PR bleed by Dr. Arfa Mahmood. Includes types and treaments.

PR bleed types and treatment

1. BLEEDING PER RECTUM and perianal pathology By DR USAMA SHAFIQUE PGR General Surgery CMATRH, LAHORE

2. objectives Understand Review relevant surgical anatomy of the anal canal and natal cleft region The pathophysiology underlying anal fissure, haemorrhoids and pilonidal sinus Discuss clinical presentation and diagnosis of each condition Outline conservative and surgical management strategies Cover pre‑operative preparation and post‑operative care for these patients

3. CASE PRESENTATION 32 Y/M PRESENTED IN OPD WITH COMPLAIN OF SEVERE PAIN DURING DEFECATION FOLLOWED BY BURNING SENSATION LASTING FOR SEVERAL HOURS HE ALSO NOTICED STREAK OF BRIGHT RED BLOOD. HE HAS HISTORY OF CONSTIPATION WITH PASSAGE OF HARD STOOLS.

4. o/e Local Examination (Per Rectal) A linear tear at the posterior midline of the anal verge . Sentinel skin tag noted at distal end. No discharge or perianal abscess. Digital Rectal Examination (DRE): Deferred due to severe pain . Diagnosis: Anal Fissure (posterior midline)

5. Surgical anatomy Rectum begins where the tinea coli of sigmoid colon join to form a continuous longitudinal muscle layer at the level of sacral promontary The puborectalis muscle encircles the posterior and lateral aspects of junction, creating the anorectal angle (normally 120) Rectum has 3 lateral curvatures; upper and lower are convex to right and middle is convex to left On luminal aspect, these three curves are marked by semicircular folds (Valves of houston )

6. Surgical anatomy Adult rectum is approx 12-18cm and is divided into 2 parts upper third Middle third Lower third Upper third is mobile and has peritoneal covering anteriorly and laterally Middle third has peritonium that covers anterior part and little bit lateral part Lower third lies deep in pelvis below peritoneal reflection

7. Anatomical relations of Rectum

8. BLOOD SUPPLY Superior rectal artery is the direct continuation of inferior mesenteric artery and is main arterial supply of rectum. Middle rectal artery arises on each side fron internal iliac artery which supplies the lateral sides of rectum Inferior rectal artery arises from internal pudendal artery which is the continuation of internal iliac artery

9. VENOUS DRAINAGE Superior haemorrhoidal veins draining the upper half of anal canal above the dentate line, pass onward to become the rectal veins; these unite to form the superior rectal veins which later becomes inferior mesenteric vein

10. Blood supply Middle rectal vein drains blood from middle third of rectum and drains into internal iliac vein Inferior rectal vein drains blood from lower third of rectum and drain into internal Pudendal vein which ultimately drains into int Iliac vein

11. Surgical Anatomy of anal canal

12. History taking of bleeding PR Onset of bleed Is it spontaneous or during strain or defecation, gradual or sudden in onset Duration Episodic or Continuous. How u notice the blood Is it spurt of blood or drops of blood or streak of blood on stool.

13. hx Amount of blood Colour of blood Bright red colour or dark brown or black like Tar Mucous containing Consistency mixed with stool or pure blood History of any haematological, GI or Oncological disease. Medication Antiplatelet drugs, anticoagulants or NSAIDs. Alcohol or smoking

14. Associated signs and symptoms Bowel habbits Spurious diarrhea Tenesmus Something protrude out during defecation Pain Weight loss Shortness of breath Anemia Red flag signs Spurious diarrhea Tenesmus Weight loss

15. Risk factors Diet i.e animal fat rich diet Family history IBD Smoker Alcohol consumption Hep C

16. examination DRE Proctoscopy Sigmoidoscopy

17. How to do Digital rectal examination Inspection look at the anal opening, whether there is some tear or anal tag around the sphincter.

18. palpation gently open the anal opening to see the tear or split around the sphincter and ask the pt if there is any pain. If there is no pain then u can proceed gently to insert a finger after applying local anaesthesia gel on finger.

19. dre Feel for any disruption in anal canal or swelling or lump and stool impaction. If u feel any lump or mass u can proceed for proctoscopy.

20. Proctoscopy proctoscope is an instrument used to see the anal canal. Proctoscope is inserted gently in anal canal after applying local anesthesia gel on it and stylet is removed to see the anal canal tone or any mass or any bleeding area.

