Canonical owner for diverticulosis, prior visible bleeding, April 2026 positive FOB/stool RBC, calprotectin separation, and repeat-GI escalation thresholds. The current state is yellow/watch rather than emergency: hemoglobin is normal, iron markers improved after the clean month, the 2026-05-28 repeat stool test was FOB negative with stool RBC absent, and the 2024 colonoscopy was high-quality/complete. April stool blood plus RBC still cannot be dismissed as noise; recurrence, iron drift, visible blood, medication exposure, and red flags drive the next branch. Bloating/SIBO symptoms do not explain or clear bleeding risk.
gastrointestinal · diverticular-disease · occult-blood · stool-rbc · ferritin · bleeding · calprotectin · colonoscopy
This is the single current owner for diverticular disease, occult stool blood, rebleeding-risk boundaries, and the bleeding-vs-bloating distinction.
Current classification: yellow/watch, not red.
Why not red right now: hemoglobin is normal, the 2026-05-27 iron panel improved (ferritin 61.60, TSAT 33.4%), the 2026-05-28 stool repeat was FOB negative with stool RBC absent, fecal calprotectin had normalized to 13.3 µg/g in April, and the retrieved Sept 2024 colonoscopy was complete/high-quality: BBPS 9, terminal ileum reached/examined, normal mucosa, no inflammation, no polyps, no malignancy, normal DRE/perianal/retroflexion findings, with scattered small diverticula from right flexure to sigmoid.
Why not dismiss it completely: April 2026 had FOB positive + stool RBC present. That was an occult GI bleeding signal. It is not proof of diverticular rebleeding, not explained by SIBO/bloating, and not erased retroactively by a later negative test. Late 2025 is weaker as bleeding evidence: ferritin reached 35.28 during likely heavy alcohol/smoking exposure, but stool occult blood and stool RBC were negative on 2025-12-23.
Historical context is preserved but should not drive current decisions by itself: the August 2025 visible-bleeding stool-photo comparator is privately archived; a reported pre-bleed OTC topical mupirocin genital exposure is also privately archived and graded low-plausibility/temporal-only as a lower-GI bleeding cause.
| Signal | Meaning | Action |
|---|---|---|
| Repeat FOB/direct exam negative, Hb/MCV/RDW stable, ferritin stable/rising, TSAT not persistently <20%, no visible blood/alarm symptoms | Current end-experiment pattern; bleeding branch cools | Monitor; no default repeat colonoscopy. |
| Ferritin/TSAT improve after alcohol/smoking abstinence but stool blood is not repeated | Blood-side recovery is reassuring, but bleeding status is unanswered | Keep avoidance as high-value; complete stool follow-up before calling the branch closed. |
| Repeat FOB or stool RBC remains positive | Occult source unresolved | GI-source discussion; clinician chooses anorectal/lower-GI vs upper-GI sequence rather than automatic repeat colonoscopy. |
| Ferritin falls toward <45-50, TSAT stays <20, MCV/RDW drifts, reticulocytes change, or Hb drops by about 1 g/dL / below range | Possible ongoing loss or iron restriction | GI-source planning becomes stronger; endoscopy threshold lowers. |
| Visible red/maroon stool, recurrent large bowl-red bleeding, clots, melena/black tarry stool | Active bleeding concern | Urgent assessment, not diet troubleshooting. |
| Dizziness, presyncope/fainting, tachycardia, hypotension, rapid weakness, or rapid Hb fall with suspected bleeding | Hemodynamic concern | Urgent GI-bleed pathway; CTA/angiography belongs only in active/significant bleeding localization. |
| Melena, recurrent epigastric pain/dyspepsia, ulcer symptoms, IDA, or persistent occult blood after adequate lower-GI review | Upper-GI probability rises | Gastroscopy / H. pylori / ulcer-risk logic becomes more relevant. |
| Persistent occult bleeding or IDA after adequate colonoscopy + gastroscopy | Small-bowel branch opens | Capsule endoscopy first; CT enterography if obstruction/mass concern or capsule unrevealing. |
