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The case of the bloody toilet

Editor's note: Mike Natter, a medical student at Sidney Kimmel Medical College at Thomas Jefferson University, frequently takes notes in the form of cartoons to make what he's learning more memorable. Here's how he captured, in pictures and words, a scenario he composed from his textbooks and patients he's seen during family medicine clinical rotation.

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@mike_natterRead moreMike Natter

Editor's note: Mike Natter, a medical student at Sidney Kimmel Medical College at Thomas Jefferson University, frequently takes notes in the form of cartoons to make what he's learning more memorable. Here's how he captured, in pictures and words, a scenario he composed from his textbooks and patients he's seen during family medicine clinical rotation.

Alarmed at seeing blood in the toilet after a bowel movement, a man in his late 50's went to see his family doctor. He was in no pain, and had neither nausea nor vomiting, but he was chronically constipated.

He drives to work, and doesn't get much exercise other than cutting the grass and playing an occasional round of golf.

At 210 pounds, he's overweight, and admits to preferring steak and potatoes over fresh fruit and vegetables. He takes metformin for Type 2 diabetes, a diuretic for high blood pressure, Tylenol for mild osteoarthritis, and a multivitamin every day. He quit smoking about 10 years ago.

A rectal exam showed his prostate to be normal in size and texture, however, the doctor did note small, fleshy protrusions. The guaiac test to check for blood in the stool was positive.

What's the source of the blood?

The Solution:

When evaluating lower gastrointestinal bleeding, it is important to rule out the most dangerous potential causes - such as colorectal cancer.

All adults over 50 should have a screening colonoscopy every 10 years, more often if they have a history of polyps.

Another possible cause of blood in the stool is inflammatory bowel disease (Crohn's or ulcerative colitis), which is an inflammation of all or part of the gastrointestinal tract. Diverticular disease, small out-pouchings of colonic tissue that may become inflamed, can also cause bleeding.

A less likely reason would be an infection with pathogens such as E. coli, usually from ingesting undercooked meat. However, this would typically be accompanied by diarrhea, fever, and abdominal bloating and pain.

Even rarer causes could include angiodysplasia (small, malformed blood vessels that are prone to bleed).

This patient was relieved to hear that the problem was hemorrhoids - dilated veins that push out through the rectal or anal skin. Bleeding with hemorrhoids usually is not as heavy as this patient experienced, so his alarm was understandable.

His doctor was pleased that he came in, and not just because of the many serious conditions bleeding can indicate. Hemorrhoids are often a sign that sufferers need to eat more fiber, drink more water, and exercise, as well as watch their weight - all steps that will benefit not only this patient's hemorrhoids, but also his overall health and well-being.

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