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Ask the Medical Expert Archives 2000-2004

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Rectal Bleeding
July 2000

Q. I am a 29-year-old female who has an 8 year history of rectal bleeding. It seems to frequently occur 1 week before my period. My stool is loose and the blood is always bright red. I have never engaged in anal sex and have never had hemorrhoids. I had a colonoscopy in 1996 that showed colitis. I recently had another colonoscopy and it was normal. The bleeding has gotten worse and occurs more frequently in the last year. My doctor tells me it is probably just irritable bowel syndrome and there is nothing we can do. I am still concerned and wondering if I should get a second opinion. Is their any other test than colonoscopy for such problems? Also do you have any idea what could be causing this?

A. Bright red blood from the rectum can be caused by a relatively small number of conditions. Around the anus, such bleeding can be caused by a hemorrhoid or by a fissure. Classically, a hemorrhoid produces painless bleeding whereas a fissure produces bleeding that is quite painful. Within the rectum and the sigmoid colon, such bleeding can be caused by colitis (often with associated mucous), a polyp or a cancer (you are a bit young for either one of these and a colonoscopy would have found them), or an abnormal vascular pattern within the lining of the intestine.

A colonoscopy would be very good for finding a polyp or a cancer and only marginally good at finding an abnormal vascular pattern. A hemorrhoid could be detected from an external exam. Fissures, again, are usually quite painful.

Irritable bowel syndrome does not cause significant rectal bleeding, though it is associated with loose stools. However, you can not ascribe bleeding to irritable bowel syndrome (it is always possible to have two things: for example, hemorrhoids and irritable bowel syndrome). From a pure statistical point of view, most likely you have some internal hemorrhoids that you are not aware of and possibly some irritable bowel syndrome. An anoscopy can be easily performed in the doctor's office looking for internal hemorrhoids, and there are radiologic tests that can check for a vascular anomaly.

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