1. Normal anatomy of GIT with blood supply 2. Definition of hematochezia 3. History taking of patient with PR bleed 4. Clinical features in patient with PR bleed. 5. Causes of PR bleed 6. Investigate patient with PR bleed 7. Principles of management of patient with Lower GIT bleed

Diseases/Disorders
Colon ca Rectal ca Hemorrhoids Anal fissure Inflammatory bowel disease Colonic and rectal polyps Colonic diverticulosis

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The organs of the digestive system include: the oral cavity (mouth) pharynx esophagus stomach small intestine large intestine anal the accessory organs (teeth. liver. It goes through the thoracic cavity and enters the abdominal cavity through the diaphragm.ƒ The GI tract which extends from the mouth to the anus is a continuous tube approximately 30 feet (9m) long. gall bladder and pancreas) ƒ ƒ ƒ ƒ ƒ ƒ ƒ ƒ ƒ ƒ . salivary glands.

1 .Fig.

L vat r alati (l vat r v li alati i) . Palat gl ss s 5. Palat ary g s Nerve s ly All t scl s f li y s ft alat ar s pharyngeal plexus except f r t e tens r palati. Post rior one t ird is t soft palate Muscles of soft palate 1. M sc l s v la 4.Bri f t y Bl ds ly/I rv ti Fl r f t t yt c s ra ic It is f r c cts t t g t t a i l . a i lar ct s i t fl r f t T s t t a x f t s li g al a illa R f ft t R f is f r y alat ( y alat & s ft alat ). .  Tens r palati is s pplied y mandibular nerve. A t ri r tw t ird is t bony palate ( ar alat ).T s r alati (t s r v li alati i) 2.

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It is about 12 cm long. 3 muscles running longitudinally are:  Stylopharyngeus  palatopharyngeus  salpingopharyngeus. Veins Into pharyngeal venous plexus to internal jugular vein.Brief anatomy It extends from base of skull to 6th cervical vertebra.Ascending pharyngeal. ascending palatine. Lymphatic drainage of pharynx:  Three parts: 1. Sensory nerve supply Nasopharynx. Length . Oropharynx glossopharyngeal nerve.  Blood supply/Innervation Blood supply . facial. 2. . Into deep cervical lymph nodes. It is continuous with oesophagus opposite to 6th cervical vertebra. Oropharynx .maxillary nerve. Area near the entrance into larynx internal laryngeal branch of vagus nerve. maxillary and lingual.posterior to mouth. Nasopharynx Posterior to nasal cavity. 3. Laryngopharynx posterior to larynx Muscles of pharynx 3 constrictor muscles namely: Superior constrictor Middle constrictor Inferior constrictor.

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Brief anatomy 

Blood supply/Innervation Blood supply Upper third inferior thyroid artery. Middle third branches from descending thoracic aorta. Lower third branches from left gastric artery. Lymphatic drainage Upper third drain into deep cervical nodes. Middle third drain into superior and posterior mediastinal nodes. Lower third Celiac nodes. Nerve supply By sympathetic and parasympathetic.  Vagus is parasympathetic.

It extends from pharynx to the

stomach. 

Pharynx continues as oesophagus at the vertebral level C6.

Oesophagus passes through the diaphragm at the vertebral level T10.  

Length 25 cm.

It has three parts: 1. Cervical part 2.Thoracic part 3. Abdominal part

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Parts of Stomach Fundus Body dome shaped extends from cardiac orifice to incisura angularis. Left and rig t gastric veins. left and rig t gastroepiploic veins and s ort gastric veins Nerve s ly Sy pat etic fi res from t e Celiac plex s and parasympat etic fi res from t e rig t and left vag s nerves. It is J.shaped.ranc f splenic artery Veins Drain int t e portal circ lation. Blood s ly/Innervation Arteries Left and rig t gastric artery Left and rig t gastr epipl ic artery S rt gastric artery . left and right gastroepiploic nodes and short gastric nodes. left hypochondriac and umbilical regions. Size 10 inches long. It is relatively fixed at both ends but mobile in between. It is the dilated portion of the alimentary canal. Lymphatic drainage Lymphatics follow the arteries and drain into the left and right gastric nodes.Brief natomy Situated in the upper part of the abdomen beneath the left costal margin into the epigastric.  All lymph pass to the celiac nodes. Pyloric atrrum Pyloric canal .

