This document provides information about a case presentation of a 19-year-old male student named Ahmad who presented with rectal bleeding and anal pain and swelling. On examination, he was found to have hemorrhoids and signs of anemia. Sigmoidoscopy revealed hemorrhoids that were banded. He received a blood transfusion and IV fluids and was diagnosed with anemia secondary to bleeding hemorrhoids. The document also provides background information on hemorrhoids, appendicitis, colorectal polyps, and familial adenomatous polyposis.
Whipple's procedure - Indications, Steps, ComplicationsVikas V
Whipple's Procedure - Explaining the History of Whipple's Procedure, Indications, Contraindications, Step wise detailed procedure, Complications, Perioperative Management.
The Presentation Includes Detailed Step wise approach to the procedure assisted with Pictorial Representation of The steps
This presentation gives a fine description about stoma and ostomy. This contains the details regarding types, complications and the advices that you should give to a patient with a stoma.
OPEN INGUINAL HERNIA REPAIR- OPERATIVE SURGERY
#surgicaleducator #operativesurgery #openinguinalherniarepair #usmle #babysurgeon #surgicaltutor
Dear viewers,
• Greetings from “Surgical Educator”
• Because of the popular demand by viewers of the YouTube channel “Surgical Educator”, I have decided to create and upload videos on common surgeries.
• I have already uploaded videos on open and Laparoscopic Appendicectomy, Thyroidectomy, Modified Radical Mastectomy and open and
Laparoscopic Cholecystectomy
• In this video today, I have discussed Open Inguinal Hernia Repair.
• However, these videos are not real surgeries but the theoretical aspect of operative surgery like going through an atlas of operative surgery.
• Along with these videos, I recommend you to watch real operative surgery videos as well and I will give a link for each surgery in the end of the video as end-cards, which I think will be very useful.
• This will give a very good opportunity for the surgical trainees to mentally rehearse various surgical steps in a sequential manner prior to actual surgery. You can watch the video in the following links:
• surgicaleducator.blogspot.com
• youtube.com/c/surgicaleducator
• Thank you for watching the videos.
Disclaimer: A lot from this slides were taken also from https://www.slideshare.net/babysurgeon/scrotal-swellings-1 (Dr Selvaraj Balasubramani)
This covers only :
ANATOMY
CAUSES
TORSION OF TESTIS
EPIDIDYMO-ORCHITIS
HYDROCELE
EPIDIDYMAL CYST
VARICOCELE
Whipple's procedure - Indications, Steps, ComplicationsVikas V
Whipple's Procedure - Explaining the History of Whipple's Procedure, Indications, Contraindications, Step wise detailed procedure, Complications, Perioperative Management.
The Presentation Includes Detailed Step wise approach to the procedure assisted with Pictorial Representation of The steps
This presentation gives a fine description about stoma and ostomy. This contains the details regarding types, complications and the advices that you should give to a patient with a stoma.
OPEN INGUINAL HERNIA REPAIR- OPERATIVE SURGERY
#surgicaleducator #operativesurgery #openinguinalherniarepair #usmle #babysurgeon #surgicaltutor
Dear viewers,
• Greetings from “Surgical Educator”
• Because of the popular demand by viewers of the YouTube channel “Surgical Educator”, I have decided to create and upload videos on common surgeries.
• I have already uploaded videos on open and Laparoscopic Appendicectomy, Thyroidectomy, Modified Radical Mastectomy and open and
Laparoscopic Cholecystectomy
• In this video today, I have discussed Open Inguinal Hernia Repair.
• However, these videos are not real surgeries but the theoretical aspect of operative surgery like going through an atlas of operative surgery.
• Along with these videos, I recommend you to watch real operative surgery videos as well and I will give a link for each surgery in the end of the video as end-cards, which I think will be very useful.
• This will give a very good opportunity for the surgical trainees to mentally rehearse various surgical steps in a sequential manner prior to actual surgery. You can watch the video in the following links:
• surgicaleducator.blogspot.com
• youtube.com/c/surgicaleducator
• Thank you for watching the videos.
Disclaimer: A lot from this slides were taken also from https://www.slideshare.net/babysurgeon/scrotal-swellings-1 (Dr Selvaraj Balasubramani)
This covers only :
ANATOMY
CAUSES
TORSION OF TESTIS
EPIDIDYMO-ORCHITIS
HYDROCELE
EPIDIDYMAL CYST
VARICOCELE
Information about Diverticular disease by Dr Dhaval Mangukiya.
Details of Diverticular disease, Differential Diagnosis, CT Scan Protocol, Point to look in CT, Options, Indications for Elective Surgery, Exploraion, Primary Resection, Opinion, Management etc.
http://www.youtube.com/c/DrDhavalMangukiyaGastrosurgeonSurat
https://gastrosurgerysurat.blogspot.com/
https://drdhavalmangukiya.com/
Surgery Resident clinical seminar on the management of a 60yr old male with upper gastrointestinal bleeding presented to the department of surgery, Niger Delta University Teaching Hospital, Okolobiri, Bayelsa State
Peritoneal dialysis is the most common form of renal replacement therapy performed in the home. Peritoneal dialysis is the process of removing excess fluid and metabolic by-products from the body by circulating dialysis solution through the peritoneal cavity using a peritoneal catheter.
ARTIFICIAL INTELLIGENCE IN HEALTHCARE.pdfAnujkumaranit
Artificial intelligence (AI) refers to the simulation of human intelligence processes by machines, especially computer systems. It encompasses tasks such as learning, reasoning, problem-solving, perception, and language understanding. AI technologies are revolutionizing various fields, from healthcare to finance, by enabling machines to perform tasks that typically require human intelligence.
Tom Selleck Health: A Comprehensive Look at the Iconic Actor’s Wellness Journeygreendigital
Tom Selleck, an enduring figure in Hollywood. has captivated audiences for decades with his rugged charm, iconic moustache. and memorable roles in television and film. From his breakout role as Thomas Magnum in Magnum P.I. to his current portrayal of Frank Reagan in Blue Bloods. Selleck's career has spanned over 50 years. But beyond his professional achievements. fans have often been curious about Tom Selleck Health. especially as he has aged in the public eye.
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Introduction
Many have been interested in Tom Selleck health. not only because of his enduring presence on screen but also because of the challenges. and lifestyle choices he has faced and made over the years. This article delves into the various aspects of Tom Selleck health. exploring his fitness regimen, diet, mental health. and the challenges he has encountered as he ages. We'll look at how he maintains his well-being. the health issues he has faced, and his approach to ageing .
Early Life and Career
Childhood and Athletic Beginnings
Tom Selleck was born on January 29, 1945, in Detroit, Michigan, and grew up in Sherman Oaks, California. From an early age, he was involved in sports, particularly basketball. which played a significant role in his physical development. His athletic pursuits continued into college. where he attended the University of Southern California (USC) on a basketball scholarship. This early involvement in sports laid a strong foundation for his physical health and disciplined lifestyle.
