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Hello, everyone. Er, good afternoon and welcome to our second event of the day today. We are gonna hear from Sanjay about the management of Rectal Breed bleeding, breathing, bleeding. Sorry about that. And um as always pop your questions in the chat, um we would love to have as many questions as we can. We are gonna be doing um a few questions later on Sanjay has some questions. Er, they'll pop up on your screen and we would love for you to answer them. But if you have specific questions, please pop them in the chat at the end of the event. As most of you know, you'll get a feedback form and once this is completed, you'll then have your attendance certificate on uh your medal profile. So without further ado, I'm going to hand you over. Thank you very much Sandy Cheers. Hi. Uh Good afternoon or good evening everyone depending on where you are. I am a colorectal surgeon from Leicester. I've got no disclosures and for those of you who are familiar with the UK, I've got a little uh map that tells you roughly where Leicester is. Uh, we're not a very big city, we're probably the seventh largest city in England. And uh we're famous for what's called Diwali, which is a Hindu celebration. We have the largest Diwali party. And for those of you football fans, you might remember that some years ago, it was a fairy tale when Leicester won the premiership. Of course, we're no longer in the premiership, but with that start, right. So I'm gonna talk to you about rectal bleeding. Uh The learning objectives today are how to assess and triage patients with rectal bleeding, thinking of the most appropriate investigation strategies for common causes. And I'm also going to talk about education and engagement with patients because I think that's a very important aspect when you look at rectal bleeding. So how common is it? I'm sure you'd all agree. It's a very common symptom. It might happen now and again, but it can be something that keeps happening again. This is obviously different from heavy rectal bleeding, which is dark red, which might cause the patient to collapse. And for the purpose of this talk, we are focusing on bright red rectal bleeding, which is quite a common condition that you all come across. So, trying to give you some numbers, this is an editorial from uh the uh British Journal of General Practice and it talks about the fact that every year, probably about 10% of adults complain of some form of rectal bleeding. One in five patients, ie 20% might have had it in the previous year. And thankfully, most of the time it is intermittent and it settles by itself and very few patients actually come and knock on the doctor's door to say what's going on. What is the problem? I think the first thing when you manage a patient with rectal bleeding is to ask yourself, why is the patient here? Is he troubled? Is the rectal bleeding a nuisance? Is that what he's trouble with or does he have concerns? Why? Because you may see if you go on the internet, you've got some doctor advertising that, you know, blood in your pool or blood in your stool cancer. Go see a private GP or a private doctor. You've got bowel cancer screening advertising which says that, you know, don't disregard bleeding from your bottom or blood in your pool and all these things will invariably scare patients. And it's not uncommon to see a young 25 year old or a 26 year old just because some family members had colorectal cancer suddenly pitch up and say, oh, I'm really worried about it. So I think it's very important that when you speak to them, you ask yourself and answer that question, why are they there again? Color cancer? This is, these are just a couple of slides from the gut and it tells you that if you look at the countries in dark blue, that's where coloring cancer is a significant problem. And if you look at mortality again, you can see essentially it's a disease of the western world, but you can see parts of Africa, you can see parts of uh you know, China, South America where it is becoming a problem. Now, what is the difficulty given the fact that it's such a common condition? If you're a doctor sat in clinic or you're a junior or, you know, wherever you are, you have a patient with you. And the question is this is like, you know, looking and trying to find a problem in this herd of sheep. Who do you investigate? Who do you think you need to worry about? Are you missing something? And more importantly, what are we worried about? We worried about missing colorectal cancer. So the first question I have for you, if you have a patient under the age of 60 what do you think if they have rectal bleeding? What is the positive predictive value of rectal bleeding as a symptom of cancer? I'm gonna give you probably 15 seconds to try and answer this question, right. So at this point, we're looking at roughly about 10% majority is what the risk is. I'm going to go on to the next question now. So the next question is that in a 70 to 80 year old, if someone has rectal bleeding, what is the positive predictive value of rectal bleeding as an indicator of cancer or as a diagnostic testing for cancer. So again, when you say 0.2 you're telling me that's 20% that's reasonably high. But you can see that most of you are quite concerned about that. No, this is an old slide. It's