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GASTROINTESTINAL TRACT Begashaw M (MD). Gastrointestinal bleeding has high mortality & morbidity persistent bleeding and/or recurrence carries worse outcomes.

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Presentation on theme: "GASTROINTESTINAL TRACT Begashaw M (MD). Gastrointestinal bleeding has high mortality & morbidity persistent bleeding and/or recurrence carries worse outcomes."— Presentation transcript:

1 GASTROINTESTINAL TRACT Begashaw M (MD)

2 Gastrointestinal bleeding has high mortality & morbidity persistent bleeding and/or recurrence carries worse outcomes without immediate intervention

3 DEFINITION UGIB  blood loss proximal to ligament of Treitz LGIB  blood loss distal to ligament of Treitz Hematemesis  vomiting of blood Melena  passage of black tar stool Hematochezia  passage of blood per rectum

4 UPPER GASTROINTESTINAL BLEEDING  Etiology - PUD –commonest,DU 4x - Varices-cirrhosis, portal hypertension - Gastritis-NSAID - Gastric ca - Stress ulcer -trauma, shock, sepsis, burn - Mallory-Weiss tear-prolonged violent vomiting - Esophagitis

5 WORK-UP & MANAGEMENT - Immediate intervention - Having a clinical suspicion of the possible site  History- Collapse - Sweating - Anxiety, restlessness - Large amount of bloody vomitus - Hematochezia/melena

6 History Scoiodemographic -Age PUD hx - past or present Drugs Liver disease Co-morbid diseases Symptoms of bleeding diathesis

7 Examination - Rising PR & RR - Decreasing BP & pulse pressure - Restlessness - Increasing pallor - Cold nose and extremities - Sweating - Decreased urine output

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9 Management  Insert large bore intravenous cannula  Rapid crystalloid infusion  Blood transfusion  Monitor-VS, urine output  Anxiety & pain - diazepam, analgesic  NG tube - monitor rate of bleeding,saline lavage

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11 Stabilized -laboratory data,further treatment Blood transfusion Ixns -Esophago-gastro-duodenoscopy - Medical therapy - Endoscopic therapy - Surgical (operative) - to control the bleeding

12 LOWER GI BLEEDING  DDX - Small intestinal bleeding - Colorectal bleeding - Anorectal bleeding

13 Small intestinal bleeding  Is uncommon  rarely massive  difficult to diagnose  Usually a diagnosis of exclusion

14 Colonic bleeding  Acute & massive  chronic  occult blood positive stool & anemia  Causes : -Neoplasms /polyps -Diverticulosis/ diverticulitis -Vascular malformations -Inflammatory causes

15 Anorectal bleeding  Causes - Hemorrhoids - Anal fissure - Tumors /polyps - Proctitis

16 Clinical evaluation  Hemodynamic status  Hx -Hematochezia  massive UGIB/bleeding from right colon -Chronic bleeding Unexplained anemia Orthostatic hypotension Fatigue/weight loss

17  Visible bleeding in assosiation with: - Pain - Change in bowel habits- Stool frequency - Stool consistency - Excessive mucus discharge per rectum - Sense of incomplete defecation - Tenesmus - Pruritus - ani

18 Physical examination  Vital sign  indices of tissue perfusion  signs of chronic blood loss  Complete abdominal Exm-DRE  pelvic examination-Female

19 Treatment  Resuscitation -first priority - NG tube lavage to exclude UGIB - CBC -WBC, HCT/Hb, platelet count - Esophago-gastro-duodenoscopy (EGD) - Blood chemistry - Coagulation profile - Stool examination - Lower GI Endoscopy  Procto-sigmoidoscopy

20 COLORECTAL TUMOUR Colorectal carcinoma-common causes of death Symptoms are largely nonspecific Mortality & morbidity-GI bleeding & acute abdomen High index of suspicion-Very important

21 COLORECTAL CARCINOMA common second commonest cause of death Usually over 50 years of age F>M Sigmoid/rectum  most frequent site

22 Pathology  Macroscopic -Polypoid -Malignant ulcer -Annular -Tubular  Microscopically -Adenocarcinoma

23 Predisposing factors -pre-existing polyps -Familial adenomatous polyposis -Ulcerative colitis

24 Spread  Local spread  Slow growth  Lymphatic spread  Regional LNs  Blood stream  liver /lungs/skin/bone  Trans-coelomic  malignant deposits peritoneal cavity & to non-adjacent organs

25 Clinical features  Right colon - Anemia - Loss of appetite/weight loss/ generalized body weakness - Palpable lump

26  Left colon - Change in bowel habit - Passage of mucus - Tenesmus /sense of incomplete defecation - Rectal bleeding - Intestinal obstruction - Pain-> late - urinary: due to pressure /invasion

27 Investigations  S/E - Parasites, WBC, occult blood, culture  Sigmoidoscopy  colonoscopy  Barium enema  Biopsy under endoscopic guide

28 Staging investigations  Ultrasonography  Chest x-ray  Liver function test

29 Management  depends on - mode of presentation - stage of the disease - site of the primary lesion - presence or absence of multiple lesions

30 Modalities  Surgery - Emergency laparotomy - bleeding, acute abdomen - Elective surgery After pre-operative colon preparation Resection for resectable tumors (curative) - Palliative: palliative surgery, Cytotoxic chemo therapy, Radiotherapy

31 ANORECTAL ABSCESSES  In association with underlying systemic or local diseases - AIDS, Diabetes mellitus, rectal tumors, inflammatory bowel disease  Complications - fistula in ano - sepsis  perianal sepsis

