Colonoscopy.net.au

An elderly patient was referred with rectal bleeding thought to be from haemorrhoids(The patient has just had colonoscopy <2 years ago by a gastroenterologist which showed only haemorrhoids and was otherwise reported as normal) The patient’s bleeding had not really settled at all since the previous colonoscopy and the patient’s bleeding was attributed to the haemorrhoids reported in the colonoscopy. The patient was referred recently for the haemorrhoidal bleeding and a colonoscopy was performed. A low rectal cancer measuring about 5cm was found(the cancer was arising from a tubulovillous adenoma, located just above the anal canal, the tumour can be felt on rectal examination – mobile, T2 on MRI). Fortunately, this could be treated with a transanal excision of the rectal cancer and the patient recovered quickly from the surgery.

The points to learn from here is that :

1. One should not always assume any rectal bleeding is due to haemorrhoids- especially if this persist despite treatment of the haemorrhoids. (If haemorrhoids have been bleeding up to the colonoscopy, it would be a good idea to band them at the end of the colonoscopy) If symptoms persist, reinvestigate or refer on.

2. A rectal examination is still useful even in the 21st century- As Norman Browse’s book on Symptoms and Signs of Surgical Diseases says “”Every patient with a rectal complaint should have a rectal examination”". This still holds true today. Be thankful that there are gloves these days – I have heard in the past in places where gloves were not easily available, doctors used to put soap into their fingernails before doing the rectal examination. ( A good tip is to double glove the hand doing the rectal examination – that way you can throw away the top glove after the rectal exam before doing anything else)

3. On colonoscopy, care must be taken to look carefully at the anal canal and what is just above. Sometimes faeculent fluid can obscure the view – this should be sucked out. A J manouvre at the end in the rectum is also useful. In fact during my training, I remembered one of my mentors telling me how he heard about a case of a low rectal cancer being missed during a colonoscopydue to too rapid an insertion.

Small haemorrhoids can be banded during a colonoscopy procedure(Generally most gastroenterologists  do not band the haemorrhoids but refer that on to the surgeons)

The benefits of banding compared to surgery to excise the haemorrhoids are that: 1. It is relatively painless(if the rubber bands are placed high above the anal canal) 2. It does not require any more anaesthesia than the one for the colonoscopy.

It is a relatively quick procedure to perform. A short proctoscope is inserted. The rubber band is loaded onto the suction bander. The haemorrhoids is sucked up onto the suction head and the rubber band is then applied. This rubber band strangulates the neck of the haemorrhoid. This is then repeated on the other haemorrhoids seen.

Complications are uncommon. Sometimes they may be discomfort or feeling or an urge to go to the toilet after the procedure. Occassionally, if the haemorrhoids is large, it can be painful. Bleeding and blood clots may be notice when the haemorrhoids sloughs off over the next 2 weeks.(If there is severe bleeding one should see a doctor immediately – patients on blood thinners and with liver problems are at higher risk of bleeding)

Bowel cancer is so common (About 1 in 20 Australians will develop bowel cancer in their lifetime) and so are haemorrhoids. It is not safe to assume once symptoms is due to haemorrhoids alone. It is best that this is discussed with your general practitioner. And if there are any concerns, you should be referred to a surgeon or endoscopist.

There has certainly the cases where patients present with clear symptoms of bleeding from haemorrhoids but on colonoscopy, a bowel polyp or even bowel cancer has been found!

Haemorrhoids can present in a variety of ways.

Presentations:

1. Bleeding – either blood on the toilet paper or blood dripping on the toilet bowl. The latter can be quite alarming for the patients

2. Palpable lump – usually comes out after one opens the bowels and can either go back in spontaneously or needs to be pushed back in

3. Pain – uncommon. This is caused by a thrombosed haemorrhoid (the blood in the dilated blood vessel within the haemorrhoid becomes clotted)  The pain can be severe especially in the first 3 days.  After that, as the swelling subsides, the pain reduces.  On examination, one can find a large swollen tender lump in the perianal area