blood in stool
Introduction
Introduction to blood in the stool Hematochezia: The blood is excreted from the anus. The color of the stool is bright red, dark red or tar-like (black stool), which is called blood in the stool. Blood in the stool is just a symptom, not a disease. Blood in the stool is more common in lower gastrointestinal bleeding, especially in colon and rectal lesions, but it can also be seen in upper gastrointestinal bleeding. The color of blood in the stool depends on the location of the gastrointestinal bleeding, the amount of bleeding and the time the blood stays in the gastrointestinal tract. Blood in the stool, accompanied by bleeding from the skin, mucous membranes or other organs, is more common in blood system diseases and other systemic diseases such as leukemia and disseminated intravascular coagulation. basic knowledge The proportion of illness: 0.001% - 0.004% Susceptible people: good for the elderly Mode of infection: non-infectious Complications: nausea and vomiting anemia anal fissure acne
Cause
Cause of blood in the stool
Anal disease (25%):
Anal disease is the most common cause of blood in the stool. Hemorrhage caused by hemorrhoids and anal fissure is blood after the stool. Severe blood can be spurted, blood color is bright red, blood and feces are not mixed, and blood in the stool caused by anal fissure is often accompanied by anal after defecation. It hurts. Hemorrhoids hemorrhage, often in the case of defecation force, there is a small mass protruding from the inside of the anus, and there are drops or spray-like blood discharge, the amount of bleeding can be large or small, hemorrhoids are often painless.
Rectal disease (25%):
Rectal polyps are benign tumors of the rectum. Blood in the stool is the main symptom of rectal polyps. Rectal polyps that are close to the anus sometimes come out of the anus. This disease is common in children. If someone continues to have blood in the stool, there is a feeling of falling, the frequency of bowel movements increases, and constipation and diarrhea appear alternately. At the same time, when there is a significant decrease in body weight in a short period of time, it may indicate that there may be rectal cancer. Such a situation must be caused. Highly valued, especially for the elderly.
Colonic disease (20%):
Like the rectum, the colon can also have polyps and cancer. Ulcerative colitis, dysentery and other diseases can also cause blood in the stool. The blood in the stool caused by such colitis is mostly mixed with mucus or pus and blood, accompanied by abdominal pain. Fever, urgency and other symptoms. In addition, some relatively rare diseases, such as intestinal typhoid, intestinal tuberculosis, intussusception, etc., may also have symptoms of blood in the stool.
Systemic disease (15%):
Leukemia, aplastic anemia, idiopathic thrombocytopenic purpura, hemophilia, blood clotting disorders, collagen disease, uremia, and some rare infectious diseases such as plague, typhus, etc., can cause blood in the stool. However, in these diseases, blood in the stool is only a part of systemic bleeding. At the same time as blood in the stool, there will be bleeding in other parts of the body. Therefore, it is not difficult to identify.
Prevention
Blood in the stool prevention
(1) Develop the habit of regular bowel movements, and the stool is better with a thin paste.
(2) reduce the posture of increasing abdominal pressure, as follows, suffocating the breath, avoid sitting for a long time and overworked.
(3) Do not eat spicy, greasy, coarse and slag food, avoid alcohol and tobacco.
(4) Eat more foods with clearing heat, nourishing nutrient, mucous membrane, laxative, hemostasis, such as raw pear juice, oyster sauce, oyster sauce, reed juice, celery juice, carrot, white radish (cooked food), bitter gourd, eggplant, cucumber , spinach, day lily, cabbage, egg yolk, apple, fig, banana, black sesame, walnut meat, white fungus, etc.
(5) To be cheerful, do not anger and anger, and the mood is not wide, irritability and depression will make the intestinal mucosa shrink blood.
(6) to reduce sexual intercourse, excessive intercourse will make the intestinal mucosa congestion, aggravation of bleeding.
Complication
Blood in the stool Complications nausea and vomiting anemia anal fissure acne
Blood in the stool and blood mixed with feces, frequent urination, defecation is not enough, the frequency of defecation is abnormal, and the problem is heavy after the emergency. Diarrhea, fever accompanied by abdominal pain, diarrhea, nausea, vomiting, mucus, abdominal pain with nausea, vomiting, abdominal pain with diarrhea, nausea, nausea and vomiting watery stool, fecal pus and blood.
