Fifty Shades of Red: Calling a GI Consult for Rectal Bleeding

When calling Gastroenterology (GI) for a consult for bleeding, there are many descriptors you should provide to help determine the location of a bleed and the urgency in which a bleed needs management.

The first and most important descriptor is color. Describing the color of the stool accurately, helps the GI team to determine the location of the bleeding. Coffee ground, bright red, maroon, or black are all acceptable descriptors. Dark, however, is not! Are you describing dark brown (which is normal) or black (which is abnormal). The best way to tell is to do a rectal exam and smear the stool. If it’s still too difficult to determine, take a picture or leave the stool in the toilet bowl for the Gastroenterology team.

Melena describes black, tarry stool; black like the color of my hair or black like ink are ways that I describe melena to patients. This stool has a very distinct foul smell. Usually upper GIBs causes melena; however, a slow small bowel or right sided colon bleeding can also cause melena. Maroon or dark red blood or burgundy can occur from bleeding anywhere in the tract, but are more likely from the colon. Being able to differentiate this from melena and bright red blood is difficult but key. Bright red blood is self-explanatory. It reflects arterial bleeding usually from an anorectal source, but can reflect more brisk bleeding from diverticular disease or even upper GIB.

Melena Upper GIB or slow small bowel or right colonic bleed
Maroon Lower GIB
Bright red blood Lower GIB or brisk upper GIB

Just today, I got called about a patient with “maroon” stools, but on rectal exam, the stool was the epitome of melena: black and tarry. It isn’t uncommon to hear every person of a team to report a different color. In fact, a survey of house staff’s perception of stool color was assessed and compared to the GI fellow and attending. Turns out over 50% of the time, the stool color was described inappropriately.

Other important descriptors:

  1. Quantity: A few drops of blood on the toilet paper suggest rectal outlet issues like hemorrhoids or a fissure; however, a cupful of blood might suggest more of a diverticular bleed, which would need more immediate attention. Encourage patients to report estimates in common measurements: teaspoon, tablespoon or cup.
  2. Presence of clots: Clots can indicate a more significant bleeding requiring intervention. Don’t worry, no one expects you to sift through the stool looking for clots. Just ask the patient or the medical assistant that has to clean the patient up.
  3. Medications: Aspirin (81mg-baby dose or 325mg-big mama dose), anti-coagulants, and anti-platelet agents increase your risk of bleeding. NSAID use is another huge risk factor for bleeding. Patients rarely know them as NSAIDS, so you have to ask about individual drugs: Advil, Ibuprofen, Aleve, Motrin, Naproxen, etc. Lastly, is the patient taking any medications that can stain the stools black like iron or bismuth containing products (like Pepto Bismol) or red (like beets and red food coloring).

If you’re calling a GI consult for bleeding, these are some important details to provide your GI fellow. This way they can triage patients who need a procedure urgently. 





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