Download GASTROINTESTINAL TRACT

GASTROINTESTINAL
TRACT
Begashaw M (MD)
Gastrointestinal bleeding

has high mortality & morbidity
 persistent bleeding and/or recurrence carries
worse outcomes without immediate
intervention
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

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
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
-
History
• Scoiodemographic -Age
• PUD hx - past or present
• Drugs
• Liver disease
• Co-morbid diseases
• Symptoms of bleeding diathesis
Examination
- Rising PR & RR
- Decreasing BP & pulse pressure
- Restlessness
- Increasing pallor
- Cold nose and extremities
- Sweating
- Decreased urine output
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



Stabilized -laboratory data ,further treatment
Blood transfusion
Ixns
-Esophago-gastro-duodenoscopy
- Medical therapy
- Endoscopic therapy
- Surgical (operative) - to control the bleeding
LOWER GI BLEEDING
 DDX
- Small intestinal bleeding
- Colorectal bleeding
- Anorectal bleeding
Small intestinal bleeding

Is uncommon
 rarely massive
 difficult to diagnose
 Usually a diagnosis of exclusion
Colonic bleeding

Acute & massive
 chronic  occult blood positive stool &
anemia
 Causes :
-Neoplasms /polyps
-Diverticulosis/ diverticulitis
-Vascular malformations
-Inflammatory causes
Anorectal bleeding

Causes
- Hemorrhoids
- Anal fissure
- Tumors /polyps
- Proctitis
Clinical evaluation

Hemodynamic status
 Hx
-Hematocheziamassive UGIB/bleeding from
right colon
-Chronic bleeding
Unexplained anemia
Orthostatic hypotension
Fatigue/weight loss

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
Physical examination

Vital sign
 indices of tissue perfusion
 signs of chronic blood loss
 Complete abdominal Exm-DRE
 pelvic examination-Female
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
COLORECTAL TUMOUR

Colorectal carcinoma-common causes of
death
 Symptoms are largely nonspecific
 Mortality & morbidity-GI bleeding & acute
abdomen
 High index of suspicion-Very important
COLORECTAL CARCINOMA

common
 second commonest cause of death
 Usually over 50 years of age
 F>M
 Sigmoid/rectummost frequent site
Pathology

Macroscopic
-Polypoid
-Malignant ulcer
-Annular
-Tubular
 Microscopically
-Adenocarcinoma
Predisposing factors
-pre-existing polyps
-Familial adenomatous polyposis
-Ulcerative colitis
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
Clinical features

Right colon
- Anemia
- Loss of appetite/weight loss/ generalized
body weakness
- Palpable lump

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
Investigations
 S/E
- Parasites, WBC, occult blood, culture
 Sigmoidoscopy
 colonoscopy
 Barium enema
 Biopsy under endoscopic guide
Staging investigations



Ultrasonography
Chest x-ray
Liver function test
Management
 depends
on
- mode of presentation
- stage of the disease
- site of the primary lesion
- presence or absence of multiple lesions
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
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
Pathogenesis

Caused by mixed micro organisms
 Infection of anal gland spreads along
tissue planes
 Risks -Perianal hematoma
-Perianal injurie
-extension from cutaneous boils
Classification

Perianalsubcutaneous 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
Anorectal Abscess
Clinical features

Pain -severe, fever
 Constitutional –sweating/anorexia
 Constipation
 Lump visible/tender /brownish induration
 Rectal tender mass
Management

Drainage
 Irrigation
 Packing with saline soaked gauze
 Sitz bath twice daily
 Antibiotics if systemic manifestations
in immunocompromised
 Analgesics /mild laxatives
Perianal abscess drainage
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
Risk factors

Untreated /inadequately treated anorectal
abscess
 Granulomatous infections
 IBD -multiple external openings
Tuberculous proctitis
Crohn’s disease
Classification
 Low
 internal opening below anorectal
ring
 High internal opening at/above anorectal
ring
Fistula in ano
Classification
Goodsall's Rule
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
-
Management
- Emergency treatment for abscesses
- Treatment of underlying cause
- Surgery for fistula in ano
- Preceded by
Preoperative bowel cleansing (enema)
Examination under anesthesia
Surgery

Low level fistula
-fistulotomy/fistulectomy
-Wound care
 High level fistula
-Protective colostomy to prevent infection
and facilitate healing
-Staged operation
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
Etiology

is not completely understood
 Passage of hard fecal mass precipitates &
aggravates the condition
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
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
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
Management

Conservative management small acute/
superficial fissure
- high fiber diet
- high fluid intake
- mild laxative-liquid paraffin
- Local anesthetic ointment/suppository
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
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
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)
Etiology

idiopathic
 underlying causes
- Straining accompanying constipation
- Straining at micturition
- Recto Sigmoid mass
Clinical features

usually asymptomatic
 Rectal bleeding-earliest, bright red painless
 Prolapse of varicose masses
 mucoid discharge
 Pruritus ani
 Pain
 Anemia
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
Examination

Abdominal/pelvic examination - underlying
causes aggravating factors
 Rectal examination
_prolapsing hemorrhoids (piles)
_redundant skin folds/skin tags
_prolapsing /thrombosed
Investigations

Proctoscopy- to visualize internal
hemorrhoids & exclude other lesions
Complications

Hematochezia
 Strangulation-acute pain
 Thrombosis- swollen, dark, tense & feel
solid / tender
 Ulceration
 Gangrene - infection/sepsis
 Abscess formation
Management

Conservative measure
- High fiber-diet
- Hydrophilic creams /suppositories
- Local application of analgesic ointment
/suppository
- pregnancy and post partum hemorrhoids
Operative treatment

Hemorrhoidectomy
- Third degree hemorrhoids
- Failure of conservative Mx
- Fibrosed hemorrhoids
- Intero external hemorrhoids
Treatment of CXN
 Strangulation/thrombosis
/gangrene
-Immediate surgery
-antibiotic coverage
-pain relief
-bed rest, frequent hot sitz bath
-warm saline compress
EXTERNAL HEMORRHOIDS

Thrombosed external hemorrhoid - is
usually associated with pain
 appear inflamed tense tender & easily
visible
 Treatment
 Analgesics
 Avoid constipation
 Surgical evacuation of clot
Surgical drainage of
thrombosed hemmoroid