ANORECTALDI SEASES

Thesecanoccuratanyageandi nmanyofthem,symptomsar enon-speci

fi
c.
Generallyt heinf
lammator
yonesar
ecommoni nyoungerpati
entsandt umorsint
he
middleaged
andtheel derl
y.I
tiswort
hrememberi
ngt
hatcommondi stall
esionscanpresentwit
h
proxi
mal onesandt heymaybemanif
est
ati
onsofproxi
mal di
seasesf orwhi
chthe
pati
ent s
needf ul
l ev al
uat
ion.

ANORECTALABSCESSES
Localizedi nfectionwi thcollectionofpusIt heanorectal area
Causesandr i
skf actors
 Mi croor ganismsl ikeE. coli
 Maybet hepr esenti
ngmani fest
ati
onofanunder l
y i
ngsy stemicorlocaldiseases
(
e.g.
- AI DS, Diabetesmel l
it
us,r
ectal t
umors,inflammat orybowel diseases…)
Pathogenesi s
Inmanycasest heinf ect
ioni scausedbymi xedmi cr
oor gani
sms.I nfect
ionofanal
glandi s
theiniti
atingf actorint hemaj orityofcases,whichspr eadsal ongt i
ssueplanes.An
abscess
canal sodev el
opf ollowinginf ecti
onofaPer i
analhemat oma, i
nfecti
onfoll
owing
Perianal
i
njuries,ext ensionfrom cut aneousboi l
set c.

Classification
Basedont heiranatomicallocati
on,anor ect
al abscessesareclassif
iedi
ntofourmai
n
varieti
es:
Per i
anal (
subcut aneous)abscess: -
Thisi sthecommonestt ypeandcanaf fectpeopl eofallagegroups.
Ischiorectalabscess: -
I
sal socommonandi slocatedintheischiorectalfossa
Submucousabscess: -
Thisanabscessl ocatedundert hemucousmembr ane
168
Pelvirectalabscess: -
Thisi sanabscessl ocatedabov elevatorani andf oll
owsspreadfrom pel
vi
cabscess
Clinicalfeat ur
es:
 Pai nespeci all
yonsi t
ting
 Fev er
  Mal aise
 Pur ulentdi scharge
 Onexami nati
ont hepat ientshoul dbel yi
ngont hesi dekneesupt othechestt his
will r
eliev etheanal ar ea.Youwi llseeaf l
uatuantswel l
ingpat chofindur atedskin.
Digi t
al exam isdonei fthereissusci pinofdeeperabscessesf oll
owingr egional
exami nat i
onPatientcompl ai
ntsincludepai n(usuallysev er
e),fever,consti
tutional
symptomssuchassweat ingandanor exia,featuresofpr octi
ti
sandconst ipati
on
Physi
calf indings( r
ectal exami nat i
on)i
ncl ude
-Alumpv i
sibleandpal pabl eatt heanal mar gin/analcanal orischiorect
alfossa
whichist enderbr ownishi ndur ationpalpabl eont heaffectedsi de
-Rectaltender ness,rectal tendermass
Ddx
 Bar tholisabscessi nf emal es
 Ext ernal hemor r
hoi ds
 Anal fi
ssur e
 Pi lunidal cyst
 Fi stulai nanal

Managementofanor
ect
alabscess:

 Theabscessneedsdr ai
nageassoonasi tisdiagnosedfoll
owedbyi
rr
igat
ion,
packingwithsali
nesoakedgauze
 Sit
zbat htwicedai
lyti
llwoundhealing.
 Anti
bioti
csshouldbeusedt ogetherwithsurgi
caltr
eatment.
 Theyareneededwhent herearesystemicmanifestat
ionsandin
i
mmunocompr omisedpati
ents.
 Analgesicsandmildlaxati
ves

PERIANALFISTULAS( FISTULAINANO)
Defi
niti
on:Afist
ulainanoisatr
ack,l
inedbygranulat
iont
issue,
whichconnect
stheanal
canalorrect
um int
ernal
lywit
htheski
nar oundtheanusexter
nall
y.

