Poop chronicles: there is blood in my stool, and I am skeptical of my doctor's explanation.

July 24, 2012 6:09 PM

My colorectal surgeon has only done a proctoscopy and says the blood in my stool is coming from my hemorrhoids. He wants to treat with sclerotherapy, but I don't want that kind of intervention and still have a weird feeling in my descending colon. What's the medical best practice in a case like this?

Am I worrying unnecessarily, or do I need to demand a colonoscopy? And if so, what's the best way to do that?

Yes, I am not a doctor, you are not a doctor, you are not my doctor, you are not a lawyer, you are not my doctor's lawyer, and you are not my mother. But I'd still like your advice.

The following goes into positively fecal detail. Reader discretion is advised.

My story:

I've been living in Germany for about three years.

I have had anemia on and off for years. The anemia, when present, has always been very mild. I had been a vegetarian for twenty years, and my doctor in Canada (who is also an instructor in family medicine at the university hospital in our area) never felt it was much reason to be concerned. My ferritin was checked a couple of times and always hovered around 95 µg/L.

Last fall, I decided to start giving blood. I wanted to challenge myself and do something good for someone else. I had tried giving blood in my late teens and had a pretty nasty syncope with seizure, so I had always thought that I was done donating blood for good. Well, I tried again in August of last year, and it worked -- I was nervous and I sweated a bit but stayed conscious through the whole thing and walked home a changed man.

I did it two more times in the next five months.

By the time February rolled around, though, I was feeling pretty atrocious. On a visit to see family, I saw my doctor back home in Canada again, and he did a complete blood work up. I had the light anemia again, and a ferritin level of 11 µg/L, which is rather low for a guy in his late thirties.

So I started on iron replacement and changed my diet, switching to a "paleo"-style diet that includes meat, and after about six weeks, I started to feel markedly better.

It is now about four months since I started the iron replacement. About halfway through I switched formulations, and am taking ferrous glycine-sulfate. This works very well. When taking it, I feel better in almost every respect except one: the wicked constipation, which is a well-documented side effect of oral iron supplementation, so I can only assume that's the cause.

Last Tuesday, I had a particularly awful bout. I had not had a bowel movement in three days, which is very unusual for me and also very uncomfortable -- I had pain just under the rib on my left side, about where the descending colon begins. I used a lecithin-bicarbonate suppository, which had the intended effect. When I wiped, though, there was a huge streak of blood on the paper. As this has never happened to me before, I was shocked. There was a dollop of fresh-looking blood in the toilet, perhaps a teaspoon. Concomitant with this - despite my now empty bowel - was a much sharper pain around the upper part of the descending colon. I don't recall any pain in the anal area, but maybe I was too stunned by the blood to notice.

I continued to have blood on and off in the following days. It does seem to be tapering off now. The pain in the colon has also subsided and is almost totally gone now.

I saw my doctor here in Germany today. I explained what was happening and that I was worried. He said that I needn't be; that in someone my age this was almost invariably just a hemorrhoid. He asked me about malignancies in my family history, and I said I didn't know of any (my mother later told me that her grandmother had died of colon cancer). He did a digital rectal exam but couldn't feel anything. He referred me to a colorectal surgeon just to be safe.

I saw the colorectal surgeon right afterward. After hearing my story, he said "that is certainly consistent with hemorrhoids". He stuck a proctoscope in me, told me I had two grade I hemorrhoids, and offered to treat them with sclerotherapy (polidocanol) right on the spot. Now, if there's one thing I have learned over the years, it's that it is a bad idea to make decisions about your treatment when somebody has a cold metal instrument in your ass. I demurred and said I would like to think about it before we go ahead. When I thought about it later, I thought he'd been awfully quick to suggest this kind of treatment, especially for grade I. (He also failed to mention the very high rate of recidivism with sclerotherapy.)

My question is this: is this sufficient investigation? Perhaps this blood came from the hemorrhoids, but what if it came from farther up the colon? I was struck by the fact that the blood was only ever visible at the end of the stool, plus I hadn't really had much in the way of anal pain.