Symptom
Symptoms of blood in the stool Common symptoms will be red blood is dripping... Intestinal bleeding fecal discharge process abnormal cold sweat menstrual bloody stool black gastrointestinal bleeding elderly constipation dysentery
Bloody stool
Mostly, it is an acute (instant) hemorrhage. The blood flows out of the blood vessels for a short time and is discharged through the anus with the feces, or directly after the stool. The blood flowing out looks like a traumatic hemorrhage. The color is bright red or purple red and dark red. After a little time, it can be solidified into a blood clot. Often the following diseases:
(1) Hemorrhoids: Both external hemorrhoids and mixed hemorrhoids can cause hemorrhage in the stool. Generally, blood is attached to the feces or blood is dripped after the stool. The external hemorrhoids generally have no bleeding from the stool.
(2) Intestinal polyps: bleeding for painless stools. Bleeding during defecation, stop after the end of defecation, the amount is not equal, the general blood is not mixed with the feces, or the polyp position is high, the number is large, can also be mixed with the feces.
(3) rectal prolapse: after a long illness, there may be bleeding during defecation.
(4) Anal fissure: blood in the stool. The way of bleeding is that there is blood on the side of the fecal surface, not mixed with feces, and some patients will drop blood afterwards.
2. pus and blood / mucus
That is, there are both pus (viscous) fluid and blood in the discharged feces. Pus (viscous) fluid is often seen in the rectum or colon tumors and inflammation. The following diseases are common:
(1) Rectal cancer: The blood color is fresher or darker red, and there may be mucus in the feces, often mixed with blood, mucus and feces.
(2) Colon cancer: Gradually hemorrhage occurs gradually with the prolongation of the disease course, mostly bloody stools containing pus or mucus, and the blood color is dark.
(3) ulcerative colitis: mucus or pus and bloody stool, accompanied by left lower abdominal pain or lower abdomen pain.
(4) Intestinal infectious diseases: such as bacterial dysentery, amoebic disease, and the like.
Black stool
Also known as tar, the stool is black or brownish black. One of the most common symptoms of upper gastrointestinal bleeding. If the amount of bleeding is small and the bleeding rate is slow, the blood stays in the intestine for a longer period of time, and the discharged feces are black; if the amount of bleeding is large and the residence time in the intestine is short, the discharged blood is dark red; The amount of bleeding is particularly large and can be bright red when quickly discharged.
4. Hidden blood
A small amount (micro) of gastrointestinal bleeding does not cause a change in stool color, and is only positive in the fecal occult blood test, called occult blood. All diseases that cause gastrointestinal bleeding can cause occult blood, common ulcers, inflammation and tumors. The occult blood test detects small (micro) blood components in the feces. Early fecal occult blood in intestinal polyps (cancer) can be positive, and regular fecal occult blood testing is an important way for colorectal tumor screening (primary screening).
5. Accompanying symptoms
(1) anal and perianal lesions: blood in the stool is red, anal pain is unbearable, or swelling has a nucleus, or accompanied by an anal fissure.
(2) Upper digestive tract disease: Hematemesis is usually accompanied by urinary tract. When the amount of bleeding is large and the speed is fast, there may be bloody stools.
(3) Lower gastrointestinal diseases: According to the primary disease of bleeding, the symptoms are different.
Examine
Blood test
1. In the early stage after blood in the stool, hemoglobin, red blood cell count, etc. may not change significantly, but when the isotonic fluid is supplemented, the blood volume is expanded, the red blood cell count, the hemoglobin and the hematocrit are determined to help determine the blood loss, blood urea nitrogen The degree of elevation also favors the judgment of the amount of bleeding (called intestinal urea nitrogen elevation).
2. Red blood cell count, hemoglobin and hematocrit no longer progressively reduced, or blood urea nitrogen decreased to normal, indicating that bleeding has stopped.
3. X-ray barium meal or barium enema examination for double angiography of the gastroduodenal duodenum, jejunum examination or total colon examination, for intestinal tuberculosis, Crohn's disease, schistosomiasis, ulcerative colitis, intestinal torsion, Diagnosis of diseases such as intussusception, polyps or cancer is of great help.
4. Sigmoidoscopy or total colonoscopy Because the rectum, sigmoid colon is a predilection of inflammatory lesions, polyps or cancers, sigmoidoscopy is very helpful in the diagnosis of these lesions, except for colonoscopy. In addition to diseases, the diagnosis of hemorrhagic lesions of the descending colon, transverse colon, ascending colon, and cecum can be helpful. For example, enteroscopy enters the end of the ileum, and lesions at the end of the ileum such as tuberculosis, Crohn's disease, lymphoma, etc. Diagnostics can help, if combined with biopsy, and histological examination, can significantly improve the correctness of the diagnosis.
