1. Bleeding per rectum
Hemorrhoids/Piles
Anal fissure

2. 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

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

4. 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.

5. 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.

6. 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

7. Anorectal Pain

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

11. Conservative treatment
Avoid constipation
Soothing ointment

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

17. Causes of Severe Anorectal Pain
Thrombosed Hemorrhoid
Abscess
Anal Fissure

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

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

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

26. Conservative treatment
Avoid constipation
Ointment

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

31. 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