| New progressive bowel-habit change, unexplained weight loss, nocturnal symptoms, persistent localized pain, fever, guarding, vomiting, obstruction symptoms | Alarm/structural concern | Clinician-directed GI/abdominal evaluation. |
| Calprotectin rises again with inflammatory symptoms | Inflammation/SUDD/IBD branch reopens | Repeat calprotectin/GI inflammation logic; still separate from hemorrhage localization. |
| Task | Practical rule |
|---|---|
| Repeat stool testing | Biomed publicly lists FOB ($7.50) and Stool Direct Exam ($2), no FIT. Best local repeat is 2-3 spontaneous bowel movements if feasible, sampled before toilet-water dilution and from more than one stool area. One paired end-experiment set is acceptable if logistics are tight. |
| Pair with blood trends | CBC/Hb with indices and platelets, ferritin, serum iron, TIBC/transferrin/TSAT, reticulocyte; CRP/ESR/fibrinogen are context, not bleeding localization. |
| Keep colonoscopy context accurate | The 2024 exam quality gap is closed and reassuring. Do not repeat colonoscopy solely because the old report was once unavailable; do revisit source localization if stool blood persists or iron/Hb drifts. |
| Separate symptom and bleeding dashboards | Bloating/circumference/meal timing belongs to SIBO/SUDD/motility. FOB/RBC/visible blood/iron/CBC/medications belong to bleeding risk. |
| Maintain diet/fiber sanely | Long-term normal/high-fiber plant-forward diet as tolerated; no seed/nut/popcorn avoidance by default. Short low-fiber periods are only for immediate post-bleed/clinician-directed recovery. |
| Reduce exposures that worsen risk/noise | Avoid NSAIDs; no self-directed aspirin/antiplatelet prevention while stool-blood risk is live. Smoking cessation is strongly relevant to diverticular complications and ASCVD. Alcohol avoidance should stay the default while stool-blood/iron/CBC branches are unresolved: personal history now makes alcohol-plus-smoking look like a major gut/iron-marker destabilizer, though not proven direct bleeding causation. |
| Exercise | Continue ordinary walking/jogging unless active bleeding or major symptoms appear; exercise is generally protective rather than a diverticular-bleed trigger. |
| Avoid | Reason |
|---|---|
| Do not use bloating improvement as proof bleeding risk fell | SIBO/SUDD symptoms and occult blood are separate branches. |
| Do not use bloating worsening as a validated early warning for diverticular hemorrhage | Diverticular bleeding is classically sudden painless hematochezia/maroon bleeding, not a fermentation prodrome. |
| Do not repeat calprotectin reflexively for occult blood alone | Calprotectin tracks inflammation; it does not localize or clear bleeding. |
| Do not endlessly cycle local FOB tests if positivity persists | Persistent positivity or iron/Hb drift should move toward clinician source review. |
| Do not treat Biomed FOB as FIT-equivalent | Local FOB is a pragmatic guaiac-style bridge; FIT/quantitative FIT would be preferable for CRC-style lower-GI screening if reliably available. Positive FIT still goes to colonoscopy, not repeat FIT reassurance. |
| Do not default to abdominal CT/full-body CT | CT is not the routine answer for occult blood/bloating without acute or structural triggers. |
| Do not let topical mupirocin exposure explain away current blood | It is preserved as historical/temporal context only; current FOB/RBC/iron trends decide current risk. |
Preserved evidence anchors include diverticular bleeding/rebleeding reviews (PMID: 40012838; PMID: 38989865; PMID: 40109318; PMID: 40542969; PMID: 40865763), diverticular diet/fiber evidence (PMID: 33919755; PMID: 40651334; PMID: 39976023), exercise/diverticular evidence (PMID: 23668524), alcohol/smoking meta-analysis context (PMID: 41760075), occult blood/FIT/gFOBT logic (PMID: 23547576; PMID: 34003218; PMID: 25492500; PMID: 10022627; Cochrane PMC9169237), IDA guidance (PMID: 32810434; PMID: 34497146), small-bowel bleeding guidance (PMID: 26303132), CTA active-bleeding pathway (PMID: 36735555), and calprotectin/diverticular inflammation literature (PMID: 18941760; PMID: 22572679).