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Inferior pancreaticoduodenal vein Drains into superior mesenteric vein. Inferior pancreaticoduodenal artery branch of ii) Jejunum upper two fifth superior mesenteric artery.  Parasympathetic supply is vagus nerve. .Brief anatomy It extends from pylorus of the stomach to the ileocecal junction Blood supply/Innervation Duedenum Artery Superior pancreatico duodenal artery branch of It has three parts. Nerves Sympathetic and Parasympathetic. (2/5). Lymph vessels drains into celiac and superior mesenteric lymph nodes. i) Duodenum 25 cm. (3/5). Total length of jejunum & ileum 6 meters. gastroduodenal artery (coeliac trunk). Veins Superior pancreaticoduenal vein Drains into portal iii) Ileum lower three fifth vein.

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Veins length.5 c length.5 c in rain into superior mesenteric vein. Jejunum begins at the duodenojejunal flexure Ileum ends at the ileocaecal junction.Bri f t Blood s ly/I rv tion Blood supply (Jejunum nd ileum) Jejunal and ileal branches (12 15 in number) from superior mesenteric artery They anastomose with one another to form a series of arcades which give off the vasa i) First art (s erior) 5 c in length. recta to the gut ii) econd art (descending) -7. The parasympathetic supply is by the vagus nerve. . Duodenum It is sit at in th i astric and ilical r gions and is divided into 4 arts iii) Third art (inferior) -1 c in length. iv) Fourth art (ascending) -2. ymphatic drainage nodes. uperior mesenteric in Nerve supply: Sympathetic and parasympathetic.

JEJUNUM ƒ ILEUM ƒ ƒ ƒ ƒ ƒ ƒ ƒ Present in upper part of peritoneal cavity. No peyer's patches Walls are thicker Circular folds larger Jejunal mesenteric vessels form 1 or 2 arterial arcades Jejunal end of mesentery fat is present near the root ƒ ƒ ƒ ƒ Present in the lower part of the peritoneal cavity. Peyer's patches (aggregations of lymphoid tissue ) are present in mucous membrane of lower ileum Walls are thinner Circular folds smaller & in lower part absent. Ileal mesenteric vessels form 3 or 4 arterial arcades Ileal end of mesentery fat is present throughout. .

Ileum showing peyer s patches --------------------------- Peyer s patches .

Nerve supply Sympathetic and Parasympathetic. (6 cm long)  Appendix is attached to its posteromedial surface. Caecum It is blind-ended pouch present in the right iliac fossa. from ileum to the anus and is divided into: Cecum Appendix Ascending colon Right colic flexure Transverse colon Left colic flexure Descending colon Sigmoid colon Rectum and anal canal.  Parasympathetic is vagus nerve. Lymphatic drainage . Veins Drain into superior mesenteric vein.  .Brief anatomy It extends Blood supply/ Innervation Caecum Artery Anterior and posterior caecal branches from ileocolic artery branch of superior mesenteric artery.drain into superior mesenteric nodes.

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--------mesoappendix .

It is 12 cms long. It is 8 cm long. It t rns to the left to form the right colic flex re. Transverse colon It occupies the umbilical region. of ascending colon. reater omentum is attached to the transverse colon. It extends from right colic flexure to left colic flexure.( Left colic flexure is higher than the right colic flexure) Transverse colon is suspended by the transverse mesocolon to the Peritoneum covers the front and sides posterior abdominal wall.Ascending colon Extends from caec m to the inferior s rface of right lobe of liver. Continues as the transverse colon. .

The blood vessels supplying the sigmoid colon are present in sigmoid mesocolon.  .Descending colon  Sigmoid colon Approximately 0 cm long It connects descending colon with rectum It has a long mesentery. It is 25 cm long. Its root is having an inverted V shaped attachment. the sigmoid mesocolon. The peritoneum covers the front and sides of descending colon.   It is continuous with sigmoid colon. It extends from left colic flexure to the pelvic brim (Fig.8).