Transition to Acting
Selleck's transition from an athlete to an actor came with its physical demands. His first significant role in "Magnum P.I." required him to perform various stunts and maintain a fit appearance. This role, which he played from 1980 to 1988. necessitated a rigorous fitness routine to meet the show's demands. setting the stage for his long-term commitment to health and wellness.
Fitness Regimen
Workout Routine
Tom Selleck health and fitness regimen has evolved. adapting to his changing roles and age. During his "Magnum, P.I." days. Selleck's workouts were intense and focused on building and maintaining muscle mass. His routine included weightlifting, cardiovascular exercises. and specific training for the stunts he performed on the show.
Selleck adjusted his fitness routine as he aged to suit his body's needs. Today, his workouts focus on maintaining flexibility, strength, and cardiovascular health. He incorporates low-impact exercises such as swimming, walking, and light weightlifting. This balanced approach helps him stay fit without putting undue strain on his joints and muscles.
Importance of Flexibility and Mobility
In recent years, Selleck has emphasized the importance of flexibility and mobility in his fitness regimen. Understanding the natural decline in muscle mass and joint flexibility with age. he includes stretching and yoga in his routine. These practices help prevent injuries, improve posture, and maintain mobilit
Prix Galien International 2024 Forum ProgramLevi Shapiro
June 20, 2024, Prix Galien International and Jerusalem Ethics Forum in ROME. Detailed agenda including panels:
- ADVANCES IN CARDIOLOGY: A NEW PARADIGM IS COMING
- WOMEN’S HEALTH: FERTILITY PRESERVATION
- WHAT’S NEW IN THE TREATMENT OF INFECTIOUS,
ONCOLOGICAL AND INFLAMMATORY SKIN DISEASES?
- ARTIFICIAL INTELLIGENCE AND ETHICS
- GENE THERAPY
- BEYOND BORDERS: GLOBAL INITIATIVES FOR DEMOCRATIZING LIFE SCIENCE TECHNOLOGIES AND PROMOTING ACCESS TO HEALTHCARE
- ETHICAL CHALLENGES IN LIFE SCIENCES
- Prix Galien International Awards Ceremony
MANAGEMENT OF ATRIOVENTRICULAR CONDUCTION BLOCK.pdfJim Jacob Roy
Cardiac conduction defects can occur due to various causes.
Atrioventricular conduction blocks ( AV blocks ) are classified into 3 types.
This document describes the acute management of AV block.
Ozempic: Preoperative Management of Patients on GLP-1 Receptor Agonists Saeid Safari
Preoperative Management of Patients on GLP-1 Receptor Agonists like Ozempic and Semiglutide
ASA GUIDELINE
NYSORA Guideline
2 Case Reports of Gastric Ultrasound
Ethanol (CH3CH2OH), or beverage alcohol, is a two-carbon alcohol
that is rapidly distributed in the body and brain. Ethanol alters many
neurochemical systems and has rewarding and addictive properties. It
is the oldest recreational drug and likely contributes to more morbidity,
mortality, and public health costs than all illicit drugs combined. The
5th edition of the Diagnostic and Statistical Manual of Mental Disorders
(DSM-5) integrates alcohol abuse and alcohol dependence into a single
disorder called alcohol use disorder (AUD), with mild, moderate,
and severe subclassifications (American Psychiatric Association, 2013).
In the DSM-5, all types of substance abuse and dependence have been
combined into a single substance use disorder (SUD) on a continuum
from mild to severe. A diagnosis of AUD requires that at least two of
the 11 DSM-5 behaviors be present within a 12-month period (mild
AUD: 2–3 criteria; moderate AUD: 4–5 criteria; severe AUD: 6–11 criteria).
The four main behavioral effects of AUD are impaired control over
drinking, negative social consequences, risky use, and altered physiological
effects (tolerance, withdrawal). This chapter presents an overview
of the prevalence and harmful consequences of AUD in the U.S.,
the systemic nature of the disease, neurocircuitry and stages of AUD,
comorbidities, fetal alcohol spectrum disorders, genetic risk factors, and
pharmacotherapies for AUD.
Title: Sense of Taste
Presenter: Dr. Faiza, Assistant Professor of Physiology
Qualifications:
MBBS (Best Graduate, AIMC Lahore)
FCPS Physiology
ICMT, CHPE, DHPE (STMU)
MPH (GC University, Faisalabad)
MBA (Virtual University of Pakistan)
Learning Objectives:
Describe the structure and function of taste buds.
Describe the relationship between the taste threshold and taste index of common substances.
Explain the chemical basis and signal transduction of taste perception for each type of primary taste sensation.
Recognize different abnormalities of taste perception and their causes.
Key Topics:
Significance of Taste Sensation:
Differentiation between pleasant and harmful food
Influence on behavior
Selection of food based on metabolic needs
Receptors of Taste:
Taste buds on the tongue
Influence of sense of smell, texture of food, and pain stimulation (e.g., by pepper)
Primary and Secondary Taste Sensations:
Primary taste sensations: Sweet, Sour, Salty, Bitter, Umami
Chemical basis and signal transduction mechanisms for each taste
Taste Threshold and Index:
Taste threshold values for Sweet (sucrose), Salty (NaCl), Sour (HCl), and Bitter (Quinine)
Taste index relationship: Inversely proportional to taste threshold
Taste Blindness:
Inability to taste certain substances, particularly thiourea compounds
Example: Phenylthiocarbamide
Structure and Function of Taste Buds:
Composition: Epithelial cells, Sustentacular/Supporting cells, Taste cells, Basal cells
Features: Taste pores, Taste hairs/microvilli, and Taste nerve fibers
Location of Taste Buds:
Found in papillae of the tongue (Fungiform, Circumvallate, Foliate)
Also present on the palate, tonsillar pillars, epiglottis, and proximal esophagus
Mechanism of Taste Stimulation:
Interaction of taste substances with receptors on microvilli
Signal transduction pathways for Umami, Sweet, Bitter, Sour, and Salty tastes
Taste Sensitivity and Adaptation:
Decrease in sensitivity with age
Rapid adaptation of taste sensation
Role of Saliva in Taste:
Dissolution of tastants to reach receptors
Washing away the stimulus
Taste Preferences and Aversions:
Mechanisms behind taste preference and aversion
Influence of receptors and neural pathways
Impact of Sensory Nerve Damage:
Degeneration of taste buds if the sensory nerve fiber is cut
Abnormalities of Taste Detection:
Conditions: Ageusia, Hypogeusia, Dysgeusia (parageusia)
Causes: Nerve damage, neurological disorders, infections, poor oral hygiene, adverse drug effects, deficiencies, aging, tobacco use, altered neurotransmitter levels
Neurotransmitters and Taste Threshold:
Effects of serotonin (5-HT) and norepinephrine (NE) on taste sensitivity
Supertasters:
25% of the population with heightened sensitivity to taste, especially bitterness
Increased number of fungiform papillae
These simplified slides by Dr. Sidra Arshad present an overview of the non-respiratory functions of the respiratory tract.
