This document provides guidance on taking a history and performing a physical examination for a patient presenting with lower gastrointestinal bleeding. Key aspects of the history include determining the onset, nature, and color of bleeding or stools. The physical examination aims to identify potential sources of bleeding based on symptoms like abdominal pain, tenesmus, or pain related to defecation. Differential diagnoses depend on the location and characteristics of bleeding, with colonic sources making up 95% of cases such as diverticulosis, ischemia, or anorectal diseases. A full examination can help narrow the potential causes but may not be diagnostic on its own.

1. HISTORY TAKING AND PHYSICAL
EXAMINATION FOR LOWER GI BLEED

2. HISTORY TAKING
Onset
 acute-ischaemia,meckel’s
diverticulum,angiodysplasia
 Chronic-piles,IBD,Ca,polyps
PILES

3. AGE
 < 50 yrs- infection, anorectal disease, IBD
 > 50 yrs- malignancy, diverticulosis
 Any age- piles
DIVERTICULOSIS

4. PAIN
 Painful-anorectal lesions, Ca anal canal, piles
 Painless- polyps, Meckel’s diverticulum
PAIN IN RELATION TO DEFEACATION
 On defeacation- piles, Ca anal canal
 After defeacation- solitary rectal ulcer
POLYPS

5. TENESMUS
 rectal Ca, ulcerative proctitis, irradiation proctitis
ABDOMINAL PAIN AND BLOODY DIARRHEA
 IBD, infectious diarrhea, Ca colon

6. NATURE OF BLOOD AND STOOLS
 Anorectal bleeding- straining and passing of hard
stools, with dripping of blood
 Piles- blood may splash or drip after defeacation
 Ca anal canal and rectum- streaking of blood on
stools
MALIGNANCY

7. COLOR OF STOOLS
 Brown stools streaked with blood- rectosigmoid or
anal cause
 Large volume of bright red blood- colonic source
 Black stools- upper GI bleed
 Maroon stools- small intestine or right colon
 Bright red blood- anal canal

8.  Bleeding from other sites- indicates systemic
disease/ drug induced bleeding
 Weight loss, anorexia, abdominal pain, vomitting –
malignancy
 Sexual abuse- trauma to anal canal

9. PAST HISTORY
 Radiation
 Heart disease- mesenteric embolism
 Drugs- warfarin, heparin, NSAIDs
 Liver disease- variceal bleeding
 Chronic renal failure

10. FAMILY HISTORY
 Carcinoma

11. PERSONAL HISTORY
 Smoking- peptic ulceration, colorectal Ca
 alcohol

12. CLINICAL EVALUATION
history and physical examination are not usually
diagnostic of the source of GI bleed
Examine all system in detail with special reference
to per rectum examination

13. Patients with massive LGIB usually present with
 bright red blood per rectum
 hypotension
 markedly reduced hematocrit

14. Patients with mild bleeding who may present with
 intermittent passage of maroon-colored stools.

15. DIFFERENTIAL DIAGNOSIS
Colonic bleeding( % Small bowel
95%) bleeding(5%)
Diverticular ds 30-40 Angiodysplasia
ischaemia 5-10 Ulcer
Anorectal ds 5-15 Radiation
neoplasia 5-10 neoplasia
polyp 3-7
IBD 3-4
angiodysplasia 3

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