21. SIGMOIDOSCOPY Pt presenting with Per rectal bleed,after proctoscopy no haemorrhoids or bleeding area recognised, then we can go for sigmoidoscopy SIGMOIDOSCOPY Sigmoidoscopy is of 2 types Flexible sigmoidoscopy Rigid sigmoidoscopy

22. Flexible sigmoidoscopy Flexible sigmoidoscopy is somewhat similar to as Colonoscopy flexile sigmoidoscopy is used to see the rectum, sigmoid colon, upto the splenic flexure of large gut Flexible sigmoidoscopy can be done in outdoor

23. RIGID SIGMOIDOSCOPY RIGID SIGMOIDOSCOPY It is generally used to see the rectum and sigmoid colon upto 30cm. It is less significant than Flexible sigmoidoscopy

24. CAUSES OF BLEEDING PER RECTUM Most common causes are; Constipation Haemorrhoids Anal fissures Colorectal carcinoma Diverticulae Less common causes are; Inflammatory bowel disease Rectal polyps Rectal ulcers Gastroenteritis Proctitis

25. Types of Bleeding PR Haematochezia (Bright red blood) means bleeding through lower colon or rectum e.g in haemorrhoids, anal fissure or rectal ulcers. Dark red or Maroon coloured blood means upper colon or small bowel. E.g in right colon carcinoma Malena (Tar coloured blood) means bleeding from upper GI tract. E.g in peptic ulcer disease. Duodenal ulcer or oesophageal varices. Malena appears as black, tar-like, sticky stools. The black colour is caused by enzymes breaking down and digesting the blood as it moves through the GI tract. This color is often accompanied by a strong, foul odour.

26. Association of painfull or painless bleeding Painful bleeding Anal fissure External haemorrhoids Anal fistula Rectal ulcers Painless bleeding Internal haemorrhoids Colorectal carcinoma Diverticulas IBD Rectal polyps

27. Association of bleeding with disease Spurt of blood (bright red) ------- Haemorrhoids Streak of blood------ Anal fissure Drops of blood----- colorectal carcinoma In colorectal carcinoma if carcinoma is on right colon it causes bleeding and if carcinoma is in left colon it causes obstruction and constipation

28. HAEMORRHOIDS Hamorrhoids are swollen veins in the rectum ( internal haemorrhoids) or anus(external haemorrhoids) It is the most common cause of bleeding per rectum Haemorrhoids can be developed for many like chronic constipation, straining, pregnancy, obesity etc Passing a small amount of bright red blood in stool and after defecation is often the only sign that a person has haemorrhoids There can be perianal discomfort during or after defecation.

29. Types of Haemorrhoids Internal haemorrhoids Develops above the dentate line Covered by anal mucosa Lacks sensory innervation (that's why painless) Bright red or purple in colour External Haemorrhoids Arise below the dentate line Innervated by inferior rectal nerve (painful) Internal haemorrhoids drains into superior rectal vein external haemorrhoids drains into inferior rectal vein

30. Grades of Haemorrhoids First degree Haemorrhoids protrudes into the anal canal But does not prolapse outside the anus. Treatment: for 1 st degree haemorrhoids high fiber diet and lexatives are suggested to minimise the constipation. 1 st degree

31. Second degree Haemorrhoids protrude out through anus but reduces spontaneously after the defecation. Treatment For second degree hemorrhoids conservative managment is started like 1 st degree but can be Proceeded to painless in orifice Haemorroids treatment procedures i -e rubberband ligation, inj sclerotherapy or infrared coagulation

32. 3 rd and 4 th degree Third degree Haemorrhoids protrude out through anus and has to be reduced manually. Fourth degree Haemorrhoids protrude out through anus and can not be reduced neither spontaneously nor manually. Treatment of 3 rd and 4 th degree haemorrhoids Surgical haemorrhoids excision ( haemorroidectomy )or surgical haemorrhoid stappling Procedure is done in 3 rd or 4 th degree haemorrhoids.

33. Surgical Techniques Indications: Grade III/IV haemorrhoids Recurrent bleeding, Symptomatic prolapse not controlled by office procedures, Thrombosed external haemorrhoids with necrosis. Traditional excisional haemorrhoidectomy (open or closed, e.g., Milligan‑Morgan, Ferguson). Stapled haemorrhoidopexy (circular stapler) – less pain, faster recovery but higher recurrence risk in some studies. Doppler‑guided haemorrhoidal artery ligation (DG‑HAL) with mucopexy (in selected centres ). Thrombosed external haemorrhoid : emergency excision of clot if within 72 h for pain relief

34. ANAL FISSURES Anal fissure is a Crack, split or tear in the mucosa of the anus. Trauma causes The lining to tear which can be strain, chronic constipation, pregnancy Etc. Anal fissure causes severe pain and bleeding in which streak of blood can be seen on the stool. Other possible causes are; IBD, chronic diarrhea , STDs like syphillis , herpes etc

35. location Most common location of anal fissure is the posterior midline as this area receives less than half of the blood supply as compared to the rest of the anal canal.

