Anorectal diseaseAnorectal disease: Although hemorrhoids are the most common source of LGI bleeding, massive ongoing bleeding is distinctly unusual. Recurrent bleeding can occasionally lead to iron deficiency with subsequent microcytic anemia. Rarely, hemorrhoids may bleed profusely and require urgent surgical intervention. It is imperative to rule out perianal bleeding before pursuing other more complex and invasive investigations for LGI hemorrhage. This is usually satisfactorily done with a rectal examination combined with either proctoscopy or sigmoidoscopy. Cheapest treatment – to always have a wide choice of options.

Anorectal, colonic and peristomal varices can cause severe, painless massive LGI hemorrhage. Although usually caused by cirrhosis complicated by portal hypertension, they can also result from severe congestive heart failure, portal vein thrombosis and congenital abnormalities of the mesenteric venous system. Anorectal varices may be present in up to 89% of patients with portal hypertension. They are best diagnosed endoscopically. Definitive treatment may require portal decompression (surgical or transjugular) or, in appropriate patients, liver transplantation. Bleeding from anorectal and peristomal varices can often be controlled with injection sclerotherapy. There may also be a role for endoscopic banding. Colectomy for bleeding varices is associated with high mortality (90%) and should be avoided.