PROBLEM 5

FORTUNE DE AMOR
405140230
KEL. 14
 Physiology of Defecation
• Peristaltic waves move the feces into the sigmoid
colon and the rectum
• Sensory nerves in rectum are stimulated
• The very first defecation feeling is when the
pressure in rectum reach 18 mmHg and when it
reach 55 mmHg, both sphincter will limp and
cause an expulsion reflex
• Individual becomes aware of need to defecate
• Feces move into the anal canal when the internal
and external sphincter relax
 Physiology of Defecation
• External anal sphincter is relaxed voluntarily if
timing is appropriate
• Expulsion of the feces assisted by contraction
of the abdominal muscles and the diaphragm
• Moves the feces through the anal canal and
expelled through anus
• Facilitated by thigh flexion and a sitting
position
 Diverticulosis
Definition
• fiber deficiency disease

• disorders that cause a herniation of mucosal / submucosal

and only covered by the serous tunica ( pseudodivertikular
/ false diverticular – acquired ) on the location of a weak
colonic wall is a place where the Vasa rekta penetrate the
colon wall

• if all the walls of the colon called a true experience

diverticular herniation - congenital
Diverticulosis
 Diverticulosis
 fibre diet
Etiology

 stool volume

 intraluminal pressure

 colonic wall tension

 tensile strength
 age
 elasticity
muscular hypertrophy,
pulsion diverticula
 Diverticulosis
Epidemiology
• This disease can occur along the digestive tract but mainly
in the colon
• Most : sigmoid colon / colon descenden
• < 50 years : male
• > 50 years : female
 Diverticulosis
Etiology & Pathophysiology
• Lack of fiber and low residue in food consumed that processed such as
wheat, grains, sugar consumption, flour, meat, and canned food a lot 
changes in the colonic milieu interior

• Consumption of foods high fiber, especially cellulose

– forming a more solid stool and large  to shorten colonic transit time
in Stool and reduce intraluminal pressure  preventing the
emergence divertikel
– important in the function of bacterial fermentation in the colon
– The main substrate in the production of short chain fatty acids that
affect the procurement of energy needed in colonic mucosa
 Diverticulosis
Etiology & Pathophysiology
 Less fiber:
 decrease in fecal mass becomes small and hard
 colonic transit time more slowly  more absorption of water 
increased pressure in the colon to push stool out  excessive colonic
segmentation

 Excessive consumption of red meat and high fat foods

 Old age  changes in collagen structure of the intestinal wall  decrease

colonic wall mechanical pressure

 Smoking and use of anti-inflammatory drugs (acetaminophen) to increase

the risk of complications
 Diverticulosis
Signs & Symptoms
 Abdominal pain on left lower quadrant
 Fever
 Leukocytosis
 Palpation in the left abdomen pain
 Rebound pain  an peritoneal irritation-inflammatory

