Per-Rectal Bleeding
Patient Demographic
55 Old , Teacher
History of PR bleeding
1. Duration of bleeding (long / intermittent or short / recent) how noticed? In stool or
in underwear?
2. Nature of bleeding (fresh blood-streaked or stale / mixed blood with stool)
3. Bowel habit:
same as before or no persistent bowel habit change
increased frequency or looser stool or both persistently over 6 weeks*
less frequency of defecation and harder stool persistently over 6 weeks
4. Anorectal symptoms:
Anal Pain
Onset? Location? Duration? Character? Aggravating and reliving factors?
Radiation? Time? Severity?
5. Anal Discomfort
Itchiness
Lump(S)
Prolapse or piles noticed? Can it be reduced by itself or manually?
Significant recent weight loss
N/V / fever
Other history
1. Personal history of: Colorectal cancer /Colorectal polyp /Inflammatory bowel disease
2. Drug history
3. Medical / surgical history
4. Significant family history of colorectal cancer: > 1 first-degree relative (brother,
sister, parent or child) had colorectal cancer before the age of 50
5. Social history
Summary : Blood during toilet , 1weak , fresh/bright , separate from stool , no diarrhea ,
no constipation (consistency and frequency , color ) no pain with passing stool . mass or
flash with defecation , lose weight 5kg in month , no abdominal pain , no travel history
Physical examination
1. General every thing normal
2. Vitals normal
3. Abdominal examination
definite palpable abdominal mass
4. Pr examination ? left lateral position
Inspection : skin change (itching , lesion , scratching, discoloration )/fistula, fissure
in midline/ swelling , can see 4th degree
Palpation : little finger for children / index for adult / gel / enter finger 6 position and
apply pressure : the sphincter will open /feal masses then rotate finger and feal all the
walls / look for tone of sphincter / prostate (anterior wall )/ present of blood / blood
mix with stool (upper ) or separate (hemorrhoids or fissure ) /
Diagnose :
Hemoride 3rd stage
investigation :
Proctoscopy: yes if we don’t fell the mass ,
CBC : Anaemia: Hb < 11 g/dL in men or Hb < 10 g/dL in postmenopausal women
without obvious cause
Colonoscopy ( above 50 year )
Management :
[Link] operable,
- Rubber banding, sclerotherapy,
2. operation :
Hemorrhoidectomy.
Complications of hemorrhoidectomy:
1. incontinence
2. Secondary bleeding
Gas incontinence as complications of lateral sphincterotomy >>in fissure in ano
So if pt present with pain : may be as 4th degree or thrombosed haemorrhoid
1st conservative then haemorrhoidectomy
1. Tramadol or pethidine, if pain not relieve
2. Reduce the mass immediately gently ,, once the mass come inside ,
3. Treat antibiotic (must reduce it by warm saline , or by gentle pushing it inside )
4. Bcz if do haemorrhoidectomy without reduce ,, will lead to oedema and pain and will
not relive ,if no prolapse or pain then in next day will do the surgery .
Q:
How to differentiate Partial prolapse and complete
How to differentiate: Rectal prolapse(not go inside /mucosa there ) /common in
children and bedridden elderly and hemorrhoids prolapse (if you insert your
finger easily go inside )
Most common cause of lower git bleeding : diverticulosis
Upper : peptic ulcer
Complication of post hemorrhoidectomy : incontinence , bleeding , anal stenosis
Lateral sphincterotomy (fissure in ano ) complication : flatus incontinence
