Anatomy of lower GIT

Histology of lower GIT

Gastrointestinal bleeding
Bleeding from the gastrointestinal (GI) tract may present in 5
ways.

1. Hematemesis: vomitus of red blood or "coffee grounds"

material
2. Melena: black, tarry, foul-smelling stool
3. Hematochezia: passage of bright red or maroon blood from
the rectum
4. Occult GI bleeding: blood in the stool in the absence of overt
bleeding
5. Symptoms of blood loss or anemia (e.g., lightheadedness or
shortness of breath)
 Differentiation of upper GI bleeding from lower
GI bleeding
Hematemesis
Vomiting of blood or altered blood ("coffee grounds" appearance)
indicates an
upper GI source of bleeding (above the ligament of Treitz).

Melena
Altered (black) blood passed by rectum (>100 mL blood for 1 melenic
stool)
Indicates that blood has been present in the GI tract for at least 14 hours
Usually indicates bleeding proximal to ligament of Treitz, but may be as
distal as ascending colon
The more proximal the bleeding site, the more likely melena will occur.
Hematochezia

Bright red or maroon rectal bleeding

Usually represents a lower GI source of bleeding, although an upper GI
lesion may bleed so briskly that blood does not remain in the bowel long
enough for melena to develop.
When hematochezia is the presenting symptom of upper GI bleeding, it is
associated with hemodynamic instability and decreasing hemoglobin
concentration.
Bleeding lesions of the small bowel may present as melena or
hematochezia.
Hematochezia that presents with abdominal pain may represent ischemic
colitis, particularly in elderly persons or those with cardiovascular risk
factors.
Hematochezia associated with diverticulosis and colonic tumors is typically
painless.
Laboratory Tests

1. Complete blood count

2. Serum chemistry
3. Occult blood testing
4. Stool studies
Physical examination

Clinically significant bleeding leads to postural changes in

heart rate or blood pressure, tachypnea, tachycardia, and
recumbent hypotension.

Hemodynamic changes
- Orthostatic decrease in blood pressure > 10 mmHg usually
indicates > 20% reduction in blood volume.
-Systolic blood pressure < 100 mmHg usually indicates < 30%
reduction inblood volume.
Treatment
Hemodynamic resuscitation and stabilization
Procedural intervention
Endoscopic hemostatic therapy
Colonoscopic removal of bleeding polyp or
mass
Surgical resection if necessary
Targeted medical therapy
Hemodynamic resuscitation and stabilization
Venous access
Monitor vital signs, urine output, and hemoglobin and hematocrit
(decrease may lag).
Intubation may be required to protect the airway.
Support blood pressure with isotonic fluids (normal saline) and blood
products as necessary.
Type and cross-match blood (6 units for major bleeding)
Reverse coagulopathy (if present) with fresh-frozen plasma and vitamin K.
Intravenous calcium if serum calcium level decreases due to transfusion of
citrated blood
Surgical standby when bleeding is massive
Indications for emergency surgery
Complication
Hypovolemic shock and subsequent end-organ
damage
Complications related to blood transfusions, such as
acquired infections or transfusion reaction
Complications related to procedural interventions,
such as perforation and infection
Hemorrhoid
 What Are Hemorrhoids?
Alternative Names
Rectal Lump
Piles
Lump in the Rectum
Definition:
Dilated or enlarged veins in the lower
portion of the rectum or anus.
 Hemorrhoid
Two Types:
Internal- Under the skin
External- Around the anus
Grades:
I- Hemorrhoids only bleed
II- Prolapse and reduce spontaneously
III- Require replacement
!V- Permanently Prolapsed
 DERAJAT HEMOROID
DERAJAT 1 DERAJAT 2 DERAJAT 3 DERAJAT 4

Terjadi Pembesaran Prolaps

pembesaran hemoroid Pembesaran hemoroid
hemoroid yang hemoroid yang
yang tidak prolapse dan yang prolaps permanen.
prolapse menghilang dapat masuk Rentan dan
keluar kanal atau masuk lagi ke dalam cenderung
anus. Hanya sendiri ke anus dengan untuk
dapat dilihat dalam anus bantuan mengalami
dengan secara dorongan jari trombosis
anorektoskop spontan dan infark
 Frequency
10 million
Peak ages: 45-65 years
of adults experience hemorrhoids by age 50
Common among pregnant women
Temporary
 Symptoms
Rectal Bleeding
Bright red blood in stool
Pain during bowel movements
Anal Itching
Rectal Prolapse
Thrombus
 Causes

Pressure
Constipation
Diarrhea
Sitting or standing for long periods of time
Obesity
Heavy Lifting
Pregnancy
 Risk factors
Constipation and straining at defecation
Increased intra-abdominal pressure because
of tumor
Prenancy
Old age
Peranal sex
 PATOGENESIS HEMOROID
Dilation and inflammation of blood vessels in
the anal region come from hemorrhoidalis
plexus.
 Signs and Tests
Rectal Examination
Visual
Digital
Tests
Stool Guaiac (FOBT)
Sigmoidoscopy
Anaoscopy
Proctoscopy
 Referral
Gastroenterologists

