Blood in the stool is a sign of bleeding from your intestinal tract. While blood in the stool is common, it is never normal.

You may see bright red blood dripping into the toilet bowl or on toilet paper after wiping. Blood may also streak the stool or sometimes it can be mixed into the stool. Hemorrhoids are the most common reason for bright red rectal bleeding but the diagnosis should never be assumed without a thorough physical examination.

When should you see a doctor?

While a single episode of blood is not a cause for alarm (especially blood seen on toilet paper after a hard bowel movement), recurrent episodes should be evaluated by your doctor. An evaluation will include a physical exam where the doctor performs a digital rectal evaluation; i.e. inserts a digit or finger into your anus to physically examine the anus and rectum and find the cause for bleeding.

Another test called anoscopy may be performed at the same time to visualize the inside of the anus with a small viewing scope. If a deeper look is needed, a flexible sigmoidoscopy or proctoscopy can also be performed in the office to evaluate the rectum and lower sigmoid colon.

It may feel awkward or embarrassing to get this exam; but remember, doctors see these parts all the time. We ALL have an anus and they all pretty much look the same!  

Different types of rectal bleeding

Intestinal bleeding may manifest in several forms.

• Tarry or black stool may be a result of blood further up in the GI tract. Dark stools may also be caused by medication or supplements (Iron).
• Maroon colored stools may be due to a source in the colon, such as a polyp, inflammation, or cancer. It may also be caused by red foods, such as beets!
• Bright red blood is the most common type of rectal bleeding. It may be seen in the toilet bowl or seen on toilet paper after wiping. Bright red blood usually means that the source is closer to the rectum. The most common reason for painless bright red blood is hemorrhoids. Anal fissure (a tear at the outer opening of the anus) is another common reason for bright red rectal bleeding. Anal fissures are typically painful, often causing a sharp tearing or burning pain during or after bowel movements. Rectal cancer may also cause bright red rectal bleeding because the blood is coming from a source close to the anus. The blood may be seen on toilet paper after wiping, drip in the toilet bowl after bowel movements, or seep into one’s underwear. Rectal cancer may be painless if it is higher up in the rectum or painful if closer to the anal opening. The only way to differentiate between bright red bleeding caused by rectal cancer or benign conditions such as hemorrhoids is by physical exam or proctoscopy (scoping the rectum).

Do I need a colonoscopy?

A colonoscopy is a test where a doctor (gastroenterologist or surgeon) inserts a long narrow scope into the anus and advances it through the entirety of the colon or large intestine. The test is performed with light sedation (twilight anesthesia) and allows for identification of bleeding anywhere in the colon or rectum.

The good news is that most patients with bright red rectal bleeding do not need a colonoscopy. The reason for this is that bright red bleeding is generally coming from the anus or low rectum, which are easily accessible through a finger evaluation, anoscopy, or office proctoscopy. Once we have confirmed hemorrhoids and ruled out other conditions arising in the rectum, we can treat the hemorrhoids with close followup to make sure the bleeding stops. If the bleeding continues despite treatment, then we generally recommend a deeper look to make sure there isn’t another cause.

Certain types of bleeding raise greater concern and should be evaluated by colonoscopy in a more expeditious manner. These include maroon stools which suggest bleeding from higher up in the colon. Black or tarry stools may suggest bleeding in the stomach or small intestine and may indicate a need for upper endoscopy. 

The bottom line

You are your own health advocate. If you have rectal bleeding, please see a doctor and make sure you have at least a digital rectal exam. If diagnosed with hemorrhoids, the directed treatment – often dietary modification and topical ointments – should result in symptom resolution. If your symptoms continue, a referral to a colorectal surgeon or gastroenterologist should be made. We can often do a thorough evaluation to assure a correct diagnosis, and sometimes this involves a colonoscopy. In the setting of hemorrhoids or anal fissure, simple prescription topical therapies and office-based treatments can help resolve symptoms without a need for surgery.