5. Abdominal B-mode ultrasound or CT, MRI examination for the diagnosis of intermediate and advanced colon cancer, such as found intra-abdominal or retroperitoneal lymph node enlargement, it has reference value for the diagnosis of intestinal tuberculosis, lymphoma and other diseases.
6. Selective angiographic examination of blood in the stool, selective mesenteric upper and lower arterial catheter angiography, can identify the location of bleeding, but also conducive to the diagnosis of vascular malformations and other diseases, therefore, for patients with unexplained blood in the stool, to be clear Selective angiography is an essential test for bleeding sites or causes.
7. Wireless capsule endoscope examination: In recent years, wireless capsule endoscopy (also known as capsule endoscopy) examination has begun to be applied to the clinic. This examination is non-invasive, patients can tolerate, no adverse reactions, capsules It is slightly larger than the general drug capsule, which is equipped with a flash device and a photographic chip. It takes about 40 minutes for the capsule to reach the pylorus after swallowing. The average time for the gastrointestinal tract is 350 minutes. When the capsule passes through the gastrointestinal cavity, it is taken. The image is stored in the computer through the remote control receiver signal of the abdomen, and then the clear images are analyzed one by one; the capsule endoscope is finally discharged along with the feces by the colorectal (a disposable item), and some scholars believe that after cleaning the intestines, The advantages of swallowing the capsule endoscope are more favorable, which is better for obtaining the accurate residence time of the capsule through multiple parts to determine the exact location of the lesion. The sensitivity and accuracy of this examination are higher than that of the small intestine. Surgery, but sometimes the inaccurate positioning of the lesion and the inability to perform biopsy on the lesion are the main defects of capsule endoscopy. According to foreign data, capsule endoscopy is for occult elimination. The positive diagnosis rate of tract bleeding can reach more than 80%. It can diagnose small intestinal lesions such as vascular malformations, polyps, tumors, Crohn's disease, ulcers, celiac disease, etc. Therefore, some foreign scholars believe that gastrointestinal bleeding is considered. For patients, capsule endoscopy should be preferred when the routine examination is negative, but in China, due to the high cost of examination, the popularization is still limited.
8. New type of enteroscopy (push enteroscope PE) examination has a new type of pusher enteroscopy for clinical use, and can perform biopsy on the lesion, which is said to be of great value in the diagnosis of difficult small bowel disease, new enteroscopy Overcome the difficulties of the operation of the old enteroscopy, difficult to pass the junction of the duodenum and the jejunum (flexion ligament) and other shortcomings.
Diagnosis
Diagnosis of blood in the stool
diagnosis
1. Clinical manifestations.
2. Laboratory and other auxiliary inspections.
3. The determination of the amount of bleeding: the number and amount of bloody stools, according to the number and number of bloody stools to estimate the blood loss of blood in the stool is not very accurate, but the number of bloody stools, the amount of each time, is undoubtedly a large amount of bleeding, in addition If the patient discharges bright red or dark red blood, even if the blood clot is discharged, it is also a testimony to the large amount of bleeding. The patient has less blood volume, fewer times, and even one solution in a few days, indicating that the amount of bleeding is small; if the red blood cells are in the intestine In the destruction of the channel, when hemoglobin is combined with sulfide to form ferrous sulfide, the feces can be black or tar-like.
4. Judgment of whether bleeding stops: After active treatment, the number and amount of bloody stools of the patient are significantly reduced, suggesting that the bleeding is relieved. When the patient does not defecate or discharge yellow stool for several days, it often indicates that the bleeding has stopped.