Causes(r
iskf actor s)-Itresul
tsfrom:
• Usuallyanunt reatedorinadequatelytr
eatedanor
ect
alabscess(
seeal
socauses
andr i
skf act orsforanorectalabscesses)
 Chronsdi sease
 Lymphogr anulomav enereum
 Radiati
ont herapyl i
keinproctit
is
 Rectalforei gnbody
  act i
nomy cosi
s
•Classif
icati
on:
Itcanbegr oupedint
ot woaccordingt
othelev
eloftheinter
nal
opening:
-Lowl evel
:withaninter
nalopeningbel
owtheanorect
al r
ing
-Highlevel:wi
thaninternal
openingatorabovet
heanor ect
alr
ing.

Typesaccor dingpar ks’ classifi

cation
1.I nter-sphi nct eri
cf istula
2.Tr ans- sphi nct ericf i
stula
3.Supr a-sphi nctericf i
stula
4.Ext r
asphi nct ericf i
stula
Cli
nicalfeat ures
-Seropur ulentdi schar gewi thper i
analir
rit
ati
on
-Anext ernal openi ng( frequent l
ysingle)seenasasmallel
evat
edopeni
ngontheski
n
aroundt heanuswi thagr anulation
-Ani nternalopeni ngmaybef el
tasanodul eondigi
tal
rect
alexami
nati
on(
almost
al
way ssingle)irr espect iveoft henumberofext er
nalopeni
ngs)
-Signsofunder lying/ associ ateddiseases
• Pr urit
is/itchyanal area
• Reddeni ngofper ianal skin
Dx
• CT/ MRI
• Fi stulogr aphy -
usi ngcont rast

Management
-Emer gencytreat mentf orabscesses
-Treatmentofunder l
yi
ngcause
-Surgeryforfist ul
ainano
-Precededby
•Preoperati
vebowel cleansing( enema)
•Exami nati
onunderanest hesia
Lowl evelfi
stula
•Layingopent heent i
ref i
stuloust r
act,f
ist
ulot
omythoughassociat
edwi t
hincont
inence
buthashi ghsuccessr ate
•Woundcar e
Fi
brinsealant
Highlevelfi
stul as
•Protecti
vecol ostomyt oprev entinfect
ionandfaci
l
itat
eheali
ng
•Stagedoper at i
ont hathast obeper for
medbyanexper tandthepat
ientneeds
r
efer
ral
tohospi
tal
.

ANALFI SSURE( FISSUREINANO)

Defini
ti
on:Analfissur
eisanel ongat
edtear(
ulcer
)inthel
oweranalcanal,
whichlies
along
thelongaxisofthecanal.Theupperendstopsatthedentat
eli
ne.I
tislocated
commonl yin
theposter
iormidline,
occasionall
yal
ongtheanter
iormidl
i
neandrarelyatmulti
plesit
es.

Et
iol
ogy
:Thecauseofanalf
issurei
snotcomplet
elyunder
stood.Passageofhar
dfecal
masspr
eci
pit
atesandaggr
av at
esthecondi
ti
on.

Classifi
cation:Anal fi
ssurecanbecl assif
iedasacuteorchr oni
cbasedoni ts
pathologic
features.
-Acut efi
ssur e:isadeepski ntearattheanal margi
next endi
ngint otheanalcanal
withedgesshowi ngli
ttlei
nfl
ammat oryindurati
onsoredema. Iti
saccompani edwith
spasm oft heanal sphinct
ermuscle.
-Chr oni
cfissur e:ischaract
eri
zedbyI nf
lamedandi nduratedmar ginsasaresultof
i
nflammat or yfibrosi
sandcont ract
ureoft heint
ernalsphinct
erinlongstandi
ngcases

NB:speci
fi
ccausesaremuchmor ecommonwi t
hachr
oni
cfi
ssur
e(e.
g.sy
phi
l
is,
t
ubercul
osi
s,Cr
ohn’sdisease,
andcar
cinoma.

Cli
nicalfeatures:Apatientwi t
hanal fi
ssurepr esent
swi t
h:
-Painisthecommonestf eature
-Characteri
sticsharp,severepai nstar
ti
ngdur ingdef ecati
onandlasti
nganhouror
mor eandceasessuddenl ytor eappearduringt henextbowel motion.
-Constipati
on: t
hepat i
enttendst obeconst ipatedforf earoft
hepainondefecat
ion.
-Bl
eeding: usuall
yappear i
ngasbr i
ghtstreaksont hest oolsur
faceorthet
oil
etpaper
-Discharge:commonwi t
hchr oniccases
-Manifestati
onsr el
atedtounder l
yi
ngdiseasesand/ orcompl i
cat
ions

