this a CPD talk given to GPs in POrt Dickson on 24.11.18

1. A Primary Care Approach To PR
Bleeding
Dr Abd Hamid Mat Sain
General Surgeon
ColumbiaAsia Hospital
Seremban

2. Definitions/Disclaimer;
 Red / Reddish blood
 Lower GIT bleeding
 Not Melaena / Haematemesis / Coffee Grounds
 Massive upper GIT bleeding

3. Haemorrhoids
Anal Fissures
Colitis / Proctitis / Ulcers
Colorectal Tumours (Cancers/Polyps)

4. Associated Clinical Features
 Age
 Very young ; fissures , tumours , intussusception
 Young / Middle Age ; Piles , Cancers
 Middle Age / Old ; Cancers / Angiodysplasia
 Anal Pain
Painless ; Piles , Cancers
Painful ; Fissures , Complicated Piles , Cancers

5.  Volume
Low Volume ; elective
Piles  cancers
Large Volume ; emergency
Piles  cancers, angiodysplasia
Upper GI bleeding
 Defecation
With Stools ; piles  cancers
Spontaneous ; NOT piles , NOT fissure

6.  Abdominal pain
piles / constipation
Colitis , Ulcers
Cancers
 Number of Visits / Duration
First visit
Second onwards *
Systems Review**

7.  Past Medical / Surgical history
Cancers / polyps / piles
Cardiac conditions ; anti-coagulation
Warfarin , anti-platelets
 Family History
Siblings , parents
Cancers
Polyps

8. Other Associated GI symptoms;
 Anal mass ; reducible(piles) , prolapsed(piles , ca)
 Mucus discharge ; polyps , cancers, piles , colitis / ulcers
 Incontinence ; cancers
 Tenesmus ; cancers , (post PPH)
 Vomiting / Diarrhoea ; AGE(Colitis) , Ulcers
 Obstructive features ; cancers
 Loss Appetite / Loss Weight ; cancers

9. Physical Examinations;
 General
Pallor
BP / P
 Abdominal
Soft-tender ; AGE / colitis
Soft-nontender ; anorectal lesions
Mass ; cancers , fecal matter
Distended abd ; cancers

10. Anal Examination ;
 Anal Inspection ;
 Prolapsed piles
 External piles
 Sentinel piles
 Anal wounds
 Rectal prolapse
 Digital Rectal Examination
 “routine / selective” – primary care
 endoscopy

14. Haemorrhoids
 Young
 Low volume
 Painless
 Not pale
 BP/P stable
 Soft abd
 Anal exam NAD
 Treatments;
 Laxatives-fibres
 Medications ; Daflon , Papase , Reparil
 Suppositories ; Proctosedyl , Xyloproct
 Lifestyles; toilet habits , exercises , chillis
 2 weeks

15. Refer
 Recurrent episodes
 Short term ; weeks
 Prolapsed piles
 3rd and 4th degrees
 Pregnant
 Refused referral
 Hospital treatments
 Colonoscopy ; rubber banding(1st and 2nd)
 Haemorrhoidectomy ; open , stapled(3rd and 4th)
 LASER
 Medications ; laxatives , daflon , painkillers
 Sitz baths
 (potential)Complications ; bleeding , recurrence

16. Anal Fissures
 Young
 Painful defecation
 Minor bleeding
 Sentinel piles
 Fissures at 6 and 12 o’clocks positions
 Treatments
 Laxatives
 Suppositories
 Painkillers / oral and local / anti-inflammatory / opiates
 2 weeks
 Refer if persistent

17. Anorectal cancers
 middle age and beyond
 Mucus discharge
 Weight loss
 obstruction
 Treatments;
 Refer stat
 Fluids only
 Simethicone / coca-cola

18. Conclusion
 Most minor PR bleeding can be managed in Primary
Care setting with assumed diagnoses of Haemorrhoids
and Anal Fissures
 Complicated Piles and Fissures need referral for
diagnostic re-evaluation and further treatment
 Chronic or Major PR bleeding with clinical evidence of
systemic effects need urgent referral