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

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

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

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

44. Classification

45. Goodsall's Rule

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

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)

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

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