Exami nationmayr eveal

:
-Tightlyclosedanusduet othesphincterspasm
-Sentinelpile(
skint ag)vi
sibleattheanalverge
-Lowerendoft hef issur
eongent leparti
ngofthebuttocks
•Digit
al examination
-Shouldbedoneusi nglocalanestheti
cgel,acottonwoolsoakedinl
ocal
anest
hetic.
-Fissuremaynotbepal pableinearl
ycases.
-Infull
yest abl
ishedcasest hef i
ssuremaybef eltasavert
icalcr
acki
ntheanalcanal
.
NB:
-Bi
gul
cer
sandf
issur
escanbef
oundi
npat
ient
swi
thHI
Vandot
herv
iral
inf
ect
ions.

Management
Conser vat ivemanagement :Thisisrecommendedespeci all
yf orasmallacuteand
super f
ici
al fi
ssur e,whichmayheal spontaneousl y.Itincludes:
-Ahi ghf iberdi etandhi ghfluidi
ntakewi t
hami l
dl axative,suchasl i
quidparaffin,t
o
encour agepassi ngofsoft,bulkystools
-Admi nist rat
ionofal ocalanestheticoi
ntmentorsupposi tory
SurgicalMeasur es:
Surgicalmeasur esareneededwhent heabov emeasur esfail
,inchroni
cfissureswi t
h
fi
brosis,aski nt agoramucouspol yporrecur rentanal fi
ssures.Proceduresinclude:
•Lateral anal sphi nct
erotomy
•fi
ssur ect omyand
•sphincter otomy
Thispr ocedur ecanbeusedf orcaseswi t
hachr oni cfissure.Itneedsanexper ienced
operatort or educecompl icati
ons,whichi ncludehemat omaf or mat
ion,i
ncontinenceand
mucosal pr olapse.
Aftercar e:Thi sconsi stsofbowel care,dailybathandsof teningthestoolti
llwound
heali
ng.

HEMORRHOI DS( PILES)

Def initi
on:Hemor rhoidsar edilatedsubmucosal vei
nsi ntheanus.Theymaybe
classi fi
ed
i
nt o:
Internal hemor rhoids( Internal totheanal or i
fice)
Ext ernal hemor r
hoids( External totheanal or i
f i
ce)
Interoext ernal hemor rhoi ds/Mi xed( Prolapsingi nt
ernal hemor r
hoids)
INTERNALHEMORRHOI DS
Internal hemor rhoidsr ef ert odilatationoft hesubmucosal i
nternalvenouspl exusand
drainingsuper iorhemor rhoi dal veins.Theydev elopwi thinareasofenl argedanal l
ini
ng
(anal
cushi ons’ )ast heysl i
dedownwar dsdur i
ngst raining.Sincet hei
nternal andexternal
(subcut aneousper ianal )v enouspl exuscommuni cate(Porto-sy
stemi canastomosi s)
engor gementoft heint er nal pl
exusi sli
kelytol eadt oinv ol
vementoft hel at
ter.
Wi tht hepat ientint hel ithot omyposi ti
on, i
nternal hemor rhoidsarefrequentlyar r
anged
i
n
threegr oupsat3, 7and11o’ clockposi t
ions.Thi sarrangementcor r
espondst othe
distributionoft hesuper iorhemor rhoidalvessel s( 2ont heright
,oneont heleft)but
therecan
besmal
l
erhemor
rhoi
dsi
nbet
weent
het
hreegr
oups.

Eti
ology:Thoughmosthemor r
hoidsarei
diopat
hic,
theymayal
sobesecondar
yto
underl
yi
ngcauses,whichi
nclude:
-Str
aini
ngaccompany i
ngconstipat
ion
-Str
aini
ngatmi ct
uri
ti
on
-RectoSigmoidmass