an old paper from the, uh, from a GE General Practice journal in the UK. And this is some research done which tells you about the risk of colorectal cancer depending on whether you have a change in bowel habit, which are the bar charts in blue or in red. If you have rectal bleeding. And if you look at above 60 that risk is roughly between 0.04 and 0.05 which means rectal bleeding in a 60 year old male has about a 4 to 5% risk of cancer. So it's really quite low. If you look at it, when you look at it, uh, more than uh 80. Again, you can see for a female, it's about 3%. The question I asked you is that less than 60? You can see it's less than 1%. So, actually, the risk of colorectal cancer is significantly lower than what you all thought. And if you look at this, this is from the American uh registry and it talks about the risk of colorectal cancer. This is a paper from, uh, looking at the incidence between 2014 and 2018. And you can see that the average lifetime risk is about 5%. Your risk of colorectal cancer at the age of 40 is about one in 1630. And if you're roughly 60 it's almost about 1% for a man and less than, you know, one in 145 for a woman. So that's your risk of colorectal cancer. But it steeply rises somewhere after about 50. This is interesting because this is recent. This is an article actually that came out in the economist recently and someone had pulled out some figures from the US. And this is similar across, I think Europe across Australia, across the UK. That whilst we've noticed that the risk of colorectal cancer is going down in people, you find that in a younger age group between 15 and 30 there's been a marked increase in colorectal cancer and this is something which is very interesting and of course, very worrying and this increase is probably double that for rectal cancer rather than for colon cancer. So something is happening. We don't know whether it's diet. What exactly is it? But there's certainly in the West, there is an increase in younger people getting colorectal cancer with increased mortality. So now coming to what are the causes of bright red rectal bleeding. So I'm gonna break them up into two most commonly painless. And I would say 95% of rectal bleeding is due to hemorrhoids, painful rectal bleeding, anal fissures, classically, someone with an anal fissure will get pain related to the act of defecation. And you find that pain then takes an hour, maybe half an hour, maybe a couple of hours to settle polyps of the rectum or in the colon. Rarely cause can, uh, cause rectal bleeding. Proctitis might present with a bit of bloody mucous inflammatory bowel disease. Again, might cause you bloody diarrhea, rectal ulcers, rare cancers. Again, majority of cancers will present with a change in bowel habit. Patients might have cancer and also hemorrhoids and they may confuse the two. But these are things you'd want to exclude diverticular disease. If you do get bleeding and divertic disease, it's generally large volume, it's quite heavy, often associated with collapse and the color of blood is darker. So essentially, what are you trying to do when you see a patient with rectal bleeding, you're trying to identify patients at high risk so that you don't miss cancer or you don't miss a diagnosis of say inflammatory bowel disease or something else. So, you're down to history, symptoms of bleeding. How long they've had it for nature of bleeding? You want to go into the risk factors because you want to make sure that they aren't at high risk for colorectal cancer. And then you want to examine them, general examination, looking for anemia, abdominal examination, rule out any abdominal masses and most important a rectal examination. So again, this is another question for you. So which of the following patients would require an urgent referral to second secondary care. I haven't seen any responses yet. Ok. Yeah. So, uh, I think that's great because you're right. Majority 60%. I got it right to say that someone who's had rectal bleeding for a while, if suddenly something changes, I'd be worried about that as a sign. So when I look at red flags or discuss red flags, someone who's got Melena or dark blood per rectum blood that's altered with mucus and stool I would want to look into because that doesn't sound like hemorrhoids. I'd be worried about either a colorectal cancer or inflammatory bowel disease or an infective diarrhea. Anyone with anemia, anyone with a change in bowel habit along with some bleeding, which is not classically dry, red, anyone with a change in caliber or consistency of stools, weight loss. These are all things that would make you worry whether this patient has got a colorectal malignancy or not. Family history. If someone gives you a family history of, you know, members of the family having died at a young age, I do. You know less than 50. Yes, I would worry about genetic, uh, colorectal cancer patients with rectal bleeding, hemorrhoids are quite common and a patient might tell you that, you know what I've had bleeding now and again, for the last, you know, 10 years, but in recent weeks, the bleeding has changed or I'm suddenly finding that I get this sensation that I haven't emptied my bowel completely. So again, it's important not to disregard them and say, ok, just because you've got a history of hemorrhoids, ask yourself