5. Establishment of diagnosis of blood in the stool: When diagnosing blood in the stool, the upper gastrointestinal bleeding should be excluded as much as possible. Generally speaking, according to the history, signs and characteristics of bleeding, preliminary judgment can be made. Those with history of ulcer disease or cirrhosis suggest upper gastrointestinal bleeding. The possibility is large, and those with a history of inflammatory bowel disease suggest that the possibility of blood in the stool is high. The tar-like or black stools with hematemesis are generally upper gastrointestinal bleeding. However, only those with blood in the stool, the possibility of blood in the stool is slightly larger, but Many duodenal ulcers can only be manifested as blood in the stool. At this time, it is necessary to analyze according to the history, symptoms and signs, and the characteristics of bloody stools to determine whether it is the upper digestive tract or the blood in the stool. The amount of bleeding is large, the blood stays in the intestine for a short time, and the dark red or bright red blood can be discharged through the anus. However, at this time, the patient usually has hematemesis, so there is often no difficulty in identification, fever, white blood cells, blood urea nitrogen. Significantly elevated, often suggest higher bleeding site, that is, the possibility of upper gastrointestinal bleeding is greater, when the identification is difficult, can be inserted into the nasogastric tube into the stomach, such as pumping out coffee-like or dark Color gastric juice, it is prompted for upper gastrointestinal bleeding; such as gastric juice containing bile without blood, can rule out upper gastrointestinal bleeding; such as pumping out without bile, and clear gastric juice, can only exclude esophagus and Gastric hemorrhage, can not completely rule out duodenal hemorrhage, the most reliable identification method is gastroscopy, can immediately establish or exclude upper gastrointestinal bleeding (gastroscopically reached the duodenal descending still no bleeding, basically Exclude upper gastrointestinal lesions).
6. Diagnosis of the cause of blood in the stool: According to the patient's medical history, symptoms and signs, some patients with blood in the stool, the cause can be diagnosed. For example, the patient has a history of nucleus, and each time it is expressed as blood in the stool or blood and feces are not mixed. (The blood is attached to the outside of the feces). When the blood is bright red, hemorrhoids should be considered. In young patients, when the blood adheres to the outside of the feces and is not mixed with the feces, the possibility of a left colon polyp should also be considered. When the patient has Excretion of mucus, pus and bloody stools should consider intestinal inflammation, ulcerative lesions, such as accompanied by urgency and severe cases, should also consider the possibility of rectal cancer, but the diagnosis still depends on laboratory tests and special examinations.
(1) Laboratory examination: If the amoebic trophozoites or schistosomiasis eggs are found in the stool examination, it is conducive to the diagnosis of amoebic dysentery or schistosomiasis; if there are red blood cells in the stool and pus cells, the intestinal tract is inflammatory. Diseases and stool culture are conducive to the discovery of pathogenic bacteria; if considering the blood in the stool caused by blood diseases, it should be checked for platelet count, clotting time, prothrombin time and clotting factors, and if necessary, bone marrow examination should be performed.
(2) anal finger examination: patients with blood in the stool should be used as a routine examination, anal examination can find guinea, polyp or rectal cancer and stenosis and other lesions.
Differential diagnosis
1. nucleus or anal fissure, anal fistula
(1) is one of the common causes of blood in the stool, especially the bleeding of internal hemorrhoids is very common.
(2) The color of the blood is generally bright red, and it is not mixed with the feces, and does not contain mucus. In most cases, it is characterized by dripping blood after the stool, especially when the stool is indurated.
(3) Patients with anal fissure often have pain when defecation.
(4) Anal examination and finger examination can often be diagnosed.
(5) Anoscope or proctoscopy is conducive to diagnosis, and can directly peep into the hemorrhoids such as the nucleus.
2. Bacterial dysentery
(1) In the acute phase, there are often chills, fever, pain in the lower abdomen and other symptoms. The stool is often a pus-like blood sample. Each time the amount is not much, often accompanied by urgency and sensation; the chronic phase is mucus of intermittent seizures, pus and bloody stools.
(2) A large number of pus cells, red blood cells and macrophages can be found in routine stool examinations; pathogenic bacteria (Shigella dysenteria) can be found in stool culture, but the positive rate of chronic period stool culture is not high, only 15% to 30%.
(3) Colonoscopy showed diffuse hyperemia, edema, ulcers, and often uneven edges.
3. Amoebic dysentery
(1) The stool is mostly jam-like, or dark red, with a large amount, often accompanied by purulent mucus. The patient has fever, abdominal distension, abdominal pain and heavy performance.
(2) routine examination of stool can be found in piles of red blood cells and a small number of white blood cells, such as the discovery of lytic tissue amoeba trophozoites or cysts have a diagnostic value.
(3) Colonoscopy can be seen mucosal congestion, but the edema is not obvious, the ulcer is generally deep, often a small bottle-like ulcer with small mouth and small mouth, the mucosa is normal between the ulcers, and the lesion can occur in any part of the large intestine.
