Test your medicine knowledge with the MKSAP challenge, in partnership with the American College of Physicians.

A 39-year-old woman is evaluated for fatigue, intermittent rectal bleeding, and abdominal pain over the past 2 months. She reports that the bleeding is not accompanied by anal pain or itching. She has experienced an unintentional 2.3-kg (5.1-lb) weight loss since her symptoms started. She has no personal or family history of colon cancer or other cancers. She takes no medication.

On physical examination, her pulse rate is 102/min; other vital signs are normal. BMI is 22. Abdominal examination reveals mild tenderness in the left lower quadrant with no rebound or guarding. Rectal examination shows no masses. Large, friable hemorrhoids are present.

Laboratory studies show a hemoglobin level of 10.5 g/dL (105 g/L) and a serum ferritin level of 5 ng/mL (5 µg/L).

Which of the following is the most appropriate next step in management?

A. Anoscopy
B. Colonoscopy
C. Flexible sigmoidoscopy
D. Topical hemorrhoid treatment

MKSAP Answer and Critique

The correct answer is B. Colonoscopy.

Colonoscopy is the most appropriate next step in management for this patient. Her symptoms of weight loss, abdominal pain, and rectal bleeding with iron deficiency anemia warrant further evaluation with colonoscopy. Inflammatory bowel disease is a possibility in this patient; however, colon cancer also needs to be excluded. In the United States, the overall incidence of colon cancer has decreased by 3% to 4% since the early 2000s; however, in adults younger than age 50 years, the incidence of colorectal cancer is increasing at a rate of 2.1% per year.

Anoscopy enables a limited examination and would not assist in evaluating the patient’s iron deficiency anemia and weight loss.

Flexible sigmoidoscopy allows examination of only the lower third of the colon, and if negative, a full colonoscopy would still be required. There has been a gradual shift from left-sided to right-sided colon cancers. A number of factors have been suggested to explain this, including inadequate colon preparation, incomplete colonoscopy, and difficulty recognizing serrated polyps that are typically flat and occur more often on the right side. However, there also appears to be a true increase in tumors of the proximal and right colon that may be missed if only a sigmoidoscopy is performed.

Hemorrhoids are arteriovenous communications covered by cushions of connective tissue in the anal canal. Internal hemorrhoids cause most hemorrhoidal symptoms (bright red blood dripping in the toilet bowl or seen on toilet paper, with no accompanying pain; a protrusion of tissue; itching; and pain). Patients with alarm features (such as unexplained weight loss, change in bowel movements, iron deficiency anemia, age older than 50 years, or personal or family history of colorectal cancer or inflammatory bowel disease) warrant colonoscopy. Initial treatment of internal and external hemorrhoids consists of dietary and lifestyle modifications to soften bowel movements and avoid constipation, straining, and prolonged time on the toilet. Increased fiber intake has been shown to reduce symptomatic prolapse and bleeding. Local therapy such as topical anesthetics and glucocorticoids may relieve pain and itching, but data to support their use are scant.

Key Point

• Red-flag symptoms such as rectal bleeding with iron deficiency anemia, abdominal pain, and weight loss should prompt evaluation by colonoscopy for colorectal cancer regardless of the patient’s age or the presence of bleeding hemorrhoids.

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