Blood in the stool: when it is piles, and when it is not

Most rectal bleeding in adults turns out to be haemorrhoids or an anal fissure. But most is not all, and nothing about the way blood looks can tell you which it is with certainty. That is what an examination is for.

Bright red blood on the paper, in the bowl, or streaked down the outside of the stool is the commonest reason people come to a proctology clinic in Dubai. It is also the symptom people put off longest, usually because the bleeding stops for a few weeks and the worry goes with it.

What bleeding from piles usually looks like

Haemorrhoidal bleeding has a fairly consistent pattern. It is bright red rather than dark. It appears at the end of opening the bowels rather than mixed through the stool. It is often painless, which surprises people. It may drip into the bowl or coat the paper, and it usually settles within a minute or two.

None of that is diagnostic on its own. It is a pattern that makes haemorrhoids likely, and it is the pattern that laser haemorrhoidoplasty is designed to treat once the diagnosis is confirmed and the grade is known.

What an anal fissure looks like instead

If the bleeding comes with sharp pain during and after opening the bowels, often described as passing glass or a burning that lasts an hour, a fissure is more likely than piles. The blood volume is usually smaller. Patients often start avoiding the toilet, which hardens the stool and makes the tear worse.

The distinction matters because fissure treatment has a different aim from pile treatment. Treating the wrong one leaves you bleeding.

When bleeding needs more than a proctology examination

Some patterns of bleeding point away from the anal canal and towards the colon. None of them means cancer. All of them mean the bowel should be looked at properly rather than assumed.

• Blood mixed through the stool rather than coating it
• Dark red, maroon or black tarry stool
• A change in bowel habit lasting more than three weeks
• Weight loss you did not intend
• Anaemia, or being told your iron is low
• A family history of bowel cancer or polyps
• New bleeding over the age of 45

Any of these is a reason for colonoscopy rather than treatment on the assumption of piles. It is also worth saying plainly: having haemorrhoids does not protect you from having something else at the same time. Both can be present, and the piles are the easier one to find.

What the appointment actually involves

This is the part people dread, and it is shorter and less undignified than they expect. A history, then an inspection, then a digital examination, then in most cases a proctoscopy, which is a short lubricated instrument that lets the anal canal be seen directly. The whole thing takes a few minutes and does not require sedation.

You leave knowing what you have, what grade it is if it is piles, and what the options are, including the option of doing nothing for now. Nobody is booked for a procedure on the day of a first consultation.

When to be seen the same week

Heavy bleeding that soaks the bowl, bleeding with dizziness or breathlessness, or bleeding with severe unremitting anal pain should not wait for an outpatient appointment. Go to an emergency department.

The point of this page

Not to frighten you. The odds are strongly in your favour. But two or three years of assuming it is piles is two or three years of not knowing, and the examination that settles it takes about ten minutes.

Dr Kerim Erdem Ulucay is a DHA-licensed Specialist General and Laparoscopic Surgeon and a certified laser proctologist, consulting in Jumeirah 1 and JLT. To ask a question before booking, message +971 55 558 4957 or use the contact page.

This article is general information, not a diagnosis. Rectal bleeding should be assessed in person.