Colonoscopic Findings of Patients with Rectal Bleeding: Insights from a Single Centre Study

Abstract

Introduction

Rectal bleeding is a common symptom prompting an urgent investigation. Colonoscopy plays a crucial role in diagnosing the underlying cause and guiding treatment. We aimed to analyze colonoscopic findings in patients with rectal bleeding at a single center.

Methods

A retrospective review was conducted on the medical records of patients who underwent colonoscopy for suspected rectal bleeding. Data collected included demographics, clinical presentation, colonoscopic findings, and final diagnoses.

Results

A total of 205 patients underwent colonoscopy for rectal bleeding. The mean age was 47.35 ± 14.6 years, with a male predominance of 57.5%. Hematochezia was the most common presentation (73%), followed by melena (18%) and maroon stools (9%). Colonoscopy identified 5 different sources of bleeding. Hemorrhoids were the most common endoscopic finding (76%), followed by combined hemorrhoids and colonic polyps (38%), colonic polyps alone (28%), and colorectal cancer (20%). No lesions were detected in 10% of patients. The left colon emerged as the most frequent site for bleeding lesions (88.1%). Age influenced the distribution of endoscopic findings. Hemorrhoids were prevalent in both age groups, but the presence of both hemorrhoids and polyps/masses was more frequent in younger patients (<45 years). Rectal ulcers were observed exclusively in younger patients, while CRC showed a slightly higher prevalence in this group.

Conclusion

Hemorrhoids are the leading cause of LGIB in Upper Egypt, with a higher prevalence compared to other regions. The left colon was the common location for bleeding lesions. Age may influence the causes of LGIB, younger patients present more frequently with combined pathologies.

Keywords

colonoscopy - lower gastrointestinal bleeding - LGIB - hemorrhoids - colon cancer

Introduction

Gastrointestinal (GI) bleeding is a term used for defining any bleeding that occurs within the GI tract from mouth to anus. GI bleeding can be categorized according to its origin into upper and lower GI bleeding; both are differentiated commonly by the ligament of Treitz. Bleedings proximal to the ligament are considered upper GI bleedings, while distal bleedings are considered lower GI bleedings. Categorization into one of the two groups is important as it directs the evaluation and management of the patients.[1] Lower gastrointestinal bleeding (LGIB) presents a significant clinical challenge, causing anxiety for patients and demanding meticulous investigation by gastroenterologists. Characterized by rectal bleeding in various forms, ranging from bright red blood to melena (dark, tarry stools), LGIB, while less frequent than upper GI bleeding (UGIB), can lead to substantial healthcare resource utilization and poses a potential risk of serious underlying pathologies.[1] Understanding the diverse causes of LGIB is crucial for optimal management. Etiology encompasses a spectrum of factors categorized as anatomic (hemorrhoids, diverticular disease), vascular (angiodysplasia), inflammatory (inflammatory bowel disease- IBD), and neoplastic (malignancies).[2] Additionally, risk factors can vary depending on age, medical history, and medication use. For instance, elderly patients and those taking antithrombotic medications are at an increased risk of bleeding complications.[3] Rectal bleeding is regarded as a warning sign, particularly for colorectal cancer, which is the second-leading cause of cancer-related death worldwide.[2] The epidemiology of rectal bleeding in the community is poorly understood. Therefore, it would be crucial to determine what characteristics might lead rectal bleeders to seek medical assistance. Rectal bleeding prevalence data are available, but population-based research is few, and healthcare-seeking behavior is not clearly understood.[3] Accurate diagnosis of the LGIB source is paramount for effective patient management and preventing recurrent bleeding episodes. Colonoscopy has emerged as the gold standard diagnostic tool, offering both visualization and therapeutic capabilities.[4] Advancements in colonoscopic techniques and improved bowel preparation protocols have significantly enhanced its accuracy and efficiency for LGIB evaluation.[5] Understanding the specific clinical characteristics and contributing factors associated with LGIB in a particular population is essential for tailoring diagnostic and therapeutic approaches. Regional variations in disease prevalence and risk factors necessitate geographically focused research to inform local clinical practice. This study delves into the characteristics and endoscopic presentations of patients presenting with LGIB at Aswan University Hospital in Upper Egypt. Our primary objectives were to: describe the demographics and baseline medical history of the study population, evaluate the completion rate and factors influencing successful colonoscopy for LGIB diagnosis, analyze the prevalence of different causes of LGIB identified through colonoscopy, investigate the distribution of bleeding lesions within the colon, and finally identify potential associations between specific comorbidities and the identified causes of LGIB. Through this comprehensive analysis, we aim to contribute valuable insights into the unique clinical presentation and risk factors associated with LGIB in patients from Upper Egypt. These findings can inform the development of culturally sensitive and evidence-based diagnostic and management strategies for LGIB in our region.