Classification
 stage 1: peridiverticular phlegmon with microabscess
 stage 2: pericolic / pelvic macroabscess
 Stage 3 : generalized purulent peritonitis
 stage 4: generalized peritonitis with fecal feculen
 Diverticulosis
Examinations
 Barium enema
 Endoscopy ( flexible sigmoidoscope )
 Colonoscopy
 distinguishes the source of the bleeding such as colorectal cancer, etc.
 CT Scan
 found colonic wall thickening, streaky mesenteric fat, a sign of an
abscess / plegmon
 X-ray abdomen
 abnormal dilatation of the small intestine / large intestine, which is a
sign ileus, obstruction, fat tissue density (the plegmon / abscess)
 Abdominal ultrasound - found colonic wall thickening and cystic mass
 Diverticulosis
Conservative Treatments
 Fiber
 divertikel prevent
 reduce and improve symptoms
 prevent complications
 Bran cereal
 reducing the transit time along the gastrointestinal tract
 Reduce meat and fat food
 Consume more vegetables and fruit
 An additional 30-40 grams of fiber / day / giving lactulose
 increase fecal weight
 Diverticulosis
Treatments
• reduced oral intake
• fluids / electrolytes intravenous
• spectrum antibiotic ( cover anaerobic bacteria )
• anti-metalloproteinase
• anti- cholinergic ( works on the autonomic nervous intrinsic
/ extrinsic )
• anti-spasmodik ( work directly on smooth muscle of the
gastrointestinal tract )
 Diverticulosis
Surgery
 Classification
 elective surgery
 emergency surgery
 Conditions:
 free perforation with generalized peritonitis
 obstruction
 abscesses that can’t be resolution through percutaneous
devices
 Fistula
 conservative treatment isn’t successful and the patient is getting
worse
 Diverticulosis
Complications
 perforation
 increased intraluminal pressure / divertikel clogged with
feces or foodstuffs  divertikel wall erosion
 abscess
 bleeding
 occurs suddenly  the right colon
 micro / macro perforation
 intestinal obstruction
 fistula
 total obstruction (rare) / partial obstruction (often)
 UC CD
Definition Is a chronic inflammatory Is an idiopathic
disease that causes inflammatory disorder that
ulceration of the colonic affects any part of GIT from
mucosa and extends the mouth to the anus
proximally from the rectum
into the colon
Etiology  dietary  Mutations gene
 infectious genetic CARD15/NOD2
 immunologic factor  smoking / tobacco use
 commensal / pathogenic
enteric microorganisms with
increased mucosal
adherence and invasion and
persistent activation of T
cells
 UC CD
Pathophys  limited to the Inflammatory begins in
iology mucosa the intestinal
 not transmural submucosa  mucosa
 the mucous layer and serosa
thinner than normal
 impairment of the
epithelial barrier
 Features UC CD
Age of Onset Any Age; 10-40 years Any Age; 10-30 years most
most common common
Family History Less Common More Common
Gender Women = Men Women = Men
Cancer Risk Increased Increased
Location Colon and Rectum, no All of GIT; “skip” lesion
“skip” lesions common
Granulomas Rare Common
Friable Mucosa Common Common
Fistula & Abcesses Rare Common
Stricture & Rare Common
Possible
Obstruction
 Features UC CD

Abdominal Pain Occasional Common

Diarrhea Common Common

Bloody Stools Common Les Common

Abdominal Mass Rare Common

Small Intestine Rare Common

Malabsorption

Steatorrhea Rare Common

Potential of Common Common

Malignancy
 Features UC CD
Antineutrophil Common Rare
Cytoplasmic Ab
AntiSaccharomy Rare Common
ces cerevisiae
Ab
Clinical Course Remissions and Remissions and
exacerbations exacerbations
 Hemorrhoids
DEFINITION

• Hemorrhoids, often called piles, are

clusters of veins in the anus, just
under the membrane that lines the
lowest part of the rectum and anus.
They occur when veins in your rectum
enlarge from straining or pressure
• Occur : proximal(internal) or distal
(external) to the anal sphincter
 Epidemiology
• 10 million
• Peak ages: 45-65 years
• ½ of adults experience hemorrhoids by age
50
• Common among pregnant women
– Temporary
 Pathogenesis
Constipation or prolonged straining at stools

Stretching or disruption of Treitz’s muscle and venous engorgement

Lax anal mucosa

Sliding
downward

Distal displacement of the anal cushion

Type of hemorrhoids

• Prolapsed into the anal canal and make the painless

Internal anal bleeding
• Internal hemorrhoids originate above the pectinate or
Hemorrhoids dentate line in the anal canal and are covered by a
mucous membrane

• Lose the connective tissue support  tend to dilate 

blood flow through veins tends to slow  thrombosis
External • External hemorrhoids are swollen areas of skin and
Hemorrhoids blood vessels around the anus (below the dentate line).
They are lined with squamous epithelium that is highly
innervated and sensitive

