Case of a 22-Year-Old Female with Acute Rectal Bleeding and Perianal Pain

Case at a Glance

A 22-year-old female presented with an acute onset of bright red rectal bleeding and a persistent burning sensation following a hard bowel movement. Her symptoms developed despite a recent increase in dietary fiber, highlighting a common clinical pitfall related to inadequate fluid intake.

Patient's Story

The patient is a 22-year-old female with no significant past medical history who presented with concerns about rectal bleeding that began on the morning of admission. She reported passing a hard stool around 10:00 AM, which was associated with a burning sensation. After using a bidet, she noticed several droplets of pinkish, blood-tinged water on the toilet seat. There was no blood mixed in with the stool itself. A second, smaller bowel movement shortly thereafter was unremarkable. Throughout the day, she experienced a persistent burning sensation in the perianal area, particularly when sitting. In the evening, she discovered a small amount of bright red blood staining her underwear. The patient felt a sensation she described as a 'tear' in the anal area. She noted this was not her first episode of bleeding after a hard bowel movement, but she was perplexed because she had recently increased her dietary fiber with chia seeds and fruits, expecting softer stools.

Initial Assessment

The patient was alert and in mild discomfort. Vital signs were stable. The history strongly suggested a benign anorectal source of bleeding. The key features were: bright red blood (hematochezia) separate from the stool, pain localized to the anus that is exacerbated by defecation and pressure, and a recent history of constipation/hard stool. The patient's age and the nature of the bleeding made an upper gastrointestinal source or a more sinister pathology like colorectal cancer highly unlikely.

The Diagnostic Journey

The diagnosis was pursued based on the classic clinical presentation. A careful history revealed the crucial missing element in her dietary changes: while she had increased fiber, she had not proportionally increased her fluid intake. Fiber without adequate hydration can bulk up stool and make it harder, paradoxically worsening constipation. A physical examination was performed. Gentle inspection of the perianal region revealed a single, linear tear in the posterior midline of the anal verge, consistent with an acute anal fissure. The area was tender to palpation. Given the clear visual diagnosis and patient discomfort, a digital rectal exam was deferred.

Final Diagnosis

Acute Anal Fissure, secondary to constipation.

Treatment Plan

The treatment plan was conservative and focused on symptomatic relief and promoting healing by ensuring soft stools.

1. Dietary and Lifestyle Education: The patient was educated on the critical importance of increasing fluid intake (aiming for 2-3 liters of water per day) to work in concert with her high-fiber diet. She was advised to continue consuming fiber-rich foods.
2. Symptomatic Relief: Warm sitz baths for 15 minutes, 2-3 times daily and especially after bowel movements, were recommended to soothe the area, reduce sphincter spasm, and improve blood flow.
3. Behavioral Modification: The patient was instructed to avoid straining during defecation and not to delay the urge to have a bowel movement.

Outcome and Follow-up

The patient was counseled that most acute anal fissures heal within a few weeks with conservative management. She was advised to follow up in 2-4 weeks or sooner if symptoms worsened or did not improve. At a telephone follow-up two weeks later, the patient reported a complete resolution of bleeding and pain. She had successfully modified her diet to include adequate hydration and was having regular, soft bowel movements. She was educated on the importance of maintaining these habits to prevent recurrence.