GASTROINTESTINAL TRACT Begashaw - PowerPoint Presentation

Slide1

GASTROINTESTINAL TRACT

Begashaw

M (MD)

Slide2

Gastrointestinal bleeding

has

high mortality

& morbidity

persistent

bleeding and/or

recurrence carries

worse outcomes

without

immediate intervention

Slide3

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

Slide4

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

Slide5

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

Slide6

History

•

Scoiodemographic

-Age

•

PUD

hx

-

past or present

• Drugs

•

Liver

disease

•

Co-morbid diseases

•

Symptoms of bleeding diathesis

Slide7

Examination

-

Rising

PR & RR

- Decreasing

BP &

pulse pressure

- Restlessness

- Increasing pallor

- Cold nose and extremities

-

Sweating

- Decreased urine output

Slide8

Slide9

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

Slide10

Slide11

S

tabilized -laboratory

data

,further treatment

Blood transfusion

Ixns

-

Esophago

-gastro-

duodenoscopy

-

Medical

therapy

-

Endoscopic therapy

-

Surgical (operative) -

to control

the

bleeding

Slide12

LOWER GI BLEEDING

DDX

- Small intestinal bleeding

- Colorectal bleeding

-

Anorectal

bleeding

Slide13

Small intestinal bleeding

Is uncommon

rarely massive

difficult

to diagnose

Usually a

diagnosis of

exclusion

Slide14

Colonic bleeding

Acute &

massive

chronic



occult blood positive stool & anemia

Causes :

-

Neoplasms

/polyps

-

Diverticulosis

/ diverticulitis

-

Vascular

malformations

-

Inflammatory causes

Slide15

Anorectal bleeding

Causes

- Hemorrhoids

- Anal fissure

- Tumors /polyps

-

Proctitis

Slide16

Clinical evaluation

Hemodynamic status

Hx

-

Hematochezia



massive

UGIB/bleeding from right colon

-Chronic

bleeding

Unexplained

anemia

Orthostatic

hypotension

Fatigue/weight

loss

Slide17

Visible bleeding in

assosiation

with:

-

Pain

- Change in bowel

habits-

Stool frequency

-

Stool consistency

Excessive

mucus discharge per rectum

Sense

of incomplete

defecation

T

enesmus

-

Pruritus

-

ani

Slide18

Physical examination

Vital sign

indices

of tissue perfusion

signs

of

chronic blood

loss

Complete

abdominal

Exm

-DRE

pelvic examination-Female

Slide19

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



P

rocto-sigmoidoscopy

Slide20

COLORECTAL TUMOUR

Colorectal carcinoma-common causes

of death

Symptoms

are largely

nonspecific

Mortality & morbidity-GI

bleeding & acute

abdomen

High

index of

suspicion-Very important

Slide21

COLORECTAL CARCINOMA

common

second

commonest cause of death

Usually over

50 years of

age

F>M

Sigmoid/

rectum



most

frequent

site

Slide22

Pathology

Macroscopic

-

Polypoid

-Malignant ulcer

-Annular

-Tubular

Microscopically

-

Adenocarcinoma

Slide23

Predisposing factors

-pre-existing

polyps

-Familial

adenomatous

polyposis

-Ulcerative

colitis

Slide24

Spread

Local

spread

S

low

growth

Lymphatic

spread

R

egional

LNs

Blood

stream



liver

/lungs/skin/bone

Trans-

coelomic



malignant

deposits

peritoneal

cavity

& to non-adjacent

organs

Slide25

Clinical features

Right

colon

- Anemia

- Loss of

appetite/weight loss/ generalized

body weakness

- Palpable

lump

Slide26

Left colon

- Change in bowel

habit

- Passage of mucus

-

Tenesmus

/sense

of incomplete

defecation

- Rectal

bleeding

- I

ntestinal obstruction

-

Pain-> late

-

urinary:

due to pressure /invasion

Slide27

Investigations

S/E

-

Parasites

, WBC, occult blood,

culture

Sigmoidoscopy

colonoscopy

Barium enema

Biopsy

under endoscopic guide

Slide28

Staging investigations

Ultrasonography

Chest x-ray

Liver

function

test

Slide29

Management

depends

on

- mode

of

presentation

- stage

of the

disease

site

of the primary

lesion

- presence

or absence of multiple

lesions

Slide30

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

Slide31

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

Slide32

Pathogenesis

Caused

by mixed micro

organisms

Infection

of anal gland



spreads

along tissue

planes

Risks -

Perianal

hematoma

-

Perianal

injurie

-extension

from

cutaneous

boils

Slide33

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

Slide34

Anorectal

Abscess

Slide35

Slide36

Clinical features

Pain -severe, fever

Constitutional –sweating/anorexia

C

onstipation

Lump visible/tender /brownish

induration

Rectal

tender mass

Slide37

Management

Drainage

Irrigation

Packing

with saline soaked gauze

Sitz

bath twice daily

Antibiotics



if systemic

manifestations



in

immunocompromised

Analgesics

/mild

laxatives

Slide38

Perianal abscess drainage

Slide39

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

Slide40

Risk factors

Untreated /inadequately

treated

anorectal

abscess

Granulomatous

infections

IBD -multiple

external openings

Tuberculous

proctitis

Crohn’s

disease

Slide41

Classification

Low



internal

opening below

anorectal

ring

High



internal

opening

at/above

anorectal

ring

Slide42

Fistula in ano

Slide43

Slide44

Classification

Slide45

Goodsall's

Rule

Slide46

Slide47

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

Slide48

Slide49

Management

-

Emergency treatment for abscesses

- Treatment of underlying cause

- Surgery for fistula in

ano

- Preceded by

Preoperative

bowel cleansing (enema)

Examination

under anesthesia

Slide50

Surgery

Low

level fistula

-

fistulotomy

/

fistulectomy

-Wound care

High

level

fistula

-Protective

colostomy to prevent infection and facilitate healing

-Staged operation

Slide51

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

Slide52

Etiology

is

not completely

understood

Passage

of hard

fecal mass

precipitates

&

aggravates the

condition

Slide53

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

Slide54

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

Slide55

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

Slide56

Management

Conservative management



small acute/ superficial fissure

- high

fiber diet

- high

fluid intake

- mild laxative-liquid paraffin

- Local

anesthetic

ointment/suppository

Slide57

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

Slide58

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

Slide59

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)

Slide60

Slide61

Etiology

idiopathic

underlying

causes

- Straining accompanying constipation

- Straining at

micturition

- Recto Sigmoid mass

Slide62

Clinical features

usually

asymptomatic

Rectal

bleeding-earliest, bright red painless

Prolapse

of

varicose masses

mucoid

discharge

Pruritus

ani

Pain

Anemia

Slide63

Grading

First

degree



do

not

prolapse

out side

Second degree



prolapse

on defecation but

reduce spontaneously

Third

degree



replaced

manually/stay reduced

Fourth

degree

r

emain

permanently

prolapsed outside

anal margin

Slide64

Examination

Abdominal/pelvic examination -

underlying causes

aggravating factors

Rectal examination

_

prolapsing

hemorrhoids (piles)

_redundant

skin

folds/skin tags

_

prolapsing

/

thrombosed

Slide65

Slide66

Investigations

Proctoscopy

- to visualize internal hemorrhoids

& exclude

other lesions

Slide67

Complications

Hematochezia

Strangulation-acute pain

Thrombosis-

swollen, dark, tense

& feel

solid

/ tender

Ulceration

Gangrene - infection/sepsis

Abscess formation

Slide68

Management

Conservative measure

- High

fiber-diet

- Hydrophilic creams

/suppositories

- Local application of analgesic ointment /

suppository

-

pregnancy and post partum

hemorrhoids

Slide69

Operative treatment

Hemorrhoidectomy

- Third degree hemorrhoids

- Failure

of conservative

Mx

-

Fibrosed

hemorrhoids

-

Intero

external hemorrhoids

Slide70

Treatment of CXN

Strangulation/thrombosis /gangrene

-Immediate

surgery

-antibiotic coverage

-pain relief

-bed

rest, frequent hot

sitz

bath

-warm

saline

compress

Slide71

EXTERNAL HEMORRHOIDS

Thrombosed

external hemorrhoid

- is

usually associated

with pain

appear

inflamed tense tender

& easily visible

Treatment

Analgesics

Avoid constipation

Surgical

evacuation of

clot

Slide72

Surgical drainage of thrombosed

hemmoroid