Medically Fit For Exams
Medically Fit For Exams

Rectal bleeding history taking


  • Wash hands and introduce yourself

Differential diagnoses


Anal fissure

Colorectal cancer


Diverticular disease

Upper GI bleed

Bleeding varices (liver disease/portal hypertension)

Advanced prostate cancer

  • Check the patient’s name and DOB
  • Ask if you can talk to the patient before they see the doctor


History of presenting complaint

  • Ask what brought the patient in today
  • Ask them to tell you a bit more about the bleeding and what’s been going on
  • Site
    • In women, clarify that bleeding is from the rectum, rather than urethra or vagina
  • Onset
    • How long for?
    • Did anything cause it? Large bowel movement? (fissure) Upset stomach? (gastroenteritis)
  • Type of blood
    • How much?
      • Just when you wipe
      • In the bowl
      • Pouring out (varices, advanced cancer)
    • Colour
      • Bright red (fissure, haemorrhoids, anal cancer, IBD, possible diverticular disease)
      • Darker red (colorectal cancer, IBD, diverticular disease)
      • Black/coffee ground, smelly, tarry: melena (upper GI bleed, small bowel cancer, Crohn’s disease)
    • Coating the stool? (fissure, haemorrhoids, varices, IBD)
    • Mixed in? (cancer, diverticular disease, IBD)
    • Mucus? (IBD)
    • Has it happened before?
    • Does anything make it worse?
      • Constipation? (fissure)
      • Straining? (fissure)
      • Stress? (fissure)
  • Change in bowel habit
    • Diarrhoea? (IBD)
      • Watery (ulcerative colitis, gastroenteritis)
      • How often?
      • What is normal?
    • Constipation
  • Pain when passing stools
    • Tearing? (fissure)
    • Burning? (haemorrhoid)
  • Anal itching? (anal fissure)
  • Weight loss/anorexia (cancer, liver disease)
  • Ascites, leg swelling (liver disease/varices)
  • Anaemia symptoms (cancer)
    • Breathlessness
    • Chest pain
    • Pallor
  • Tiredness
  • Recent travel abroad (gastroenteritis)
  • ICE
    • Is there anything in particular that you are concerned about
    • Is there anything that you think could be causing this bleeding
  • Summarise and check what the patient has told you
  • Systems review if necessary
    • Headaches, faints, fits
    • Weight loss
    • Fever
    • Change in vision or sensation
    • Cough, SOB
    • Nausea/vomiting
    • Abdominal pain
    • Change in waterworks
    • Aches and pains


Past medical history

  • Ask if they have any current or past medical problems
  • Ask about PR HIM
    • Peptic ulcer
    • Recent surgery
    • Haemorrhoids
    • IBD and diverticulitis
    • Malignancy


Drug history

  • Ask if they are taking any medications, and if there has been a recent change
    • Warfarin
    • Anticoagulants
    • NSAIDs
    • Laxatives
    • Anti-diarrhoeals eg immodium, codeine
  • Ask about over the counter medication
  • Ask about supplements



  • Ask if they have any allergies
  • Ask what happens


Family history

  • Ask if anyone in their family has a history of bowel problems
    • Bowel cancer
    • Ovarian cancer
    • IBD
  • Ask if any other conditions run in their family


Social history

  • Ask about smoking and pack year history (Crohn’s, cancer)
  • Ask about drinking and weekly units
  • Ask about occupation
  • Ask about home situation
  • Ask about how the bleeding has been affecting their life
  • Ask about travel, if not already asked



  • Ask if they have any questions or concerns
  • Ask if there is anything that you’ve missed that they wanted to tell you about
  • Summarise again if necessary
  • Thank the patient for talking to you



Internal: often non-painful, blood in bowl, on paper and on stool, bright red

External: painful, visible: bulging, purple/red, blood on paper and stool, in bowl, bright red

History of constipation and straining

Anal fissure

Bright red blood on paper and bowl, sharp tearing pain on passing stool. May be linked to constipation and stress, pruritis ani

Colorectal cancer

Blood likely to be mixed in, and darker, but could be bright if rectal.

Weight loss, anaemia


Bloody diarrhoea, copious/watery, frequent bowel movements, abdominal pain, nausea, anorexia, weight loss, abdominal mass


Pain in left iliac fossa, fever, nausea vomiting

Usually older patients, often with history of diverticulosis

Anal varices

History of liver disease/alcoholism

Large volume of blood loss, resuscitation required

Upper GI bleed

Dark, tarry stool (melaena)

Haematemesis (vomiting blood( may be present)

History of peptic ulcer, NSAID use or liver disease


History of travel or undercooked food

Associated with nausea, vomiting, fever, malaise, diarrhoea




Next steps

In all cases


Anal fissure

Recommend increase fibre and fluid. Movicol or fibrogel. Local anaesthetic or steroid cream. Generally goes away with time.


Increased fibre and fluid, movicol or fibrogel to prevent constipation. Topical steroid cream. Surgical options for chronic. Most go away with time

Colorectal cancer

2 week wait colonoscopy and biopsy, CT scan, FBC, CRP/ESR, LFTs, U&Es


Colonoscopy, FBC, CRP/ESR, p-ANCA, p-ASCA, referral to gastroenterology


Advise to increase fibre, laxatives. FBC, CRP/ESR

Upper GI bleed

Urgent endoscopy/admission, BP, fluid resuscitation if necessary


Rehydration, antibiotics if foreign travel or bloody diarrhoea





Rectal bleeding history taking.docx
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