Methods

This study employed a retrospective cohort design to investigate factors associated with lower gastrointestinal bleeding (LGIB) among adult patients at Aswan University Hospital in Egypt. The study received ethical approval from the Institutional Review Board (IRB) at Aswan University Hospital (Asw.U. / 675 / 10 /22).

Data Source and Participants

Electronic medical records (EMR) from the Department of Tropical Medicine and Gastroenterology at Aswan University Hospital served as the data source. The study period spanned four years, from September 2015 to September 2019. We identified a total of 256 adult patients (aged 18 years or older) who underwent colonoscopy for suspected rectal bleeding during this period. Patients with incomplete medical records or those who underwent colonoscopy for reasons other than suspected rectal bleeding (e.g., surveillance colonoscopy for a previous diagnosis) were excluded. This resulted in a final sample size of 205 patients for analysis.

Data Collection

A standardized data collection form was developed to extract relevant information from the EMRs. This form captured demographic details (age, gender, ethnicity), and clinical presentation (symptoms such as bleeding frequency, abdominal pain, and changes in bowel habits; medical history including comorbidities and previous surgeries; and medications used). Additionally, colonoscopic findings were recorded, including the location and type of colonic lesions (e.g., polyps, angiodysplasia, diverticula, colitis) and any biopsies performed. Finally, the form documented final diagnoses based on a combination of colonoscopy findings, pathological reports, and other investigations (e.g., imaging studies).

Data Analysis

Statistical analysis was performed using the Statistical Package for Social Science (IBM SPSS) version 20. Descriptive statistics were employed to summarize both qualitative data (presented as numbers and percentages) and quantitative data (presented as mean, standard deviation, and ranges for parametric data and median with interquartile range for non-parametric data). Chi-square and Fisher exact tests were used for comparisons of categorical variables, while independent t-tests and Mann-Whitney tests were used to compare continuous variables depending on their distribution (parametric or non-parametric). For comparisons involving more than two groups, one-way ANOVA and Kruskal-Wallis tests were employed for parametric and non-parametric data, respectively. The significance level was set at p < 0.05. To maintain patient confidentiality, all data were anonymized during analysis and reporting.