Learning objectives:
1. Enlist the non-respiratory functions of the respiratory tract
2. Briefly explain how these functions are carried out
3. Discuss the significance of dead space
4. Differentiate between minute ventilation and alveolar ventilation
5. Describe the cough and sneeze reflexes
Study Resources:
1. Chapter 39, Guyton and Hall Textbook of Medical Physiology, 14th edition
2. Chapter 34, Ganong’s Review of Medical Physiology, 26th edition
3. Chapter 17, Human Physiology by Lauralee Sherwood, 9th edition
4. Non-respiratory functions of the lungs https://academic.oup.com/bjaed/article/13/3/98/278874
Explore natural remedies for syphilis treatment in Singapore. Discover alternative therapies, herbal remedies, and lifestyle changes that may complement conventional treatments. Learn about holistic approaches to managing syphilis symptoms and supporting overall health.
These lecture slides, by Dr Sidra Arshad, offer a quick overview of physiological basis of a normal electrocardiogram.
Learning objectives:
1. Define an electrocardiogram (ECG) and electrocardiography
2. Describe how dipoles generated by the heart produce the waveforms of the ECG
3. Describe the components of a normal electrocardiogram of a typical bipolar leads (limb II)
4. Differentiate between intervals and segments
5. Enlist some common indications for obtaining an ECG
Study Resources:
1. Chapter 11, Guyton and Hall Textbook of Medical Physiology, 14th edition
2. Chapter 9, Human Physiology - From Cells to Systems, Lauralee Sherwood, 9th edition
3. Chapter 29, Ganong’s Review of Medical Physiology, 26th edition
4. Electrocardiogram, StatPearls - https://www.ncbi.nlm.nih.gov/books/NBK549803/
5. ECG in Medical Practice by ABM Abdullah, 4th edition
6. ECG Basics, http://www.nataliescasebook.com/tag/e-c-g-basics
4. • 19 year-old Malay gentleman, was admitted yesterday
with a chief complaint of bleeding per rectal for the past 1
week.
• It was sudden in onset, fresh blood and presented after
passing stool. The amount was about 1 cup.
• He also complained of a painful protruding swelling which
reduced spontaneously after defaecation. The pain is
burning in nature, relieved momentarily after defaecation,
no radiation, pain score: 5/10
• Associated with dizziness, lethargy and palpitations 1
week.
• However, patient denied any syncope, pruritus, tenesmus,
fever, chest pain, shortness of breath, abdominal pain,
nausea, vomiting, LOW, LOA, constipation or diarrhoea.
5. • PMHx: Diagnosed with haemorrhoids x 4 years
No known drug allergy, No known medical illness.
• Family Hx:
No significant family history of malignancy or similar complaint among
family members.
• Social Hx:
Student in Cyberjaya, prefer spicy food, eat less red meat, smoker – 12
ciggarettes/day, no history of high risk behaviour.
6. Summary
• Ahmad, 19 year old student with underlying haemorrhoids from
Cyberjaya came to HS with a chief complaint of painful PR bleed
associated with protruding swelling at the rectum associated with
symptoms of anaemia for 1 week.
7. • Physical Examination:
• Alert, conscious, lethargic, mild pallor, CRT<2s
• BP: 132/75 mmHg
• PR: 110 bpm
• RR: 20bpm
• T: 37
Abdomen: soft, non tender, no mass palpable, bowel sounds
are normal, no bruits.
Other systemic examinations are unremarkable
8. • Sigmoidoscopy:
• Haemorrhoids seen in 4 columns at 3, 5, 7, 11 o clock
• Banding done
• FBC:
• Hb 3.5
• HCT 11.8
• PLT 384
• WBC 9.8
16. Accessory signs
• Rovsing sign- to indicate peritoneal irritation
• Obturator sign- appendix at pelvic, inflammation of obturator muscle
• Psoas sign- appendix at retrocecal, inflammation of psoas muscle
17.
18.
19.
20. Alvarado Score (>7 suggest appendicitis, 4 – 6 :
suspicious of appendicitis – keep under observation,
<4 – not appendicitis. )
20
21. Differential Diagnosis of Appendicitis
GIT O&G Renal Pulmonary
Acute Gastroenteritis
Acute Meckel’s
Diverticulitis
Acute Mesenteric
Lymphadenitis (kids)
Acute Regional Ileuitis
Chron’s disease
Perforated Peptic Ulcer
Acute Pancreatitis
Caecum Cancer (elderly)
Acute Cholecystitis
(subhepatic appendix –
rare)
Intestinal obstruction
(elderly)
Right acute salphingitis
Ruptured right ectopic
pregnancy
Endometriosis
Right twisted/ruptured
ovarian cyst
Pelvic inflammatory
disease
Mittelschmerz
Right Ureteric Colic
Right acute pyelonephritis
Urinary Tract Infection
Lobar Pneumonia(kids)
21
22. Routine Investigation:
• Full blood count
• Urinalysis
Selective Investigation:
• Pregnancy test
• Urea and electrolytes
• Supine abdominal radiograph
• Ultrasound of the abdomen/pelvis
• Contrast-enhanced abdomen and pelvic computed
tomography scan
Investigations
23. Management
• Appendisectomy is the definitive management.
Other management:
Pre Op preparation
• IV isotonic fluid replacement
• Nasogastric suction for pt with peritonitis
• NSAIDS – reduce pain and fever
Antibiotics
• Antibiotic therapy – 2nd generation cephalosporin
• In pt with acute non-perforated appendicitis, a single dose prophylactic antibiotic is adequate.
• Antibiotic in perforated / gangrenous appendicitis should be continued for 3 – 5 days.
23
Pre Op preparation
• IV isotonic fluid replacement
• Nasogastric suction for pt with peritonitis
• NSAIDS – reduce pain and fever
Antibiotics
• Antibiotic therapy – 2nd generation cephalosporin
• In pt with acute non-perforated appendicitis, a single dose prophylactic antibiotic is adequate.
• Antibiotic in perforated / gangrenous appendicitis should be continued for 3 – 5 days.
