This document provides guidance for primary care physicians on evaluating and managing patients presenting with rectal bleeding. It outlines common causes of lower gastrointestinal bleeding including hemorrhoids, anal fissures, colitis, and colorectal tumors. Clinical features that help determine the likely cause are discussed. Evaluation involves assessing factors like age, pain, bleeding volume, defecation patterns, and physical examination. Treatment approaches for common conditions like hemorrhoids and anal fissures are described. Referral is recommended for recurrent, complicated, or higher risk cases to rule out more serious underlying issues.

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