Case 5 - GIT

Priscilla Sari

Defecation Sherwood, Human Physiology

• Mass motility in colon push colon contents into the rectum rectum streched stimulate the strech receptor on the wall of rectum defecation reflex

• Reflex by : relaxation of M. Sphincter Ani Internus (smooth muscle) colon sigmoid & rectum contraction stronger

• And M. Sphincter Ani Externus (striated muscle) relax defecation process

• Defecation is helped by simultaneous contraction by stomach muscle and force expiration increase intra-abdominal pressure push out the stool

DefecationKrause’s food & nutrition Therapy

WEIGHT OF STOOL FREQUENCY TRANSITE TIME

ADULTS 100-200 g daily From one stool every three days to three times per day 30-48 hours

CHILDREN Lesser than adult Two or three stools daily 8,5 hours

•Individuals who consume a diet that contains the recommended amounts of dietary fiber in the form of fruits, vegetables, and whole grain breads and cereals, legumes, seeds, and nuts tend to have larger, softer stools that are relatively easy to pass•The recommended amounts of dietary fiber = 14 g/ 1000 kcal

•Children = 19-25 g daily•Adults = 25-38 g daily

Normal defecation frequents for children

Age Defecation per week Defecation per day

0-3months-Breastfeeding-Formula feeding

5-405-28

2,92,0

6-12moths 5-28 1,8

1-3years 4-21 1,4

>3years 3-14 1,0

Defecation Constipation Sherwood, Human Physiology

• Defecation is delayed too long time constipation, why???

• Colon contents detained H2O absorp↑ stool becomes hard and dry constipation

ConstipationKrause’s food & nutrition Therapy

• Definition of constipation tend to be highly subjective but usually include hard stools,straining with defecation and infrequent large bowel movements

• Most common causes in adults : – Lack of response to the urge to defecate– Lack of fiber in diet– Insufficient fluid intake– Inactivity– Chronic use of laxatives

ConstipationBuku Ajar Gastroenterologi – Hepatologi IDAI

• Most common causes in children :– Functional– Anal fissure– Virus infection with ileus– Diet– Drugs

Epidemiology of Constipation Current Surgical : Diagnosis & Treatment

Buku Ajar Gastroenterologi-Hepatologi IDAI

• Severe idiopathic constipation is more common in women, often begins in adolesence and worsens during 20s or 30s

• In children, most common etiology of constipation is feces retention cause of pain when defecation before, usually with anal fissure

Diagnosis of constipation

STEP 1 : Constipation / Pseudoconstipation ??• Consistency and frequent of feces• Palpation of abdomen• Digital rectal examination (if needed)STEP 2 : Acute / Chronic Constipation ??• Acute constipation : 1-4 weeks or less • Chronic : more than 1 month

Chronic Constipation in childrenAnamnesis • Constipation • Anorexia• Weight loss• Encopresis Physical Examination • Abdominal distention with disorder of peristaltic frequent• Abdominal mass on palpation in lower quadrant abdomen• Feces mass in rectum, colon sigmoid, colon descenden, all

parts of colon• In severe case : anal fissure and distention of ampula recti

Pemeriksaan penunjang

• Foto polos abdomen• Barium enema test• Biopsi hisap rektum• Pemeriksaan manometri• Pemeriksaan lain untuk mencari penyebab

organik

Complication of constipation in children

• Anal pain and abdominal pain• Anal fissure• Encopresis• UTI / ureter obstruction• Prolaps rectum• Solitary ulcer• Stasis syndrome

Colitis : inflammation of colonINFECTIVE COLITIS

Shigellosis Lower abdominal pain, dysentery, fever

Tuberculosis Colitis Mass in RLQ, diarrhea with blood, subfebris

Amebic Colitis Dysentery and the other symptoms (based on the clinical condition)

Pseudomembran Colitis Diarrhea, cramp and pain abdominal, fever, leucositosis, abdominal tenderness

