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GASTROINTESTINAL TRACT

GASTROINTESTINAL TRACT. Begashaw M (MD). Gastrointestinal bleeding. has high mortality & morbidity persistent bleeding and/or recurrence carries worse outcomes without immediate intervention. DEFINITION. UGIB  blood loss proximal to ligament of Treitz

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GASTROINTESTINAL TRACT

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  1. GASTROINTESTINAL TRACT Begashaw M (MD)

  2. Gastrointestinal bleeding has high mortality & morbidity persistent bleeding and/or recurrence carries worse outcomes without immediate intervention

  3. DEFINITION UGIB blood loss proximal to ligament of Treitz LGIBblood loss distal to ligament of Treitz Hematemesis vomiting of blood Melenapassage of black tar stool Hematochezia passage of blood per rectum

  4. UPPER GASTROINTESTINAL BLEEDING • Etiology - PUD –commonest ,DU 4x - Varices-cirrhosis, portal hypertension - Gastritis-NSAID - Gastric ca • Stress ulcer -trauma, shock, sepsis, burn • Mallory-Weiss tear-prolonged violent vomiting - Esophagitis

  5. WORK-UP & MANAGEMENT • Immediate intervention • Having a clinical suspicion of the possible site • History- Collapse - Sweating - Anxiety, restlessness - Large amount of bloody vomitus - Hematochezia/melena

  6. History • Scoiodemographic -Age • PUD hx - past or present • Drugs • Liver disease • Co-morbid diseases • Symptoms of bleeding diathesis

  7. Examination - Rising PR & RR - Decreasing BP & pulse pressure - Restlessness - Increasing pallor - Cold nose and extremities - Sweating - Decreased urine output

  8. Management • Insert large bore intravenous cannula • Rapid crystalloid infusion • Blood transfusion • Monitor-VS , urine output • Anxiety & pain - diazepam, analgesic • NG tube - monitor rate of bleeding,salinelavage

  9. Stabilized -laboratory data ,further treatment Blood transfusion Ixns -Esophago-gastro-duodenoscopy - Medical therapy - Endoscopic therapy - Surgical (operative) - to control the bleeding

  10. LOWER GI BLEEDING • DDX - Small intestinal bleeding - Colorectal bleeding - Anorectal bleeding

  11. Small intestinal bleeding • Is uncommon • rarely massive • difficult to diagnose • Usually a diagnosis of exclusion

  12. Colonic bleeding • Acute & massive • chronic  occult blood positive stool & anemia • Causes : -Neoplasms /polyps -Diverticulosis/ diverticulitis -Vascular malformations -Inflammatory causes

  13. Anorectal bleeding • Causes - Hemorrhoids - Anal fissure - Tumors /polyps - Proctitis

  14. Clinical evaluation • Hemodynamic status • Hx -Hematocheziamassive UGIB/bleeding from right colon -Chronic bleeding Unexplained anemia Orthostatic hypotension Fatigue/weight loss

  15. Visible bleeding in assosiation with: - Pain - Change in bowel habits- Stool frequency - Stool consistency • Excessive mucus discharge per rectum • Sense of incomplete defecation • Tenesmus - Pruritus- ani

  16. Physical examination • Vital sign • indices of tissue perfusion • signs of chronic blood loss • Complete abdominal Exm-DRE • pelvic examination-Female

  17. Treatment • Resuscitation -first priority - NG tube lavage to exclude UGIB - CBC -WBC, HCT/Hb, platelet count - Esophago-gastro-duodenoscopy(EGD) - Blood chemistry - Coagulation profile - Stool examination - Lower GI Endoscopy Procto-sigmoidoscopy

  18. COLORECTAL TUMOUR Colorectal carcinoma-common causes of death Symptoms are largely nonspecific Mortality & morbidity-GI bleeding & acute abdomen High index of suspicion-Very important

  19. COLORECTAL CARCINOMA common second commonest cause of death Usually over 50 years of age F>M Sigmoid/rectummostfrequent site

  20. Pathology • Macroscopic -Polypoid -Malignant ulcer -Annular -Tubular • Microscopically -Adenocarcinoma

  21. Predisposing factors -pre-existing polyps -Familial adenomatouspolyposis -Ulcerative colitis

  22. Spread • Local spreadSlow growth • Lymphatic spreadRegional LNs • Blood streamliver /lungs/skin/bone • Trans-coelomicmalignantdeposits peritoneal cavity & to non-adjacent organs

  23. Clinical features • Right colon - Anemia - Loss of appetite/weight loss/ generalized body weakness - Palpable lump

  24. Left colon - Change in bowel habit - Passage of mucus - Tenesmus/sense of incomplete defecation - Rectal bleeding - Intestinal obstruction - Pain-> late - urinary: due to pressure /invasion

  25. Investigations • S/E - Parasites, WBC, occult blood, culture • Sigmoidoscopy • colonoscopy • Barium enema • Biopsy under endoscopic guide

  26. Staging investigations • Ultrasonography • Chest x-ray • Liver function test

  27. Management • depends on - mode of presentation - stage of the disease • site of the primary lesion - presence or absence of multiple lesions

  28. Modalities • Surgery - Emergency laparotomy - bleeding , acute abdomen - Elective surgery After pre-operative colon preparation Resection for resectable tumors (curative) - Palliative: palliative surgery, Cytotoxic chemo therapy, Radiotherapy

  29. ANORECTAL ABSCESSES • In association with underlying systemic or local diseases - AIDS, Diabetes mellitus, rectal tumors, inflammatory bowel disease • Complications • fistula in ano - sepsis perianal sepsis

  30. Pathogenesis Caused by mixed micro organisms Infection of anal gland spreads along tissue planes Risks -Perianal hematoma -Perianalinjurie -extension from cutaneous boils

  31. Classification • Perianal-subcutaneous abscess -commonest type • Ischiorectal abscess -also common -located in ischiorectalfossa • Sub mucous abscess -located under the mucous membrane • Pelvirectal abscess -located above levatorani -follows spread from pelvic abscess

  32. AnorectalAbscess

  33. Clinical features Pain -severe, fever Constitutional –sweating/anorexia Constipation Lump visible/tender /brownish induration Rectal tender mass

  34. Management Drainage Irrigation Packing with saline soaked gauze Sitzbath twice daily Antibiotics if systemic manifestations in immunocompromised Analgesics /mild laxatives

  35. Perianal abscess drainage

  36. PERIANAL FISTULAS (FISTULA IN ANO) is a track, lined by granulation tissue, which connects the anal canal or rectum internally with the skin around the anus externally

  37. Risk factors Untreated /inadequately treated anorectal abscess Granulomatousinfections IBD -multiple external openings Tuberculousproctitis Crohn’sdisease

  38. Classification • Low  internal opening below anorectal ring • High internal opening at/above anorectalring

  39. Fistula in ano

  40. Classification

  41. Goodsall's Rule

  42. Clinical features • Seropurulentdischarge • perianalirritation - External opening  small elevated opening with a granulation - Internal openingfeltas a nodule on DRE - Signs of underlying/associated dss

  43. Management - Emergency treatment for abscesses - Treatment of underlying cause - Surgery for fistula in ano - Preceded by Preoperative bowel cleansing (enema) Examination under anesthesia

  44. Surgery • Low level fistula -fistulotomy/fistulectomy -Wound care • High level fistula -Protective colostomy to prevent infection and facilitate healing -Staged operation

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