Differentials
Anal fissure
SIGNS / SYMPTOMS
Anal fissures are associated with painful bleeding on defecation and possibly a sentinel skin tag (sometimes reported by the patient as a "painful hemorrhoid"). Fissures are seen as linear tears in the anal mucosae, most commonly in the posterior midline of the anal canal.
INVESTIGATIONS
Physical exam.
Crohn disease
SIGNS / SYMPTOMS
Crohn disease affecting the large bowel can present with rectal bleeding and is associated with diarrhea rather than constipation. Family history of inflammatory bowel disease is often present.
INVESTIGATIONS
Endoscopy findings highly variable, depending on disease activity. Characteristically shows "skip areas" with areas of disease with intervening areas of normal mucosa. Usually most severe in the cecum and right colon, with rectum often spared.
Ulcerative colitis
SIGNS / SYMPTOMS
Ulcerative colitis commonly presents with rectal bleeding and is associated with diarrhea rather than constipation. Family history of inflammatory bowel disease is often present.
INVESTIGATIONS
Endoscopy reveals diffuse inflammation and ulceration in cases of acute ulcerative colitis.
Colorectal cancer
SIGNS / SYMPTOMS
History of altered bowel habit (diarrhea and/or constipation), abdominal pain, weight loss, iron-deficiency anemia, colonic polyps, and positive family history suggest colorectal cancer.
INVESTIGATIONS
Endoscopy may reveal mass, stricture, and obstruction. Blood tests commonly reveal anemia.
Anal fistula
SIGNS / SYMPTOMS
Commonly bleeding with a history of a preceding abscess, with continued intermittent bloody/purulent drainage. Visualized as a punctate opening on the anal margin adjacent to the anal canal.
INVESTIGATIONS
Physical exam.
Rectal prolapse
SIGNS / SYMPTOMS
Usually presents as protruding mass per rectum especially with straining. May be associated with mucus or blood-stained discharge, pain, and or fecal incontinence.
INVESTIGATIONS
Physical exam. A defecogram may help distinguish between mucosal prolapse and a full thickness rectal prolapse. Examination under anesthesia may be required to confirm and assess severity.
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