25. Open vs Laparoscopic Appendisectomy
Open Appendisectomy Laparoscopic Appendisectomy
• Incision over McBurney’s point or point of maximal
tenderness – Lanz incision / Gridiron incision
• Shorter operative time
• Cost effective
• Better exposure, straightforward and technically
easier
• Lower intraoperative complication
• Longer recovery
• Postoperative pain
• Higher risk of adhesions, hernia and infection (post
op)
• Can’t visualize pelvic structures too well
• Keyhole incisions, insert 3 ports
• Long operative time – also need routine diagnostic
laparoscopy before starting
• More costly
• Requires proper technique and experience
• May have intraoperative complications eg
incomplete appendisectomy, visceral injury,
bleeding, leaking of purulent content from
appendiceal abscess
• Shorter recovery and less post- op pain
• Lesser post op complications
25
29. Adenomas
• Large adenomas (10%) have higher chance(10%) of malignancy
• Tubular adenomas (60% - 80%)
- Pedunculated polyp
• Villous adenomas (5%-10%)
- Large sessile (more worrying as endoscopic removal will be more difficult)
- More precancerous cellular change
- Hypersecretory syndrome causing hypokalemia
30.
31. Symptoms
• Hematochezia
• Symptoms of anemia (pale, lethargy)
• Diarrhea/ constipation (severe diarrhea if villous adenoma)
• Mucus production
• Family history of polyps
32. Signs
• Typically normal findings
• Signs of iron deficiency anemia (central pallor, glossitis, angular
stomatitis)
• Digital rectal examination- to detect distal rectal polyps
33. Investigations
• FBC – check for anemia
• Occult blood test
• Air contrast barium enema
- Can detect large colonic polyps while missing smaller ones
• Colonoscopy
• Allow direct visualisation of the entire large bowel and polyps may be removed at
the same time
• ‘Gold standard’ and first line investigation
• Most polyps can be removed during colonoscopy using electrocautery techniques.
• Surgical removal is indicated only when an experienced endoscopist cannot completely
remove the polyp safely
34. Management
• Non-surgical:
-NSAIDs
*A study suggests that aspirin may be beneficial in reducing the incidence of
recurrent polyps.
• Surgical
- Polypectomy
Rate of colonic recurrence at 1 year is small. Repeated 3-12 months endoscopy is
done if in doubt.
- Colonic resection
In case of multiple colonic polyps associated with FAP
36. • Presence of more than 100 colorectal adenomas
• Less common than HNPCC
• Male=female
• 80% of cases come from patients with a positive family history
Familial Adenomatous Polyposis
37. • Polyps visible at sigmoidoscopy by age of 15 years and will always be
visible at the age of 30
• Carcinoma develop 10-20 years after onset
Symptomatic
• Loose stool, diarrhea, lower abdominal pain, weight lose, passage of
blood and mucus
Clinical features
38. • At-risk family members are offered genetic testing in their early
teens.
• At-risk members of the family should started to be examined at the
age of 10–12 years annually
• Most of those who are going to get polyps will have them at 20
years, and these require operation.
• If there are no polyps at 20 years, continue with five yearly
examination until age 50 years
• If there are still no polyps by 50 years, there is probably no inherited
gene.
Screening policy
39. Surgery:
• Aim: to prevent the development of colorectal cancer
• Options are:
• colectomy with ileorectal anastomosis (IRA)
• restorative proctocolectomy (RPC) with an ileal pouch-anal anastomosis, the
anastomosis may be defunctioned with a loop ileostomy
• total proctectomy and end ileostomy (normally reserved for patients with a
low rectal cancer).
Management
43. • The majority of colorectal cancers are adenocarcinomas derived from
epithelial cells. About 71% of new colorectal cancers arise in the colon
and 29% in the rectum.
Toms JR, ed. CancerStats monograph 2004. London: Cancer Research;
2004
44. WHO Classification of Colorectal ca
• Adenocarcinoma in situ / severe dysplasia
• Adenocarcinoma
• Mucinous (colloid) adenocarcinoma (>50% mucinous)
• Signet ring cell carcinoma (>50% signet ring cells)
• Squamous cell (epidermoid) carcinoma
• Adenosquamous carcinoma
• Small-cell (oat cell) carcinoma
• Medullary carcinoma
• Undifferentiated Carcinoma
45. Risk factors for Colorectal ca
• Age (> 40 yeard old )
• Race: Chinese
• Adenomas, Polyps
• Sedentary lifestyle, Diet, Obesity
• Family History of Colorectal ca
• Inflammatory Bowel Disease (IBD)
• Hereditary Syndromes (familial adenomatous polyposis (FAP)).
• Acromegaly
46. Dietary factors implicated in
colorectal carcinogenesis
Increased risk
• consumption of red
meat
• animal and saturated fat
• refined carbohydrates
• alcohol
48. Pathogenesis
• Risk factors inactivation of tumor supressor genes with activation
of oncogenese dysplasia of the epithelium
49. Colon cancers result from a series of pathologic changes that
transform normal epithelium into invasive carcinoma.
50. Symptoms of Colorectal ca
• Unspecific
• Symptoms of anaemia
• Alternating bowel habits
• Constitutional symptoms
• Abodminal mass
• Haematochezia
• PR bleed
• Tenesmus
51. Symptoms based on anatomical site
RIGHT SIDED LESION
• Assymptomatic until advanced
stage
• Mass on the right side of the
abdomen
• Less obstructive symptoms;
- Fecal matter is liquid in nature
LEFT SIDED LESION
• Obstructive symptoms
- Fecal matter is solid
• Rectal bleeding
• Altered bowel habit
• Colicky, dull aching pain
54. The barium enema instills the radiopaque barium sulfate into the colon, producing a
contrast with the wall of the colon that highlights any masses present. In this case, the
classic "apple core” lesion is present, representing an encircling adenocarcinoma that
constricts the lumen.
56. Dukes staging system
A Mucosa
B1 Into or through muscularis propria
B2 Into or through the whole bowel wall
C1 Not through bowel wall + Lymph node
C2 Through whole bowel wall + Lymph nodes
D distant metastatic spread
57.
58.
59.
60. Treatment & Management of Colorectal ca
• Surgical resection for localised colorectal cancer is the mainstay of curative
treatment.
• Surgery should be avoided when the risks are thought to outweigh the
potential benefits such as when the patient is unfit for major surgery or has
advanced disease (stage IV).
61. Stage 1 – Stage 3
• Stage I tumours are T1-2, N0, M0; stage II-III tumours are T3-4, N0, M0 to any
T, N1-2, M0. Segmental resection is the primary treatment in patients with
colon cancer without metastases. Malignant colonic obstruction can be
treated with segmental resection and immediate anastomosis if technically
feasible or endoscopic colonic stent insertion with semi-elective surgical
resection.
62. Stage 4
• These patients are considered to be unsuitable candidates for surgery. Given
that the stages are pathologically dependent it is not possible to accurately
determine precisely the actual stage of the tumour in the absence of surgical
resection. As such, all treatment is appropriately palliative, with the possibility
of a stent for obstructing tumours.
• Prioritise treatment to control symptoms if at any point the patient
has symptoms from the primary tumour.