36. Anal fissure vs Hemorrhoids Haemorrhoids and anal fissures have almost similar causes and symptoms And it is easy to mistake one for the other. Both can be caused due to strain during defecation And both can cause rectal bleeding, pain and itching While haemorrhoids are more common the anal fissure are the common cause of anal pain. Haemorrhoids do not always cause pain while 90% of the anal fissure do cause the pain. However the pain from anal fissure is episodic and pain from a haemorrhoids is constant. It is important to know the anal fissure area as we can rule out the etiology of anal fissure by its area e.g fissure at 6 o clock (posterior wall of anus) is due to strain or constipation while fissure at lateral walls show pathology like chronic diarrhea , IBD or carcinomas etc.

37. TREATMENT OPTION OF ANAL FISSURE Anal fissure are self healing called acute anal fissure but if the anal fissure due to any reason could not be healed over the time period of 6-8 weeks, it is called chronic anal fissure. MEDICAL TREATMEMT If anal fissure become chronic Medical treatment focuses on relaxing the sphincters of anus. Nitroglycerine ointment Nitroglycerine is a vasodilator which allows to heal the fissure quickly be dilating the blood vessels surrounding the fissure which increases the blood supply to fissure area , also it relaxes the sphincter of anus which helps in healing the fissure.

38. Medical management Calcium channel blocker Diltiazim and nefedipine also help in relaxing the anal sphinter . Lexatives help in stool softening decreasing the strain on anal spincter during defecation Botox Botox injection in the anal sphincter also help in relaxing the Anal sphincter. Its effect is for about 3 months which give time to heal the anal fissure.

39. SURGICAL TREATMENT Gold standard: partial lateral internal sphincterotomy (LIS) – division of a portion of internal anal sphincter LATERAL INTERNAL SPHINCTEROTOMY (LIS) Pain and muscle clenching can cause the anal muscle to become tense and spasm, which pull the fissure apart and reduces the blood flow, due to which healing become compromised. An incision is given intra sphincteric at 3o clock position to identify the internal sphincter which is cut 2/3 rd ( upto the dentate line) to release the tension of the sphincter Alternatives : Fissurectomy + advancement flap (for low‑tone sphincter fissure), botulinum toxin injection (in selected cases). Indication: chronic fissure (failure of non‑operative management), high sphincter tone, sentinel tag, fibrotic edges.

40. Pilonoidal sinus A sinus or cyst in the natal cleft/sacrococcygeal area containing hair, often with open sinus tracts, sometimes abscess formation (“nest of hairs” More common in young males (16‑30 yrs), in people with dense hair, prolonged sitting

41. aetiology Congenital pits in natal cleft vs acquired hair penetration or trapping due to friction, pressure, sweating and hair movement. Pathogenesis: Hair penetrates skin, acts as foreign body → inflammation → sinus tract formation. Repeated infection → abscess → chronic sinus with multiple tracts.

42. Clinical presentation Clinical Features Discomfort , pain in natal cleft, swelling, purulent or serous discharge, recurrent abscess formation. Some asymptomatic until infection. Examination: midline pit(s) in natal cleft, often with sinus tracts, may have lateral openings, signs of infection (tenderness, erythema, fluctuant swelling) Acute vs chronic: Acute – abscess formation; Chronic – sinus with tracks and discharge Diagnosis: Clinical

43. Management ( Conservative & Minimally Invasive) Minor disease: removal of hair, hygiene, shave or laser hair removal of natal cleft, keep area dry, avoid prolonged sitting. Acute abscess: incision and drainage (I&D) is first step; hair removed, wound left open or semi‑closed. Minimally invasive procedures: e.g. pit excision under local, sinusectomy , endoscopic sinus tract ablation

44. Surgical Techniques Options: Wide excision and healing by secondary intention (open) Excision and primary closure (midline or off‑midline) Flap procedures to flatten the natal cleft ( eg Limberg flap, Karydakis flap) Key goals: remove sinus tracts, eliminate hair, flatten natal cleft to reduce recurrence Indications: recurrent disease, chronic sinus with multiple tracts, failure of conservative or minimally invasive treatment, significant discomfort or infection .

45. Limberg flapand z plasty

46. cleft lip and Bascom

47. Take‑Home Points Anal fissure, haemorrhoids and pilonidal sinus are common in surgical practice – early recognition and management improves outcomes Conservative measures remain cornerstone for each but surgical referral is indicated when symptoms persist or complications arise Surgical technique matters: accurate anatomy, patient selection and peri‑operative care reduce complications Post‑operative care and patient education (diet, hair removal, hygiene, avoiding straining) are as important as the surgical procedure Multidisciplinary care (nutrition, physiotherapy, wound care nursing) enhances healing and reduces recurrence

48. THANK YOU