Internal- • When internal and external hemorrhoids occur

simultaneously, they are referred to as mixed
External hemorrhoids
 Sign & Symptoms
Internal Hemorrhoids
• Bleeding during a bowel movement. As the hard stool passes through the rectum, the
swollen veins will begin to bleed. In most cases, there is no pain experienced because
nerve endings are lacking in this area. The amount of blood loss is usually small and
bright red in color
• Mucus can be on the toilet tissue or on the bowel movement. Mucus can drain steadily
from the anus.
• Rectal itching and burning symptoms come from the drainage caused by the
hemorrhoids. The skin around the anus can not handle the irritating fluids as the
internal tissue can.
• Leakage of stool from the anus. Stool can escape with the drainage from this swollen
area.
• An internal hemorrhoid can fall down (prolapse) and protrude outside the anus.
Usually, there are two stages associated with prolapsed hemorrhoids. The first one is
when the hemorrhoid will fall out of the anus during a bowel movement, but then it
retracts back inside after defecation. The second stage is when the prolapsed
hemorrhoid no longer retracts, and it remains outside the anus.
• A feeling of rectal fullness as if you need to have a bowel movement.
 Sign & Symptoms
External Hemorrhoids
• A painful swelling or hard lump around the anus which
results from a blood clot forming in the veins. These
hemorrhoids are said to be thrombosed because the
blood in them cannot return to circulation in the body
and is strangulated. This can be a serious condition that
leads to gangrene (tissue death).
• Pain can be severe because of the nerve endings
around the outside of the anus.
• Skin irritation can cause itching, burning and bleeding.
• Drainage of mucus and stool.
•Bright red
bleeding
•Prolapse

Interna
associated with
defecation

Externa
•Anoderm
l
•Swell,
discomfort,
difficult hygiene
 Classification of hemorrhoids
First-degree
• do not bulge from the anus
• internal viewed through anoscope

Second-degree
• bulge from the anus during bowel movements but
spontaneously reduce

Third-degree
• bulge from the anus during bowel movements, but they
can be manually reduced

Fourth-degree
• strangulated internal and thrombosed external
• bulge outside the anus all the time (cannot be reduced)

Reference : Sabiston Textbook of Surgery, 18th Edition

 GRADE SYMPTOMS AND SIGNS MANAGEMENT
First degree Bleeding; no prolapse Dietary modifications

Second •Prolapse with spontaneous •Rubber band ligation

degree reduction •Coagulation
•Bleeding •Dietary modifications

Third degree •Prolapse requiring digital •Surgical

reduction hemorrhoidectomy
•Bleeding •Rubber band ligation
•Dietary modifications

Fourth •Prolapsed, cannot be reduced •Surgical

degree •Strangulated hemorrhoidectomy
•Urgent
hemorrhoidectomy
•Dietary modifications
Reference : Sabiston Textbook of Surgery, 18th Edition
 Work Up
Laboratory •Hematocrit testing is suggested if excessive bleeding
Studies with concomitant anemia is suspected.
•Coagulation studies are indicated if the history and
physical examination suggest coagulopathy
Imaging Studies Barium enema is carried out in any case where symptoms
such as alteration in bowel habit point to some more
sinister condition than internal hemorrhoids
Diagnostic •Inspection
Procedures •Ask patient to strain as on defecation (valsalva
maneuvers)
•Detect: Skin tags, a thrombosed external plexus or
permanent prolapse
•Palpation
•Detect: areas of thrombosis, hypertrophied anal
papilla, fibrous anal polyp
•Uncomplicated hemorrhoids are impalpable
Diagnostic •Sigmoidoscopy
Procedures •Excluding other disease (inflammatory bowel disease,
hemangioma of the rectum). Is performed routinely, again
to eliminate a lesion higer in the rectum-procititis, polyp or
carcinoma
•Proctoscopy
•Examine anal cushion for enlargement and prolapse and
squamous ephitelial change, will visualize the internal
haemorrhoids
•Colonoscopy
•May be indicated to visualize and biopsy any lesion thus
revealed
Histologic Findings •Routine histologic examination of hemorrhoidal tissue is usually
unrewarding, especially if it is grossly examined by an
experienced anorectal surgeon.
•Any suspicious tissue must be sent for microscopic evaluation.
•External hemorrhoids are classified by underlying pathology
and symptoms, which include thrombosed veins, bleeding from
eroded blood clots, and skin tags causing hygiene problems.
 SIGMOIDOSCOPY

FIGURE 1.Hooking and straightening technique used to pass through a

tortuous sigmoid colon. (A) The scope is inserted to the angled sigmoid. (B)
The scope tip is turned to a sharp angle, and the sigmoid is hooked as the
scope is withdrawn. (C) The sigmoid is straightened as the scope is
withdrawn. The scope can then be inserted through to the descending
colon.
 Other Techniques
FIGURE 2.Paradoxic
insertion. (A) The
scope is bowing out
the sigmoid colon,
which has a mobile
mesenteric
attachment. (B)
Paradoxic insertion
describes the
insertion of the tube
without
advancement of the
scope tip. Paradoxic
insertion can be very
uncomfortable for
the patient.
Anaoscopy

