A 47-year-old female presented with a one-year history of rectal bleeding. Examination revealed a low rectal ulcer involving half the rectal circumference, from which fresh blood was observed. She was initially treated for hemorrhoids and dysentery without success. A colonoscopy was reported as normal except for internal hemorrhoids. Upon further examination, Dr. Al-Gailani discovered a rectal carcinoma. The patient was advised to undergo a biopsy of the rectal ulcer and staging scans before considering an abdomino-perineal resection of the rectum. The case highlights the importance of performing a thorough physical examination, including a digital rectal exam, for any patient presenting with rectal bleeding,
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Rectal Bleeding Diagnosis
1. Back to Basics! PR Exam
DR. MOHAMAD AL-GAILANI FRCS
CONSULTANT SURGEON
MEDICAL EDUCATION & TRAINING DIRECTOR
SUWAIDI
RIYADH, KSA
MAY 2017
2. The Case of a 47 Year Old Female
A 47 year old female patient presented with a One Year history of
Per Rectal (PR) bleeding.
Bowels open 1-3 times per day, no constipation.
No family history of bowel problems.
Fit otherwise.
Treated herself as a case of Haemorrhoids with no benefit.
DR. MOHAMAD AL-GAILANI Back to Basics! PR exam May
2017
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3. 47 Year Old Female:
Progress
Treated initially as a case of Dysentery with no benefit.
Seen by a surgeon (in another hospital), who then ordered a
Colonoscopy.
The colonoscopy was reported as normal apart from internal
Haemorrhoids.
Advised to have Haemorrhoidectomy.
Presented to my clinic requesting that.
DR. MOHAMAD AL-GAILANI Back to Basics! PR exam May
2017
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4. 47 Year Old Female:
Clinical Examination
Middle aged Female of Average Build.
Pale.
Abdomen: No Masses, No Organomegaly.
No inguinal lymph Nodes.
PR: Low Rectal Ulcer, Hard to Touch.
Ulcer involving Ant wall extending nearly to half the
Rectal circumference.
Fresh Blood on tip of the Finger
DR. MOHAMAD AL-GAILANI Back to Basics! PR exam May
2017
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5. Diagnosis:
Rectal Carcinoma
Advised to undergo Urgent:
1. Proctoscopy & Rectal ulcer Biopsy
2. Staging CT: Chest, Abdomen & Pelvis
3. Consider Abdomino-Perineal Resection Rectum
(APR)
Patient requested time to first discuss with family.
DR. MOHAMAD AL-GAILANI Back to Basics! PR exam May
2017
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6. Bleeding PR & PR exam
Patient had 1 year of bleeding per rectum assumed to
be piles!
Did not seek any medical attention until recently!
According to her, None of the doctors she saw did a
PR exam!
A Colonoscope inserted without a prior PR exam could
bypass the rectum & miss low rectal pathology!
DR. MOHAMAD AL-GAILANI Back to Basics! PR exam May
2017
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8. PR exam:
Position & Technique
Left lateral, both knees drawn towards abdomen.
Feet pointing away from examiner.
KY jelly gloved index finger pulp rests on anus.
Once sphincter relaxes, finger inserted.
On withdrawal, look for any blood on tip of finger.
DR. MOHAMAD AL-GAILANI Back to Basics! PR exam May
2017
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9. PR Exam: Procedure
DR. MOHAMAD AL-GAILANI Back to Basics! PR exam May
2017
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1 32
4 5 6
Preparation Part Buttocks & Inspect Apply KY Jelly
Rest Finger Pulp on Anus
Gently
Insert Finger & Examine Inspect Finger Tip for Blood
10. PR exam:
At the End, Don’t Forget To Clean Up!
DR. MOHAMAD AL-GAILANI Back to Basics! PR exam May
2017
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11. PR Bleeding:
Essentials
Never assume PR bleeding is due to Haemorrhoids, especially above
the age of 40 years!
For cases of Bleeding PR always do:
1. PR exam
2. Proctoscopy
3. Rigid sigmoidoscopy
Arrange for Flexible Sigmoidoscopy if you suspect Proximal Pathology.
DR. MOHAMAD AL-GAILANI Back to Basics! PR exam May
2017
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12. Take Home Message
PR exam is an Integral part of the Abdominal
Examination.
PR exam MUST be done for PR Bleeding
All Haemorrhoids bleed, but not all PR bleeds are
Haemorrhoids!
DR. MOHAMAD AL-GAILANI Back to Basics! PR exam May
2017
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13. Finally…
“The only reason why a PR
exam is not done is if the patient
has no rectum or the doctor has
no finger!”
DR. MOHAMAD AL-GAILANI Back to Basics! PR exam May
2017
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Dr. Mohamad Al-Gailani FRCS د.الكيالني محمد
Consultant Surgeon
Medical Education & Training Director
SUWAIDI
www.alhammadihospital.com
RIYADH, KSA
Tel: +966 11 4250000