A patient on NSAIDs and hydrocodone reports rectal bleeding; what is the most likely diagnosis?

• A. GI bleed from NSAIDs
• B. Hemorrhoids
• C. Tissue friability from NSAIDs
• D. Unrelated to NSAIDs

Answer: (B)

Hemorrhoidal bleeding fits best here because the combination of constipation from the opioid and rectal bleeding is a classic pattern. Opioids like hydrocodone slow gut motility, leading to straining during defecation. This increased pressure on the anal veins makes hemorrhoids swell and rupture, producing bright red blood with defecation. Hemorrhoids are a common, expected source of painless or minimally painful rectal bleeding, especially in someone with constipation.

NSAIDs raise overall bleeding risk by impairing platelet function and irritating mucosa, but the presentation of localized rectal bleeding during defecation with a history of constipation points more specifically to hemorrhoids rather than a generic NSAID-induced GI bleed, which often presents more diffusely (upper GI symptoms like melena or generalized GI bleeding). “Tissue friability from NSAIDs” isn’t a distinct clinical diagnosis, so it doesn’t best explain this pattern.