Ease Into Prep with a PANCE^® Question of the Day

The correct answer is C. Normal colonic mucosa does not bleed in response to anticoagulation, but lesions with a predisposition to do so may be more likely to become symptomatic at such time. The bleeding lesion in this case may indeed be the internal hemorrhoids that were diagnosed, but a malignant source has to be ruled out before making such assumption. At the very least, the patient needs a 60-cm examination with a flexible endoscope. If one of the answer choices was colonoscopy, that would be the next best step, because this allows visualization of the entire colon. Because the patient is older than age 50 years, a colonoscopy is warranted as part of the evaluation for potential colon cancer.

Discontinuing the aspirin (choice A) or reducing the dosage (choice E) might indeed get rid of the bleeding, but in doing so we may miss the opportunity of diagnosing a potential malignancy that had been asymptomatic until now. There is little evidence that this bleeding is related to aspirin, especially in the setting of the patient not having melena caused by stomach irritation or gastritis.

Rubber-band ligation (choice B) may indeed be done eventually if there are no other lesions and one wishes to eliminate the internal hemorrhoids. Bleeding caused by hemorrhoids should be a rule out diagnosis when another potentially serious lesion has been successfully eliminated.

Stool softeners (choice D) could also help if the hemorrhoids are not removed and the patient wishes to continue taking aspirin, but as pointed out, all these decisions have to follow after cancer has been ruled out.

PEARL: After the age of 50, screening recommendations include a yearly fecal occult blood test and flexible sigmoidoscopy every 5 years or colonoscopy every 10 years. Colon cancer is a common malignancy in this country and this condition often has a long latency period for detection and early intervention.