Colonic, anorectal and peristomal varices arise as a complication of portal hypertension and can cause painless, massive lower GI hemorrhage. Nevertheless, it is the more humble anorectal conditions that present more typically with lower GI bleeding. In a review of nearly 18 000 patients with lower GI bleeding, haemorrhoids, fissure and fistula-in-ano were the cause in 11% of patients. It is, therefore, important to thoroughly examine the anorectum early in the evaluation before proceeding to more invasive and complex diagnostic methods. Digital rectal examination, proctoscopy and sigmoidoscopy should be performed in all patients with rectal bleeding. Discovery of benign anorectal disease does not eliminate the possibility of a more proximal bleeding source, and complete colonic evaluation is recommended.
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