ƒ Left colic artery branch of inferior mesenteric artery. ƒ Right colic artery . ƒ . ƒ Sigmoid arteries ( 2-3 in number) branch of inferior mesenteric artery.branch of superior mesenteric artery. ƒ Superior rectal artery Branch of inferior mesenteric artery. ƒ Middle colic artery branch of superior mesenteric arterty.branch of superior mesenteric artery.The large intestine is supplied by the following arteries: Ileocolic artery .

13 Blood supply of large intestine .Fig.

Blood supply of large intestine (Note the ileocolic. right colic and middle colic branches of superior mesenteric artery) .

sigmoid arteries and superior rectal branches of inferior mesenteric artery) .15. Blood supply of large intestine ( Note the left colic.

Rectum Rectum is the terminal fixed part of large intestine  It is cotinuous with sigmoid colon at the level of S3 vertebra.Inferior rectal artery a branch of internal pudendal artery. Lymphatic drainage -Along the superior rectal artery to inferior mesenteric lymph nodes.  It runs downward and backward from the ampulla of rectum to the anus. Lymphatic drainage Drains into superficial inguinal lymph nodes. It follows the curve of sacrum and coccyx. Nerve supply . Arterial supply . Upper anal Nerve supply . It ends as anal canal. . the rectum is dilated to form the rectal ampulla.  Anal canal  It is cm long.superior rectal artery a branch of inferior mesenteric artery. Lower anal Arterial sypply .Derived from autonomic plexus.  Rectum is continuous with anal canal inferiorly  It is 12 cm long.3 cm from the tip of coccyx).From inferior rectal nerve.  The junction is at the lower end of mesentery of sigmoid colon. (2 .  In the lower part.

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Nerve supply Sympathetic and Parasympathetic from the celiac plexus. Lymphatic drainage The efferent vessels pass to the celiac nodes . It divides into right and left terminal branches that enter the porta hepatis (Fig.3. a branch of celiac artery. ).Brief anatomy Divided into a large right lobe and a small left lobe by the attachment of falciform ligament . which extends from liver to the anterior abdominal wall Blood supply/Innervation Hepatic artery. Veins Portal vein divides into right and left branches that enter the porta hepatis.  Right lobe is further divided The hepatic veins emerge from the posterior surface into quadrate lobe and of liver and drain into the I.12).C caudate lobe (Fig.V.

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Parasympathetic is the vagus nerve. The pain fibres from the gall bladder and bile ducts ascend through the celiac The peritoneum completely surrounds plexus. lymph node. body and neck Blood supply/Innervation Blood supply Cystic artery a branch of right hepatic artery Veins Cystic vein which drains into portal vein. From here the lymph vessels pass to hepatic nodes and then to celiac nodes. The neck is continuous with the cystic  Sympathetic and Parasympathetic form the celiac plexus. Parasympathetic. Fundus can be surface marked on the anterior abdominal wall at the level of the Lymphatic drainage Drains into cystic tip of the right 9th costal cartilage.Brief anatomy It has three parts Fundus. duct. the fundus of gall bladder. The body of gall bladder lies in contact Nerve supply Sympathetic and with the visceral surface of liver. .

The Gall bladder and bile duct .

6-8 inches long and weighs about 90 gms. 1.Brief anatomy It is lying across the upper part of the posterior abdominal wall from the duodenum to the spleen (vertebral level . Superior pancreatico duodenal artery branch of gastroduodenal artery (branch of coeliac trunk). L2). Lymphatic drainage . Parts Head. Blood supply/Innervation Arterial supply Pancreas is supplied by the following arteries. size and weight .Drain into the celiac nodes and superior mesenteric nodes.  Parasympathetic is vagus.L1.Sympathetic and Parasympathetic. Inferior pancreatico duodenal artery (branch of superior mesenteric artery).J . . neck. Veins The veins of pancreas drain into the portal system. body and tail Nerve supply .shaped. Shape. 3. Pancreatic branches of splenic artery 2.

Parts of pancreas .