the question that has anything changed in their history. That makes me worry that they may have something in the bowel investigations of full blood count. Yes, for everyone. Because it might tell you if they're anemic, it's tempting to assume that the anemia is due to their bleeding. You would want to, uh, corroborate that with their history because if someone says I bleed a bit now and again, then if someone is anemic, I'd worry about right sided colonic cancer or any other significant pathology. On the other hand, if someone says that I'm bleeding every day, large amounts, they're anemic, it would be reasonable to assume that that's a result of the hemorrhoids or bleeding crp. If someone had a bloody diarrhea, I would think about probably inflammatory bowel disease. Check of inflammatory markers, platelets are increased. I would send off a stool for microscopy and cultures. If someone gives you a history of travel abroad or you're worried about, you know, any kind of infective diarrhea, fecal calprotectin is a test. We do as a screening tool to help us decide whether patients have inflammatory bowel disease or not. If it's significantly elevated, more than 200 it would make you refer this patient for a flexible sigmoidoscopy so that you can exclude an infective or inflammatory bowel disease. What other investigations I've got this lovely picture of someone's finger. And I think a digital examination is mandatory in patients with rectal bleeding. Because with a good digital rectal examination, you can least feel the lower third of the rectum and exclude anything there. If you have a proctoscope or an anal scope, you can have a look. And if you find someone with a history of bright red rectal bleeding, he's got hemorrhoids that you can identify on proctoscopy. You're reasonably sure what you've got the next question then is that ok? You've got the diagnosis. Does this patient require investigations to reassure you and him whether or her, whether they have colorectal cancer, you can use something called a rigid sigmoidoscope. This allows you to have a look at most of the rectum. It's a 15 centimeter long plastic or a stainless steel tube with a magnifying glass, a light source and you can have a look at the rectum. You may have dedicated rectal bleeding clinics where you refer patients for an endoscopy along with facilities for banding. So these are the kind of tests you would consider. These are just some pictures for you. And what I want to highlight on this is that not all lumps around the back passage are hemorrhoids. So if you look at the right side of your screen, you've got two images there and these are essentially large fleshy skin tags. Whereas on the left, you can see prolapsed mucosa or the hemorrhoid and the patient will have some mucous leakage. And I'm trying to drive home the message that there's a difference between these two. You might leave a patient with skin tags alone whereas someone who's symptomatic with his hemorrhoids might warrant surgical intervention. Again, some more pictures. And the picture A is a flexible sigmoidoscopy view of. If you retroflex the camera, what do hemorrhoids look like on endoscopy? B? Again, you can see prolapsed hemorrhoids. C is what I would call a perianal hematoma. Some people might argue this is a thrombo hemorrhoid, but you can't see any mucosa. And here what you're seeing is a blood clot from someone's straining and you can see an associated swelling and these normally settle by themselves in about 10 days or so, they're painful. You can try draining this under a local anesthetic. But if you leave them alone with cold compresses and analgesia, they should settle. So how do we treat hemorrhoids in capital letters? Patient education? Why? Because this is something that is gonna happen time and again. And it's important that you educate your patient, you reassure him that everything is ok. What are the other options? You can give them dietary, uh you know, manipulate their diet, make sure they have a high fiber diet. They're drinking enough water, you could offer them injection with a sclerotherapy or banding. If hemorrhoids are falling out, you could offer them surgery. Some patients complain of just mucous leakage or itching and both these symptoms of hemorrhoids do not respond very well to surgery. So, unless someone has prolapse, I would be reluctant because mucus rectum and itching are multifactorial and hemorrhoids might contribute to it. But on definitely, uh that, you know, aren't definitely bound to improve surgery will not improve it. Now, you, there's a question in there saying flexible sigmoidoscopy versus rigid sigmoidoscopy. I think it's a question of resource. If you have a rigid sigmoidoscope in your clinic, you examine someone, you get good views of the rectum, you might satisfy yourself that if this is a patient who is 25 years old or 30 years old, you don't need to do anything more. And I'm happy with that in some countries, people would think that hang on with the sigmoidoscopy is a waste of time. We've got access to flexible sigmoidoscopy or colonoscopy. And depending on what's available in your clinic in your healthcare setting, then you can uh uh send them for that. There's a question about banding and I'm going to come to that later. So when it comes to patient education, we know that if