Bleeding per rectum

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Bleeding per rectum

• Hemorrhoids/Piles
• Anal fissure

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Objectives You students will be able to

1. get a detailed history and associated symptoms
2. Evaluate and manage bleeding per rectum
3. Recognize and conservatively treat piles and anal
   fissure

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Bleeding per rectum DD

• Hemorrhoids (piles)
• Fissure
• Cancer
• Polyp
• Inflammatory bowel disease (IBD)

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Hemorrhoids/Piles

• Enlargement of the normal spongy blood-filled
  cushions in the wall of the anus (internal
  hemorrhoids), usually a consequence of prolonged
  constipation or, occasionally, diarrhea.

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Anal Fissure

• A break in the skin lining the anal canal,
  usually causing pain during bowel movements and
  sometimes bleeding. It occurs as a consequence of
  constipation or sometimes of diarrhea.

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Diagnostic Grading System for Piles
Degree Description
First Second Third Fourth No prolapse, asymptomatic Prolapse during defecation, spontaneous reduction Prolapse manual reduction Prolapse difficult to be reduced by the patient
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Anorectal Pain
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Mild to Moderate Discomfort

• Heaviness / burning piles/ hemorrhoids
• Itching hemorrhoids, infection, parasites,
  fistula
• Chronic soreness / tenderness coccyx

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Conservative treatment

• Avoid constipation
• Soothing ointment

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Severe Pain, especially with defecation

• Need to examine
• with
• Anesthesia!

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Causes of Severe Anorectal Pain

• Thrombosed Hemorrhoid
• Abscess
• Anal Fissure

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Thrombosed Hemorrhoid

• Sudden onset
• Visible externally on inspection
• Can I D when early

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Abscess

• Gradual onset
• Erythema, edema, pointing
• May be no evidence on inspection
• I D

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Anal Fissure

• Onset with defecation / tearing sensation
• Posterior midline skin tag
• Extreme discomfort / spasm
• Need to examine under anesthesia

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Conservative treatment

• Avoid constipation
• Ointment

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Atypical Anal Fissure

• Little pain
• Atypical location
• Consider
• Infection
• Crohns Disease
• Cancer

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Objectives You students will be able to

1. get a detailed history and associated symptoms
2. Evaluate and manage bleeding per rectum
3. Recognize and conservatively treat piles and anal
   fissure