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 It divides into five to six branches & enters the hilum of spleen. It is the largest branch of coeliac trunk.diaphragmatic and visceral  The long axis of spleen lies along the Blood supply/Innervation Blood supply Splenic artery .  The splenic vein joins the superior mesenteric vein to form the portal vein. It has a tortuous course. shaft of 10th rib. 3 borders superior. Nerve supply Derived from Coeliac plexus.2.3). Lymphatic drainage Drain into Celiac nodes.Brief anatomy External features 2 ends . 2 surfaces . Veins Splenic vein drains the spleen . 6).anterior end (pole) and posterior end (pole).   Its superior border is notched (Fig. Its lower end (anterior pole) extends forward as far as the midaxillary line (Fig.  Splenic artery forms the stomach bed. . inferior and intermediate borders.

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.RIB Fig.3 Lower end of spleen extending to the midaxillary line.

Appendix lies in the right iliac fossa. Nerve supply Sympathetic and Parasympathetic. Veins Appendicular vein drains into posterior caecal vein.In front or behind the terminal part of ileum. . iv) Pre ileal and post ileal.Into the pelvis against the right pelvic wall. Blood supply/Innervation Blood supply Appendicular artery branch of ileocolic artery (branch of superior mesenteric artery).6). iii) Subcaecal. ii) Pelvic . Lymphatics Drain to the nodes present in mesoappendix and then to superior mesenteric nodes.Brief anatomy Location . This position is commonest (Fig. Length varies from 5 15 cms.Below the caecum. Mc Burney's point A point is taken at the junction of the lateral 1/3 and medial 2/3 of the line drawn across the right anterior superior iliac spine with the umbilicus (where the base of appendix is situated) Positions of appendix i) Retrocaecal (retrocolic) .Behind the caecum.

5 Mc Burney s point 1. 2.umbilicus. 3 Right anterior superior iliac spine .Fig.Mc Burney s point.

Positions of appendix .

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ƒ ƒ Hematochezia is the passage of fresh blood per anus. the rectum or the sigmoid colon is usually bright red while bleeding from the transverse colon and the right colon is darker or of a maroon colour. usually in or with stools. bleeding from the anus. Accordingly. .

shigellosis. amebiasis) Anal fissures Chronic ulcerative colitis Granulomatous colitis Adenocarcinoma Benign tumors Ischemic colitis Upper tract lesion (massive bleeding) Children Juvenile polyps Chronic ulcerative colitis Granulomatous colitis Infections Intussusception Meckel's diverticulum Neonates Anal fissure Necrotizing enterocolitis Midgut volvulus .. Causes of Hematochezia Adults Internal hemorrhoids Vascular malformation Diverticulosis Infections (campylobacter.

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When did it start? ƒ When did the patient first notice the bleeding? ƒ Is this the first episode? ƒ Does the bleeding occur every time the patient goes to the toilet? .

during or after defecation? ƒ Is the blood mixed with the stool? .Are there any aggravating or relieving factors? ƒ Is it worse on straining? ƒ Is it better after resting? ƒ Did the patient take any supplements or medication for this problem? ƒ Did it help? What is the nature of the bleeding? ƒ How much is the bleeding? ƒ What is the colour of the blood? ƒ Does the bleeding occur right before defecation.

Are there any associated symptoms? ƒ ƒ ƒ ƒ ƒ ƒ ƒ ƒ ƒ ƒ ƒ ƒ Is the bleeding painful or painless? Does the patient notice mucous together with the blood ? Does the patient have abdominal pain when the bleeding occurs? Does the patient experience fever? Is it associated with melaena or haematemesis? Does the patient present with malignancy symptoms? Does the patient show any anaemia symptoms secondary to the blood loss? Other relevant history Past medical and surgical history Family history Drug and allergy history Social history .