• An anoscopy is an
examination using a
small, rigid speculum
anoscope inserted a few
inches into to the anus
in order to evaluate
problems of the anal
canal.
Proctoscopy

• Proctoscopy is a
common medical
procedure in
which an
instrument called
a proctoscope
(also known as a
rectoscope,
although the
latter may be a bit
longer) is used to
examine the anal
cavity, rectum or
sigmoid colon
 Treatment
Pharmacologic Non pharmacologic
•Improve defecation •Bowel managment program
•Fiber supplement  (BMP) improve diet, fluid, fiber,
psyllium, isphagula husk stools softener, the way of
•Stools softener  natrium defecation
•The way of defecation 
dioctyl sulfosuccinat squatting
•Symptomatic •Soak anus in the water for
•Local anesthesia  reduce 10-15 minutes (2-4
pain times/day)
•Corticosteroid  reduce •More exercise
inflammation •Drink water (30-
•Stop bleeding 40ml/kgBB/day)
•Psyllium, daflon •High fiber (vegetables,
•Healing and preventing fruits, cereal, fiber
supplement)
hemorrhoid
•Diosminthespridin 
improve symptom of
inflammation, congestion,
edema, and prolapse
• Minimally invasive procedures

– Rubber band ligation

Places one or two tiny rubber bands around the base of
an internal hemorrhoid to cut off its circulation. The
hemorrhoid withers and falls off within a few days. This
procedure is effective for many people
– Injection (sclerotherapy)
Injects a chemical solution into the hemorrhoid tissue to
shrink it. While the injection causes little or no pain, it
may be less effective than rubber band ligation.
– Coagulation (infrared, laser or bipolar)
These techniques use laser or infrared light or heat.
While coagulation has few side effects, it's associated
with a higher rate of hemorrhoids coming back
(recurrence) than is the rubber band treatment.
• Surgical procedures
If other procedures haven't been successful or
you have large hemorrhoids
– Hemorrhoidectomy
• Removes excessive tissue that causes bleeding
• The surgery may be done with a local anesthetic
combined with sedation, a spinal anesthetic or a
general anesthetic
• Hemorrhoidectomy is the most effective and complete
way to remove hemorrhoids, but it also has the highest
rate of complications
• Most people experience some pain after the procedure
• Medications can be used to relieve your pain. Soaking
in a warm bath also helps
– Stapled hemorrhoidectomy or stapled
hemorrhoidopexy
• Blocks blood flow to hemorrhoidal tissue
• Stapling generally involves less pain than
hemorrhoidectomy
• Stapling has been associated with a greater risk of
recurrence and rectal prolapse, in which part of the
rectum protrudes from the anus
NORMAL ANATOMY HEMORRHOID

HEMMORHOID SURGERY AFTERCARE

 Prevention
• Give the patient and the caregiver verbal and written instruction. Provide
them with the name and telephone number of a physician or nurse to call
if question arise
• Review any explanation about treatment and specific follow-up care
• Explain and discuss the development of hemorrhoids, causes or
contributing factors, care, treatment, and potential for recurrence
• Diets : high fiber  promote regular bowel movements and soft stools
• Drink plenty of fluids (2-3L/day), unless contraindicated
• Use stool softeners and laxatives prevent constipation
• Defecate promptly after the urge  pressure in the rectum prevented
• Avoid prolonged sitting , squatting, or standing
• Avoid straining during defecation
• Advise the patient to abstain from anal intercourse until healing is
complete
• Advise the patient to use topical anesthetics, astringents, and prescribed
antiinflammatory preparations
 Prognosis
• The outcome is usually very good for most
people
• Eating a high-fiber diet, and avoiding
constipation may help to prevent hemorrhoids
from coming back
• However, you may still develop new
hemorrhoids.
 Complication
• 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.

• Thrombosis
 DD
• Anal fissure • Infections (sexually
• Anogenital warts transmitted
(condyloma diseases - STDs)
acuminata) • Levator syndrome
• Anorectal abscess • Neoplasm
• Anorectal fistula • Pruritus
• Diverticulosis • Rectal polyps
• Eczema • Rectal prolapse
• Fistula • Rectal trauma
• Fungal infection • Viral infection
• Impaction
Entamoeba histolytica
 Amoebiasis
• Amoebiasis ←protozoan Entamoeba histolytica.
E. histolytica must be differentiated from Entamoeba
dispar, which is a flora normal of the gastrointestinal tract.