The points suggestive hemorrhoids as the cause are:

- I've been on iron therapy for months, and constipation is a problem
- I have had to strain when taking a dump for some time
- When it appears, the blood is pretty fresh
- I have a tendency toward venous varicosities and have them in a couple of other spots (it runs it the family :) )
- my dad had a similar stubborn anemia, was scoped in his fifties, and came up clean.

On the other hand...

- this sensation in the descending colon is strange
- the blood has so far appeared only at the very end of the log
- my great-grandmother died of colon cancer (albeit in her 70s)
- although I've always thought I had a logical explanation for the mild anemia, this event has got me reevaluating.

Finally, the psychological factor: I lost a very good friend to colon cancer in 2010. He had visible blood in his stool for years (on and off for at least five) and his doctors explained it away as hemorrhoids the whole time. Finally the bleeding got so severe that a colonoscopy was ordered. He was 30 years old, and it turned out to be stage IV, with tumours in the liver. He died at 33.

posted by rhombus to health & fitness (16 answers total)

What exactly does your "descending colon" feel like?

No offense, but I'd listen to the doctor who recently saw your innards, over a vague weird felling.
posted by pla at 6:15 PM on July 24, 2012 [1 favorite]

Based on your last sentence alone, I would be surprised if anything short of a full colonoscopy would make you feel better. And even if there's only a 1% chance that anything is wrong, I think given your history (both familial and friend), if it were me, I would do it.

Note - I have no opinion on if it is *necessary*, but suspect for you it would be worth it. Doctors make mistakes all the time, and are, in my experience, doctors rarely admit a mistake. (I am a former med-school student who quit partially due to the "god-doctor" syndrome.)
posted by dotgirl at 6:17 PM on July 24, 2012 [1 favorite]

For pla and anyone else reading and feeling skeptical, the descending colon is on the left side of the body and inflammation in the descending colon is frequently felt as pain on the left side of the abdomen. It isn't abnormal to be able to identify that.

Personally, I would get a colonoscopy. I don't think you have cancer (it really is very rare in young people, and your symptoms sound consistent with IBS and hemorrhoids brought on by IBS), but it's possible that you have IBD and active inflammation in the colon, and that's something that would be identified by the colonoscopy.

Not sure if things work differently in Germany, but if you can see a gastroenterologist (as opposed to a surgeon) I would also consult with them about your iron supplement as iron supplements are notorious for aggravating bowel problems.
posted by telegraph at 6:45 PM on July 24, 2012

You have been suffering from constipation and now you've got some bright red blood. It certainly sounds very suspicious for hemorrhoids. Hemorrhoids do not have to be painful - they tend to only get painful when they are thrombosed or irritated, and remember some of them are internal so those don't tend to get irritated as often.

If you have bleeding coming from higher up in the GI tract, as you alluded to, the blood is typically not bright red, but dark/black/tarry. That is because blood quite quickly oxidizes (think about how long it takes for it to turn dark after you bleed from a cut - not long) and it takes time for it to get through the bowels. If the bleeding is heavy, it can move fast and come out bright red, but this sounds streaky and not heavy.

The unfortunate fact for you is that even though you know someone who was a statistical anomaly, and had colon cancer at a very young age, that doesn't mean that you are now more likely to be a statistical anomaly too. And because our healthcare system tries at least half-heartedly to control costs, most tests that typically do not get done just because people are worried about something that is unlikely to be happening to them. Tests get done because you have a reasonable likelihood for having the disease, and that means we do miss diagnoses on people who are outside the norm. As they tell us in med school - "when you hear hoofbeats, think horses, not zebras." Doesn't mean the zebras aren't out there, it just means that you shouldn't be looking for them first.

