Anorectal bleeding is frequently encountered and is reported to be the sixth most common symptom prompting an outpatient clinic visit. Community-based surveys indicate a 13 to 20 percent prevalence of rectal bleeding, while only about 14 to 31 percent of such patients seek medical attention. The anal canal is roughly 4 to 5 centimeters in length in an adult, and the rectum is lower 10 to 15 centimeters of the large intestine. Most anal pathologies can be detected on digital examination and by endoscopy. There is an extensive intramural anastomotic network between the superior, middle, and inferior rectal arteries. Rectal ischemia is therefore a relatively rare occurrence. Internal drainage occurs into both the systemic and portal circulation. The rectum and upper anal canal are drained into the portal system. Lower portion of the anal canal is drained into the internal pudendal veins. In the upper anal canal, proximal to the dentate line, there are three submucosal cushions composed of sinusoids within the connective tissue. The term hemorrhoid is used to describe the downward displacement of these cushions along with associated sinusoidal dilatation. In some patients, 1 to 3 anal papillas can be observed, and these are normal findings. Assessment of a patient with anal rectal bleeding consists of inspection, palpation, and examination with the aid of instruments. Examination of the anal canal with an anal scope can assess the entire anal canal and the distal part of the rectum. To examine the entire rectum, sigmoidoscopy is required. These are disposable anal scopes. This is the anal scope. This is the obturator. It fits through there. When you're doing anoscopy, you never want to turn this while it's inside the anal canal. Because if you turn it, these edges can tear a hemorrhoid or something like that. So you just look at one quadrant at a time. You put this in. You pull it out and look inside. And then you put this back in and extract it. And then you put it in another quadrant. So you never turn it like this inside the anal canal. First just lubricate the anal canal with this. I know it's not easy. Try to relax if you can. I'm just going to gently feel inside. I'll take the anal scope. We'll put this in. Inside, you can see those are pretty large hemorrhoids and they fill up the lumen of the anal scope. So they bulge through that slot and they bulge into the lumen of the anal scope and fill up the whole lumen of the anal scope. And that's usually a pretty good indication of grade 3. And also when they're that big, then we consider surgery. Grade 1 hemorrhoids are ones that don't protrude out. Grade 2 are hemorrhoids that protrude out but go back in on their own. Grade 3 protrude out and require manual reduction to push them back inside. Grade 4 are ones that you can't push back in or are hard to get back in. And this one you see is also very friable. And she has a lot of bleeding and discomfort and they come out every time. We've tried her on medical therapy, high dose fiber, and she's no better. And this is a right posterior quadrant. Usually it seems like the biggest ones are right posterior quadrant, right anterior quadrant, and left lateral quadrant. And that's the ones that we usually treat surgically. But that's a real good example. So we'll put this in and come out. Go in again, the right anterior quadrant. And you can see that they're not quite as big, but almost. Try to aim that flashlight in a little better there. And you can use any kind of light source here. That's good. So you see that. That's a good view on the screen there. And look left lateral quadrant. Moderate. There, not quite as... That's excellent, yeah. Are you zoomed in all the way? That's great, yeah. Okay, now we'll look at the bad side, the right posterior quadrant again. I'll try to zoom in now. The view here, you can just see a little bit of the skin here. There's the dentate line right there. And that's the friable internal hemorrhage. See how it's raw and pink and raw there from chronic protrusion and getting irritated. Now on this back here, where we always look for fissures, is just inside here. And somebody takes a lot of traction, but the fissure is right in the posterior midline. This lady does not have one, but... In your left hand, take this thing here. Well, I guess... But a fissure would generally be right here. Either the posterior midline or the anterior midline. And that's where you look for fissures. And you usually have to... Sometimes you can see them, but sometimes you have to pry the skin apart. And where you'd see it is