Clinically, whether it is defecation followed by bleeding, bleeding followed by defecation, or mixed hematochezia, or simple hematochezia, all are referred to as bloody stool.

The symptom of bloody stool has been given different names in medical literature throughout the ages. Lingshu . Baibing Shisheng called it "posterior bleeding"; Suwen . Yinyang Bie Lun called it "hematochezia"; "Cold-Damage Disease Treatise" called it "bloody stool"; Jingui Yaolue called it "lower bleeding", and based on the sequence of bleeding and defecation, proposed the terms "distal bleeding" and "proximal bleeding". Later, Yixue Rumen also referred to it as "bloody sweating", "because the hematochezia is forceful, like an arrow shot far". Shoushi Baoyuan referred to bloody stool, where blood appears before stool, splashing out, and the blood is clear and fresh, as "bloody defecation". Yixue Rumen and Xiezheng Lun referred to bloody stool that is turbid and unclear, dark and not fresh, with swollen and painful anus, as "perianal abscess".

bubble_chart Pattern Analysis

1. Wind-fire Harassing the Large Intestine︰Bloody stool, accompanied by dry lips and mouth, thirst with preference for cold drinks, swollen and painful gums, bitter taste in mouth, fetid mouth odor, mouth and tongue sores, severe constipation, burning sensation in the anus, red tongue with yellow coating, rapid and forceful pulse, and other symptoms. It is mostly caused by wind pathogens invading the Yangming Meridian, stagnating and transforming into heat, or by wind-wood pathogens from the Liver Meridian internally attacking the intestines and stomach, leading to the interaction of wind and fire, injury to the yin collaterals, and failure to retain yin blood, resulting in bloody stool. Hence, the *Zhong Zang Feng* states: "Extreme heat in the large intestine leads to bloody stool, and wind attacking the large intestine also causes bloody stool." This type of bloody stool generally falls under what later generations refer to as "bloody defecation." Clinically, it is often accompanied by thirst with preference for cold drinks, swollen and painful gums, bitter taste in mouth, fetid mouth odor, dry and accumulated stool, yellow coating, and rapid pulse. Moreover, due to the nature of wind-fire syndrome, which arises and manifests quickly, the course of the disease is brief. Its characteristics include bloody stool, blood appearing before stool, blood spurting out, clear and bright-colored blood, or even pure fresh blood. The treatment principle generally focuses on cooling blood, purging heat, calming wind, and stopping bleeding, with Sophora Flower Powder being a commonly used formula. If accompanied by symptoms of internal stirring of wind-heat in the Liver Meridian (such as hypochondriac distension and fullness, dysphoria, frequent anger, wiry and rapid pulse, etc.), the treatment should clear the liver and stop bleeding, using Skullcap Decoction with additions like Bupleurum and Moutan Bark. If accompanied by excessive fire-heat toxin in the Yangming Meridian, forcing blood to flow recklessly (bright and thick bloody stool, dry mouth and lips, red tongue with yellow coating, rapid and forceful pulse, etc.), the treatment should cool blood and clear heat, using Yue Ying Jian.
2. Large Intestine Dampness-heat Toxin Accumulation︰Bloody stool accompanied by yellowing of the face and eyes, dry and bitter mouth, loss of appetite, chest and gastric stuffiness, nausea and vomiting, reduced food intake, abdominal distension and fullness, difficulty in defecation with foul-smelling stools, or swelling and pain in the anus, scanty and dark urine, or turbid urine, yellow and greasy tongue coating, slippery and rapid pulse, etc. These symptoms are mostly caused by excessive consumption of alcohol, spicy foods, or rich and greasy foods, leading to internal dampness, or prolonged exposure to damp environments or frequent exposure to mist and dew, resulting in external dampness. All these factors cause dampness to accumulate in the body, descend to the large intestine, transform into heat and toxins, scorch and damage the yin collaterals, and obstruct qi and blood, leading to bloody stool. Clinically, this type of bloody stool often falls under the category of "perianal abscess." Due to prolonged accumulation of toxins, the bloody stool appears dark purple, turbid, and dull, resembling black soybean juice, or even forming clots and masses. The stagnation of dampness-heat often manifests clinically as chest and gastric stuffiness, nausea and reduced food intake, abdominal distension and fullness, constipation, greasy tongue coating, and slippery pulse. The lingering dampness-heat accumulates and transforms into toxins, causing swelling and pain in the anus. Treatment should focus on clearing heat and resolving dampness, harmonizing the nutrient level and removing toxins, using Chidou Danggui San combined with Sanguisorba powder to clear heat, resolve dampness, harmonize the nutrient level, and stop bleeding. If the bloody stool is particularly turbid, Huanglian Jiedu Tang can be selected to resolve dampness and remove toxins.
3. Liver-kidney Yin Deficiency︰Bloody stool accompanied by dizziness and blurred vision, flushed cheeks, vexing heat in the chest, palms, and soles, restless sleep, steaming bone fever with night sweats, seminal emission during dreams, soreness in the waist and fatigue in the limbs, emaciation, a crimson tongue texture, and a thin, rapid pulse. This condition often arises from prolonged illness depleting the nutritive yin, excessive indulgence in alcohol and sexual activity leading to kidney yin deficiency, or from excessive worry and anger causing the five minds to transform into fire, thereby damaging yin and blood. These factors result in liver and kidney yin-blood depletion, a deficiency of water and excess of fire, which disturbs the yin collaterals and leads to bloody stool. This syndrome belongs to deficiency-heat. Clinically, it often manifests as stool preceding blood, with deep red blood dripping out in small amounts. After bloody stool, the patient often feels extreme fatigue, along with dry mouth and throat, vexing heat in the chest, palms, and soles, insomnia, and dream-disturbed sleep—all signs of yin deficiency with effulgent fire. Treatment should focus on nourishing yin and reducing fire, as well as nourishing blood and calming blood. The commonly used formula is Three-Carapace Pulse-Restoring Decoction. For cases with vexation and insomnia, Coptis and Ass Hide Glue Decoction is recommended.
4. Spleen-kidney Yang Deficiency︰Bloody stool, dull pain in the epigastrium and abdomen, dull complexion, limb fatigue and reluctance to speak, reduced appetite, loose stool, or even fear of cold and cold limbs, clear and profuse urine, pale tongue texture, deep and thin weak pulse. Mostly caused by constitutional yang deficiency, excessive overstrain, incomplete recovery from severe illness, and other factors leading to injury of spleen and stomach yang qi. Impaired spleen qi loses its ability to control, and deficient kidney qi loses its foundation of storage, resulting in blood overflow from the yin collaterals and the occurrence of bloody stool. This type of bloody stool often manifests as "distal bleeding" where stool precedes blood, with clear and thin texture, dull color, or black and greasy like tar. This pattern is also commonly seen in prolonged bloody stool, where yin impairment affects yang, and yang deficiency fails to restrain yin. Therefore, clinical manifestations often include a pale and lusterless complexion, shortness of breath and reluctance to speak, cold limbs and fear of cold, dull pain in the epigastrium and abdomen, clear urine and loose stool, pale tongue, and faint pulse. Treatment should focus on strengthening the spleen and warming the kidneys, tonifying qi to control blood, using Oven Yellow Earth Decoction; if prolonged sinking of middle qi leads to prolapse of the anus, combine with Middle-Tonifying Qi-Replenishing Decoction; if bloody stool persists, combine with Intestine-Securing Powder to consolidate the intestines and stop bleeding to prevent slippage.