By the way, just because you had just had a large bowel movement doesn't mean your bowels were empty. People with constipation have a TON of stool in their colon and it takes time for it all to move along. And constipation can be pretty painful. Not making any diagnosis on you, just saying. I cannot assure you that you don't have colon cancer, no one can. But I can tell you just as your doctor did that it's very unlikely, and that assuming that it is hemorrhoids is reasonable. Why not just get the hemorrhoids treated, and in the unlikely event you still have significant bleeding - then you'll have much better grounds to argue it might be coming from someplace else.
posted by treehorn+bunny at 7:12 PM on July 24, 2012 [11 favorites]

I just realized I did not answer the main question at the end - what's the medical best practice in this case? I'm not a colorectal surgeon or even a doctor who typically treats hemorrhoids, except thrombosed ones or bleeding ones (they come to the ER).

I believe the medical best practice for grade I hemorrhoids is conservative treatment with sitz baths, high fiber diet, plenty of fluid intake, and stool softeners. If I were you I'd definitely treat them this way before turning to sclerotherapy, although it will take you longer to see results..

You may get a better opinion on this from your primary care doctor instead of a colorectal surgeon. If you go to a surgeon.... well, they do surgery. Although procedures like ligation and sclerotherapy are not major surgery. Yes, there is a recurrence rate that's relatively high with such procedures, but generally if they recur years later, you can again get one of these minor procedures done instead of actual hemorrhoidectomy (see reference above).
posted by treehorn+bunny at 7:42 PM on July 24, 2012

I had hemorrhoids and I bought this thing that my husband makes fun of Best of luck with your bottom.
posted by ibakecake at 8:06 PM on July 24, 2012 [3 favorites]

I had bleeding of the type you describe, along with a feeling like I had to poop even when I didn't have to poop. (The medical term for that is "tenesmus," btw, in case you want something to google.) I'd never had trouble with hemorrhoids until after the birth of my second child, when I had a whopper. I had no other pain.

I called my doctor, who said "Well, it's probably hemorrhoids, but you know, colon cancer has a really bad mortality rate, and it's because people would rather die than have a doctor look at their butthole. So they do. So why don't you come in, and I'll do an exam."

She did her exam, told me I had a couple of internal hemorrhoids that looked as though they might have been bleeding, and said I didn't need to worry -- but I should let her know every time I had blood with defecation. "It won't be an exam every time, but I want to keep track of it." It's never happened again, though I occasionally have the tenesmus.

Given your friend's experience, it is reasonable for you to want a colonoscopy. Largely for psychological reasons, mind you, but psychological reasons are definitely valid, particularly in the presence of symptoms and with a family history. Based on what you're describing, I'd say you almost certainly have hemorrhoids and nothing worse, but I am not a butt doctor or other butt care provider of any stripe.
posted by KathrynT at 9:35 PM on July 24, 2012 [1 favorite]

I have a friend who was diagnosed with stage four colon cancer at 38, and my mother had surgery a few years ago for very early-stage colon cancer, so I'm pretty firmly on the side of "be careful and trust your gut here." But that said, you've had multiple doctors check things out up your butt and they have all declared that hemorrhoids are the likely culprit. Also, bright red blood is a classic hemorrhoid sign, it's getting irritated by the bowel movement. If you had old, dark bloods in your stool sample, that'd be a different thing.
posted by desuetude at 11:38 PM on July 24, 2012

Perhaps this blood came from the hemorrhoids, but what if it came from farther up the colon?

As has been mentioned, blood from further up isn't red and fresh looking so it seems pretty likely that your haemorrhoids are bleeding rather than your colon.

But you've been iron deficient for a decent amount of time and you're an adult male, why has no one been trying to track down the cause of that? I'm not a medical doctor but I did my MSc in iron absorption and iron deficiency and the medical papers I've read all state that the standard of care for an otherwise healthy adult male presenting with iron deficiency is to do a colonoscopy to make sure you're not losing small amounts of blood in there (be it from precancerous lesions or polyps or whatever). At the very least they can do an occult blood test on your stool (although bleeding is generally intermittent so it's not at all conclusive). Trace amounts of blood coming from higher up can't really be seen in your faeces. Your ferritin dropped rather a lot for no apparent reason, this is something to be concerned about and followed up on regardless of the haemorrhoids.