63. Stage 4
• If both primary and metastatic tumours are considered resectable,
anatomical site-specific MDTs should consider initial systemic
treatment followed by surgery, after full discussion with the patient.
The decision on whether the operations are done at the same time or
separately should be made by the site-specialist MDTs in consultation
with the patient.
65. Preoperative preparation
• Dietary restriction to fluids only for 48 hours before surgery; on the
day before the operation, two sachets of Picolax (sodium
picosulphate) are taken to purge the colon.
• Rectal washout
66. Adjuvant Therapy
• Adjuvant Chemotherapy in colonic cancer is indicated in patients with
stage B2 to C3.
• The recommended for adjuvant chemotherapy for colonic cancer is:
• 5-fluorouracil 450 mg/m2 i.v. bolus D1 D2 D3 D4 D5
• Recycle Day 29 for a period of one year
• Levamisole 120mg orally twice a week during each injection week for 1
year. (e.g. Monday and Thursday)
67. EBM
• Meta-analysis of 4 randomised controlled trials has shown FOBT
screening reduced the risk of death from colorectal cancer by 25% in
those who were actually screened. It is estimated that FOBT screening
can prevent approximately one in 6 colorectal cancer deaths.
Hewitson P, Glasziou P, Watson E, et al. Cochrane systematic review of
colorectal cancer screening using the fecal occult blood test
(hemoccult): an update. Am J Gastroenterol. 2008
68.
69. STOMAS
• A stoma is an opening, either
natural or surgically created,
which connects a portion of the
body cavity to the outside
environment.
70.
71. Stomas
Colostomy:
An artificial opening made in the large
bowel to divert faeces and flatus to the
exterior, where it can be collected in an
external appliance.
Temporary
Permanent
Ileostomy:
Used as an alternative to colostomy,
particularly for defunctioning a low
rectal anastomosis.
71
72. • Temporary Loop colostomy
1. Bringing a loop of colon to the surface, where it is held in place by a plastic bridge
passed through the mesentery.
2. Once the abdomen has been closed, colostomy is opened edges of the colonic
incision are sutured to the adjacent skin margin.
3. When firm adhesion of the colostomy to the abdominal wall has taken place, the
bridge can be removed after 7 days.
4. The colostomy can be closed once the surgical cure or healing of the distal lesion
for which the temporary stoma was constructed.
72
Colostomy
73. • Temporary Loop colostomy
Colostomy closure
is most easily and safely accomplished if the stoma is mature, i.e. after the
colostomy has been established for 2 months.
is usually performed by an intraperitoneal technique, which is associated with
fewer closure breakdowns with faecal fistulae.
73
Colostomy
74. Permanent end colostomies:
• This is usually formed after excision of the rectum for a carcinoma by
the abdominoperineal technique.
• It is formed by bringing the distal end (end-colostomy) of the divided
colon surface in the left iliac fossa sutured in place joining the
colonic margin to the surrounding skin.
74
Colostomy
75. • Used as an alternative to colostomy, particularly for
defunctioning a low rectal anastomosis.
• The advantages of a loop ileostomy over a loop colostomy are
the ease with which the bowel can be brought to the surface
and the absence of odour.
75
Ileostomy
76. Early
• Ischaemia/ necrosis
• Retraction
• Stenosis
• Haemorrhage
• Fistula formation
Late
• Prolapse
• Parastomal herniation
• Obstruction of small
bowel
• Diversion collitis
• Dermatitis
• Pscyhological
76
Complications
80. Inflammatory bowel disease
• A disease that causes chronic inflammation of the gastrointestinal
tract
• There are two major types of IBD : ulcerative colitis and Crohn
disease.
• Ulcerative colitis affects only the colon (large intestine) but Crohn
disease can affect any part of the GI tract, most often the end of the
small intestine and beginning of the colon.
81. ULCERATIVE COLITIS
• Main symptoms: Per rectal bleeding, tenesmus and mucous discharge
• Colitis is almost associated with profuse bloody diarrhoea resulting in
anaemia, hypoprotenaemia and electrolyte disturbance.
• Abdominal pain
• Fever
• Fatigue
• Weight loss
82. Extraintestinal manifestations
• Arthritis
• Sacroiliitis and ankylosing spondylitis are 20 times more common in
patients with UC than the general population and are associated with
HLA-B27.
• Sclerosing cholangitis is associated with UC and can progress to
cirrhosis and hepatocellular failure.
• Ptients with UC and sclerosing cholangitis are also at a greater risk of
developing large bowel cancer,
83. • Often, symptoms can be stable and then suddenly worsen during a
flare, which can require extra treatment. Flares can be very
dangerous, even life-threatening, if untreated because they may lead
to severe infection, bleeding, or bowel perforation.
84. Investigations
• FBC: Hb level
• Renal profile: dehydration and electrolyte imbalance in severe cases
• LFTs: hypoproteinaemia or abnormal
• AXR: perforation
• Barium enema- double contrast; loss of haustrations, mucosal distortion,
colonic shortening,stricture due to carcinoma
• Sigmoidoscopy: red, inflamed mucosa, contact bleeding, pseudopolyps
• Biopsy: to establish the extent of inflammation
• Colonoscopy: to exclude carcinoma
85. Ulcerative colitis. There is
shortening of the colon with
loss of haustrations (‘lead pipe’
appearance)
86.
87. Treatment
Medical
• IV fluids
• Blood transfusion
• Parenteral nutrition
• Corticosteroids: topically or systemically
- 5-aminosalicylic acid (5-ASA) derivatives
• If patient deteriorates, or toxic dilatation or perforation supervene,
urgent surgery is required
88. Operative
• In elective settings, four operations are available:
1. Subtotal colectomy and ileostomy (as in emergency)
2. Proctocolectomy and permanent end ileostomy
3. Restorative proctocolectomy with ileoanal pouch
4. Subtotal colectomy and ileorectal anastomosis
89. Crohn’s disease
• Chronic inflammatory disease of ileum characterised by a chronic full
thickness inflammatory process that can affect any part of the
gastrointestinal tract from the lips to the anal margin.
• 15-35 age group
90. Clinical features
• Symptoms and sign resembling those of acute appendicitis, or even
free perforation of the small intestine resulting in local or diffuse
peritonitis.
• Patients may complain of pain, particularly in the right iliac fossa , and
a tender mass may be palpable. Intermittent fever, secondary
anaemia and weight loss are common.
• Many patients with CD presents with perianal problems where the
perianal skin appears bluish
• Deep cavitating ulcers usually found in upper anal canal; can be
painful and cause perianal abscess and fistulae.
91. • After months of repeated attacks with acute inflammation, the
affected area of intestine begins to narrow with fibrosis, causing
obstructive symptoms.