you manage dietary fiber, obviously, if someone has a high fiber diet, adding more fiber is not going to help. In fact, if they have a bit of I BS, you might make them feel more bloated and worse drinking water. Definitely, particularly in hot climates. It's important, you're drinking more water because if you don't have enough water in your system, you're bound to get constipated and your stools are hard and pellet. Like you will advise uh avo uh sorry, advise patients to avoid straining, avoid constipation. And in today's world where you've got tablets and mobile phones, you can sit on your phone. I don't think people read anymore. But my advice to patients is avoid sitting on the toilet for more than 3 to 5 minutes. Get up. If you haven't opened your bowels, come back later. Don't keep sitting there all day. Now, talking about banding of hemorrhoids. Banding is something which is very simple and straightforward. This is a paper called the Hubble trial, which was in the Lancet, which talked about comparing banding in a randomized controlled trial compared to uh ligation or what's called uh A DH D procedure. Now, it's very important when you band hemorrhoids that you consent, the patient and explain to him what you're doing before you put the proctoscope in. If you have a patient on your examination couch, you put a proctoscope in, you take it out and tell him right? Can I band you and then you do that? Five minutes later, I don't think that's a good consent process. I would in clinic tell my patient before I examine him that. Listen, I think you've got hemorrhoids. I'm going to have a look, I can band you banding. This is what banding is. It might make you feel uncomfortable. These are the risks. These are the benefit. Are you happy for me to band you or do you want to go back, think about it and come back another time. So I think this is very important that you can send them before you actually start examining them and because you consent them or ask them and you've got the proctoscope inside the, the anal canal saying, can I band you? I don't think that's good. Now, there's a question saying, can I band skin tags? No, you can't band hemorrhoids. If you remember hemorrhoids occur below the dentate line, they have sensation. If you put a rubber band on something there, the patient is going to jump, going to be uncomfortable, you have to bend above the hemorrhoid. You've got to bed in the lower rectum above the pedicle of the hemorrhoid. And the aim is that you're not bending the hemorrhoid, you're causing a banned ulceration and you're trying to cause submucosal fibrosis at a later date, which will fix uh the hemorrhoids. Now, there's a question there saying that which particular molecules are good for medical management. I'm not sure I get that I would request the person to put up this question later when we can do that in the Q and A session. Also, even if you have one hemorrhoid, I would probably apply three bands. And the idea being is that you're trying to cause ulceration and fixation of the lower uh rectum stroke, upper anal canal rather than, you know, just band the hemorrhoids. So it's very important to understand how it works. It's almost like causing sclerotherapy, but you're causing an ulcer above and that ulcer is what's going to heal by scarring. How useful is binding. If you look at it for second degree hemorrhoids, you find that it is a very good treatment for 1st and 2nd degree hemorrhoids. It is very good treatment. I haven't gone into classification of hemorrhoids, but I'll just mention it. Now I break or I do not look at hemorrhoids as grade 1234. I just look at them as prolapsing, not prolapsing because one, you might assess someone's hemorrhoids and say this is grade one. Someone else says grade two. More importantly, if a patient tells you that my hemorrhoids come out when I open my bowels and I need to push them back in, he's got prolapsing piles. And I think from a management point of view, that's more helpful than telling them whether it's first degree, second degree or third degree. Also, we know that if you have third degree hemorrhoids, then probably these are piles that, that prolapse when you open your bowels, they may go back themselves. But then you're starting to consider surgery is probably more effective if they aren't prolapsing and bleeding is the main issue. Then I think ru blind ligation certainly must be tried once or twice because repeating it does improve its efficacy Now, in terms of what is the operation that one talks about for hemorrhoids, classically, you cut out the hemorrhoid here. You can see an image where you've got what's called a ligature device. And you can see that you've cut the hemorrhoids and you can see three wounds there. Obviously, this is gonna be quite painful. You've got newer procedures, you've got something called a staple hemorrhoidectomy. You've got something called THD, which is transanal hemorrhoidal dearer or whether you call it hemorrhoid artery ligation. These are devices using a Doppler where you try and stitch up the artery. You've got something called laser hemorrhoids. You've got a radiofrequency, uh you know, ablation procedure and these are all newer procedures which claim to be less painful for patients. So the question I have is the next poll is on these newer operations. Are they less