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bright red blood on stool and toilet paper .Fissure in ano ƒ ƒ ƒ * The brighter red the blood is.ƒ ƒ Severe abdominal pain. the lower down its source . stops spontaneously. It is present in rectal cancer. small volumes. mucus discharge suggestive of solitary rectal ulcer Bright red bleeding post-defaecation. feeling of lump in anus . collapse and shock suggestive of ischaemia Tenesmus differentiates colon cancer from rectal cancer. perianal irritation suggestive of haemorrhoids Extreme pain post-defaecation. Bleeding post-defaecation.

large volume. long history. previous history of constipation . intermittent course. associated with systemic upset. mostly fresh blood. painless. diarrhoea prominent .Ulcerative colitis Retching and colicky abdominal pain Intussusception ƒ ƒ .ƒ Spontaneous onset.Diverticular disease Blood mixed with mucus.

anal canal  Separate from the faeces. either after or unrelated to defecation Follows defecation from anal canal . diverticular dx. haemorrhoids Passed itself . IBD  On the toilet paper after cleaning Minor bleeding at the anal margin .ƒ Recognizable blood:  Mixed with the faeces Higher than the sigmoid colon  On the surface of the faeces Lower sigmoid colon. rectum. haemorrhoids . fissure. bleeding ca.

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ƒ ƒ ƒ ƒ ƒ Diverticular Disease .Crohn s disease Neoplasm .arteriovenous malformations Inflammatory Bowel Disease .Hemorrhoid .Colon ca Anorectal Disease .Diverticulosis Angiodysplasia .

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intraabdominal abscesses confirms the diagnosis with characteristic pathological appearances ie demonstrate transmural involvement. calcification. PT and APTT absence of infectious elements seen on microscopy or culture small bowel or colonic dilatation. surrounding inflammation. fistulae tissue biopsy Colonoscopy and sigmoidoscopy CT and MRI . abscess. stool testing plain abdominal films RESULT anaemia. bowel wall thickening.TEST FBC electrolyte values and coagulation profile. leukocytosis Electrolyte status. sacroiliitis. the degree of tumour differentiation mass/stricture/inflammation/ulcerati on skip lesions.

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. surgery may be necessary.Resuscitation And Stabilization 2.Treatment of lower GI hemorrhage can be simultaneously performed with the diagnostic methods used to localize the bleeding source. 3.1.If these therapeutic options fail or are inadvisable and the hemorrhage continues.

1.Endoscopic Treatment
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The lesions most amenable to colonoscopic treatment of lower GI bleeding are usually angiodysplasia or diverticulosis. Once identified as the source of bleeding, angiodysplasias are usually coagulated by some method, including heater probe, bipolar coagulation

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2. Angiographic Treatment
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Angiographic treatment of lower GI bleeding can involve the intra-arterial infusion of vasopressin or transarterial embolization. If vasopressin infusion is chosen, the infusion can begin immediately after the bleeding site is localized by arteriography.

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Vasopressin leads to arterial vasoconstriction and bowel wall contraction that results in lower blood flow. The catheter is positioned in the artery supplying the site of bleeding and infusion is started at a rate of 0.2 units per minute. If the bleeding continues, the rate of infusion can be increased up to 0.4 units per minute.

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infusion continues at the same rate for 6 to 12 hours and then decreased by 50 percent. During the ensuing 12 to 24 hours. the infusion can be tapered down and the catheter eventually removed ƒ .ƒ A repeat angiogram can be performed after 20 to 30 minutes to assess whether the bleeding is continuing or slowing down. If it seems that the bleeding has stopped.

ƒ Left-sided diverticulosis was once thought to be the source of most lower GI bleeding before right-sided diverticula and right-sided angiodysplastic lesions were recognized as additional significant sources . and persistent or recurrent hemorrhage. transfusion requirements >6 units. clinical deterioration.Surgical Options ƒ The usual indications for an operation are hemodynamic instability.3.