right in the midline. Usually right here. If you see a fissure laterally, you have to think of Crohn's disease. Okay. In the endoscopy lab, the endoscope can be used as a light source and for image documentation. Endoscopic examination of the anal rectum should include forward and retroflexed views. Optimally, high-definition endoscopes with digital chromoendoscopy should be used for imaging. Optimally, high-definition endoscopes with digital chromoendoscopy such as narrowband imaging or MBI capability should be used. Normal rectal mucosal vascular patterns are noticed. Vascular patterns are better visualized under digital chromoendoscopy. We are slowly withdrawing the endoscope to inspect the anal canal. Efforts should be made to examine every corner of the anal canal and between the crevices in a systematic fashion. The entire length of the anal canal should be examined carefully. Ancillary studies, such as cynic defecography and anorectal manometry, can aid in the diagnosis of internal rectal prolapse, interception, enterocele, and pelvic floor disorders. On defecography, this patient has non-relaxing puborectalus disorder. Anorectal manometry is demonstrated in this patient. This is a case of entour seal Whereas in this patient, both rectal seal and enteral seal are demonstrated. These are various etiologies accounting for anorectal bleeding. Hemorrhoids, anofissure, fistula, postpolypectomy bleeding, trauma, ulcerations that include ischemia, infections, stercoral ulcer, solitary rectal ulcer syndrome, and diversion colitis. Inflammatory bowel diseases, chronic radiation proctopathy, vascular lesions including rectal varices, angioictasia and hemangioma, various neoplasms, inflammatory polyps, and endometriosis. In this video presentation, we describe more commonly encountered etiologies. Hemorrhoids are classified as external or internal based on their origin below or above the dentate line. Internal and external hemorrhoids often coexist and they communicate with each other. They do not have a direct communication with the portal system and therefore hemorrhoids are not more commonly seen in patients with portal hypertension than the general population. This patient has prolapsed internal hemorrhoids with associated skin tag on the outside. The dentate line can be observed with a change in the texture and color of the mucosa. In this patient, the prolapsed internal hemorrhoids have been present for five years. The prolapsed internal hemorrhoids have been present for five years. There is no evidence of thrombosis or ischemia. When internal hemorrhoids prolapse, the prolapse is either at one quadrant or the prolapsed mucosal fold run radially in shape. This is at least grade 3 internal hemorrhoids. Sometimes the prolapsed internal hemorrhoids can mimic external hemorrhoids. The protruded hemorrhoids lack pigmentation. A mucosal tear is observed, and this is acute bleeding stigmata. Both forward and retroflexed examinations should be performed. The prolapsed internal hemorrhoids are reduced during endoscopic manipulation. In this patient with complete rectal prolapse, the prolapsed mucosal folds assume circular shape. This is intermediate degree and can be fixed with the peroneal proctosigmoidectomy. This patient has external anal condynomia or anal warts. Occasionally, inflammatory polyps can form on the chronically prolapsed internal hemorrhoids. Biopsy should be performed to route anal warts and neoplasm. This is another case of inflammatory polyp form on the internal hemorrhoids. Gallagher's classification clinically grades internal hemorrhoids based on the degree of prolapse. The grade 2 hemorrhoids prolapse with straining, but spontaneously reduce. The grade 3 hemorrhoids need manual reduction, while grade 4 prolapsed hemorrhoids cannot be manually reduced. These are grade 2 internal hemorrhoids. These are prolapsed grade 3 internal hemorrhoids. Grade 4 internal hemorrhoids. Needs surgery. Anorectal bleeding can be suggested by seeing fresh blood or clots limited to the rectum. In this case, the stool is brownish in the sigmoid colon. Infrequently, active bleeding can be seen from the internal hemorrhoids during endoscopy. More frequently, hemorrhoidal bleeding is suggested by acute bleeding stigmata such as the red markings, tears, ulcerations on the hemorrhoids. In this case, besides red markings, acute thrombosis is seen within the hemorrhoids. In this patient with small internal hemorrhoids, no stigmata can be seen during retroflexed examination. A mucosal tear or ulceration can be seen within the upper anal canal