painful and better with lower recurrence rates or not? Simple? Yes or no. Right. Ok. I think we've got an answer there. So I'm afraid majority of you got that wrong. There is no doubt that a conventional hemorrhoidectomy is more painful, but all studies would tell you that it has a lower failure rate or a lower recurrence rate. There are numerable papers out there. I've just mentioned one of them and this is a systematic review from the British Journal of Surgery. But essentially these newer procedures cause there's no doubt they're less painful, but they have a high recurrence rate. So when I consent to patient or talk to patient about surgery, I tell them that, listen, you have a choice of these options. You can have something which is simple. We cut them out, more pain, the pain settles. But you know, the failure rate is lower or you can have something which is less painful and see if that doesn't recur or not. So it's important to have, take that message and share that with the patient because the patient is making a choice. The other common condition that we're gonna talk about today is anal fissure. What is an anal fissure? You can have an acute anal fissure which is a split in the lining of the anal canal. Quite painful. It's an ulcer, it becomes a chronic anal fissure if it continues for more than six month, uh six weeks, classically, it's generally in the midline, most commonly posteriorly, sometimes anteriorly. If you do get someone with multiple fissures, think about Crohn's disease. The hallmark is anal pain and this pain is brought on when they open their bowels. Because if you imagine that someone's got a painful ulcer over the internal sphincter, the internal sphincter does not relax and the patient complains of a throbbing ache that goes on for a short while, probably at times up to a couple of hours. Uh after he's opened his bowels, the bleeding is bright red and sometimes patient might give you a history that they felt something split or cut inside when they were opening their bowels. Most fissures generally heat spontaneously. If they're acute, we can help them heal by making sure that patients aren't constipated. Their bowels are soft, give them a non constipating analgesic. I avoid things like codeine and morphine and or if we do use them, give them a laxative along with it. And we know that chronic fissures are generally associated with increased internal sphincter tone to try and help them heal. We can use drugs like GTN and dilTIAZem, which is something that we ask patients to use by applying it to the anal canal. I do think there's a lot of importance on explaining how the patient should use GTN and dilTIAZem telling them that they may get a headache because compliance is a big thing. If you tell someone to apply a cream twice a day to the anal canal, morning and evening, I'm not sure many patients are gonna do it for more than maybe 34 days, five days a week. And I think it's very important to explain to them why they're doing it and that they need to do it for at least 3 to 4 weeks. You can use Botox. Botox is what you inject into the internal sphincter. The biggest benefit is that it's a one off treatment that you can give into the internal sphincter, the patient doesn't need to do anything. So, thereby compliance is not an issue. What is a surgical option. You can do something called a lateral sphincterotomy where you weaken the internal sphincter. How much of it do you cut, you cut the internal sphincter to the length of the uh fissure? Now, in terms of which treatments, this is another question I have for everyone. The first question is about whether dilTIAZem or sic is better. And the second question is whether Botox is better. Yeah, I think, uh Right. That's pretty good. 50 50 is always a good uh option. So if you look at the Cochrane review from 2012, there isn't anything new but there are other articles out there and it says that GTN is probably slightly better than placebo, but recurrence is quite often if you look at Botox and other calcium channel blockers such as dilTIAZem, they're more or less similar, probably less problems with headaches, which is the most common effect that patients complain of when they're on uh GTN. And I think the key bit is to tell patients that listen, if you do have a headache, you need to probably reduce the amount of GTN you use, but you should apply enough G TT N that you feel slightly lightheaded. Obviously, with the zem headache is not such a problem. Neither of these medical treatments are as good as a sphincterotomy, but the problem with a sphincter toomy is that there is a risk of minor incontinence occasionally if you cut the wrong sphincter, obviously, the patient is going to be in trouble for all chronic fissures. Everyone would agree that medical therapies are far less effective than surgery though surgery does have the risk of minor incontinence. And obviously, if you cut the wrong muscle then more problems. This is a recent review. Looking at all the randomized control trials, out of all the studies, they could only pick up nine studies, 775 patients. And what did they tell us at eight weeks that healing rates with the sphincter toomy were about 95%. I only a 5% failure. And obviously in this group, they felt that Botox, GTN dilTIAZem were all between 50 to 65%. So recurrence they said