Humans are the only reservoir, and infection occurs by ingestion

of mature cysts in food or water, or on hands contaminated by
faeces

• Incubation period: 7 days and tissue invasion mostly occurs

during first 4 months of infection.
• Patofisiologi:
The cysts of E. histolytica enter the small intestine →release
trophozoites, which invade the epithelial cells of the
large intestines →flask-shaped ulcers.
Infection can then spread from the intestines to other
organs, e.g. liver, lungs and brain, via the venous system.

• Invasive amoebiasis most often causes an amoebic liver

abscess but may affect the lung, heart, brain, urinary
tract and skin.
• Symptoms: • DD:
– lower abdominal pain
– diarrhoea and later
develop dysentery (with
blood and mucus in
stool).
– Abdominal tenderness
– Abdominal distension
– Fever
– infective colitis,
– ulcerative colitis,
– colorectal carcinoma
– Crohn's disease,
– ileocaecal tuberculosis,
– diverticulitis,
– anorectal
lymphogranuloma
venereum
• Investigations:
– Full blood count (leucocytosis), increase ESR, abnormal liver function
tests (increase alkaline phosphatase and transaminases)
– Stool examination
– Serology: antibody testing is nearly positive 100% of patients with
amoeboma.
– PCR tests (faeces, abscess aspirate or other tissues).
– Barium studies are contraindicated in acute amoebic colitis because of
the risk of perforation.
– Proctoscopy, sigmoidoscopy or colonoscopy: mucosal scrapings for
biopsy and E. histolytica testing.

• Management :
– blood transfusion
– Diloxanide furoate : std.kista
– Metronidazole and tinidazole : tropozoit
• Complications:
– Amoebic colitis may lead tonecrotising colitis, toxic
megacolon, amoeboma or a rectovaginal fistula.
• Prognosis
– In uncomplicated disease, mortality rate is less than 1%.
But is much higher in complicated severe disease, e.g.
fulminant amoebic colitis, chest involvement or cerebral
amoebiasis.
– More severe illness occurs in children (especially
neonates), the immunosuppressed, malnourished,
pregnancy and post-partum.
• Prevention
– adequate sanitation, safe food and water, and good
personal hygiene of the population.
IBS
 Definition
• A functional bowel disorder characterized by
abdominal pain or discomfort and altered
bowel habits in the absence of detectable
structural abnormalities
• IBS symptoms tend to come and go over time
and often overlap with other functional
disorders such as fibromyalgia, headache,
backache, and genitourinary symptoms
 CLINICAL MANIFESTATIONS
• Abdominal pain
• Altered bowel habits
• Gas and flatulence
• Upper GI symptomps
DIAGNOSIS
TREATMENT
• Non – pharmacologic
 Patient counseling
Reassurance and careful explanation of the functional nature
of the disorder and of how to avoid obvious food
precipitants are important first steps in patient counseling
and dietary change
 Dietary alterations
- A meticulous dietary history may reveal substances (such
as coffee, disaccharides, legumes, and cabbage) that
aggravate symptoms
- Excessive fructose and artificial sweeteners, such as
sorbitol or mannitol, may cause diarrhea, bloating, cramping
or flatulence
Ca colon
 Risk Factors
1. Genetic risk factors
• Family history of colon cancer
• Family history of Intestinal polyps
• Intestinal polyps
• Previous colon cancer
• Ulcerative colitis
• Crohn’s disease
2. Lifestyle related risk factors
• Chronic constipation
• Diet:
–High-fat diet
–low fiber diet
• Obesity
• Smoking
 Symptoms
Initial symptoms of colorectal cancer include:
1. Blood in the stool
2. Red stools
3. Black stools
4. Changes in frequency of bowel movements:
– Frequent loose stools
– Constipation
5. Abnormal appearing stools :
– Changes in the size of the stools
– Changes in the shape of the stools
Additional symptoms of colorectal cancer include:
1. Anoreksia
2. Abdominal pain
3. Abdominal swelling
4. Excessive fatigue
5. Unintentional weight lost
6. Vomiting
 Stages
Staging colon cancer usually includes some combination of the
following tests:

1. CT scan of the abdomen

2. MRI scan of the abdomen
3. Bone scan
4. Carcinoembryonic antigen blood level
5. Chest x-ray
6. Complete blood count
7. Lymph node biopsy
8. Surgery with tissue biopsy
Colon Cancer Stage 0
Stage 0 cancer is also called carsinoma in situ. In stage 0,
the cancer is found only in the innermost lining of the
colon.

