back to basics! pr exam

Back to Basics! PR ExamDR. MOHAMAD AL-GAILANI FRCS

CONSULTANT SURGEON

MEDICAL EDUCATION & TRAINING DIRECTOR

SUWAIDI

RIYADH, KSA

MAY 2017

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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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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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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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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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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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

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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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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

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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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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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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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 محمد الكيالني . دConsultant Surgeon

Medical Education & Training Director

SUWAIDI

www.alhammadihospital.comRIYADH, KSA

Tel: +966 11 4250000