Note that it is totally possible to have iron deficiency anaemia with no colon involvement as an adult male. My father had the colonscopy and everything and his was basically just caused by stress, as an example. But at the very least you should be questioning your doctors about why they aren't concerned about your chronic iron deficiency because it's still not normal.
posted by shelleycat at 12:01 AM on July 25, 2012

Anecdata: my husband had blood in his stool, was told it was probably due to haemorrhoids, but his GP said there was no harm in having a full work up to make doubly sure, so he went for a colonoscopy. They found several large polyps over the course of two procedures, all benign, and he has consistently said how glad he is that he had it done, how much it put his mind at rest about it all.
posted by catch as catch can at 12:54 AM on July 25, 2012 [1 favorite]

OP here. Thank you, everyone, for the thoughtful answers. I want to expand a bit, and would welcome additional feedback if you have any to offer.

@treehorn+bunny: Thanks for the tips on conservative treatment of grade I hemorrhoids, the sober explanation of the chances, and the joys of constipation! I suppose what I really meant was, "what is the medical best practice when a person presents with blood in the stool?" I can totally see the valid arguments for not doing routine colonoscopies on asymptomatic people under 50, but blood in the stool is a symptom (if a common one) and I have to wonder how this affects the probability. (What is that called? Conditional probability, I think -- that's different from independent probability.) One of my physician friends, upon hearing about my afflicted friend, was dumbfounded and asked me why he wasn't scoped sooner, and the only criterion that counted for him was the blood in the stool. He thinks it was inexcusable. Now, he's not a GI doc and this is outside of his specialty, but he's also my "man on the inside" and says that physicians make mistakes all the time, as often as not due to ego and misplaced self-assurance. (I'm thinking about asking him for an opinion on what I should do.)

@treehorn+bunny,shelleycat,desuetude: I get the difference between melena and hematochezia, but I was under the impression that it's a smooth function of where the bleed is located. Is it not possible to have unoxidized or minimally-oxidized blood in the stool that originates in the descending or sigmoid colon? And beyond the concerns about malignancy, there's the simple possibility of a brisk bleed going on just because shards of rock-hard crap are going around a corner. (On the other hand, perhaps that's just normal constipatory pain.) Even if it is only a bleed of purely mechanical origin, though, I'd kinda want to know. Especially considering that I am trying to correct an iron deficiency, here.

@treehorn+bunny: I not keen on the sclerotherapy, because it involves an injectable non-biological substance, leaves scar tissue behind *and* does not prevent recurrence. Ligation is an option I'd be willing to consider but the hemorrhoids are too small. I have to say that this is the first time I've heard of someone wanting to treat a grade I hemorrhoid in this way. Maybe I need to track down a GI doctor. It's funny how similar surgeons are: the colorectal surgeon's practice was vibrating with type A energy, and you're right: surgeons are often not happy unless they are doing something with their hands. When your tool is a hammer, everything looks like a nail.

@shelleycat: this is a legitimate point. As I hinted, the origins of the iron deficiency seemed obvious. I had been vegetarian, and several ferritin tests in the past year put the level at above 90 µg/L, which is supposed to indicate an iron replete condition in most people. Then I donated blood three times in six months. The rule of thumb is a 30 µg/L drop in ferritin for every unit drawn unless there is increased intake, and that kinda fits: 3 x 30 = 90, my previous tests put me at between 90 and 100 µg/L, and when I was tested in February it was 11 µg/L. Ferritin is also an acute phase protein. I suspect there was/is some inflammation somewhere that is skewing the ferritin level upward. Fecal occult blood testing is a waste of time at this point because the standard test is for heme and gives false positives under iron supplementation.

It is interesting to me how different the reactions of doctors have been to my history. The family medicine prof was concerned when he saw the ferritin level until I told him I had donated blood three times in six months (he's the one who prescribed the iron replacement.) The colorectal surgeon thinks the blood donations had nothing to do with it and it's all down to my diet, but that contradicts what I've read, and if just one unit of blood contains 250 mg of iron, I can't see how that wouldn't at least cause a blip.