Colon Cancer Stage 1

Stage 1 colon cancer is sometimes called Dukes' A colon
cancer. In stage 1, the cancer has spread beyond the
innermost tissue layer of the colon wall to the middle
layers.
Colon Cancer Stage 2
Stage 2 colon cancer is also called Dukes' B colon cancer.

Stage 2 colon cancer is divided into stages:

1.Stage 2A: cancer has spread beyond the middle tissue
layers of the colon wall or has spread to nearby tissues
around the colon or rectum.
2.Stage 2B: cancer has spread beyond the colon wall into
nearby organs and/or through the peritoneum.
Colon Cancer Stage 3
Stage 3 colon cancer is also called Dukes' C colon cancer.

Stage 3 colon cancer is divided into:

1. Stage 3A: cancer has spread from the innermost tissue layer of the
colon wall to the middle layers and has spread to as many as 3
lymph nodes.

2. Stage 3B: cancer has spread to as many as 3 nearby lymph nodes

and has spread:
– beyond the middle tissue layers of the colon wall; or
– to nearby tissues around the colon or rectum; or
– beyond the colon wall into nearby organs and/or through the
peritoneum.

3. Stage 3C: cancer has spread to 4 or more nearby lymph nodes and
has spread:
– to or beyond the middle tissue layers of the colon wall; or
– to nearby tissues around the colon or rectum; or
– to nearby organs and/or through the peritoneum.
Colon Cancer Stage 4
Stage 4 colon cancer is also called Dukes' D
colon cancer. In stage 4,cancer may have
spread to nearby lymph nodes and has spread
to other parts of the body, such as the liver or
lungs.
 Imaging studies
• Barium enema
• CT scanning of the abdomen: an excellent test for excluding
internal injury
• MRI scan of the abdomen
• Virtual colonoscopy:
– Uses a special type of CT scanner that takes many pictures
of the colon in super thin slices. A computer reassembles
the images into a 3-D model of the colon. The more slices
the CT scanner is capable of taking in rapid succession, the
better the image quality.
• Bone scanning
 Laboratory
• Stool guaiac:
– Testing stools for the presence of blood not visible to the
naked eye
• DNA stool testing:
– A test that looks for abnormal DNA in a stool sample.
• Complete blood count
• Liver profile
• Kidney profile
• Urinalysis
• Anoscopy
• Colonoscopy
• Sigmoidoscopy
 Treatment
• Surgery
• Polypectomy
– For small tumors that have not spread
• Chemotherapy
• Radiation therapy
• Colorectal cancer clinical trials
 Prevention
• Stop smoking
• Avoid exposure to secondary smoke.
• Eat a healthy heart diet
– High fiber diet
– Low fat diet
• Calcium supplements
• Vitamin D may help cut the risk for colon cancer
– The Institute of Medicine recommends 200 IU daily for children and
adults up to age 50, and 400 IU for adults aged 51-70; people over age
70 should get 600 IU daily.
• Weight loss if overweight
• aspirin therapy:
– Some studies have shown that it can reduce the risk of colon polyps in
those who have previously had colon cancer.
FISSURA
 Definition
• An anal fissure is a small split or tear in the
thin moist tissue (mucosa) lining the lower
rectum (anus).

http://www.nlm.nih.gov/
 Causes
• In adults, fissures may be caused by
constipation, the passing of large, hard stools,
or by prolonged diarrhea. In older adults, anal
fissures may be caused by decreased blood
flow to the area.
• Anal fissures are also common in women after
childbirth and persons with Crohn's disease.

http://www.nlm.nih.gov/
 Pathophysiology
• The muscles surrounding the anal canal are contracting
too strongly (spasm).
• Generating a pressure in the canal that is abnormally
high.
• After the internal sphincter finally does relax to allow a
bowel movement to pass, instead of going back to its
resting level of contraction and pressure, the internal
anal sphincter contracts even more vigorously.
• The high pressure and contraction of the sphincter may
lead to a tear of the skin in the analis canalis resulting
in fissures.
 Symptoms
• Painful bowel movements and bleeding.
• There may be blood on the outside of the
stool or on the toilet tissue following a bowel
movement.
• A crack in the skin that can be seen when the
area is stretched slightly.
• Constipation.