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It was the top and third most frequently reported cancer in males and females respectively in West Malaysia Chinese had the highest reported incidence The cause of colorectal cancer is not completely understood .ƒ ƒ ƒ 2002 .

such as ulcerative colitis or Crohn's disease. History of ovarian. and has also been known to develop in younger people. while men are more likely to develop rectal cancer. ƒ Personal history. ƒ Gender. Women have a higher risk for colon cancer. More common in people over 50. Adenomas are non-cancerous polyps that are considered precursors. also are at higher risk of developing colorectal cancer. or breast cancer. uterine.Risk factors ƒ Age. . person who already has had colorectal cancer may develop the disease a second time and people who have chronic inflammatory conditions of the colon.. ƒ Polyps.

don't get enough exercise. siblings. Parents.ƒ Family history. smoke. Lifestyle factors. ƒ ƒ ƒ . A family history of familial polyposis. and if you are overweight. Diabetes. You may be at increased risk for developing colorectal cancer if you drink alcohol. adenomatous polyps. or hereditary polyp syndrome also increases the risk as does a syndrome known as hereditary non-polyposis colon cancer Diet. A diet high in fat and calories and low in fiber may be linked to a greater risk of developing colorectal cancer. People with diabetes have a 30-40% increased risk of developing colon cancer.

or bloating . cramps.ƒ ƒ ƒ ƒ ƒ Fatigue. red or dark blood in stool) Weight loss Abdominal pain. weakness Shortness of breath Change in bowel habits (diarrhea or constipation.

Right colonic ca Typically present at a more advanced stage with symptoms of weight loss and anaemia The tumour grows outwards from one location in the bowel wall. This very rarely causes obstruction of feces. and can obstruct the bowel much like a napkin ring. change in bowel habit. and presents with symptoms such as anemia Left colonic ca Often present with rectal bleeding. Left-sided tumours tend to be circumferential. and tenesmus. .

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75% of carcinoma occur in the lower part of the rectal ampulla. especially diet with high fat content.ƒ ƒ ƒ ƒ The etiology of colorectal cancer is unknown Diet may have an etiologic role. they tend to be papiliferous or simple ulcer with an everted edge 25% are in the upper part of the rectum and are often annular in shape .

may passed out without faeces) Alternating episodes of diarrhea. constipation Tenesmus Weight loss Abdominal pain (colic) Vomitting Pain on defecation .ƒ ƒ ƒ ƒ ƒ ƒ ƒ Rectal bleeding (dark-red blood streaked on the stool.

ƒ ƒ Usually rectal bleeding is more common in rectal ca rather than in left colonic ca In left colonic ca. sometimes the blood interspersed among faeces . the blood is dark and plumcoloured.

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can a/w external skin tag.ƒ ƒ ƒ Def : abnormal enlargement of the anal cushions They consist of enlarged congested patches of mucosa and submucosa. . process of prolapse stretches perianal skin below it. Skin tag + haemorrhoid. skin tags may occur alone. Chronic. sometimes term a pile mass.

ƒ ƒ chronic constipation. pelvic tumours. pregnancy.g. portal hypertension ƒ RECTAL CARCINOMA . and vigorous straining. prolonged sitting. Lifestyle: low fibre diet (+ constipation) Other conditions: ƒ IMPAIRED VENOUS RETURN e.

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painless bleeding (bright red, occur after defaecation. if small quantity, may just streak the feaces or be noticed on toilet paper. if profuse, it may splash into toilet pan and even cause iron deficiency anemia. ) palpable lump. (pt may notice lump when cleaning after defaecation) when lump is permanent, may largely consist of skin tag, element of the pile mass. sensation of prolapse after defaecation. peri anal discomfort mucous discharge (which leads to pruritis caused by exudation of mucous from surface mucosa leaking on to peri-anal skin. this dampness cause itching and maceration)

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Classification 
Basis of the theory
Feat re Bleed but DO NOT prolapse Tx : : high fibre/bulk diet, sitz baths, steroid cream, rubber band ligation,sclerotherapy, photocoagulation Bleed but prolapse with straining, spontaneous reduction Tx : rubber band ligation, photocoagulation Prolapse and need reduction or may not go back at all Tx : same as 2nd degree + may require haemorroidectomy

Degree First degree

Second degree

Third degree

- Based on the proctoscopic appearance
Primary Piles those in commonest sites- 3, 7 and 11 o clock. (with patient in lithotomy position) Secondary Piles - Those seen at other positions in the anal canal - Usually smaller and appear between the primary piles