Results

Our analysis included a total of 205 patients with lower gastrointestinal bleeding (LGIB). Men were slightly more prevalent, accounting for 57.6% (n = 118) of the study group compared to 42.4% (n = 87) of females. Age distribution across different groups showed no statistically significant differences. Interestingly, over 90% (n = 188, 91.7%) of the patients reported no family history of colorectal cancer (p-value < 0.0001). [Table 1]. Among the 205 patients enrolled in the study, endoscopy completion was achieved in a high proportion (81.5%, n = 167). However, incomplete examinations due to poor bowel preparation occurred in 18.5% (n = 38) of cases, highlighting the importance of proper preparation procedures (p-value < 0.0001). Baseline hemoglobin levels varied considerably, ranging from 5.9 to 15.8 g/dL. The average hemoglobin level was 11.57 g/dL with a standard deviation of 1.95 g/dL. This study investigated the endoscopic findings of 205 patients who underwent colonoscopy for suspected LGIB at Aswan University Hospital. As illustrated in [Fig. 1], hemorrhoids emerged as the most prevalent endoscopic diagnosis, identified in 37.3% of patients. Interestingly, 18.6% of patients were presented with both hemorrhoids and colonic polyps. Colonic polyps alone were observed in 13.7% of cases, followed by colorectal cancer in 9.8%. Notably, 4.9% of patients had no detectable lesions during colonoscopy. Our analysis of colonoscopic findings revealed a significant trend regarding the location of colonic lesions (p-value = 0.047). The left colon emerged as the most frequent site for these lesions, accounting for 88.1% of cases. Notably, a small percentage of patients presented with lesions in both the right and left colon (7.7%), while lesions solely located in the right colon were identified in only 4.1% of patients. This finding underscores the importance of complete colonoscopy during LGIB evaluation, particularly for patients in our region where right-sided colonic lesions appear to have a significant prevalence. This distribution is depicted in [Fig. 2]. Regarding endoscopic findings and age distribution ([Table 2]), While hemorrhoids were the most common endoscopic finding overall, our analysis in [Table 2] revealed interesting age-related trends (p-value = 0.001). Here's a breakdown of the key observations: Both age groups exhibited a high prevalence of hemorrhoids, with 27% in patients under 45 years old and 37.3% in those over 45. The presence of both hemorrhoids and colonic polyps or masses was more frequent in the older age group (25.4%) compared to the younger group (3%). Rectal ulcers were identified exclusively in patients under 45 years old (19.4%), suggesting a potential association with factors more prevalent in this age group. The prevalence of colorectal cancer was present in both age groups, with a slightly higher prevalence in older patients (13%) compared to younger patients (3%). Colonic polyps were observed in both age groups (12.3% in older patients and 16.4% in younger patients), with a slightly higher prevalence in the younger age group. These findings suggest that age may influence the underlying causes of LGIB. Further investigation into the specific risk factors associated with each age group could be valuable for informing targeted diagnostic strategies. The workflow of the study is summarized in [Fig. 3].

Fig. 1 Prevalence of Endoscopic Lesions in Patients with Lower Gastrointestinal Bleeding.

Fig. 2 Distribution of Colonic lesions according to their site (no = 194)

Fig. 3 workflow of the study

Table 1 Socio-demographic and clinical characteristics of the studied patients with bleeding per rectum

Variables	No = 205
Age /years (± SD)	47.3 ± 14.6 (13-75)
Gender (M/F)	118/87
First-degree family history of Cancer colon	17 (8.3%)
Co-morbidities DM HTN DM + HTN CKD CKD +/DM, HTN&IHD IDH No	24 (11.7%) 39 (19.02%) 11 (5.3%) 5 (2.4%) 18 (8.7%) 1 (0.5%) 107 (52.2%)
Examination Complete colonoscopy Incomplete colonoscopy	167 (81.5%) 38 (18.5%)
HB level at the time of examination mg/dl (± SD)	11.7 ± 1.9 (5.9–15.8)

Table 2 The relationship between age and the colonoscopic findings as a cause of LGIB in the studied patients

Cause of LGIB (no = 205)	Age group / years		P value
	Patients less than 45years n (%)	Patients more than 45 years n (%)
Polyp	11 (16.4%)	17 (12.3%)	0.001
Hemorrhoids	25 (37.3%)	51 (27.0%)
Vascular telangiectasia	1 (3.0%)	7 (5.1%)
Rectal ulcer	13 (19.4%)	0 (0.0%)
Colorectal cancer	2 (3.0%)	18 (13.0%)
Diverticulosis	2 (3.0)	3 (2.2%)
Anal fissure	2 (3.0)	2 (1.4%)
Hemorrhoids & polyp/mass	3 (3.0%)	35 (25.4%)
Normal	7 (10.4%)	3 (2.2%)
Other lesion	1 (1.5%)	2 (1.4%)