94. In this case there is cobblestoning
which is due to serpiginous
longitudinal and transverse ulcers
separated by areas of oedema. There
is also separation of small bowel loops
due to bowel wall thickening. Deep
mucosal ulcers are seen, sometimes
referred to as rose-thorn ulcers.
95. Treatment
• Steroids are the mainstay of treatment of CD
- 40 mg daily of prednisolone in acute exacerbations
• Correction of fluid and electrolyte imbalance
• Give antibiotics ; metronidazole and ciprofloxacin may be used
• Immunomodulatory agent- cyclosporine treatment is used as steroid-
sparing effect and is now standard maintenance therapy.
• Monoclonal therapy
• Nutritional support
96. Operative
Indications for surgery:
• recurrent intestinal obstruction
• Bleeding
• Perforation
• Failure of medical therapy
• Intetsinal fistula
• Fulminant colitis
• Malignant change
• Perianal disease
97. Range of operations performed for CD depending on disease pattern:
• Ileocaecal resection
• Colectomy and ileorectal anastomosis
• Temporary loop ileostomy
• Proctocolectomy
• strictureplasty
98. Diverticular disease
• Diverticula (hollow out-pouching)are a common structural
abnormality that can occur from the oesophagus to the rectosigmoid
junction (but not ususally in the rectum)
• They are:
- Jejunal diverticula
- Meckel’s diverticulum
- Diverticular disease of the large intestine
99. Meckel’s diverticulum
• Persistent remnant of the vitelointestinal duct
• Contains all three coats of the bowel wall and has its own blood
supply
• Vulnerable to obstruction and inflammation in the same way as the
appendix
• Indeed, when a nirmal appendix is found at surgery for suspected
appendicitis, a Meckel’s diverticulum should be looke dforparticularly
if free fluid or pus is found.
100. Complications
Majority are asymptomatic. However,
• Pain and inflammation
• Perforation
• Intestinal obstruction
• Haemorrhage
• Fistula formation
• Abscess
• Peritonitis
101. Treatment
• Recommended to take high-fibre diet and bulk-forming laxatives
• Antispasmodics- recurrent pain is a problem
• Acute diverticulitis is treated by IV antibiotics (to cover Gram-
negative bacilli and anaerobes) alongside appropriate resuscitation
and analgesia
• Keep nil by mouth
• CT scan can confirm the diagnosis
• An abscess can be drained percutaneously
102. Principles of surgical management of
diverticular disease
• Hartmann’s procedure is the safest option in emergency surgery
• Primary anastomosis can be considered in selective patients
• Elective resection may be offered for recurrent attacks
• Definitive treatment of colovesical fistula will require resection
103. Operative
• Aim to emergency surgery is to control peritoneal sepsis; indications
are generalised peritonitis and failure to respond to best medical
management
• Alongside, operative technique, resuscitation, anaesthesia, and post
operative management should be optimised.
105. Understanding hemorrhoids
• Engorgement of the hemorrhoidal
venous plexus with redundancy to their
coverings.
• Greek: haima = blood, rhoos = flowing;
• synonym: piles, Latin: pila = a ball
• Symptomatic anal cushions
106. Anal Cushions
• Cushions of specialized, highly vascular tissues in the
anal canal
• Located at 3 main cushions
• Right posterior (most common), Left lateral, and right anterior
• They congest during Valsalva manoeuvre or increased
intra-abdominal pressure.
• Function
• Contribute to anal continence
• Compressible lining that protects underlying sphincters
• Provide complete closure of the anus (cushions engorge and
prevent leakage with increasing intrarectal pressure)
• Account for 15-20% of anal resting pressure
• Supply sensory info- to discriminate solid, liquid and gas
107.
108. External hemorrhoid Internal hemorrhoid
Below dentate line Above dentate line
Inferior rectal artery Superior rectal artery
Lined by
squamous epithelium
Lined by
Columnar/transitional epithelium
Sensitive to touch, pain, stretch and temperature Not Sensitive to touch, pain, stretch and temperature
Prone to thrombosis if vein ruptures
(Thrombosed pile)
May prolapse outside anal canal
(prolapsed hemorrhoid)
Somatic Innervation Autonomic Innervation
Covered by Anoderm/ Skin Covered by mucosa
109. What happens in hemorrhoids?
Excessive
straining
Lowering/
displacement
of anal
cushions
Exposed
veins
Shearing
force by stool
Bleed
110. Grading
1st degree Bulge into lumen, +/-
painless bleeding, with no
prolapse
Painless bleeding
2nd degree Protrude out, reduce
spontaneously
Anal mass without
defecation, anal burning
or pruritus
3rd degree Protrude spontaneously,
requires manual
reduction
Tenesmus, mucous
leakage, difficulty
cleaning
4th degree Permanently prolapsed,
irreducible
Irreducible mass
111.
112. Complications of hemorrhoids
Portal pyaemia
Suppuration
Fibrosis
Ulceration
Gangrene
Thrombosis
Strangulation
Gripped by Ext. sphincter
Impeded venous return
prolapse
113. History
1. Bleeding
• Fresh, bright red, usually painless
• separate from motion, either splashed on pan or toilet paper upon wiping
2. Pain in anal area (when complicated by secondary infection or
strangulation)
3. Prolapse from anal canal and its reducibility
4. Pain only on prolapse
5. Mucous discharge
6. Anal mass
7. Tenesmus
8. Any presence of pruritus
9. History of risk factors
115. Physical Examination
• Patient in left lateral decubitus
• Inspection
• Look for anal tags, prolapse, swelling, lumps or bleeding
• If there is history of prolapse, ask patient to strain and look for any protruded
masses (protrusion <1 inch = partial prolapse, >2 inches = complete prolapse
• External pile – covered with skin
• Internal pile – covered with mucous membrane
• Palpation
• Perianal region palpated for any lumps
• Per rectal
116. • Per rectal
• The resting tone of the anal canal
• voluntary contraction of the puborectalis and external anal sphincter.
• mass / any area of tenderness.
• Int. hemorrhoids are generally not palpable
• Only chronically inflamed and thrombosed hemorrhoids can be palpated in
anal wall
• anoscopy is performed.
• The side viewing anoscope should be inserted with the open portion in the
right anterior then right posterior and finally the left lateral position
• Hemorrhoidal bundles will appear as bulging mucosa and anoderm within the
open portion of the anoscope.
*** Other systemic examination should be focused on the presence of clues of
risk factors especially factors causing raised intra abdominal pressure
117. External Hemorrhoids
Asymptomatic except when secondary thrombosed
Thrombosis may result from defecatory straining or extreme physical activity or may be random
event
Patient presents with constant anal pain of acute onset
Physical examination identifies external thrombosis as purple mass at anal verge
Management
- Depends on patients symptoms
- In the first 24 – 72 hours after onset, pain increase and excision is warranted
- After 72 hours, pain generally diminishes
118. Diagnostic tests
• Physical examination.
