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What is the most likely cause of bright red blood on toilet paper in a patient with constipation and without pain during defecation?

  1. Anal fissure

  2. External hemorrhoid

  3. Internal hemorrhoid

  4. Perianal abscess

The correct answer is: Internal hemorrhoid

Bright red blood on toilet paper, particularly in the context of constipation and the absence of pain during defecation, most commonly indicates bleeding from the lower rectum or anus. In this scenario, internal hemorrhoids are the most likely cause. Internal hemorrhoids develop from vascular cushions that can become engorged with blood, particularly during straining, such as during a bowel movement that is difficult due to constipation. When these internal hemorrhoids swell and subsequently bleed, the blood is typically bright red, which matches the symptom described. It is often observed on toilet paper or in the toilet after a bowel movement, especially if straining occurred. Moreover, the lack of pain during defecation supports this diagnosis because internal hemorrhoids are usually not painful, unlike conditions such as anal fissures or acute thrombosed external hemorrhoids, which are associated with significant discomfort. In contrast, anal fissures often present with sharp pain during defecation, external hemorrhoids may also cause pain and discomfort, particularly if thrombosed, and a perianal abscess typically leads to pain and swelling, making these conditions less consistent with the symptom profile described.