Bleeding per rectumBleeding per rectumHemorrhoids/PilesHemorrhoids/PilesAnal fissureAnal fissure

Objectives: You students will Objectives: You students will be able tobe able to

1.1. get a detailed history and get a detailed history and associated symptomsassociated symptoms

2.2. Evaluate and manage Evaluate and manage bleeding per rectumbleeding per rectum

3.3. Recognize and Recognize and conservatively treat piles conservatively treat piles and anal fissureand anal fissure

Bleeding per Bleeding per rectum: DDrectum: DD

Hemorrhoids (piles)Hemorrhoids (piles) FissureFissure CancerCancer PolypPolyp Inflammatory bowel Inflammatory bowel

disease (IBD)disease (IBD)

Hemorrhoids/PilesHemorrhoids/Piles Enlargement of the normal Enlargement of the normal

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

Anal FissureAnal Fissure

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

Diagnostic Grading System for Diagnostic Grading System for PilesPiles

DegreDegreee

DescriptionDescription

FirstFirst

SeconSecondd

ThirdThird

FourtFourthh

No prolapse, No prolapse, asymptomaticasymptomatic

Prolapse during Prolapse during defecation, defecation, spontaneous spontaneous reductionreduction

Prolapse – manual Prolapse – manual reductionreduction

Prolapse – difficult to Prolapse – difficult to be reduced by the be reduced by the patientpatient

Anorectal PainAnorectal Pain

Mild to Moderate Mild to Moderate DiscomfortDiscomfort

Heaviness / burning: piles/ Heaviness / burning: piles/ hemorrhoidshemorrhoids

Itching: hemorrhoids, Itching: hemorrhoids, infection, parasites, fistulainfection, parasites, fistula

Chronic soreness / Chronic soreness / tenderness: coccyxtenderness: coccyx

Conservative treatmentConservative treatment

Avoid constipationAvoid constipation Soothing ointmentSoothing ointment

Severe Pain, Severe Pain, especially with defecationespecially with defecation

Need to examine Need to examine

withwith

Anesthesia!Anesthesia!

Causes of Causes of Severe Anorectal PainSevere Anorectal Pain

Thrombosed Thrombosed HemorrhoidHemorrhoid

AbscessAbscess Anal Fissure Anal Fissure

Thrombosed HemorrhoidThrombosed Hemorrhoid

Sudden onsetSudden onset Visible externally on Visible externally on inspectioninspection

Can I & D when earlyCan I & D when early

AbscessAbscess

Gradual onsetGradual onset Erythema, edema, pointingErythema, edema, pointing May be no evidence on May be no evidence on inspectioninspection

I & DI & D

Anal FissureAnal Fissure

Onset with defecation / Onset with defecation / tearing sensationtearing sensation

Posterior midline “skin tag”Posterior midline “skin tag” Extreme discomfort / spasmExtreme discomfort / spasm

Need to examine under Need to examine under anesthesiaanesthesia

Conservative treatmentConservative treatment

Avoid constipationAvoid constipationOintmentOintment

Atypical Anal FissureAtypical Anal Fissure

Little painLittle pain Atypical locationAtypical location Consider:Consider:

InfectionInfectionCrohn’s DiseaseCrohn’s DiseaseCancerCancer

Objectives: You students will Objectives: You students will be able tobe able to

1.1. get a detailed history and get a detailed history and associated symptomsassociated symptoms

2.2. Evaluate and manage Evaluate and manage bleeding per rectumbleeding per rectum

3.3. Recognize and Recognize and conservatively treat piles conservatively treat piles and anal fissureand anal fissure