A 36-year-old man comes to the office after experiencing intermittent episodes of rectal bleeding over the past 2 months. Initially, he noted only small streaks of blood on the tissue when wiping, but yesterday he dripped bright red blood after defecating and the stool was coated with blood. He has had no anal or abdominal pain, nausea, vomiting, anorexia, or weight loss. The patient has been having bowel movements every 2 or 3 days, which is unchanged from his previous routine. He has no other medical concerns and takes no medications. The patient's father was diagnosed with colon cancer at age 54. Blood pressure is 130/70 mm Hg, and pulse is 80/min with no orthostatic changes. Physical examination shows a soft and nontender abdomen with no masses or organomegaly. Inspection of the perianal skin shows no abnormalities. No mass or tenderness is palpable on digital rectal examination. Anoscopy reveals purplish mucosal bulges. Which of the following is the best next step in management of this patient?

Question

A 36-year-old man comes to the office after experiencing intermittent episodes of rectal bleeding over the past 2 months.  Initially, he noted only small streaks of blood on the tissue when wiping, but yesterday he dripped bright red blood after defecating and the stool was coated with blood.  He has had no anal or abdominal pain, nausea, vomiting, anorexia, or weight loss.  The patient has been having bowel movements every 2 or 3 days, which is unchanged from his previous routine.  He has no other medical concerns and takes no medications.  The patient's father was diagnosed with colon cancer at age 54.  Blood pressure is 130/70 mm Hg, and pulse is 80/min with no orthostatic changes.  Physical examination shows a soft and nontender abdomen with no masses or organomegaly.  Inspection of the perianal skin shows no abnormalities.  No mass or tenderness is palpable on digital rectal examination.  Anoscopy reveals purplish mucosal bulges.  Which of the following is the best next step in management of this patient?

Quizplus · Accepted Answer

11ec25c8_d0cf_0e29_bc81_6f8754a49b0a_MD0003_00 This patient has painless, bright red rectal bleeding and mucosal bulges on anoscopy consistent with internal hemorrhoids. Hemorrhoids are the most common cause of low-volume rectal bleeding, especially in patients who do not have red-flag features (eg, passage of dark blood or blood mixed with stool, fever, abdominal pain, change in bowel habits) to suggest more serious causes. The diagnosis is usually obvious based on clinical findings. Anoscopy is useful for those whose hemorrhoids are not palpable on examination, but further diagnostic testing is not usually required for young, otherwise healthy patients with typical symptoms, such as this patient. Initial management of uncomplicated hemorrhoids includes increased intake of fluid and fiber (eg, psyllium husk), reduction in fat and alcohol intake, and regular exercise. Additional measures may include phlebotonics (eg, calcium dobesilate), topical hydrocortisone, astringents (eg, witch hazel), and local anesthetics (eg, benzocaine, lidocaine). More aggressive management, including rubber band ligation and surgical hemorrhoidectomy, is generally advised only for patients with refractory symptoms or prolapsed hemorrhoids that cannot be reduced manually (ie, grade IV hemorrhoids) (Choice D). grade IV hemorrhoids (Choice A) Biopsy is warranted for pedunculated or sessile colorectal polyps, which typically present as pink, red, or flesh-colored papules or masses. The purplish bulges in this patient are typical for hemorrhoids, and biopsy would lead only to unnecessary bleeding. (Choice C) Colonoscopy is recommended for patients who have profuse rectal bleeding or who are at high risk for colorectal cancer. High risk features include prior adenomatous colon polyps, age ≥50 (unless the patient has had a negative colonoscopy within the last 2-3 years), age 40-49 with a first-degree relative with colorectal cancer at age <60, or a familial colon cancer syndrome (eg, Lynch syndrome). Younger patients, such as this patient, with low-volume bleeding (eg, blood on the surface of the stool, drips in the toilet) and a benign explanation (eg, hemorrhoids) may be monitored without colonoscopy. (Choice E) Topical nifedipine is used to reduce anal sphincter pressure in patients with anal fissures. Fissures can cause bright red rectal bleeding, but are typically associated with severe pain and would not present as a purplish mucosal bulge. Educational objective: Initial management of uncomplicated hemorrhoids includes increased intake of fluid and fiber, reduction of fat and alcohol intake, and regular exercise. Additional measures may include phlebotonics, topical hydrocortisone, astringents, and local anesthetics. Rubber band ligation and surgical hemorrhoidectomy are advised only for patients with refractory symptoms or prolapsed hemorrhoids that cannot be reduced manually. References: Adequate dietary fiber supplement and TONE can help avoid surgery in most patients with advanced hemorrhoids. (http://www.ncbi.nlm.nih.gov/pubmed/28150480)

A 36-Year-Old Man Comes to the Office After Experiencing Intermittent