Final point: one might ask why in hell a person would go to ask metafilter with something like this. The answer is that most doctors have 4000 patients in their waiting rooms and only a few minutes -- there simply isn't time for this kind of discussion and a patient almost never gets the chance to address all the questions. It's one thing to say, "go see a doctor", but when you've already seen two and the answers have been less than satisfying, then what?

At this point I'm leaning towards at least talking about this with a GI doctor and going from there.
posted by rhombus at 1:48 AM on July 25, 2012

Well, here's a lesson: it's all in whom you ask. I called the local GI, and before I was even finished explaining myself the secretary was asking if a colonoscopy had been done yet.

That is now booked for next Tuesday. It's probably nothing, but I'm going to feel better for having done it. Thanks again, everyone.
posted by rhombus at 2:29 AM on July 25, 2012

Can't say anything useful about the colonoscopy aspect - especially since it's scheduled but I do suggest you switch to a liquid iron supplement like Floradix - far less constipating.
posted by leslies at 4:35 AM on July 25, 2012

IANAD and all that, but your description of the pain in the upper end of your descending colon and lower down (plus the blood) sounds extremely similar to my own experience with what turned out to be.... bleeding diverticulae. A sigmoidoscopy revealed that. I would insist on having at least that.
posted by Decani at 4:56 AM on July 25, 2012 [1 favorite]

I'm glad you're getting the colonscopy. I don't know that the recent bleeding is even relevant because there's a likely cause and the anaemia happened first. But just being vegetarian isn't a good reason for a healthy male to be iron deficient, you're not supposed to be losing iron anywhere and you only need very small amounts to keep your iron status normal and there is some iron in vegetables. Then you had that big drop despite eating meat, so you should have been able to replenish the red blood cells even after giving blood (yeah ferritin goes down, but that's just storage, it goes down because it gets used up replenishing your working supply of haemoglobin really fast so the depletion of erythrocytes should be pretty short lived, then the ferritin comes back in it's own time ready to act as a buffer next time to you lose blood).

I can only assume your actual haemoglobin levels never quite got low enough despite the very low ferritin or the places you've been seen use different standard of care guidelines than the UK. Because the NICE guidelines are quite clear. An otherwise healthy adult male with haemoglobin levels of 11 g/100 ml or below is reason enough alone for urgent diagnostic work (and the related guideline says colonoscopy is the best test to start with), you don't need other risk factors or excuses. I've read so many journal papers over the years backing this up, I just assumed that all doctors know this stuff by now.

Fecal occult blood testing is a waste of time at this point because the standard test is for heme and gives false positives under iron supplementation.

Good point and I should totally know that already!


(And don't take Floridix, it's horribly expensive for very little iron plus full of crap that lowers iron absorption. Like so many stupid iron supplements. The iron salt you're taking now is fine and possibly better if you add vitamin C.)
posted by shelleycat at 10:23 AM on July 25, 2012 [1 favorite]

I got the colonoscopy, and it was clean. Not just clean, but really clean: there were not even any hints of polyps.

I did it without sedation (in Europe, that is not uncommon) and I would recommend doing it without sedation. I was able to watch the whole procedure on a video screen. It's only mildly uncomfortable, and only at certain points in the procedure. Other than that it was very relaxed. The best part was that I was able to drive immediately afterwards, no waiting.

I am immensely relieved I had this done, and it would have been worth it to me even if I'd had to pay for the whole procedure out of pocket (which I did not -- the insurance covered it, no questions asked).

The blood almost certainly came from a haemorrhoid (I have that now from not one but two doctors). Better that than something else. (@shelleycat: my haemoglobin was never below 13 g/dL, but the labs flags values under 13.8 in males.)

I've been able to ease up on the iron replacement some, and at the maintenance dose, it is no longer causing grievous constipation. I continue to feel better with each passing month.

Thanks to everyone who answered! You helped me a lot, and I hope to return the favour.
posted by rhombus at 1:14 PM on December 20, 2012 [1 favorite]