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Examination
examination -Examine the abdomen ,external inspection of the anus and peri-anal skin, perfom PR - piles not prolapsed nor thrombosed, don t felt on PR. -may see external skin tags -all pt with rectal bleeding must then be sigmoidoscoped. -may see the piles on sigmoidoscopy, but need to carry out proctoscopy -Commonest sites ~ 3, 7, 11 0 clock (lithotomy position) - bluish-purple swellings, feature mucosal covering that is soft,smooth, mucus- exuding surface -usually a/w skin tag. -if piles remain prolapse, they ulcerate and bleed. -if thrombsed, piles becomes tense, hard and oedematous

Degree 1st and 2nd

3rd

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Diagram of the anorectum showing the fissure or ulcer triad. most commonly during defecation. an ulcer is associated with a skin tag (sentinel pile). . Fissures typically occur in the midline just distal to the dentate line.ƒ ƒ ƒ ƒ ƒ Fissures result from forceful dilation of the anal canal. An anal fissure is a longitudinal split in the skin of the anal canal An anal ulcer is a chronic fissure. The classic triad of a proximal hypertrophied anal papilla above a fissure with the sentinel pile at the anal verge may be identified. hen mature.

.Essentials of Diagnosis 1. but it is not mixed in the stool. Blood is noted on the tissue and stool or dripping into the toilet water. 5. worst during defecation. Although less common. Tearing pain upon defecation. Constipation may develop because of fear of recurrent pain. Persistent perianal pain or spasm following defecation. fissures may present as painless nonhealing wounds that bleed intermittently. 3. Sphincter spasm. 4. 2. and subsides over a few hours. Blood on tissue or stool. The pain is often tearing or burning. Disruption of anoderm ƒ ƒ ƒ ƒ Fissures cause pain and bleeding with defecation.

Tx : stool softeners. sitz baths Tx : surgery. botulinum toxin inhibits release of acetylcholine (ACh). stops sphincter spasm . hypertrophied papillae Pruritus . topical nitro increases local blood flow & promoting healing .o Very painful bright red bleeding especially Very painful bright red bleeding especially after defecation after defecation Bleed sufficiently to streak the stool with blood & stain the toilet paper Bleed less & produce a little bloodstaining on the toilet paper Triad: fissure. sentinel skin tags.the fibrosiss around the ulcer prevents a good seal & a small amount of mucus leak on to the peri-anal skin & set up reaction which is itchy.Ac te fiss re Common in children Chronic fiss re Common in pt ages 2 -4 y.

Gentle. limited digital examination will confirm internal sphincter spasm. a sentinel pile may be seen at the inferior margin of the ulcer.Physical examination by simple. ƒ . This may be all there is in an acute fissure. ƒ Chronic (> 1 month history) or chronic-recurrent ulcers should considered for surgery. or alternatively the procedure can be performed under anesthesia. ƒ Anoscopy and proctosigmoidoscopy should be delayed until healing occurs. gentle traction on the buttocks will evert the anus enough to reveal a disruption of the anoderm in the midline at the mucocutaneous junction. ƒ In a chronic fissure.

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driven by the presence of normal intraluminal flora. divided into two: Crohn s disease ulcerative colitis . Chronic inflmmation conditions from inappropriate and persistent activation of the mucosal immune system.ƒ ƒ ƒ a. b.

ƒ ƒ ƒ dx is suspected clinically and confirmed with colonoscpy and biopsy crypt distortion with marked lmphoctes distinguish IBD with other colitis Differentiation between Crohn s and UC is possible in mucosal biopsies. .

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ileum 5 % Transmural.Ulcerative colitis Pathology Inflammation Recurrent acute inflammation Continuous involvement Always Backwash ileitis only Musocal only Crohn s disease Chronic relapsing inflammation Skip lesions in any part of GIT About 25% Involved in 8 %. including serosa General distribution Rectal involvement Ileal involvement Depth of wall involved Mucosal changes Granuloma formation Widespread irregular Fissured ulceration causing superficial ulceration w/wo cobblestone appearance pseudopolyps Absent Characteristic but not always present .

often causing incontinence Very common Mild cramping predefecation pain with diarrheal attacks No Unusual Less prominent Rectal bleeding Abdominal pain Less common Dominant features colicky pain Abdominal mass General debility Relatively common Characteristic . granulomas may be present Marked Fibrosis of wall Main clinical features Diarrhea Minimal Severe during acute attacks.Mesenteric adenopathy Reactive hyperplasia LN often enlarged.