Liver-kidney yin deficiency and spleen-kidney yang deficiency causing hematochezia both belong to deficiency pattern, characterized by frequent recurrence upon exertion.

To differentiate the symptom of hematochezia, in addition to examining the disease cause, mechanism of disease, and main accompanying symptoms, special attention should be paid to the characteristics of the main symptom (such as the distance, color, and texture of the hematochezia), which are crucial for determining the location of disease, clarifying the nature of disease, and establishing treatment principles. Zhengzhi Huibu states: "Pure clear blood indicates wind. Color like smoke and dust indicates dampness. Dark color indicates cold. Red color indicates heat." Leizheng Zhicai also states: "Bright and thick blood indicates excess heat... Pale and thin blood indicates deficiency-cold of spleen and stomach." Therefore, in cases of "proximal bleeding" where blood appears before stool and the blood is bright and fresh, the disease is located in the rectum and anus, often caused by wind-fire dampness-heat, belonging to heat and excess, and the condition is relatively mild, so the treatment should focus on expelling pathogens; in cases of "distal bleeding" where stool appears before blood and the blood is dark, the disease is located in the small intestine and stomach, often caused by dietary overstrain, injury to visceral qi, zang - fu organs yin-yang disharmony, the condition is severe, mostly deficiency pattern, so the treatment should prioritize supporting the body's vital energy. For example, blood spurting out, clear and bright in color, indicates "bloody defecation" caused by external wind invasion or internal wind descending to the large intestine; if the blood is turbid, with swollen and painful anus, it indicates "perianal abscess" caused by dampness transformation toxin descending to the large intestine and anus, injuring the yin collaterals.

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1. Jingyue Quanshu．Miscellaneous Syndrome Discussion: "Stagnation of yin hematochezia is caused by the accumulation of wind-cold pathogens in the yin aspect, which is not comparable to cold-damage disease. It resides in the five zang-organs and does not disperse, hence it is called stagnation of yin. When yin is internally bound and cannot move outward, the disease returns to the yin aspect, resulting in hematochezia. The classic states, 'Stagnation of yin causes hematochezia: one knot results in one liter, two knots in two liters, and three knots in three liters,' which refers to this condition. It is appropriate to externally moxibustion at Zhongwan, Qihai, and Zusanli to disperse wind pathogens, and internally to use Pingwei Sanguisorba decoction, a warming and dispersing formula, as the main treatment."
2. Xiezheng Lun．Hematochezia: "I observe that this syndrome is no different from women's menorrhagia and metrostaxis, ... both are the result of blood leaving the channels and being discharged, hence the conditions are similar. However, the orifices from which they emerge are different: menorrhagia and metrostaxis emerge from the external genitalia, hence they are often treated by harmonizing the liver to regulate the blood chamber. Hematochezia emerges from the anus, hence it is treated by also regulating the lungs and kidneys to secure intestinal qi. The kidneys govern the lower energizer and the transformation of rising qi; when the kidneys are sufficient, qi does not sink. The lungs and intestines are internally and externally related; when lung qi is astringent, intestinal qi is naturally secured. Physicians who understand this principle and apply the methods used for women's menorrhagia can fully regulate and treat this condition."

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bubble_chart Differentiation

This condition should be differentiated from dysentery with pus and blood. Dysentery with pus and blood often presents with a mixture of pus and blood, accompanied by prominent symptoms such as abdominal pain and tenesmus. In contrast, this condition is characterized by the passage of blood during defecation without pus-like material, and without prominent symptoms such as abdominal pain or tenesmus.

Hematochezia is also a common symptom of various anal diseases, including anal fissure, hemorrhoids, anal fistula, and anal abscess. Hematochezia caused by these conditions is not discussed within the scope of this section.