Back to Basics! PR exam
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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,
Back to Basics! PR exam
- 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 2
- 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 3
- 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 4
- 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 5
- 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 6
- 7. PR exam Diagnosis & Assessment of: ? Hemorrhoids ? Anal Fissure ? Anal Fistulae ? Anal and Rectal cancers ? Anal condylomata ? Perianal Abscess ? Faecal incontinence ? Constipation ? Faecal Impaction ? Pruritus Ani ? Perianal Eczema ? Prostatitis ? Prostate cancer ? Benign prostatic hyperplasia ? Inflammatory bowel disease ? Neurologic deficits ? Acute Appendicitis ? Pelvic Tumours DR. MOHAMAD AL-GAILANI Back to Basics! PR exam May 2017 7
- 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 8
- 9. PR Exam: Procedure DR. MOHAMAD AL-GAILANI Back to Basics! PR exam May 2017 9 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 10
- 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 11
- 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 12
- 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 13
- 14. 14 Dr. Mohamad Al-Gailani FRCS ???.?????????? ?????? Consultant Surgeon Medical Education & Training Director SUWAIDI www.alhammadihospital.com RIYADH, KSA Tel: +966 11 4250000