4. Schistosomiasis
(1) There is a history of contact with infected water, often manifested as chronic diarrhea, stool is pus-like blood or blood for stool.
(2) Other clinical manifestations of schistosomiasis, such as hepatosplenomegaly and decreased whole blood cells.
(3) B-mode ultrasound can detect liver fibrosis.
(4) colonoscopy can be seen in the rectal mucosa with miliary yellow nodules, sometimes ulcers or polyps can be seen, rectal mucosal biopsy can be found schistosomiasis eggs.
5. Ulcerative colitis
(1) is a non-specific colonic inflammation with unknown etiology. The lesions are recurrent, the process of remission, prolonged unhealed, abdominal pain during the attack, diarrhea, often accompanied by urgency and urgency. The disease is often the first to invade the rectum and sigmoid colon. Gradually spread upwards and go straight to the ileocecal department; a small number of patients can start from the right colon and then gradually spread to the left colon. The stool is usually a mucus pus and a bloody stool.
(2) Routine examination of stool can be seen with red blood cells and white blood cells, but the feces are repeatedly cultured without pathogen growth.
(3) During the active period of the lesion, colonoscopy showed diffuse hyperemia of the mucous membrane, edema, superficial small ulcer, increased fragility of the mucous membrane, easy bleeding of the contact; mucosal biopsy, pathological findings such as reduction of glandular goblet cells and discovery of crypt abscess It is helpful for diagnosis. In the intestines of the chronic phase, inflammatory polyps can sometimes be found, and the intestinal wall of the elderly is thickened.
(4) X-ray barium enema is also helpful for diagnosis. It can be seen that the mucosal folds disappear and the colonic bag disappears.
(5) The antibacterial treatment effect is poor, and sulfasalazine or 5-aminosalicylic acid, adrenal glucocorticoid treatment is effective, can alleviate the condition.
6. Intussusception
(1) Excretion of mucus and blood, often without stool, sometimes the abdomen can reach the nested mass.
(2) X-ray barium enema examination can not only confirm the diagnosis, but also achieve the purpose of treatment.
7. Rectal cancer
(1) It is one of the common cancers. Patients over the age of 35, suffering from chronic diarrhea or recurrent mucus pus and bloody stools, accompanied by urgency and weight, should be considered for rectal cancer when the general anti-inflammatory treatment is not effective. Possible.
(2) Rectal examination can find lesions, which is helpful for diagnosis. Rectal cancer is characterized by irregular, hard masses on the intestinal wall, tenderness, and often uneven on the surface of the mass; Pus and blood, the vast majority of rectal cancer can be found by the fingerprint.
(3) colonoscopy can directly observe the shape and extent of the cancer, combined with biopsy can confirm the histological diagnosis.
8. Colon cancer
(1) Patients with middle-aged or older have changes in bowel habits, diarrhea or constipation, thin stools, suspected mucus and pus and suspected colon cancer, and a small number of patients may only present with fixed abdominal pain.
(2) Right colon cancer is mostly abdominal pain, diarrhea is the main manifestation, routine examination of stool can be found pus cells, red blood cells, or occult blood test is positive; left colon cancer is mostly stool thinning or constipation, while stool It can also be accompanied by mucus or pus and a small number of patients with intestinal obstruction.
(3) Some cases may have a fixed mass in the abdomen and tenderness.
(4) Late cases have weight loss, anemia and other manifestations.
(5) colonoscopy can be found in the location, size and extent of the cancer, combined with biopsy to confirm the diagnosis.
(6) X-ray barium enema is also helpful for diagnosis, especially for the diagnosis of intestinal stenosis due to cancer infiltration, which is superior to colonoscopy.
9. Rectum, colon polyps
(1) is one of the common causes of blood in the stool, especially children and adolescents.
(2) When the rectum, sigmoid colon or descending colon polyps, it is characterized by fresh blood attached to the stool, and the blood and feces are not mixed. If it is a right colonic polyp, the blood can be mixed with the stool, but when the amount of bleeding When large, the blood may be dark red, and when the amount of bleeding is small, it may be black.
(3) A small number of patients have a family history.
(4) X-ray barium enema examination can be seen in the round or oval filling defect, which is helpful for diagnosis.
(5) colonoscopy can find the location, shape and quantity of polyps, and biopsy is feasible to determine the pathological type of polyps.