• Proctoscopy. – look for internal piles, note the position (usually at 3,7,
and 11 oclock positioned according to the main branches of superior
haemorrhoidal vein)
• Flexible sigmoidoscopy – transmit images of rectum and colon, to rule
out any carcinoma
• Evaluation under anaesthesia in acute pain – if any doubt about
diagnosis of hemorrhoids and if indicated, biopsy may be necessary
119. Management
• Conservative, Medical, Office and Surgical procedures.
1. Conservative
- Take high fibre diet
- Patient advised to heed the call to evacuate bowel
- Don’t spend a long time in lavatory/ straining
- Liberal water intake
- Fiber supplement
- Sitz bath, warm 40oC (soothing effect ability to relax anal sphincter)
- Exercise
- Local hygiene
120. Dietary & Lifestyle modifications
“you don't defecate in the library
so
you shouldn't read in the bathroom”
121. • Medical
- Daflon – to increase venous tone
- Stool softeners (docusate sodium)
- Topical medication (Calcium dobesilate and docusate sodium)
122. Office procedures
1. Injection of Sclerosants
• For 1st degree hemorrhoids even though
it is profusely bleeding, and 2nd degree
where prolapse is slightly noticeable.
• The aim is to create fibrosis, cause
obliteration of the vascular channels and
hitch up the anorectal mucosa.
• Patient reassessed after 8 weeks
• Contraindications – prolapsed pile and
infection
• Complications - retroperitoneal sepsis,
portal pyemia, necrotising fasciitis,
prostatitis, impotence, rectovaginal
fistula
123. 2. Rubberband ligation
• Large Gr I & Gr II witout external component
• 2 bands
• Not >2 hemorrhoids at a time
• Follow up after 1 month, success rate:50-100%
• Band causes ischemic necrosis ulceration and scarring, fix connective tissue
to rectal wall
• necrosis in 24-48 hrs & slough off in 7 days
• May cause pain for 24-48 hrs and secondary hemorrhage
• Contraindicated in pt on Coumadin/ heparin
• Complications: pain, thrombosis, bleeding, band slippage, abscess, urinary
dysfunction, life threatening – perineal/pelvic sepsis
125. Operation
Indications
• Mainly driven by impact of symptoms on quality of life
• 3rd and 4th degree piles
• 2nd degree not cured by conservative means
• Fibrosed hemorrhoid
• Interno-external hemorrhoid
• Bleeding sufficient to cause anemia
• Soiling
• Ulceration,thrombosis,gangrene
129. External Hemorrhoids
• If operative treatment is chosen, entire
thrombosed hemorrhoid has to be excised
• Incision and drainage of clot shouldn’t be
done as this can lead to re-thrombosis and
exacerbation of symptoms
131. • Anal fissure is a longitudinal split/ tear in
the distal anal canal which extends from
the anal verge proximally towards, but not
beyond, the dentate line.
• Mostly young age affected
• Posterior anal fissure
• Commonest in all cases
• Anterior anal fissue
• Commoner in females after delivery
• Acute = tear on anal mucosa
• Chronic = if acute fissure persists over time
(>6 weeks)
132. Etiology
• Traumatization of the anal mucosa by the passage of hard stool/less
commonly, from passage of repeated diarrhea
• Vaginal delivery
Risk factors:
• Trauma, from hard bowel movements, diarrhea, anal
instrumentation, childbirth
• Low fiber intake
• IBD (Chron’s)
133. History
• Severe anal pain associated with defecation (knife like tearing sensation)
• Fresh bright red rectal bleeding after bowel movement, seen on tissue
paper
• Itchiness (in chronic)
• Discharge from the ulcer or discharge from associated intersphincteric
fistula
• Presence of mucosal swelling and prolapse – indicate hypertrophied anal
papilla internally and sentinel tag externally in chronic fissures
• History of risk factors
• Exclude others: gen symptoms of weight loss, any underlying symptom that
may raise suspicion as predisposing factor of fissure
134. Physical Examination
• Knee chest position
• Gentle separation of buttocks show anal fissure as linear line or pear
shaped slit in the lining of distal anal canal
• Inspection
• Split in posterior midline, distal to dentate
• Hypertrophied anal papilla internally and sentinel tag externally
• Demarcated, fresh mucosal edges and granulation tissue at base of fissure
• Palpation
• Extremely tender anus
• Chronic fissure – classic triad of deep ulcer, sentinel pile at distal fissure
margin and an enlarged anal papillae proximal to fissure
• Anal stenosis
• Indurated, rolled mucosal margins
• Horizontal muscle fibers of internal spinchter may be apparent at base of
fissure
135. Anal Fissure
• Multiple fissures or fissures
that occur away from
anterior or posterior midline,
should raise suspicions that
other problems may be
present
136. Investigation
• Examination under anaesthesia
• Flexible sigmoidoscopy
• Colonosopy
• However, the combination of sphincter spasm and intolerable pain
often precludes proctoscopic examination, PR and rigid/flexible
endoscopes, as they are far more likely to inflict severe pain then
establish a diagnosis.
137. Treatment
Acute anal fissure
Aimed at breaking the cycle of hard stool, pain, internal anal sphincter
spasm:
- Fiber supplement
- Stool softeners
- Generous water intake
- Sitz bath
- laxatives
- Local anesthetic ointment
- Rapidly alleviate symptoms and bring about complete healing
138. • Chronic Anal Fissure
• Aimed at reducing internal sphincter spasm and anal canal pressure
-Therapeutic alternatives to promote fissure healing
• Topical Nitroglycerin (cause neurogenic relaxation of internal
sphincter(
• Nifedipine gel or ointment (reduce local demand for O2 and
mechanical contraction of the muscle
• Topical Diltiazem
• Botulinum Toxins (from clostridium botulinum) eliminate spasm and
contraction of sphincter
141. Anorectal abscess
• Suppuration of perianal tissues adjacent to the anal verge.
• The abscess results from infection of the anal glands in the
crypts of the dentate line
• Initial abscess usually starts at the intersphincteric space,
then spreads to external spinchter, ischiorectal space,
supralevator space
142.
143. History taking
1) Nature of pain
- Throbbing ( ano rectal abscess)
- Sharp cutting ( anal fissure)
- Aggravated on defecation
- Radiating to pelvic region ( supralevator abscess)
2) Infection
- Fever and leukocytosis
3) Urinary problems?
- Urine retention due to infection
144. Physical
examination
1)Inspection
-Position of patient usually left lateral or lithotomy
-Swelling in perianal region, look for erythema and any
spontaneous discharge
2)Palpation
-Indurated tender swelling with brawny edema(
ischiorectal)
3)Digital examination
-Fluctuance ( supralevator interspincteric abscess)
Investigation Anoscopy
- After pain subsides, to see any fistulas following abscess
145. Management
1)Incision and drainage
- Anatomical consideration is vital
- Pus is usually sent for culture and sensitivity
2)If there is extensive cellutis or patient is diabetic, broad
spectrum antibiotics should be given like metronidazole.