Cli
nicalf eat ures:Hemor rhoi dsar eusual lyasymptomat icbutcanpr esentwith:
-Rectalbl eedi ng:ist hemai nandear li
estsy mptom whi chisusuallysli
ghtpainl
ess
bri
ghtr edoccur r
ingonpassi ngst ool asaspl ashint othet oi
letortoil
etpapersor
coveringt hest oolatt heendofdei f
icat i
on.
-Prolapseoft hev aricosemassesi sal atemani f
est at
ion.
-Amucoi ddi schargef requent l
yaccompani esprolapsedhemor rhoidsandisduet o
mucussecr etionf rom t heengor gedmucusmembr ane.
-Pruritusani -
duet ot hedi schar geandper i
analsoil
ingaccompany ingpr ol
apsed
hemor rhoi ds.
-Pain-i snotasi gni fi
cantf eatureofuncompl i
catedi nternalhemor r
hoids.
-Anemi a-duet oper sistent /profusebl eeding
-Onexami nat i
onev erypat i
entshoul dunder goatleast :
1. Compl eteabdomi nalandpel vicexaminat i
onl ookingforunderlyi
ngcausesor
aggr avat i
ngf act ors.
2. Rect alexami nation: Inspect i
onmayshowpr olapsinghemor r
hoids(pi
les)wit
h
orwi thoutst rai ni
ngand/ orredundantski nf oldsorski ntags.
3.Di gitalrectal exami nat i
onmayshowpr ol
apsi ngort hrombosedhemor r
hoids.
Int
er nal hemor rhoidsar enotf eltunlesstheypr olapse.

I
nvesti
gat i
ons
Pr
octoscopy -tovisualizeinternal hemor rhoidsandexcl udeotherl esions
Gradi ngofHemor r
hoids
I
tisbasedont hedegr eeofpr olapseandr educibi
li
tyinto:
4.Firstdegreehemor rhoids: thoseconf inedtotheanal canal (
donotpr olapsedout
sidetheanal canal)
5.Seconddegr eehemor rhoids:pr olapseondef ecationbutr educespont aneously
ont heirown
6.Thirddegr eehemor r hoids:pr olapse, orarereplacedmanual lyandstayr educed.
evenapar tfrom def ecat i
on, andr emai npermanent lyprolapsedout si
det heanal
mar gin.Thesegi v
er isetoaf eelingofheav i
nessi nther ectum
7.Four t
hdegr eehemor rhoids:compl et
epr ol
apsedwhi chi svisi
ble.
andcanonl ybe
replacedbysur gery.
Compl
ications:
 Prof usehemat ochezia,
 Strangulationwhi chl
eadst oanacutepain,t
hrombosis,whichmakesthemass
swol len,dark,t
enseandf eel sol
i
dandtenderonexami nati
on.
 Unr eli
evedst r
angulat
ion/thrombosi
smayl eadt oul
cerati
onoftheexposed
mucusmembr ane.Gangrene-mayleadtospr eadi
nginfect
ion/
sepsi
sand
Abscessf ormation.

Management:Anyunderl
yi
ngorassoci
atedmor
ei mpor
tantcondi
ti
onordiseaseshoul
d
be
excl
udedortr
eatedaccor
dingl
ybef
orecommencingspeci
fi
ctreat
mentforhemorrhoi
ds.
Hemorrhoi
dscanbemanagedwi t
h:

Conser vativemeasur eswhichinclude:

-Highf iber-dietforaregul
arsoftandbul kymotion
-Hydr ophil
iccr eamsorsupposi tori
es
-Local appl i
cationofanalgesicointment/supposi
tory
.
Thisisr ecommendedandusual lyeffect
iveformanypati
entswithearlyhemorr
hoi
ds
parti
cul ar
lyt hosesecondarytoot hercondit
ionsandli
kel
ytoregresswi t
hremovalof
the
underlyingcondi t
ions(e.
g.pregnancyandpostpar t
um hemorrhoids)
Thef ollowingpr oceduresneedt obeper f
ormedbyexperthandst oavoid/r
educe
compl icati
ons

operati
vetr
eatment, hemor rhoi
dect
omyi ndi
cat
edfor:
-Thi
rddegreehemor rhoids
-Fai
lureofnon-
operativetreatmentofseconddegr
eehemorr
hoids
-Fi
brosedhemor r
hoids
-I
nteroext
ernal
hemor rhoidswi t
hwelldefi
nedext
ernal
hemorr
hoid

Tr
eatmentofcompl icati
ons
St
rangulat
ion,t
hrombosisandgangr ene
I
mmedi atesurgeryunderadequateantibi
oticcoveror
Adequatepainrel
ief,
Bedrest,fr
equenthotsit
zbath,
warm sali
necompr esswithfi
rm pressurefoll
owedby
l
igati
onorexcisi
onoranal di
lati
on.
Severehemorrhage
oResuscitati
onwi thIVflui
ds
oLocalcompr essionwi t
hadr enal
inesolut
ion
oPainrel
iefwhenpr esent
oBloodtransfusionwhenneeded
Al
lthesear efol
lowedbydef init
ivether
apy

EXTERNALHEMORRHOI DS
Athrombosedexter
nalhemorr
hoi
d(peri
anal
hematoma),i
susuall
yassoci
atedwi
th
consi
derabl
epain.I
tappear
sasaninf
lamedtenset
enderandeasi
lyvi
sibl
eon
i
nspecti
onof
theanalver
ge.