Discussion

Lower gastrointestinal bleeding (LGIB) is a prevalent condition, affecting 20-30% of patients with major GI bleeding.[3] Studies suggest that 80-85% of LGIB sources originate below the ileocecal valve, with the remainder stemming from the small intestine or upper GI tract.[1] Patients typically present with a variety of symptoms, including rectal bleeding (bright red blood, brisk bleeding, or melena).[1] While upper GI bleeding (UGIB) is statistically more common, underreporting of LGIB may contribute to this discrepancy.[5] LGIB incidence is higher in older individuals and those on multiple medications, particularly antithrombotic drugs, which elevate bleeding risk, recurrence, and mortality among elderly patients.[6] Colonoscopy has become the gold standard for diagnosing and managing LGIB, with increasing demand and a decreasing complication rate.[7] Its diagnostic accuracy for LGIB is estimated at 85.7%.[8] Several factors contribute to LGIB, categorized as anatomic (hemorrhoids, diverticulosis), vascular (telangiectasia, ischemia), inflammatory (infections, idiopathic, radiation-induced), and neoplastic (masses, polyps).[9] Associated symptoms can offer valuable clues. Abdominal pain, fever, diarrhea, vomiting, weight loss, or intestinal obstruction are crucial for differential diagnosis. Age and medical history (e.g., NSAID use) can also inform management strategies.[9] Our study identified hemorrhoids (37.1%) as the most prevalent cause of LGIB, followed by polyps (13.7%) and malignant growths (9.8%). Polyps and malignancies were more common in patients over 45. Diverticulosis, vascular angiodysplasia, and ulcerative proctitis were less frequent causes (2.4%, 3.9%, and 6.4%, respectively). Diverticulosis and angiodysplasia were more prevalent in those over 45, while ulcerative proctitis was more common in younger patients. Notably, 10 patients had normal colonoscopic findings. Our findings align with various studies highlighting hemorrhoids as a leading cause of LGIB.[8] However, some studies report diverticulosis as more common.[10] This variation may reflect regional differences or patient populations.