NON-INFECTIVE COLITIS

IBD Ulcerative ColitisChron’s disease Diarrhea, fever, anemia, malnutrition

Radiation Colitis Nausea, vomit, diarrhea, tenesmus, hematocezia, colic

Ischemic Colitis

Simple Colitis

Inflammatory Bowel Disease

• Two major forms of IBD : Chron’s disease and ulcerative colitis

• But, if we difficult to differentiate both : indeterminate colitis

• Cause of IBD is not completely understood, but in involves the interaction of the GI imun system, genetic, and environment factors

• General clinic characteristics of IBD : diarrhea, fever, weight loss, anemia, malnutrition, FTT

Specific clinic characteristics of IBD ULCERATIVE COLITIS vs. CHRON’S DISEASE

ULCERATIVE COLITIS CHRON’S DISEASE

Presentation

Bloody diarrheaPerianal disease Mass in abdomenAbdominal pain (65%)

Gross Pathology•Rectum always involved•Thin wall•Stricture <<•Diffuse ulceration

•Rectum may not be involved•Thick wall•Stricture >>•Cobblestone appearance

Histopathology•No granulomas•Inflammation <<•Deeper ulcers•Pseudopolyps•Abcess in crypts

•Granulomas•Inflammation >>•Shallow ulcers•Fibrosis

Cancer of the Large Intestine

RIGHT COLON :-Unexplained weakness or anemia-Occult bleeding in feces-Dyspeptic symptoms-Persistent right abdominal discomfort-Palpable abdominal mass-X-ray findings-Colonoscopic findings

RIGHT COLON :-Unexplained weakness or anemia-Occult bleeding in feces-Dyspeptic symptoms-Persistent right abdominal discomfort-Palpable abdominal mass-X-ray findings-Colonoscopic findings

LEFT COLON :-Change in bowel habits-Gross blood in stool-Obstrutive symptoms-X-ray findings-Colonoscopic or sigmoidoscopic findings

LEFT COLON :-Change in bowel habits-Gross blood in stool-Obstrutive symptoms-X-ray findings-Colonoscopic or sigmoidoscopic findings

RECTUM :-Rectal bleeding = hematochezia-Alteration in bowel habits-Sensation of incomplete evacuation-Intrarectal palpable tumor-Sigmoidoscopic findings

RECTUM :-Rectal bleeding = hematochezia-Alteration in bowel habits-Sensation of incomplete evacuation-Intrarectal palpable tumor-Sigmoidoscopic findings

Laboratory findings • Urinalysis*• Leukocyte count*• Hemoglobin*• Serum proteins• Calcium• Bilirubin• Alkaline phosphatese• Creatinine

• Chemical tumor marker = carcinoembryonic antigen (CEA)

Special examination for colon cancer

• ProctosigmoidoscopyTypical cancer : red, raised, centrally ulcerated, bleeding slightly

• Colonoscopy Should be done before operative treatment

Differential Diagnose of colorectal cancer

• Diverticular disease• Ulcerative colitis• Chron’s disease• Ischaemic colitis• Amebiasis

Polyps of the colon and rectumTYPE HISTOLOGICAL DIAGNOSIS

Neoplastic

AdenomaTubular adenoma (adenomatous polyp)Tubulovillous adenoma (villoglandular adenoma)Villous adenoma (villus papilloma)Carcinoma

Hamartomas Juvenile polypPeutz – Jeghers polyp

Inflammatory Inflammatory polyp (pseudo-polyp)Benign lymphoid polyp

Unclassified Hyperplastic polyp

Miscellaneous LipomaLeiomyomaCarcinoid

Sign and symptoms• Most polyps = asymptomatic• Large lesion• Rectal bleeding = red or dark red

Large benign tumors• Tenesmus• Constipation• Increased frequency of bowel movements

Polypoid tumors• Peristaltic cramps• Obstuctive sydrome; like IBS and diverticular disease

If polyp very long prolapse anus, most frequent with juvenile polyps