Bleeding per rectum Hemorrhoids/Piles Anal fissure

Objectives: You students will be able to get a detailed history and associated symptoms Evaluate and manage bleeding per rectum Recognize and conservatively treat piles and anal fissure

Bleeding per rectum: DD Hemorrhoids (piles) Fissure Cancer Polyp Inflammatory bowel disease (IBD)

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.

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.

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

Anorectal Pain

Mild to Moderate Discomfort Heaviness / burning: piles/ hemorrhoids Itching: hemorrhoids, infection, parasites, fistula Chronic soreness / tenderness: coccyx

Conservative treatment Avoid constipation Soothing ointment

Severe Pain, especially with defecation Need to examine with Anesthesia!

Causes of Severe Anorectal Pain Thrombosed Hemorrhoid Abscess Anal Fissure

Thrombosed Hemorrhoid Sudden onset Visible externally on inspection Can I & D when early I & D Inspect and Diagnose

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

Anal Fissure Onset with defecation / tearing sensation Posterior midline “skin tag” Extreme discomfort / spasm Need to examine under anesthesia

Conservative treatment Avoid constipation Ointment

Atypical Anal Fissure Little pain Atypical location Consider: Infection Crohn’s Disease Cancer

Objectives: You students will be able to get a detailed history and associated symptoms Evaluate and manage bleeding per rectum Recognize and conservatively treat piles and anal fissure