on the internal hemorrhoids. In another case, mucosal tears can be seen on the internal hemorrhoids on retroflexed view. Medical therapy includes conservative measure to avoid constipation and maintain soft stool, adequate fluid intake, and dietary fiber supplementation. Sitz baths and over-the-counter topical preparations containing steroids, analgesics, antiseptics, or anesthetics are often used in clinical practice. These modalities provide symptomatic relief to some patients. For grade 1 to 3 internal hemorrhoids, refractory to conservative measures. Non-surgical treatment options include rubber band ligation, injection sclerotherapy, diathermy coagulation, laser surgery, and infrared coagulation. These procedures lead to some mucosal scarring with fixation of the hemorrhoids to the underlying tissues. In this patient, the rectal bleeding is from internal hemorrhoids. Before band ligation, careful examination of the rectum and anal canal is performed. Within the left upper quadrant, we can see some hypertrophied tissue on the internal hemorrhoids due to intermittent prolapse. In this patient, the rectal bleeding is from internal hemorrhoids. Before band ligation, careful examination of the rectal canal is performed. Technique-wise, hemorrhoidal band ligation is similar to esophageal variceal ligation. In this case, we are using variceal ligation device. The rubber bands should be placed above the dentate line. During each treatment session, 1-3 band ligations are generally recommended. In this case, two rubber bands are placed at different locations. Rectal bleeding resolved after band ligation in this patient. During follow-up endoscopy, diminished sized internal hemorrhoids and scar tissue can be seen. Rubber band ligation is best suited for grade 2 and 3 internal hemorrhoids. In our experience, infrared photocoagulation is effective and safe for grade 1 and 2 hemorrhoids. This is just a standard incandescent light bulb, just like a regular old-fashioned light bulb. It sends it through a fiber optic, and it comes out the end. It has a sheath on it so that it's sterile, or not sterile, but there's no patient secretions transferred from patient to patient. And then a light comes out the end, and that's what happens when you turn it on. Usually we make it about, we leave it on for about 1 second or 1.2 seconds, and that just, that white light cauterized or fulgrates the top millimeter or so of the mucosa, so it's a way to destroy the mucosa. And we use a scope called a Hinkle-James anoscope that's a little bigger than a standard anoscope. It has a slot in it like a regular scope, but it's a little bit longer. It allows us to get in, because when you do this procedure, you don't want to go distal to the dentate line, you want to go above the dentate line. And so we're going to... And what this, the infrared coagulation does, and there, can you see in there, that's the mucosa up inside there. And it doesn't bulge in too much, but we're going to use IRC on the mucosa above the dentate line, and when that shrivels up, that will cause the hemorrhoid to pull back inside. Anything you do to reduce the amount of mucosa or cause mucosa inside to shrivel up, and then you can see real good, that's the hemorrhoidal tissue right there. So we're going to put this in and treat the tissue above it. And if we go up higher, then it won't cause too much pain. You have to be careful, because you don't want to do the... You see that little white spot inside there? That shows you that it's done its job. Maybe a little painful here. And you can treat... I'm going to get just a little bit more. Okay. Okay, so that's five treatments. You see the little white, that will shrivel up, and over time, this will hopefully pull up back inside. The advantage to this is it can be done in the office, and it doesn't require anesthesia. It's relatively painless. They get some discomfort from the heat, but it's relatively painless. It can be done without anesthesia, and you can do it as many times as you wish. It doesn't require taking the patient to the operating room, like hemorrhoidectomy, and it doesn't require general anesthesia. Surgery is indicated for hemorrhoids refractory to non-surgical procedures, significant external hemorrhoids, and grade IV internal hemorrhoids. Long-term complications of surgical management includes anal fascia, anal stenosis, and fecal incontinence. This patient has a typical anal fissure. Anal fissure is a tear within the anal canal distorted to the dentate line. Anal fissures typically develop in the posterior midline, while 