Seek emergency care if :

large amounts of rectal bleeding
Lightheadedness
Weakness
Rapid HR < 100 BPM
 Complications
The blood in the enlarged veins may form
clots and the tissue surrounding the
hemorrhoids can die (Necrosis)
This causes painful lumps in the anal area.
Severe bleeding can occur causing iron
deficiency anemia.
 treatment
Pharmacology treatment for hemorrhoid can be
divided into four kind :
1. Drugs that improve defecation
(fiber supplement and feses lubricant)
2. symptomatic medications (reduce complaints of
itching, pain, or damage to the skin in the anal
region) kortikostreoid,lidokain
3. Drug stop bleeding (Indicate a bleeding wound on
the walls of the anus or the outbreak of the
hemorrhoidal veins whose walls are thin)
psylium,vitamin c
4. Cure and prevention of attacks ardium
 A number of methods may be used to remove or
reduce the size of internal hemorrhoids :
Rubber band ligation. A rubber band is placed around the
base of the hemorrhoid inside the rectum. The band cuts
off circulation, and the hemorrhoid withers away within a
few days.
Sclerotherapy. A chemical solution is injected around the
blood vessel to shrink the hemorrhoid.
Infrared coagulation. A special device is used to burn
hemorrhoidal tissue.
Hemorrhoidectomy. Occasionally, extensive or severe
internal or external hemorrhoids may require removal by
surgery known as hemorrhoidectomy.
These self-care measures may relieve the
symptoms

Use topical treatments

Keep the anal area clean
Soak regularly in a warm bath
Apply cold
Don't use dry toilet paper
Take oral medications
 Complications
Anemia. Chronic blood loss from hemorrhoids
may cause anemia, in which you don't have
enough healthy red blood cells, resulting in
fatigue and weakness.
Strangulated hemorrhoid. If blood supply to
an internal hemorrhoid is cut off, the
hemorrhoid may be "strangulated," which can
cause extreme pain and lead to tissue death
(gangrene).
 Prevention

Eat high-fiber foods

Drink plenty of fluids
Consider fiber supplements
Don't strain
Go as soon as you feel the urge
Exercise
Avoid long periods of standing or sitting
 Prognosis
Most treatments are effective, but to prevent
the hemorrhoids from coming back, you will
need to maintain a high-fiber diet and drink
plenty of fluids.
Inflamatory bowel disease
 inflammatory bowel disease (IBD) is an
idiopathic disease
inflammation of the mucosal lining of the
intestinal tract, causing ulceration, edema,
bleeding, and fluid and electrolyte loss.
probably involving an immune reaction of the
body to its own intestinal tract
The 2 major types of IBD are ulcerative colitis
(UC) and Crohn disease (CD).
 etiology
No mechanism has been implicated as the
primary cause
 epidemiology
An estimated 1-2 million people in the United
States have ulcerative colitis or Crohn disease,
with an incidence rate of 70-150 cases per
100,000 individuals
 patophysiology
The pathophysiology of IBD is under active
investigation
Helper T cells, type 1 (Th-1), are associated
principally with Crohn disease, whereas Th-2
cells are associated principally with ulcerative
colitis
The immune response disrupts the intestinal
mucosa and leads to a chronic inflammatory
process.
 Sign and symptom
diarrhea and abdominal pain
Systemic symptoms are common in IBD and
include fever, sweats, malaise, and arthralgias.
 Ulcerative colitis attack colon
Crohn disease any segment of GI track
 Ulcerative colitis
inflammation begins in the rectum and
extends proximally in an uninterrupted
fashion to the proximal colon, eventually
involving the entire length of the large
intestine
The rectum is always involved in ulcerative
colitis, and no "skip areas" (ie, normal areas of
the bowel interspersed with diseased areas)
are present
 The small intestine is never involved, except
when the distal terminal ileum is inflamed in a
superficial manner
 Crohn disease
The 3 major patterns of involvement in Crohn
disease are disease in the ileum and cecum
(40% of patients); disease confined to the
small intestine (30% of patients); and disease
confined to the colon (25% of patients)
 Patients with IBD are more prone to the
development of malignancy
 The incidence of gallstones and kidney stones
is increased in Crohn disease because of
malabsorption of fat and bile salts
Gallstones are formed because of increased
cholesterol concentration in the bile, caused
by a reduced bile salt pool.
 With the fat malabsorption, unabsorbed long-
chain fatty acids bind calcium in the lumen
 Features Crohn Disease Ulcerative Colitis
Skip areas Common Never

Cobblestone mucosa Common Rare

Transmural involvement Common Occasional

Rectal sparing Common Never

Perianal involvement Common Never

Fistulas Common Never

Strictures Common Occasional

Granulomas Common Occasional

 diagnose
Blood or mucus in stool
Cbc
Elecrolyte
LFTs measure alanine transaminase (ALT),
aspartate transaminase (AST), alkaline
phosphatase (ALP), albumin, total protein, and
total and direct bilirubin levels
Fecal occult blood test
 X-ray
Barium enema
Sigmoidoscopy
Colonoscopy
Upper endoscopy
 treatment
The first step in medication therapy for IBD is
usually aminosalicylates (sulfasalazin)
If the patient's condition fails to respond to
aminosalicylates, the second step is
corticosteroids (prednisone), which tend to
provide rapid relief of symptoms and a
significant decrease in inflammation
 The immune-modifying agents are step III
drugs and are used if corticosteroids fail or are
required for prolonged periods. Infliximab is
also a step III drug that can be used in some
situations in patients with Crohn disease and
ulcerative colitis.