was highest for people treated with Botox and lowest for sphincterotomy. So hopefully that answers the last two questions. Now, this is just something which is probably not so relevant to people in other parts of the world. But again, the main issue as we have with any patient with rectal bleeding is you're trying to ask yourself, are you happy with just proctoscopy? Do you need any further investigations? And in a public funded healthcare service, you're obviously trying to make sure that you use your tests cost effectively. So we have in the UK A cancer referral pathway and if you have rectal bleeding or if you have anything that makes GPS worry about rectal cancer or colorectal cancer. These are the red flags abdominal mass change in bowel habit, iron deficiency, anemia, age 40 with unexplained weight loss and abdominal pain, aged under 50 with rectal bleeding, age 50 over with rectal bleeding, abdominal pain, age 60 over with anemia, even the absence of iron deficiency. And the idea being is we're using something called a fit test, which is an immunological test to measure blood in your stool. And the idea being is that if we do the test, your results are less than 10 micrograms, then the risk of colorectal cancer is less than 1% then you can be referred routinely. Whereas if it's more than that, you should be referred on what's called a fast track, fast track, fast track pathway. So this is just, you know, something to guide you and different countries might use different ways of rationing or trying to give guidance to doctors as to how should they investigate? What would I recommend? I would recommend that if you're sat with a patient who is maybe 50 or older, if they've had previous, any kind of bowel screening tests, or if they've had a colonoscopy or a sigmoidoscopy in three years, if it was done properly with good bowel preparation, then probably the risk of them having colorectal cancer is low. And you might just say that, you know what, I'll do a flexible sigmoidoscopy if you have access to it or redo sigmoidoscopy depending on your resource and manage their hemorrhoids accordingly. If someone is less than 40. The risk of colorectal cancer is much lower. And you may say that, you know what, I'm happy with just a proctoscopy. I don't think I need to do anything more. I will treat you and see how you get on or if they have an anal fissure, obviously, you've got the diagnosis, you might not do any more investigation. However, if your proctoscopy is normal, you find that there's nothing there. Then I think you do need to consider lower G I endoscopy. And I think it's very important that you share the fact that you know, yes, this is your risk of bowel cancer. It is roughly quite low and we will manage your rectal bleeding, see how you get on treat your hemorrhoids or fissure. And if that gets better, you know, you bring the patient back and review them and if things are no better, you know, you definitely need to investigate them. I think it's important that you will find that there are some patients who keep having problems with rectal bleeding and coming back to clinics time. And again, if you look at their history or you look at their notes, you will see that over the last four or five years, the GP has referred them on, on multiple occasions. I think the risk of cancer in these patients is low. But I think it's important that if you want to help them, that you actually educate them and tell them that you make sure, first of all, you haven't missed any red flags, you uh check and make sure that, you know, ok, maybe you book them an endoscopy, which is done now and, you know, for the next five years, you may not need to repeat it and you can manage them either by treating them or reassuring them. And if they do have hemorrhoids or a fissure, it's good to convince them that, you know, listen, you must have treatment for it. Otherwise, you know, every time you bleed, you're going to go through the stress of, you know, it's just something to worry about and pick up in your clinic again, which you could argue that if you do if you're a private doctor, that's great news. But if you work in a public uh funded healthcare system, you don't want these patients to keep coming back time and again. So again, I'm going to double check if you've got the risk of colorectal cancer, right? Uh We talked about it. So we're talking that in less than a 40 year old, your risk of colorectal cancer is, right? Ok. If you remember, I showed you a slide with about one in 1500 and, or 1514 160. So I think it's probably somewhere between C and D if you're 60 your risk of colorectal cancer for a male. Yeah, I think it's about 1%. So that's good. To be getting somewhere. So, whilst I've said this, I'm gonna go back and remind you that, you know, things are changing particularly. I know that in parts of Africa I've operated in Sudan, I've operated in Kenya and I've, I'm told that there is, uh, the patients who come through are younger and I do think it's important to sort of, you know, remember that, yes, the incidence is changing. If you look at it, you know, it's going down for people 55 and older. However, it's increasing for people at a younger age and this increase is largely due to rectal cancer. I don't know whether this is a different pathway, but that that is what's happening