http://www.nlm.nih.gov/
 Tests
• The health care provider will perform a rectal
exam and look at a sample of the rectal (anal)
tissue.

http://www.nlm.ni
h.gov/
 Treatment
• Most fissures heal on their own and do not require treatment.
• However, some fissures may require treatment. The following
home care methods usually heal most anal fissures.
– Cleansing more gently
– Diet changes -- eating more bulk, substances that absorb water while
in the intestinal tract
– Muscle relaxants applied to the skin
– Numbing cream, if pain interferes with normal bowel movement
– Petroleum jelly applied to the area
– Sitz bath
– Stool softeners

http://www.nlm.ni
h.gov/
 Treatment
• If the anal fissues do not go away with home
care methods, treatment may involve:
– Botox injections into muscle in the anus (anal
sphincter)
– Minor surgery to relax the anal muscle

http://www.nlm.ni
h.gov/
 Prognosis
• Anal fissures generally heal quickly without
further problems. However, people who
develop fissures are more likely to have them
in the future.

http://www.nlm.ni
h.gov/
 Possible complication
• Occasionally, a fissure becomes chronic and
will not heal. Chronic fissures may require
minor surgery to relax the sphincter.

http://www.nlm.ni
h.gov/
 Prevention
• Keep the anal area dry.
• Wipe with soft materials or a moistened cloth
or cotton pad.
• Promptly treat any constipation or diarrhea.
• Avoid irritating the rectum.

http://www.nlm.ni
h.gov/
HIRSCHSPRUNG'S DISEASE
 Hirschsprung's Disease
• Hirschsprung's disease is a blockage of the large intestine. It occurs
due to poor muscle movement in the bowel. It is a congenital
condition, which means it is present from birth.
• In Hirschsprung's disease, the nerves to trigger contraction in
intestine are missing from a part of the bowel.
• Areas without these nerves cannot push material through 
blockage  intestinal contents build up behind the blockage 
bowel and abdomen swelling.
• Hirschsprung's disease causes about 25% of all newborn intestinal
blockages.
• It occurs five times more often in males than in females.
Hirschsprung's disease is sometimes linked to other inherited or
congenital conditions, such as Down syndrome.
 Hirschsprung's Disease Symptoms
Newborns and infants Older children
• Difficulty with bowel • Constipation that gradually
movements
• Failure to pass gets worse
meconium shortly after • Fecal impaction
birth
• Failure to pass a first • Malnutrition
stool within 24 - 48
hours after birth • Slow growth
• Infrequent but • Swollen belly
explosive stools
• Jaundice
• Poor feeding
• Poor weight gain
• Vomiting
• Watery diarrhea (in the
newborn)
Hirschsprung's Disease Diagnosis
• Milder cases may not be diagnosed until
the baby is older.
• Physical exam (loops of bowel in the
swollen belly).
– A rectal exam may reveal tight muscle tone in
the rectal muscles.
• Tests used to help diagnose Hirschsprung's
disease may include:
– Abdominal x-ray
– Anal manometry (a balloon is inflated in the
rectum to measure pressure in the area)
– Barium enema
– Rectal biopsy
 Hirschsprung's Disease
Treatment
• A procedure called serial rectal
irrigation helps relieve
pressure in (decompress) the
bowel.
• The abnormal section of colon
must be taken out with
surgery. Most commonly, the
rectum and abnormal part of
the colon are removed. The
healthy part of the colon is
then pulled down and
attached to the anus.
Prognosis
• Symptoms improve or go
away in most children after
surgery.
• A small number of children
may have constipation or
problems controlling stools
(fecal incontinence).
• Children who get treated
early or who have a shorter
segment of bowel involved
have a better outcome.
 Hirschsprung's Disease Complication
• Inflammation and infection of the intestines
(enterocolitis) may occur before surgery, and
sometimes during the first 1 - 2 years
afterwards.
• Perforation or rupture of the intestine.
• Short bowel syndrome, a condition that can
lead to malnourishment and dehydration.