| R |

Patients present with any degree of bleeding from a smear on the toilet tissue to severe haemorrhage. Various causes are presented in Fig. R1.

Local causes of bleeding include excoriated skin, anal fissure, a burst perianal haematoma and anal carcinoma. A characteristic pattern of bright bleeding is found with haemorrhoids. It is usually small, non-prolapsing haemorrhoids that bleed.

Black tarry (melaena) stool indicates bleeding from the upper gastrointestinal tract and is rare distal to the lower ileum.

Rectal bleeding: diagnostic strategy model

Probability diagnosis

• Haemorrhoids/perianal haematoma

• Anal fissure

• Colorectal polyp

• Diverticulitis

• Excoriated skin (anal pruritus)

Serious disorders not to be missed

• Vascular:

  • ischaemic colitis

  • angiodysplasia (vascular ectasia)

  • anticoagulant therapy

• Infection:

  • enteritis (e.g. Campylobacter, Salmonella)

• Cancer/tumours:

  • colorectal, caecum

  • lymphoma

  • villous adenoma

Other:

• inflammatory bowel disease (colitis/proctitis)

• intussusception

Pitfalls (often missed)

• Rectal prolapse

• Anal trauma (accidental/non-accidental)

• Villous adenoma

Rarities:

• Meckel diverticulum

• solitary ulcer of rectum

Key history

Nature of the bleed, including fresh versus altered blood, mixed with faeces and/or mucus, in toilet bowl or on underwear. Quantity of bleeding: slight, moderate or torrential. Associated symptoms (e.g. weight loss, constipation, diarrhoea, pain, weakness, presence of lumps, urgency, unsatisfied defecation, recent change of bowel habit).

Key examination

• General inspection (evidence of anaemia) and vital signs

• Abdominal examination, anal inspection, digital rectal examination, proctosigmoidoscopy

Key investigations

• FBE and ESR

• Stool M&C

• Faecal occult blood

• Colonoscopy

• Consider abdominal X-ray, CT colonography, angiography, small bowel enema (depending on clinical findings)

Common presenting problems

Psychological and behavioural disorders, anaemia esp. iron deficiency, orodental disease, tropical diseases (e.g. helminths, malaria, schistosomiasis), helicobacter plyori infection, vitamin deficiencies esp. vitamin D, disorder of special senses—skin, ears, eyes, chronic disease.

Important diseases that ‘must not be missed’ include malaria, tuberculosis, schistosomiasis, HIV, typhoid fever, Hepatitis B and C, haemoglobinopathies, e.g. sickle cell, G-6-DP deficiency, meningoencephalitis and severe pyschological illness such as psychosis, major depression esp. suicide risk.

Key recommendations (ASID)

All refugees should be offered a comprehensive health assessment, ideally within 1 mth of arrival. This should include screening for and treatment of TB, malaria, blood borne viral infections, e.g. dengue, Hepatitis B and C, schistosomiasis, helminth infections esp. strongyloides, hookworm.

Refugees should have met pre-departure screening criteria (for a permanent visa): this includes CXR (if ≥11 yrs), HIV (if ≥15 yrs), Hepatitis B, syphilis ≥15 yrs, malaria (rapid antigen test), faeces for intestinal helminths.

Exclude diabetes, uraemia, hypothyroidism, anaemia, various drugs. Mainly a functional disorder affecting the elderly.

Diet: eliminate caffeine and follow a healthy diet.

Exercises: gentle stretching of legs, particularly of hamstrings and calf muscles, for at least 5 mins before retiring (Fig. R2)

Medication

1st choice: paracetamol 1000 mg (o) nocte or clonazepam 1 mg, 1 h before retiring

2nd choice: diazepam 5 mg ± paracetamol

May help: codeine, levodopa, baclofen, propranolol

Generally unhelpful: carbamazepine, quinine, antipsychotics and antidepressants

• A rare complication of influenza, chickenpox and other viral diseases (e.g. Coxsackie virus)

• Suspected causal relationship between aspirin for a febrile illness in children

• Rapid development of:

  

• 30% fatality rate and significant morbidity

• Treatment is supportive and directed at cerebral oedema.

Recommendation: Avoid aspirin for fever in young children—use paracetamol.

Acute URTI rhinitis

Viral aetiology, esp. common cold.

Treatment

• Increased fluids

• Saline insufflation or steam inhalation ( See Stuffy and running nose)

• Simple analgesics for pain (uncommon)

• If swollen and inflamed: corticosteroid spray

• If superinfected: mupirocin 2% nasal ointment

Usually no indication for oral antibiotics.

Allergic rhinitis

Hay fever

Rhinitis medicamentosa

Be wary of this reactive vasodilatation due to prolonged use (>2–4 d) of OTC decongestant nasal drops or sprays.

Vasomotor rhinitis

Usually due to chemical or environmental irritants (e.g. smoke and noxious fumes, sprays, cosmetics). Aggravated by emotional upsets, chilly damp weather, air conditioning, etc.

Treatment

• Patient education

• Trigger avoidance (if possible)

• Inhaled corticosteroids

• Anticholinergics (e.g. ipratropium bromide nasal spray)

• Nasal surgery if nec. (e.g. electrocautery, cryosurgery)

Tinea corporis

Management

• Apply cool packs if severe.

• Avoid factors that cause facial flushings (e.g. excessive sun exposure, wind, heat, alcohol, spicy foods, hot drinks—tea and coffee).

• Sun protection

Systemic antibiotics (first choice)

• Minomycin or doxycycline (preferred):

  • 50–100 mg (o)/d for at least 8–10 wks

  Repeat for recurrences. Avoid maintenance.

• Erythromycin (second choice) or poor response for above 250 mg (o) bd

• Metronidazole (for resistant cases):

  • 200 mg bd for 10 d or

  • refer for oral isotretinoin treatment

Topical agents

• Milder cases: 2% sulphur in aqueous cream apply lightly tds

• More severe cases: metronidazole gel or cream apply thin film bd, or azelaic acid gel bd or clindamycin 1% bd or erythromycin 2% gel bd

• New topical agent—brimonidine 0.5% (a vasoconstrictor) for flushed skin

  Note: Hydrocortisone 1% cream is effective, but steroids are best avoided and strong topical steroids should not be used because of severe rebound vascular changes.

Laser therapy suitable for telangiectasia, erythema and rhinophyma

• Mosquito-borne alpha virus infections with similar presentation

• Major symptoms—fever, polyarthritis, maculopapular rash (in 75%), myalgia

• Usually self-limiting, resolving in 2–4 wks

• Occasional cases are severe

• Diagnosis by specific serology

• Symptomatic treatment—may need aspirin, paracetamol or steroids (avoid if possible)