overall at this point in time, about 11% of one in 10 colorectal cancer diagnoses are under the age of 50. So this of course, are figures from the UK more relevant to the West, but I'm sure you will all have similar figures for your country or wherever you practice. So to summarize, I think the most important thing when you see a patient with rectal bleeding is to decide in yourself, is this patient low risk, do I need to investigate him? And you know, the thing is whether you use 50 as a cut off or 60 I guess that depends on your background, which health system you are in and you know what your figures are like. Uh if someone has bright red rectal bleeding you undertake, did sigmoidoscopy? It's normal and they've got hemorrhoids that you can see, then you know, that more or less you got the diagnosis. Right. Or if you found some other rectal pathology, if they've had a test done in the last couple of years, you don't get cancers overnight. Who would you investigate? I think people who are slightly older, anyone with red flag symptoms or a family history. Most important. I think it's very important to reassure the patient because at the end of the day, it's important that they understand why they bleed. They understand why the diet matter. Why should they take more fluids? You need to explain to them that even if you've had surgery for hemorrhoids, if you get constipated or strain, you might get a bit of bleeding now and again, or if you have some very spicy food or alcohol, you may get some bleeding the next day because otherwise if you don't explain this to them, don't tell them, you know, you tell them everything's ok. The test showed nothing the next time the patient bleeds, he goes to the system again with that. This is just to say thank you. And uh the bottom left is the oldest part of my hospital from 19 05. And these are new buildings are new buildings likely to come up. So with that, I'm gonna start question and answers. Brilliant. That was that, that was really, really good. And actually I was expecting worse. That is awful, isn't it? I was expecting it to be higher for some reason. I don't know why, but I did. So, does anyone have any questions, please pop them in the chat if you put a question somewhere in the chat and we haven't answered it, copy it and pop it back in again for me. Ok. So Kare Gibson has said, when would you do a colonoscopy versus a sigmoidoscopy? And how do you choose between flexi and rigid sigmoidoscopy? OK. So it, it's very interesting because rigid sigmoidoscopy, for example, in Europe is not undertaken very commonly. Most people don't do it. There's a technique to doing a rigid sigmoidoscope. If you imagine you're putting a tube that's 15 centimeters long straight into someone's rectum, the rectum has two valves, you've got to negotiate them. And I think even in a place like the UK, there are some of my colleagues who believe in rigid sigmoidoscopy and some of them feel that you know what? I can't get a good view. I have access to flexible sigmoidoscopy. I'm just going to book them a flexible sigmoidoscopy. So for me, it's a question of resource. Likewise, in Europe, people would argue that listen, if there is no shortage of endoscopies, why not just do a colonoscopy? It's a screening test as well. And if a patient is above the age of 50 definitely, why not a one off colonoscopy? And then afterwards if he bleeds again. They may, you may choose uh uh flexible sigmoidoscopy. So, in the UK, roughly speaking, it's easier to do a flexible sigmoidoscopy. You don't need to give them full bowel prep, you can give them uh a phosphate enema, it's quicker. So you might argue between the two, but that's what you're thinking of in clinic depending on your health, uh resources. Fact, our next one, what is the recurrence rate of laser hemorrhoid doxy versus open hemorrhoidectomy? So laser hemorrhoid hemorrhoid AEX is really what you're doing is you're causing sclerotherapy. So, what you're trying to do is you're putting a laser fiber in and you're causing, you know, sclerotherapy or causing sort of, you know, submucosal fibrosis between the layers and you might combine this with trying to stitch up what's called an Opex where you stitch up the hemorrhoid and try and pull it up into the lower rectum if you do that. Well, again, it's a very operator dependent uh you know, procedure and you find when it comes to comparing two surgical techniques, you can never get a good answer. But I would think that the failure rate is roughly between 10 and 20% for a hemorrhoidectomy, probably 5%. Perfect. Uh Next one, if you have a patient with significant bleeding prolapsing piles with failed conservative management, which surgery would you recommend? So I would recommend excising it because I tell patients that listen, you've had this problem for many years you've struggled with it. You're going to have an operation. You might have one operation where we cut them out because what you cut out cannot come back. And the only question is yes, the first two weeks are painful. But if you look at, uh, questionnaires of, do you know how patients feel at the end of six weeks, 95% of them are quite happy that they had a hemorrhoidectomy done. Of course, this takes into account the fact that you know how to do a good hemorrhoid operation and you're not causing