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 TreitzHematemesis vomiting of bloodMelena 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 treatmentBlood 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

-Hematocheziamassive 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 nonspecificMortality & morbidity-GI bleeding & acute

abdomenHigh index of suspicion-Very important

COLORECTAL CARCINOMA

common second commonest cause of death Usually over 50 years of ageF>MSigmoid/rectummost frequent site

Pathology

Macroscopic

-Polypoid

-Malignant ulcer

-Annular

-Tubular Microscopically

-Adenocarcinoma

Predisposing factors

-pre-existing polyps

-Familial adenomatous polyposis

-Ulcerative colitis

Spread

Local spreadSlow growth Lymphatic spreadRegional LNs Blood streamliver /lungs/skin/bone Trans-coelomicmalignant 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 organismsInfection of anal gland spreads along

tissue planesRisks -Perianal hematoma

-Perianal injurie

-extension from cutaneous boils

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

Anorectal Abscess

Clinical features

Pain -severe, fever Constitutional –sweating/anorexiaConstipationLump visible/tender /brownish indurationRectal tender mass

Management

Drainage Irrigation Packing with saline soaked gauze Sitz bath twice dailyAntibiotics 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 openingfelt 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 canalUpper end stops at dentate lineLocated commonly in the posterior midlineOccasionally along the anterior midline

Etiology

is not completely understoodPassage 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’clockcorresponds to distribution of superior hemorrhoidal vessels (2 on the right,1 on the left)

Etiology

idiopathicunderlying causes

- Straining accompanying constipation

- Straining at micturition

- Recto Sigmoid mass

Clinical features

usually asymptomaticRectal bleeding-earliest, bright red painlessProlapse of varicose massesmucoid dischargePruritus aniPainAnemia

Grading

First degreedo not prolapse out sideSecond degree prolapse on defecation but

reduce spontaneouslyThird degreereplaced manually/stay

reducedFourth degreeremain 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 painThrombosis- swollen, dark, tense & feel

solid / tenderUlceration 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 TreatmentAnalgesics Avoid constipationSurgical evacuation of clot

Surgical drainage of thrombosed hemmoroid