10 to 15 percent occur in the anterior midline. Fissure formation seems to be related to the forceful dilation of the anal canal during defecation, being perpetuated by reactive and persistent spasm. Most patients describe as a tearing pain during defecation, with rectal bleeding commonly reported as blood on the toilet paper or on the surface of the stool. Presence of anal fissure in atypical locations should raise suspicion for Crohn's disease, leukemia, HIV infection, and tuberculosis. This is another patient with Crohn's proctitis and Crohn's anal fissures. Multiple anal fissures are seen in atypical locations. For typical anal fissures, the goal of treatment is to interrupt the cycle of injury, pain, and spasm. Initial management comprises of fiber supplementation, stool softener, bulking agents, and sitz bath. These measures help in minimizing trauma during defecation and aid in the relaxation of the internal sphincter. Most acute fissures and significant proportion of the chronic fissures respond to non-surgical measures. Topical nitroglycerin and calcium channel blockers are proven to improve fissure healing. Botulinum toxin injections improve blood flow, relax smooth muscle, and reduce resting anal canal pressure. Botulinum toxin injection results in anal fissure healing in about 65% of the patients. Its efficacy has been shown to be as effective as topical nitroglycerin, but with fewer side effects. Fecal incontinence occurs rarely. The dosage of botulinum toxin varies from 20 units to 80 units. There is no consensus on the optimal dose, site of injection, or on the number of injections. If medical measures fail, lateral internal sphinctomy is the surgical treatment of choice. The healing rate is more than 90%. However, about 9% of the patients develop fecal incontinence. Anorectal fistula is usually caused by anorectal abscess. Other etiology include trauma, Crohn's disease, cancer, radiotherapy, tuberculosis, and other infections. In this patient, an anal fistula is observed. In this patient, fresh blood is seen in the rectum. After careful examination, the bleeding culprit is found to be a rectal fistula. This is the internal opening of the fistula tract. A single endoscopic clipping device is used to close the fistula opening and to achieve hemostasis. This patient has active anal bleeding from foreign body insertion. A mucosal tear can be seen within the anal canal. Although acute ischemic colitis is a common cause of lower GI bleeding, rectal involvement is very uncommon, occurring in about only 2 to 5 percent of the cases. This is due to a rich collateral arterial network supplying the rectum. Patients usually have significant atherosclerosis and cardiac risk factors. Other risk factors include aortic aneurysm replier, aorto-iliac interventions, radiation therapy, and embolic phenomenon. In some patients, aorto-iliac surgery with disruption of the collateral blood supply to the rectum appears to be the most important etiology. During endoscopy, mucosal ischemia with associated patchy erythema and ulceration, pseudomembrane, and bleeding upon biopsy can be observed. The differential diagnosis include solitary rectal ulcer syndrome, inflammatory bowel diseases, and infectious proctocolitis. Therefore, histopathologic confirmation is required. In severe cases, a pelvic CT scan may be obtained to rule out pneumatosis and extraluminal air. Although most cases respond to conservative management that includes antibiotic, in some severe cases with transmural necrosis, complete proctectomy with colostomy may be required. Stocharal ulcer refers to the ulceration in the GI tract induced by the heart stool. Heart stools constantly press on the mucosa, leading to localized ischemia, pressure necrosis, and ulceration. In this patient with chronic constipation, early mucosal ischemic change can be observed during endoscopy. The common sites of stocharal ulcer are the rectum and sigmoid colon. Patients may present with rectal bleeding and anorectal discomfort. The ulcer is usually irregular and may conform to the contour of responsible stool mass. The ulceration can be singular, multiple, or assume a geographic pattern. Endoscopic management of these ulcers follow the recommendations for peptic ulcers, including removal of the adherent clot and treatment of the visible vessel if present. Endoscopic hemostasis can be achieved with injection therapy, bipolar coagulation, and endoclip application. Cases of perforated stocharal ulcer and the resultant peritonitis have been reported. Biopsies from the ulcer edges may need to be