A 36-year-old man comes to the office for a routine preventive visit. The patient feels well, but for the past 2 days he has occasionally noticed blood on the tissue paper after defecation. Otherwise, his bowel movements have remained normal in consistency and frequency. He has no melena, vomiting, abdominal pain, or unexpected weight changes. Medical history is unremarkable, and the patient has no family history of malignancy. Vital signs are normal. The abdomen is soft and nontender with normal bowel sounds and no hepatosplenomegaly or masses. Digital rectal examination is unremarkable except for traces of red blood visible on the glove. Which of the following is the most appropriate next step in management?

Question

A 36-year-old man comes to the office for a routine preventive visit.  The patient feels well, but for the past 2 days he has occasionally noticed blood on the tissue paper after defecation.  Otherwise, his bowel movements have remained normal in consistency and frequency.  He has no melena, vomiting, abdominal pain, or unexpected weight changes.  Medical history is unremarkable, and the patient has no family history of malignancy.  Vital signs are normal.  The abdomen is soft and nontender with normal bowel sounds and no hepatosplenomegaly or masses.  Digital rectal examination is unremarkable except for traces of red blood visible on the glove.  Which of the following is the most appropriate next step in management?

Quizplus · Accepted Answer

This patient has minimal bright red blood per rectum (BRBPR). This symptom, characterized by small amounts of bright red blood on the toilet paper after wiping or a few drops of blood in the toilet bowl after defecation, most often is due to benign disorders such as hemorrhoids or anal fissures. However, more serious disorders (eg, proctitis, ulcers, colorectal polyps, cancer) are possible. Clinical factors associated with an increased risk of serious disease in patients with BRBPR include a large amount of blood mixed within stool, systemic symptoms (eg, fever, weight loss), and changes in bowel habits or stool caliber; these factors generally warrant direct visualization of the entire colon with colonoscopy (Choice B). Colonoscopy should also be considered for those age ≥45, for whom colorectal cancer screening via colonoscopy is appropriate regardless of symptoms. However, for younger patients, initial testing with less invasive methods to visualize the anal canal (eg, anoscopy) generally should be performed first. If a benign cause of bleeding (eg, hemorrhoid) is confirmed, conservative management (eg, stool softeners) and interval follow-up is appropriate (Choice E). (Choices C and D) Fecal DNA testing and CT colonography are appropriate screening options for colorectal cancer beginning at age 45 for asymptomatic patients at average risk. They have low sensitivity for small lesions and nonmalignant causes (eg, hemorrhoids, inflammatory bowel disease) of BRBPR and would not be indicated for this patient. Educational objective: Minimal rectal bleeding usually is due to hemorrhoids or other benign conditions. In patients with no clinical features suggesting a serious cause (eg, blood mixed with stool, fever, weight loss, change in bowel habits or stool caliber) and no other indication for colonoscopy (eg, age ≥45), initial evaluation with anoscopy is appropriate.

A 36-Year-Old Man Comes to the Office for a Routine