3)Sigmoidoscopy and rectal biopsy should be performed.
146. Perianal fistula
• Track lined by granulation tissue and establishes communication
between anal canal or rectum deeply and perianal skin
superficially.
• Low level and high level determined by dentate line.
• 5 types
-superficial
- Intersphincteric (common)
- Transsphincteric
- Suprasphinteric
- Extrasphincteric
147. History
• Does the patient have itchiness over perianal region?
• Pain and discomfort
• History of etiological factors
Physical examination
- inspection, perineum examination and rectal examination
148. Investigation
1) Protoscopy – may demonstrate inner opening of fistula
2) Probing and sinogram – EUA
3) MRI – gold standard for fistula imaging, usually for
difficult recurrent case
4) Fistulography and CT – extrasphincteric fistula
5) Barium enema – multiple fistula/ recurrent
151. Lower GI Haemorrhage
• Abnormal intraluminal blood loss from a source distal to ligament of
Treitz
152. Symptoms of Lower GI Bleed
• Bleeding per rectal
• Right sided bleeding: Maroon stools
• Left sided bleeding: Bright red blood per rectum (or hematochezia)
• Caecal bleeding: Malaena
• However, patient with upper GI bleeding and right sided colonic
bleeding may also present with bright red blood per rectum if the
bleeding is brisk and massive.
153. Symptoms of Lower GI Bleed
• Symptoms of anemia
• Fatigue
• Faintness
• Headache
• Dyspnea
• Palpitations
• Pallor
155. Upper GI Bleed Lower GI Bleed
Site Above ligament of Treitz Below ligament of Treitz
History Hematemesis, Melena Hematochezia (fresh blood in stool)
Nasogastric Aspiration Blood present Blood not present (clear fluid/bile
present)
Bowel Sounds Hyperactive Normal
BUN/Creatinine ratio Increased Normal
157. Colour of blood
Bright red Bleeding from rectum
-Usually due to haemorroids/polyp/growth
-Anal canal (fissure/fistula)
Dark red Bleeding from colon
Black Melena – sign of upper GI bleed
158. Relation with stool
Blood mixed with
stool
Blood has come from bowel higher than sigmoid colon, where
softness of stool gives chance for the blood to mix with stool
Blood on the
surface of the stool
Bleeding from anal canal or rectum
Blood separate
from stool
Bleeding occur some other time
-Usually in rectal/anal carcinoma
- polyp or u. colitis
Blood on toilet
paper
Minor bleeding from anal skin either due to fissure in ano or
external haemorroids
159. Bleeding per rectal
Painful Fissure in ano, fistula in ano, anal carcinoma, ruptured
perineal hematoma, ruptured anorectal abcess
Painless 1) Blood alone
- Polyps
- Villous adenoma
- Diverticular disease
- Angiodysplasia
2) Blood with mucus
- Inflammatory bowel disease
- Intussuception
- Ischemic colitis
- Rectal carcinoma
160. Painless 3)Blood with defecation
- Haemorroids
4) Blood mixed with stool
- Colon carcinoma
5) Blood streaked on stool and tenesmus
- rectal/anal carcinoma
165. • Helical CT scanning of the abdomen and pelvis can be used when a
routine workup fails to determine the cause of active GI bleeding.
Multiple criteria are used for establishing the bleeding site, including
the following:
• Vascular extravasation of the contrast medium
166. • Contrast enhancement of the bowel wall
• Thickening of the bowel wall
• Spontaneous hyperdensity of the peri-intestinal fat
• Vascular dilatations
167. Patients who have experienced multiple episodes of LGIB
without a known source or diagnosis should undergo the
following:
• Elective mesenteric angiography
• Upper and lower endoscopy
• Meckel scanning
• Upper GI series with small bowel
• Enteroclysis
168. • The 3 nonsurgical modalities used to diagnose lower gastrointestinal
bleeding (LGIB) are colonoscopy, radionuclide scans, and angiography.
• Apart from colonoscopy, endoscopic procedures, such as
esophagogastroduodenoscopy (EGD), wireless capsule endoscopy
(WCE), push enteroscopy, and double-balloon enteroscopy, are used
depending on the clinical circumstance.
• The sequence of using various modalities depends on such factors as
rate of bleeding, hemodynamic status of the patient, and inability to
localize bleeding with the initial modality.
170. The management of LGIB has 3 components, as follows:
• Resuscitation and initial assessment
• Localization of the bleeding site
• Therapeutic intervention to stop bleeding at the site
171. Initial Resuscitation
• Establishing large-bore IV access and administration of crystalloids.
• FBC & Electrolytes, Blood group & crossmatch, Coagulation profile.
• Ensure vital signs are stable.
• A hematocrit level of less than 18% or a decrease of about 6% is
indicative of significant blood loss that requires blood transfusions
172. Patients who require admission to the intensive care
unit and early involvement of both a gastroenterologist
and a surgeon include the following:
• Patients in shock
• Patients with continuous active bleeding
• Patients at high risk, such as patients with serious
comorbidities, those needing multiple blood
transfusions, or those with an acute abdomen
173. Localization of the bleeding site
• Once the patient is stable, colonoscopy should be performed initially.
• Once the bleeding site is localized, therapeutic options include
coagulation and injection with vasoconstrictors or sclerosing agents.
• In patients in whom the bleeding site cannot be determined based on
colonoscopy:
Angiography with or without a preceding radionuclide scan.
175. Vasopressive Treatment
• Initially, vasoconstrictive agents, such as vasopressin
(Pitressin), can be used.
• Vasopressin is a pituitary hormone that causes severe
vasoconstriction Reduces the blood flow and
facilitates hemostatic plug formation in the bleeding
vessel.
• Effective in diverticular bleeding, compared to
angiodysplasia.
• Intra-arterial vasopressin infusions begin at a rate of
0.2 U/min for 20 minutes.
176. Endoscopic therapy
• Endoscopic control of bleeding can be achieved using thermal
modalities or sclerosing agents. Absolute alcohol, morrhuate sodium,
and sodium tetradecyl sulfate can be used for sclerotherapy of upper
and lower GI lesions.
• Epinephrine injection
177. Therapeutic Intervention
- Diverticular bleeding:
Bipolar probe coagulation, epinephrine injection, and metallic clips may
be used. If recurrent bleeding is present, the affected bowel segment
can be resected.
- Angiodysplasia:
Thermal therapy, such as electrocoagulation or argon plasma
coagulation, is generally successful. Angiodysplastic lesions may be
missed at colonoscopy if the lesions are small or covered with blood
clots..