obtained to route malignancy. For stocharal ulcer, addressing constipation with a stool softener and laxatives is an important aspect of management and prevention. In patients with chronic constipation, anal fissure, tear, and hemorrhoids can coexist with stocharal ulcer. In this patient with stocharal ulcer, there's a large and deep tear traversing the entire anal canal. We are seeing the anal sphincter muscle at 11 o'clock. The large tear can be visualized on perianal examination. Solitary rectal ulcer syndrome was previously referred as the mucosal prolapse syndrome. The reported incidence is 1 to 3 per a hundred thousand persons. This condition represents focal rectal mucosal ischemia and ulcer formation. Patients usually present with rectal bleeding, mucous discharge, and anorectal pain. In solitary rectal ulcer syndrome, the anterior rectal wall is the most common site involved. Contrary to its name, less than one-third of the patients have a solitary ulcer. On endoscopy, singular or multiple ulcers, mucosal erythema, and polypoly mucosal changes can be observed. The proposed etiologic factors include recurrent rectal interception, pelvic floor dyssynergia, straining, and local rectal trauma, such as from recurrent digital manipulation or instrumentation. Mucosal biopsies are required for definitive diagnosis. This is another patient with solitary rectal ulcer syndrome involving the upper rectum and rectal sigmoid junction. Endoscopically, moderate luminal narrowing, mucosal edema, and erythema, polypoly tissues are present. Besides endoscopic biopsy, a CT scan is recommended to route any mass lesion around the rectum and sigmoid colon. If solitary rectal ulcer syndrome is suspected, anorectal manometry and balloon expulsion test can help to identify pelvic floor disorders. Deficography can aid in the identification of interception and non-relaxing pupal rectalis. Management consists of patient education, increasing fiber intake, use of bulk-forming agents, avoidance of straining, and biofeedback. Surgery may be required in patients with persistent rectal bleeding or significant rectal prolapse. Diversion colitis involves nonspecific chronic inflammation following surgical diversion. Although most patients are asymptomatic, endoscopic evidence of diversion colitis can be found in the majority of the patients after diversion. Clinical symptoms include abdominal pain or discomfort, tenesmus, rectal bleeding, and discharge. Endoscopically, mucosal edema, erythema, friability, erosions or ulcerations, exudates, and mucosal nodularities can be observed. The pathogenesis of diversion colitis is unknown. It is hypothesized that the absence of short-chain fatty acids in the diverted colonic segment contributes to the pathogenesis of diversion colitis. Restoring the fecal stream to the affected colon segment reverses diversion colitis. In managing symptomatic patients, variable success has been achieved with enemas with short-chain fatty acids, 5-ASA, and a combination of 5-ASA and butyrate. For localized prostate cancer, prostate brachytherapy with permanent interstitial implantation of radioactive seeds is a highly effective treatment option. Two years after prostate brachytherapy, this patient developed rectal bleeding and rectal erythrofistula. During endoscopy, a large and deep rectal ulcer is seen in the anterior rectal wall. The opening of the rectal erythrofistula is also seen. Biopsy of the ulcerated area show no evidence of malignancy. In most patients with newly diagnosed ulcerative colitis, the disease is limited to the left colon and the rectum. The term ulcerative proctitis refers to inflammation confined to the rectum. The involvement of more proximal segments of the colon denotes ulcerative colitis. 30% to 50% of the patients with ulcerative proctitis may progress to UC. Patients usually present with diarrhea, urgency, tenesmus, and rectal bleeding. Uroendoscopy, loss of normal vascular pattern, mucosal edema, friability, erythema, spontaneous bleeding, small and shallow ulcerations may be noted. For ulcerative proctitis, topical 5-ASA agents are the main state of management. A combination of topical steroids and 5-ASA agents has been shown to be more effective. In proctitis, due to Crohn's disease, there may be patches of uninvolved mucosa between involved mucosa, so-called skip lesions. Linear rig-like ulcers, along with rectal sparing, suggest Crohn's disease, instead of ulcerative colitis. In this patient, skip lesions are observed, and the lower rectum is spared. In ulcerative colitis, the ulceration is