32 Pathogenesis Caused by mixed micro organisms Infection of anal gland  spreads along tissue planes Risks -Perianal hematoma -Perianal injurie -extension from cutaneous boils

33 Classification  Perianal- subcutaneous abscess -commonest type  Ischiorectal abscess -also common -located in ischiorectal fossa  Sub mucous abscess -located under the mucous membrane  Pelvirectal abscess -located above levator ani -follows spread from pelvic abscess

34 Anorectal Abscess

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36 Clinical features Pain -severe, fever Constitutional –sweating/anorexia Constipation Lump visible/tender /brownish induration Rectal tender mass

37 Management Drainage Irrigation Packing with saline soaked gauze Sitz bath twice daily Antibiotics  if systemic manifestations  in immunocompromised Analgesics /mild laxatives

38 Perianal abscess drainage

39 PERIANAL FISTULAS (FISTULA IN ANO) is a track, lined by granulation tissue, which connects the anal canal or rectum internally with the skin around the anus externally

40 Risk factors Untreated /inadequately treated anorectal abscess Granulomatous infections IBD -multiple external openings Tuberculous proctitis Crohn’s disease

41 Classification  Low  internal opening below anorectal ring  High  internal opening at/above anorectal ring

42 Fistula in ano

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44 Classification

45 Goodsall's Rule

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47 Clinical features - Seropurulent discharge - perianal irritation - External opening  small elevated opening with a granulation - Internal opening  felt as a nodule on DRE - Signs of underlying/associated dss

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49 Management - Emergency treatment for abscesses - Treatment of underlying cause - Surgery for fistula in ano - Preceded by Preoperative bowel cleansing (enema) Examination under anesthesia

50 Surgery  Low level fistula -fistulotomy/fistulectomy -Wound care  High level fistula -Protective colostomy to prevent infection and facilitate healing -Staged operation

51 ANAL FISSURE (FISSURE IN ANO) Elongated tear in the lower anal canal Upper end stops at dentate line Located commonly in the posterior midline Occasionally along the anterior midline

52 Etiology is not completely understood Passage of hard fecal mass precipitates & aggravates the condition

53 Classification  Acute fissure: deep skin tear at the anal margin extending in to the anal canal with edges showing little inflammatory indurations /edema - is accompanied with spasm of the anal sphincter muscle  Chronic fissure:Inflamed and indurated margins as a result of inflammatory fibrosis and contracture of the internal sphincter

54 Clinical features - Pain - commonest - sharp, severe pain starting during defecation and lasting an hour - Constipation - Bleeding-bright streaks on the stool surface/toilet paper - Discharge

55 Examination - Tightly closed anus - sphincter spasm - skin tag -visible at anal verge - Lower end of fissure on gentle parting of buttocks  DRE - local anesthetic gel - Vertical crack in the anal canal

56 Management  Conservative management  small acute/ superficial fissure - high fiber diet - high fluid intake - mild laxative-liquid paraffin - Local anesthetic ointment/suppository

57 Surgery  Lateral anal sphincterotomy  Fissurectomy /sphincterotomy  used for cases with a chronic fissure _ complications- hematoma formation - incontinence -mucosal prolapse  POP care: bowel care, daily bath and softening the stool till wound healing

58 HEMORRHOIDS (PILES)  are dilated sub mucosal veins in the anus  Classification _Internal -Internal to the anal orifice _External -External to the anal orifice _Interoexternal- Prolapsing internal hemorrhoids

59 INTERNAL HEMORRHOIDS dilatation of the sub mucosal internal venous plexus and draining superior hemorrhoidal veins develop within areas of enlarged anal lining (anal cushions’) In lithotomy position- three groups _3, 7 & 11 o’clock  corresponds to distribution of superior hemorrhoidal vessels (2 on the right,1 on the left)

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61 Etiology idiopathic underlying causes - Straining accompanying constipation - Straining at micturition - Recto Sigmoid mass

62 Clinical features usually asymptomatic Rectal bleeding-earliest, bright red painless Prolapse of varicose masses mucoid discharge Pruritus ani Pain Anemia

63 Grading First degree  do not prolapse out side Second degree  prolapse on defecation but reduce spontaneously Third degree  replaced manually/stay reduced Fourth degree  remain permanently prolapsed outside anal margin

64 Examination Abdominal/pelvic examination - underlying causes aggravating factors Rectal examination _prolapsing hemorrhoids (piles) _redundant skin folds/skin tags _prolapsing /thrombosed

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66 Investigations Proctoscopy- to visualize internal hemorrhoids & exclude other lesions

67 Complications Hematochezia Strangulation-acute pain Thrombosis- swollen, dark, tense & feel solid / tender Ulceration Gangrene - infection/sepsis Abscess formation

68 Management  Conservative measure - High fiber-diet - Hydrophilic creams /suppositories - Local application of analgesic ointment /suppository - pregnancy and post partum hemorrhoids

69 Operative treatment  Hemorrhoidectomy - Third degree hemorrhoids - Failure of conservative Mx - Fibrosed hemorrhoids - Intero external hemorrhoids

70 Treatment of CXN  Strangulation/thrombosis /gangrene -Immediate surgery -antibiotic coverage -pain relief -bed rest, frequent hot sitz bath -warm saline compress

71 EXTERNAL HEMORRHOIDS Thrombosed external hemorrhoid - is usually associated with pain appear inflamed tense tender & easily visible  Treatment Analgesics Avoid constipation Surgical evacuation of clot

72 Surgical drainage of thrombosed hemmoroid


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