Treatment
Reliev
ingpai
nbylocal
oror alanal
gesi
csandav
oidconst
ipat
ion.Sur
gical
evacuat
ionof
the
clotcanbedoneunderlocalanest
hesi
a.

GALLSTONEDI SEASE( choleli

thiasis)
Gallstonedi seaseisthemostcommonpat hologyoft hebi l
iaryt
ract.
Classificati
on
1.Chol esterolst
one(6%):usuall
ysoli
tary
2.Mixedst one(90%):chol
ester
olisthemaj orcomponentwi thothersl
ikecalci
um
bi
lir
ubinat e.Thesetypeofstonesaremul t
iple,facetedandusual lyassociat
edwi t
h
i
nfect i
on.
3.Pigmentst one:mainl
ycomposedofcal cium bi l
ir
ubinate.Theyar eusuall
ysmall,
multipleandbl ack.Commonl yassoci
atedwi thhemol yti
cdi sease.

Inci
dence
Femalesexandoldagear
ethecommonr
iskf
act
ors.Butt
hecondi
ti
oncanoccuri
n
both
sexesandatanyage.

Pathogenesi s:Threeimpor t
antfactor
simpli
catedinpathogenesisofcholel
it
hiasi
sare:
1.Met abolic:chol
esterolissolubl
einbil
esaltandphospholi
pids.Whenbi l
esaltis
defici
ent
orwhent hechol esteroll
evelisinexcessi
nr el
ati
ontothebilesalt
,thebil
eformedi s
supersaturatedorlit
hogeni c
2.Infecti
on:causesi ncreasedmucuspl ugformati
onandscar r
ingwhi chf
orm anidus
for
stonef or
mat i
on.Alsomanybact
eriadeconjugatebi
ll
i
rubi
nwhi
chwil
lcombi
newit
h
calcium t
oformi nsol
ubl
ecal
cium bil
i
rubi
nat e.
3.St asi
s:i
mpor t
antforgr
owthofstone.Progester
oneinmul
ti
par
ouswomenis
believedto
becont ri
butor
y.

Cli
ni calPresentati
on
Most( 90%)patient
swi thgall st
onediseasesar easymptomat i
c.Symptomati
cpat
ient
s
presentwi th:
Hist ory:
-Rightupperquadr antcolickypai n(
bili
ar ycol
i
cky )
-Dy spepsia,fat
tyfoodintolerance,f
latulence,abnormalpostprandi
albl
oat
ing
-Sy mpt omsofacut echolecy sti
ti
sorot hercompl i
cati
ons
Phy sicalexamination:
•rightupperquadr anttender ness
•Ri skfactorscanbei denti
fied

Compl icationsofGal lbl

adderst
one
1.I
nt hegal lbladder:
•chroni cchol ecysti
ti
s
•acutechol ecystit
is
•gangr ene
•perforation
•empy ema
•mucocel e
•carcinoma

2.I
nthebil
educt:
•obst
ruct
ivej
aundice
•chol
angi
ti
s
•acut
epancreat
it
is

3.i
nintest
ine:
•acut
e

Bil
educt:
•obst
ructi
vejaundice
•chol
angit
is
•acut
epancr eat
it
is
3.i
nintest
ine:
•acuteint
esti
nal obst
ruct
ion(Gal
lst
oneileus)
Diagnosti
cwor kup
Ultr
asound:detectsst
onei nt
hegallbl
adder
Plai
nabdomi nalfil
m:Only10%ofstonesareradi
oopaqueandv
isi
bleonX-
ray

Dif
ferentialdiagnosis
1.PUD
2.HiatalHer ni
a
3.Carcinomaofst omach
4.Diverti
culardisease
5.Anginapect oris

