Rectal Bleeding—What If It’s Not What You Think It Is?

Noticing blood when you’re wiping or in the toilet can be alarming. While many people assume rectal bleeding is just hemorrhoids, it can sometimes point to other, more serious conditions. Understanding the possible causes, knowing when to seek help, and taking appropriate steps can help you address the issue early—without unnecessary worry.

Common Causes of Rectal Bleeding

Rectal bleeding refers to any blood coming from the anus, whether it’s bright red on toilet paper or darker in the stool. Causes range from mild to serious:

• Hemorrhoids
  Swollen veins in the rectum or anus.
  • Itchy or painful bumps around the anus
  • Bright red blood on toilet paper or in the bowl
• Anal Fissures
  Small tears in the lining of the anus, often due to passing hard stool.
  • Sharp pain during bowel movements
  • Bright red bleeding
• Diverticulosis
  Pouches in the colon wall that can bleed if inflamed (diverticulitis).
  • Sudden, painless bleeding
  • Can be heavy and stop on its own
• Inflammatory Bowel Disease (IBD)
  Ulcerative colitis or Crohn’s disease causes chronic inflammation in the digestive tract.
  • Frequent diarrhea, sometimes with blood
  • Cramping, urgency, weight loss
• Colorectal Polyps or Cancer
  Growths on the colon lining that may bleed.
  • Occult (hidden) bleeding detected by stool tests
  • Changes in bowel habits, weight loss, fatigue
• Upper GI Bleeding
  Sometimes bleeding from the stomach or esophagus appears darker (coffee-ground) or as black, tarry stool (melena).
  • Ulcers, gastritis, varices
  • Reference: Oakland K & Jairath V. define acute lower GI bleeding; but remember that upper sources can mimic it.¹

When It’s More Than Hemorrhoids: Red Flags

Even if you’ve had hemorrhoids before, new or severe symptoms warrant a closer look:

• Heavy bleeding or passing large clots
• Dizziness, lightheadedness, or fainting
• Rapid heartbeat or low blood pressure
• Severe abdominal or rectal pain
• Persistent bleeding despite home care
• Unexplained weight loss or fatigue

If you experience any of these, do not wait—seek medical evaluation immediately.

The Role of Liver Disease in Bleeding

Bleeding can sometimes stem from liver disease rather than the colon or rectum:

• Compensated Cirrhosis
  In early cirrhosis, the liver still works but scar tissue builds up. Over time, this can cause portal hypertension (high pressure in the vein carrying blood from the intestines to the liver).²
• Esophageal or Rectal Varices
  Enlarged veins that develop from portal hypertension can rupture and bleed heavily.
• Hyponatremia and Mortality Risk
  Low blood sodium in cirrhotic patients predicts worse outcomes and increases bleeding risk.³

If you have liver disease, regular monitoring and prompt treatment of portal hypertension are essential to prevent life-threatening bleeds.

First Steps at Home

For mild bleeding you suspect is from hemorrhoids or fissures, you can try:

• Increasing fiber intake (fruits, vegetables, whole grains)
• Drinking plenty of water to soften stools
• Over-the-counter stool softeners or bulk-forming laxatives
• Warm sitz baths for 10–15 minutes, 2–3 times daily
• Applying over-the-counter hemorrhoid creams or suppositories

Keep track of bleeding episodes: note the color, amount, and timing. This information will help your healthcare provider.

When to Seek Urgent Care

Call emergency services or go to the nearest ER if you have:

• Profuse bleeding (soaking more than one pad per hour)
• Blood clots or maroon-colored stools
• Signs of shock: cold, clammy skin; rapid breathing; confusion
• Severe abdominal pain or tenderness
• Vomiting blood or passing black, tarry stools

Delaying care in these situations can lead to serious complications.

Medical Evaluation and Testing

To pinpoint the source of rectal bleeding, doctors may recommend:

• Anoscopy or Proctoscopy
  Direct look at the anal canal and lower rectum for hemorrhoids or fissures.
• Flexible Sigmoidoscopy
  Examines the lower colon for polyps, inflammation, or bleeding sites.
• Colonoscopy
  Full evaluation of the colon; can detect polyps, tumors, diverticula, and IBD.
• Upper Endoscopy
  If melena or risk factors for upper GI bleeding are present.
• Stool Tests
  Check for occult (hidden) blood or infections.
• Imaging Studies
  CT angiography or tagged red blood cell scans if bleeding is brisk and source is unclear.

Treatment depends on the cause:

• Banding or sclerotherapy for bleeding hemorrhoids
• Endoscopic removal of polyps or cauterization of bleeding vessels
• Medications to reduce inflammation in IBD
• Beta-blockers or shunt procedures to lower portal pressure in cirrhosis
• Surgery for severe diverticulitis or tumors

Free, Online Symptom Check

Not sure where to start? You might consider doing a free, online symptom check for a quick assessment of your symptoms and guidance on next steps.

Take-Home Points

• Rectal bleeding isn’t always hemorrhoids. It could signal diverticular disease, IBD, polyps, cancer, or varices.
• Note bleeding details: color, quantity, accompanying symptoms (pain, dizziness).
• Seek urgent care for heavy bleeding, clots, faintness, or other red-flag symptoms.
• Early evaluation—through anoscopy, colonoscopy, or imaging—improves outcomes.
• If you have known liver disease, be extra vigilant about variceal bleeding.

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If you experience any life-threatening or serious symptoms—heavy bleeding, fainting, chest pain, or severe abdominal pain—please speak to a doctor or go to the nearest emergency department right away. Always discuss rectal bleeding with your healthcare provider to rule out serious conditions and get the treatment you need.

References:

1. Oakland K, Jairath V. Acute lower gastrointestinal bleeding: definition, pathophysiology… Digestion, 2018.
2. Gines P, Quintero E, Arroyo V. Compensated cirrhosis: natural history and prognostic… N Engl J Med, 1987.
3. Kim WR, Biggins SW, Kremers WK. Hyponatremia and mortality among patients on the liver-transplant… N Engl J Med, 2008.