. HILLNER, MD
This study was probably accepted in JAMA because it is so strongly contrary to most clinicians’ anticipations. There is no obvious reason to suspect that these findings are biased by the study’s being restricted to male veterans. For men over age 40, visible rectal bleeding should be actively sought in a review of systems and warrants a full colon evaluation.
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