superficial, whereas in Crohn's disease, deep and serpiginous ulcers are usually present. In patients with Crohn's disease, atypical anofacias and anorectal fistulas may be present. Deep and linear Crohn's ulcers are seen in the lower rectum. This patient has atypical anofacias from Crohn's disease. In this patient with Crohn's proctitis, the anal canal is also involved. The patients with infectious proctitis can present with tenesmus, anorectal pain, discharge, diarrhea, and rectal bleeding. Common sexually transmitted diseases that can cause proctitis include gonorrhea, chlamydia, syphilis, and herpes. STD transmitted through anal sex is a common cause of infectious proctitis. Infections that are not sexually transmitted also can cause proctitis. Salmonella, Shigella, Streptococcus, Campylobacter, Cholestridium difficile, and Amoebae. Detailed history, laboratory studies, rectal culture, anoscopy, and flexible endoscopy can be used to help diagnose this condition. This patient has anal warts on an anal papilla. Anal warts can affect the perianal area and anal canal. They first appear as tiny spots of growth. They can spread and cover the entire anal area. Some patients experience itching, bleeding, mucous discharge, and a feeling of lump or mass in the anal area. Anal warts are caused by the Cuban papillomavirus, or HPV. HPV infection is the most important ideological factor in the development of anal squamous cell carcinoma. Anal warts are better visualized under digital chromoendoscopy, such as narrowband imaging. The internal anal warts can involve the anal canal. Careful examination should be performed under forward and retroflexed view. This patient has a hypertrophied anal papilla without anal warts. In this patient, anal warts are present on a hypertrophied anal papilla. In suspected cases, biopsy should be performed to confirm the diagnosis. In symptomatic patients, various local ablative techniques and surgical excision can be applied. Surgical excision is best for large anal warts. Adenocarcinomas are the most common type of rectal cancer. Rectal bleeding is generally considered a lump symptom for colorectal cancer. The estimated risk of colorectal cancer in patients with rectal bleeding has been reported to be 3 to 11%. Colonoscopy has been suggested to be a cost-effective method of evaluating rectal bleeding. Younger patients without a history of suggested proximal colon pathology or family history of colorectal cancer may only require a flexible sigmoidoscopy. In older patients and those with a family history of colorectal cancer, colonoscopy may be more cost-effective. Adenocarcinoma is an uncommon neoplasm of the GI tract. These are recognized risk factors for adenocarcinoma. The most frequent type of anal cancer is squamous cell carcinoma, comprising 80 to 85 of all lesions. Bowen's disease is synonymous with anal intraepithelial neoplasm. When demonstrated on pathology, indicates carcinoma in situ. Anal cancer can coexist with benign conditions. Physician must maintain a high index of suspicion for medicine. For any patients with anal irregularities found on physical examination, anoscopy is complementary to flexible endoscopy. In the anal rectum, other uncommon types of neoplasm include melanoma, lymphoma, and neuroendocrine tumor. This patient has rectal neuroendocrine carcinoma, and he presented with rectal pain and bleeding. Inflammatory polyps are uncommon findings during endoscopy. They can be found either inside the colon or rectum, or on the prolapsed internal hemorrhoids. Occasionally, they can cause a small amount of rectal bleeding. This patient has rectal pain and bleeding from endometriosis. During endoscopy, an erythematous nodule is seen, and it is associated with scar tissues and small mucosal defects. In the same patient, another endometriosis is observed at the sigmoid rectal junction. The treatment is surgical resection. Rectal gastric heterotopia is very uncommon. It potentially can cause rectal bleeding and anorectal discomfort. After endoscopic removal of large polyps in the rectum, there is a small risk of post-polypectomy bleeding up to 1-2 weeks. The large polyps in the rectum tends to be sessile. The bleeding generally can be managed by endoscopic interventions. Of the GI tract, the rectum and the distal sigmoid colon are most susceptible to radiation injury. The term radiation proctitis is a misnomer, since inflammation is absent on histology. Radiation induces submucosal fibrosis, ischemic underarteritis, and angioictasias. Angioictasia is better defined under digital chromoendoscopy, such