Complications Strictures Fistulae Anal and perianal lesions Massive hemorrhage Rare Rare Uncommon Occurs in sudden and severe disease Rare Common and often multiple Common Common Rare Intestinal obstruction Incomplete obstruction is common Free perforation rare but perforation causing local abscess formation or internal fistula common Rare Perforation Complication of toxic megacolon Toxic megacolon May occur in fulminant attack High risk with severe/longstanding disease Malignant change Low risk .

steroid sparring Uncommon-usually in longstanding disease to prevent malignancy/ in fulminant colitis Less effective Severe exacerbations Less efective Rarely effective Surgery Commonly required .Management Local steroids Systemic steroids Aminosalicylates (5-ASA) Immunosuppressives All active disease Severe exacerbations Long-term maintenance Occasionally in intractable cases.

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> 60 yo.ƒ ƒ Projections arising from colonic mucosal surface that maybe neoplastic or nonneoplastic. have family history of colorectal cancer. Man . have > 3 polyps . .

leiomyomas. lymphamatous .ƒ Non Neoplasm :  Hyperplastic polyps  Inflammatory polyps  Lymphoid polyps / ƒ Morphology :      ƒ Neoplasm : hamartoma  Adenoma (commonest)  Polypoid Tubullar Tubullovillous Villous Microtubular Combined adenocarcinoma  Lipoma.

ƒ ƒ ƒ Adenoma overgrowth of epithelium due to inherited disorder ( hamartomas. Peuts Jeghar syndr. ) Family history of adenoma Previous history of polyps. .

ƒ ƒ Commonly assymptomatic Uncommon :  Rectal bleeding  Mucous discharge  Tenesmus  Change in bowel habit  Sign of malignancy .

ƒ ƒ ƒ ƒ FBC Abdominal x ray with double contrast barium enema Colonoscopy : with biopsy Histology features : Neoplasm / nonneoplasm .

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ƒ ƒ ƒ ƒ ƒ Overeactivity of colonic smooth muscle resulting in herniation of mucosa and submucosa through the muscle layer of the colon forms the diverticulum . Increase with age n commonly in sigmoid. high in US ( meat ) . Lower in vegetarian. Diverticulosis = presence of multiple diverticuli Diverticulitis = is the inflammation of the diverticuli that caused by infection.

ƒ Multi factorial :  Low fiber diet  Increase type III colagen synthesis  Elastin deposition  Disturbance of colonic motility and functions (due to imbalance excitatory and inhibitory neurotransmission)  Diverticuli infections-inflammation-diverticulitis .

peritonitis. affected diverticulum. bloating. and fitula. fever. abscess.ƒ Asymptomatic  Incidental finding by ƒ Complicated diverticulitis  Extend beyond the colonoscopy or barium enema ƒ Uncomplicated diverticulitis  Localised to the affected diverticulum  LLQ pain. perforation. . and result in bleeding. constipation or diarrhea. obstruction.

Fever Leukocytosis ( diverticulitis) Constipation PE : ƒ Pelvic tenderness on PR ƒ Guarding and rebound tebderness on LLQ (acute diverticulitis) ƒ ƒ ƒ ƒ ƒ .Asymptoms LLQ pain.

Barium enema contrast seen diverticuli . Abdominal x-ray : consider when acute diverticulitis pneumoperitoneum. leukocytosis.abscess. Ct-scan thickening of bowel wall.ƒ ƒ ƒ ƒ FBC when suspected diverticulitis.

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ƒ ƒ ƒ Asymptomatic : none Uncomplicated diverticulitis : antibiotics in 72 hours. . surgical intervention : drainage of any pus collections and resection of colon segment containing the diverticuli. Complicated diverticulitis : IV antibiotics . stabilize patients.

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