complications? Oh, wonderful. Ok. What would be the best option of pain management in patients operated for hemorrhoids if not managed with NSA S. So patients who have hemorrhoid surgery, if they have had them cut out, they go away with either Ibuprofen, which is the cheapest and, uh, simplest, uh, analgesic. We'd give them 400 mgs twice a day. I'd also give them either codeine or some Oramorph or traMADol. And I'd give them that on a PRN basis. And I would combine that with paracetamol, which they can have for a couple of weeks. So there's a lot of analgesics, there's paracetamol, there's an opioid based plus codeine, uh, plus, uh Ibuprofen and I would give them either Laxido or Cosme, which is essentially a macro glycol laxative to make sure that the bowels are soft because otherwise the patient is gonna get constipated and be very miserable. Ok. Next one can you tell a bit about the Milligan Morgan technique, which is done in the UK, predominantly versus whitehead. So white head is a technique I've never done. Milligan Morgan is what's described in the book where you start off with an incision just around the anal w and you lift up the hemorrhoid of the internal sphincter. And um in olden days, you would like it, the pedicle these days, you take it away with dither. I don't think there's much white head done in the UK at all. At least I, in the last 15 years, 15, probably more, 15 years as a consultant and probably 10 years in training. I've never seen anyone do a whitehead. I don't know what these things are but would, would a whitehead be done in other countries more so than in the UK? Or it's more, it's a historical procedure. It's there in textbooks and it's a more sort of circumferential procedure. But I haven't, you know, I would, you know, I haven't done it and I haven't been taught it so I would not offer any expert advice on it. Effect. OK. Do we have any more questions? Oh. What are the best molecules for medical management of hemorrhoids? Non prolapse? Are you talking about topical agents? I assume you're talking about things like, you know, you've got uh Proctosol, you've got Anusol, it's, it's a billion dollar or a billion pound market out there for all these creams and I always joke with patients that, you know, if you, if you can afford it, if you think it makes you feel better, you can use it. I don't think there's good evidence showing that this is better than that. And essentially, you know, I guess if you've got pain on your finger and you apply something, you feel better, there's a placebo effect to it. So, I think, you know, I tell patients that, yeah, you can have it if it makes you feel better. Some of them have an anesthetic in them, either some degree, some amount of, you know, kro canine or lidocaine and that at times might make them feel better, particularly if they have a fissure. But I don't think there's any particular topical treatment that I could recommend for hemorrhoids based on evidence out there. Ok. Um Can you tell us? 00, I can get rid of it. I can't see it. Now, angiodysplasia is something that's not very common. It's more likely seen in the colon. But you get these little vessels which are abnormal that can cause a lower G I bleed. And they would probably present with sometimes with uh you know, dark red, rectal bleeding, not bright red. It's not very common that you see angiodysplasia in the rectum. So you answered that question. I don't need to ask it. Now any more questions. I just want to give people a chance to type and is everyone happy with the answers that they got. Yes. Oh. Tas name ask again if you have a PT with bleeding piles and history of portal vein thrombosis. Do you recommend surgery? Uh That's an interesting one. So people would talk about if you had thrombo piles, there was a risk of portal hypertension or portal vein thrombosis. This is something which is, you know, very hypothetical in the sense that I can tell you now that, OK, we don't have much portal hypertension in the UK or particularly high levels. But I don't think I've seen patients with portal hypertension and hemorrhoids and we would treat them particularly if they're bleeding because that some of them can have significant bleeding. Some of them may have rectal varices. And again, you would warn these patients that you know what they're at high risk of complications, they may have more bleeding following a HED omy. And I would certainly use a vessel sealer rather than diathermy for taking their hemorrhoids away. So I would use a ligasure and I would under run the pedicle just to be sure that they don't present with secondary hemorrhage, anal abscesses and fistulas. I haven't gone into. It's a totally different thing to discuss. It's rare that they present with classical bright red rectal bleeding. And maybe, you know, if that's a topic that uh there's a need for, I might look at maybe offering that topic at another time. That would be great. I'm sure I'm sure there's lots of people that would like that topic. Sorry, just got met by a dog. Uh, any other questions? Uh Nope, that's brilliant. Ok. Well, if we have no more questions, er, Sanjay and I will say goodbye to you all. Um, we have some more er, medical education events on Friday. Please do, er, register for those and we will see you hopefully very, very soon. Ok. Thank you, everyone. Take care. Bye.