as narrowband imaging. After acute radiation exposure, about half of the patients experience diarrhea and tinnitus within six weeks of treatment. Such symptoms resolve with conservative measures within six months. Chronic radiation proctopathy is reported up to 20% of the patients. It can occur from nine months to 30 years after index treatment, although most patients present within one to two years of treatment. The patient can present with anorectal pain, diarrhea, rectal bleeding, and anemia. Although rectal bleeding is a leading sign of radiation proctopathy, it is rarely life-threatening. In most patients, the bleeding stops spontaneously. Therapy is indicated in patients with chronic rectal bleeding and iron deficiency anemia. Chronic intervention is effective in controlling bleeding. The options include argon plasma coagulation, APC, thermal coagulation with bipolar or heater probes, radiofrequency device, cryotherapy, laser therapy, and topical application of formalin. For chronic radiation proctopathy, APC is the mainstay of endoscopic therapy. APC is widely available, of low cost, effective, and is able to apply coagulation current tangentially. APC therapy results in a decrease in rectal bleeding in 80 to 90% of the patients, and may also improve symptoms such as urgency and diarrhea. In most cases, one to three treatment sessions are required. Power settings of 25 watts to 60 watts and flow rates of 0.5 liter per minute to 2.5 liter per minute have been reported. Mucosal oozing can present as a punctic bleeding spot due to underfill of the periphery of the angioictasia. During APC treatment, gentle mucosal contact with one to two seconds thermal application is recommended. Intraluminal explosions have been reported in patients who underwent only a cleaning enema prior to APC. Complete bowel preparation is therefore recommended before APC treatment. Complications such as ulceration and stretchers have been reported. It has been suggested that using power settings less than 45 watts, limiting application time less than two seconds, and targeting individual angioictasias instead of diffusely painting the mucosa may help decrease complications. In this patient, rectal bleeding almost completely resolved after one session of APC treatment. During follow-up endoscopy in five weeks, there are some healing ulcerations with a few residual angioictasias. These angioactesias are easily ablated with bipolar coagulation. During endoscopy, mucosal erythema and submucosal hemorrhage from barrel trauma can mimic angioectasia. These findings are not vascular lesion and they should not cause rectal bleeding. In addition, codon preparation artifacts can mimic angioectasias. Rectal varices represent portal hypertension, they arise proximal to the dentate line. Anatomically they are distinct from hemorrhoids. The prevalence of rectal varices in patients with portal hypertension is reported to be 40 to 77 percent. Significant bleeding is reported in less than 5 percent of such patients. In the literature, successful use of endoscopic rubber band ligation, endoclip application, injection sclerotherapy, inferior mesenteric vein ligation, and placement of transjugular intrahepatic portal system shunt procedure for the treatment of bleeding rectal varices have been reported. Hemangiomas of the rectum are rare. The majority of these vascular tumors involve the rectal sigmoid region. There are three types of hemangiomas, capillary, cavernous, and mixed type. Cavernous hemangioma is the most common type involving the colon and rectum. This patient suffers from recurrent painless rectal bleeding. The rectal mucosa appears erythematous and bulging. On mesenteric angiography, a rectal hemangioma is diagnosed. Therapeutic embolization is performed. The rectal bleeding resolved. Some scar tissues are noticed during follow-up endoscopy. Dullo-Foy's lesion is an unusual source of rectal bleeding. Dullo-Foy lesions is characterized by a single large tortuous arterios in the submucosa, and its diameter ranges from 1 to 5 millimeter. In this patient, a protruding Dullo-Foy lesion is seen within punctate erosion in the lower rectum. There is no surrounding ulceration. The lesion is successfully treated by endoclip application. Besides endoclip application, thermocoagulation and rubber band ligation can be used to ligate the rectal Dullo-Foy lesions.

Anorectal bleeding

Outpatient clinic visits

Digital examination

Endoscopy

Rectal ischemia

Internal drainage

Hemorrhoids

Rubber band ligation

Anal fissures

Infectious proctitis

Rectal cancer