Publish 21 December 2021
Crisis on The Throne
Your heart is racing while your unsanitary thumb hovers over the emergency number on your mobile phone. During a toilet tissue inspection after your daily evacuation, you discover the presence of blood. Wipe again and there’s more blood. Before assessing what’s happening, let me share the tragic reaction of one family over 20 years ago.
A meek married couple in their 70s was looking forward to hosting a breakfast in their home on the weekend. Those plans were canceled with the husband’s discovery of rectal blood in the toilet.
As an emergency contact, I received an evening call from a hospital administrator. She inquired about an acceptable alternative after the patient arriving in an ambulance refused a blood transfusion. We discussed saline as a fluid volume replacement and I was on my way there.
Arriving at the hospital emergency room, I comforted the patient’s distraught wife. As next of kin, she was the conduit of information. Attending physicians would not discuss patient details alone with me.
There was an NPO (Latin nil per os) sign over the patient’s bed. In the medical profession, this means “nothing by mouth.” As preparation for surgery, they were not feeding him.
Joined by other friends of the family, we remained throughout the night in the hospital waiting room. The next day, there was no surgery. Nurses were still pumping the NPO patient with saline at regular intervals.
I tried to ascertain how much blood volume they were endeavoring to replace. “Following doctor’s orders” was the reply. The patient could only suck on a moist sponge stick after begging through a dry voice for water. By day three, edema was evident.
The patient, categorized as too serious to transport, found himself trapped in the worst local facility for bloodless medical care. (It has since been shut down.) The doctor finally arrived to consult with the wife in my presence, indicating that they were unable to identify the source of bleeding reported by the patient. His hematocrit was hovering around 10% and kidneys were failing. This, along with his age, decreased chances for surgery.
💉 Saline infusion is a temporary emergency trauma option to keep blood vessels open. This allows the heart and marrow time to accelerate blood production. Too much saline dilutes the hematocrit. This is a measurement of red blood cells, expressed as a percentage. For men, normal hematocrit is 38.3–48.6%. For women, 35.5–44.9% is typical.
Thinking out loud here—the low blood cell count and edema is due to dilution from the massive amounts of saline pumping into the patient. Kidneys were failing because he was dying of thirst in preparation for non-existent surgery. The doctor said he was following protocol recommendations from a sister facility. My concerns were dismissed.
While I went home to freshen up, the doctor spoke to the wife alone about end-of-life options. The next day, her husband succumbed to complications resulting from blood on a toilet tissue.
Bright Red Blood on Tissue
Volume is key in assessing urgency of care. Slight bleeding can occur following excessive wiping after an incomplete evacuation. Undigested hard fiber can scrape the rectum during a bowel movement. You can also have anal fissures (anal ulcers) as a result of straining.
A swollen internal or external hemorrhoid can rupture to relieve pressure. This might expel a spot of blood before coagulation. In terms of volume, we are talking about less than a quarter teaspoon of blood. Though alarming, these are usually minor, self-resolving conditions.
Oxygenated bright red blood signals a problem within the lower part of the digestive system. Expelling a massive quantity of blood through the rectum requires medical attention. The concern becomes a possible inflammatory bowel diseases such as ulcerative colitis, Crohn’s, or rupture within the intestines, tumor.
Following radiology, a gastroenterologists may guide a camera up through the large intestines in a colonoscopy procedure. A doctor may also trace the source of red bleeding to the small intestines or right side of the colon.
Black Blood on Tissue
Foul-smelling tarry black stools is an indication of bleeding in the upper part of the digestive tract. Vomiting what looks like coffee grinds indicates the same. Stomach acid coagulates the blood and depletes it of oxygen, giving it a tarry or grainy appearance, depending upon the level of digestion.
This is a very serious indication of a possible stomach ulcer. With upper endoscopy or barium radiology, a gastroenterology doctor may look for perforations in the esophagus, stomach, or duodenum.
🫐 Taking iron pills, activated charcoal, or medicines that contain bismuth subsalicylate (such as Pepto-Bismol) or eating black licorice, blueberries, or blood sausage can cause black stools.
Without knowing what it is, most people have no idea how serious tarry stools are. An individual might have more anxiety over the presence of red blood and casually dismiss tarry stools.
Do Not Overreact
Don’t just flush in the dark. Assess what’s going on when you drop a load. Examining toilet tissue provides clues to gastrointestinal health. To minimize blood from friction, use flushable wipes or damp tissues. Health experts recommend notifying your doctor following the presence of blood—regardless of the color. Non-invasive stool kits can perform tests for colon cancer.
Based on the aforementioned patient experience, I monitor the presence of bright red blood before making an emergency call for red sirens. Evaluate quantity, color, and frequency of bleeding. For telemedicine, it might seem gross, but snapping a photo of the tissue allows your doctor to assess the situation remotely.
Bloody Stool Emergencies
- Large amount of red blood
- Recurring spots of blood
- Bleeding with blood thinner Rx
- Black tarry stools
Massive blood loss without coagulation—particularly if on blood-thinning medication—is a medical emergency. Recurring unexplained bright red blood is also a red alert. How will you react if you see the same?