Treatment
Surgery:OpenorLaparoscopi
c
1)cholecystect
omy.Themai nst
ayoftreat
ment
2)cholecystost
omyforbadr i
skpati
ent
swi t
hsever
einf
ect
ion
(Sever
eAcut echol
ecysti
ti
sorgallbl
adderempyema)

Acut
eChol
ecy
sti
ti
s
Defi
niti
on
Acutechol
ecysti
ti
sisanacuteinf
lammati
onofgall
bladderduetoobst
ructi
onofneck
ofgall
bl
adderorcysti
cductstone.Anot
herr
arefor
m ofacutechol
ecysti
ti
swhichoccur
sin
absenceofstoneiscal
l
edacalcul
ouschol
ecyst
it
is.

Pathogenesi s
Dir
ectpr essur eofcalculusont hemucosar esultsinischemi a,necr
osis,
andulcer
ation
wit
h
swellingedemaandi mpai r
mentofv enousreturn.Thispr ocessincr
easesandextends
the
extentofi nf
lammat ionandf avorsbacterial
multipl
ication.Theendr esul
tmaybe:-
-Pericholecysticabscess
-Fi
st ulaformat i
onbet weengal lbladderandbowel
-Gall bl
adderempy ema/ mucocel e
-Rarel y
,perforati
onofgal lbladderandbi leperi
tonit
is
Commonl yinv ol
vedbact eri
al speciesinacutecholecy sti
tisincl
udeE.coliKl
ebsi
ell
a
species,
Str
ept ococci speci
es, EnterobacterspeciesandCl ostridi
al speci
es.

Cl
ini
calf
eat
ures
History:
•Historyofchroni
ccholecyst
it
isorCholel
i
thi
asi
s
•Womenmor eaffect
edthanmen
•Moder atet
osev ereri
ghtupperquadr
antandepigast
ri
cpai
nwhi
chmayr
adi
atet
o
theback.
•Fev erandvomiti
ng

Physi
calexami nati
on:
•Ri
ghtupperquadr antt
endernessusuall
ywithreboundtenderness
•Gall
bladderorinfl
ammatorymassduet ooment um wrappedaroundtheGBmay
bepalpable.
•Murphy’sSignmaybeposi t
ive:suddenarr
estofinspir
ationduetotender
nessof
i
nfl
amedgal lbladderwhi
chispalpatedduri
ngdeepi nspir
ati
on.

Dif
ferent i
aldiagnosi
s
•Perforatedorpenetrat
edpepti
culcerdi
sease
•Bil
iarycolic
•Pneumoni a
•Pancr eati
ti
s
193
•Hepat it
is
•Pleuri
sy
•Appendi cit
is
•My ocardiali
schemiaorinf
arct
ion.

I
nvest
igati
on:
WBC:Leucocyt
osis
Pl
ainChestorabdominalX-r
ay:tocheckf
orpneumoniaorr
adi
oopaquestone
Ul
tr
asound:detect
scalcul
i,
gallbl
adderwall
thi
ckeni
ngandper
ichol
ecy
sti
cflui
d

Treatment
1.conser vat
ive
-Admi tthepat i
ent
-keept hepat i
entNPO
-StartonI Vflui
d
-InsertNGT
-Analgesics
-Antibiot
icstocov ercommoncausati
vebact
eri
a:usual
lyampi
cil
l
inandgent
amycinare
used.
-Foll
owt her esponsetomedicalt
reat
mentwit
hcli
nical
improv
ement(fev
er,
abdominal
fi
ndings)andWBCcountr educti
on
-Appoi
ntthepati
entt
oundergochol
ecy
stect
omyaf
ter6weeks
2.Sur
gicalt
reat
ment:Chol
ecyst
ect
omy

ASSI
GNMENT

1.Wri
teshor
tnot
esonthefol
l
owi
ngunderdef
ini
ti
on,
causes,
cli
nical
feat
uresand
howtomanage.(
10marks@)

a)Di
ver
ti
cul
osi
s

b)Di
ver
ti
cul
i
tis

c)Mer
kel
sdi
ver
ti
cul
i
tis

2.Whatar
ecompl
i
cat
ionsofhemor
rhoi
dsandhemor
rhoi
dect
omy(
10mar
ks@)

3.Cl
assi
fyf
issur
esaccor
dingt
opar
kscl
assi
fi
cat
ion(
5mar
ks)