Regarding hemorrhoids and Contributing Factors: Hemorrhoid prevalence is likely underestimated due to cultural and behavioral factors influencing help-seeking behavior, particularly in Upper Egypt. Studies suggest that roughly 5% of the US population experiences symptomatic hemorrhoids at some point.[11] Straining during defecation, often caused by constipation, is a significant risk factor.[12] The high constipation prevalence in the Middle East (around 14%)[13] [14] [15] may explain the high incidence of hemorrhoids as a cause of LGIB in our study. Interestingly, our study identified a significant association between hemorrhoids and systemic hypertension (p-value < 0.0001). While this may be partially due to both conditions being more common with age, a clearer relationship exists between hemorrhoids and portal hypertension. In our study, chronic liver disease patients exhibited a significantly higher prevalence of hemorrhoids (p-value = 0.025). As regards to polyps and colorectal cancer: Colorectal adenomatous polyps exhibit significant global variations in prevalence. Estimates suggest an average adenoma prevalence of 10% and 25% through sigmoidoscopy and colonoscopy, respectively, in asymptomatic individuals.[16] This aligns with our study's polyp prevalence in LGIB patients. Colorectal cancer (CRC) is a prevalent global malignancy, ranking as the fourth leading cause of cancer death.[17] In Egypt, previous studies report CRC representing 6.5% of all malignant tumors, with a slight male predominance (4.2% vs. 3.8% females).[18] The National Cancer Institute registry at Cairo University suggests CRC became the sixth most commonly recorded tumor in 2002-2003, with 14.0% of colonoscopies revealing its presence.[19] [20] Our study found colorectal malignancies to be the third most common cause of LGIB (9.8%). Several studies highlight diabetes mellitus (D.M.) as a risk factor for colon and rectal cancer.[21] [22] Our study observed a significantly higher prevalence of colorectal cancer among diabetic patients compared to non-diabetics (p-value < 0.0001). on the other hand, a potential link exists between colorectal tumors & polyps and ischemic heart disease. Regarding diverticulosis, angiodysplasia, and contributing factors: Our study identified diverticulosis as a contributor to LGIB in 2.4% of cases. Interestingly, we found a significant association between diverticulosis and hypertension (p-value < 0.0001) and coronary artery disease (CAD) (p-value = 0.013). This aligns with research by Yeo et al. who also reported a positive correlation between hypertension and diverticulosis.[23] Vascular angiodysplasia was identified most frequently in patients with chronic kidney disease (CKD) within our study, which is consistent with established knowledge. Angiodysplasia is recognized as the leading cause of recurrent LGIB in CKD patients.[24] Our findings further support this connection by demonstrating a significant association between angiodysplasia and CKD (p-value < 0.0001). However, our results regarding the link between angiodysplasia and diabetes mellitus (p-value = 0.011) differ from those of Kim et al. who found no such association.[25] Regarding Colon Ulcers: Several factors can contribute to colon ulcers, including inflammatory bowel diseases (ulcerative colitis and Crohn's disease), infections, ischemia, and NSAID use. All of these factors were identified as potential causes of LGIB in our study. NSAID-induced ulcers: These ulcers are a clinically significant cause of LGIB. The mechanism of injury is thought to be similar to that seen in the upper GI tract, involving a combination of direct mucosal damage and the antiprostaglandin effects of NSAIDs.[26] [27] Inflammatory Bowel Disease (IBD): IBD incidence is rising in Arab countries, with ulcerative colitis exhibiting an incidence rate of 2.33 per 100,000 persons per year and Crohn's disease at 1.46 per 100,000 persons per year.[28] Our study found a slightly higher prevalence (5.3%), potentially due to our center at Aswan University Hospital being a referral center for Upper Egypt governorates. Notably, Elbadry et al. reported that over half (54.6%) of ulcerative colitis cases presented with rectal bleeding.[28] [29] As regards to Lesion Locations: The distribution of pathological findings in our study revealed a predominance in the anal canal (57.1%). Other locations included the rectum (32.7%), sigmoid colon (16.6%), descending colon (9.8%), ascending colon (9.8%), and transverse colon (4.4%). This finding aligns with global trends, with high statistical significance (p-value < 0.0001). It's important to note that multiple endoscopic findings in various locations were observed in some patients. For instance, research suggests that angiodysplasia is most found in the cecum and ascending colon (54%), followed by the sigmoid colon (18%) and rectum (14%).[25] Similarly, colonic ulcers caused by NSAIDs are often present in the terminal ileum and proximal colon, where medications may reside for longer durations. Colorectal cancers, on the other hand, are more frequently located in the proximal colon and rectum compared to other segments.[30] While our study provides valuable insights into the characteristics of LGIB patients in Upper Egypt, it has limitations. The retrospective design and relatively small sample size restrict the generalizability of the findings. Despite these limitations, our investigation highlights the critical role of evaluating LGIB and analyzing bleeding sources for proper management. This comprehensive approach can ultimately contribute to reducing morbidity and mortality rates associated with LGIB.

Conclusion

Our analysis of 205 patients with lower gastrointestinal bleeding (LGIB) at Aswan University Hospital revealed interesting insights. While males were slightly more prevalent, age distribution showed no significant differences across groups. Notably, a very low percentage of patients reported a family history of colorectal cancer. Encouragingly, the colonoscopy completion rate was high, but improper bowel preparation hindered some procedures. In terms of comorbidities, essential hypertension was the most common, followed by diabetes. However, a significant portion of patients had no reported comorbidities, suggesting LGIB can occur even in individuals without pre-existing medical conditions. The study also identified the left colon as the most frequent location for bleeding lesions. This finding underscores the importance of complete colonoscopy for accurate diagnosis. Overall, this investigation provides valuable preliminary data on the characteristics and endoscopic presentations of LGIB patients in our center. Future studies with larger and prospective designs could further explore risk factors specific to our population and optimize management strategies for LGIB.

Conflict of Interest

The authors declare that they have no relevant competing interests.

Ethics Approval

Non-applicable, being a review article with no patient-related data.

Authors Contributions

ME, AM: Study design; MAT and NHE: data analysis; MT and NHE: patient recruitment, data collection, and writing up of the first draft of the paper. All authors revised and approved the final version of the manuscript.

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Publication History

Received: 25 July 2024

Accepted: 22 May 2025

Article published online:
20 June 2025