Lower GI Bleeding
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- 1.LOWER GI BLEEDING Clinical ConsiderationAli Salah Alkhudair Supervision by Dr. Atef Khan
- By the end of this presentation,we are able to:
- Defention of Lower GI Hemorrhage .
- Deferential Diagnosis
- Workup and investigation
- Interventions and Treatments
- Case Senario
3. LOWER GI HEMORRHAGE
- Defined as an abnormal intraluminal blood loss from a source distal to theTreitz ligamentum.
5. 6. MASSIVE LOWER GI BLEEDING
- Passage of a large volume of red or maroon blood through the rectum
- Hemodynamic instability and shock ( Systolic blood pressure of less than 90 mm Hg )
- Initial decrease in hematocrit level of 6 g/dL or less
- Transfusion of at least 2 units of packed red blood cells
- Bleeding thatcontinues for 3 days
- Significantrebleeding in 1 week
7. DEFERENTIAL DIAGNOSIS
- DIAGNOSIS OF ANAL CONDITIONS WHICH PRESENT WITH:
- PAIN AND BLEEDING:
- PAIN, LUMP AND BLEEDING:
- Prolapsed haemorrhoids
- Carcinoma of the anal canal
- Prolapsed rectal polyp or carcinoma
- Prolapsed rectum
8. DEFERENTIAL DIAGNOSIS
- DIAGNOSIS OF CONDITIONS PRESENTING WITH RECTAL BLEEDING BUT NO PAIN:
- Blood mixed with stool colon carcinoma
- Blood streak on stool rectal carcinoma
- Blood after defaecation haemorrhoids
- Blood and mucus colitis
- Blood alone diverticular disease
- Melaena peptic ulcer
9. DEFERENTIAL DIAGNOSISIN ADULT 10. DEFERENTIAL DIAGNOSISIN CHILDREN 11. HEMORRHOIDS (PILES)
- * it is one of the commonest cause of rectal bleeding
- carcinoma of the rectum
- Chronic constipation
- Also, heart failure, excessive use of laxatives and portal HTN are causes.
12. HEMORRHOIDS (PILES) TYPES
- INTERNAL HAEMORRHOIDS:
- -develops above the dentate line.
- -covered by anal mucosa.
- -lacks sensory innervation (painless)
- -bright red or purple in color.
- EXTERNAL HAEMORRHOIDS:
- -arise below the dentate line.
- -covered by St. sq. epith.
- -innervated by the inferior rectal nerve.
- Internal H. drains into sup. Rectal veinsportal system
- External H. drains into inf.Rectal veins I.V.C.
13. HEMORRHOIDS (PILES) GRADING FOR INTERNAL TYPE
- Internal H. are classified by the degree of tissue prolapse into the anal canal.
- GRADE 1:they are confined to the anal canal with minimal bleeding or maybe asymptomatic but do not prolapse.
- GRADE 2:they prolapse on defecating or straining then reduce spontaneously.
- GRADE 3:prolapse with or without straining and require manual reduction.
- GRADE 4:chronically prolapsed and if reducible fall out again. Others fall out of the anus and are irreducible (strangulated) surgical emergency.
14. HEMORRHOIDS (PILES) SYMPTOMS
- Grade 1 usually are asymptomatic or with minimal bright red bleeding on defecation.
- -the main and earliest symptom
- -starts as bright red bleeding on the surface of the stool or on the toilet paper.
- -a much later symptom
- -starts transiently on defecation, but occurs with increasing frequency
- until 3 rddegree H. develop.
- -a mucous discharge accompanies a prolapsed pile.
15. HEMORRHOIDS (PILES) SIGNS
- the pt. should be in the left lateral position.
- -1 stdegree H. show no outward abnormality
- -2 nddegree H. may show the skin covered components when the buttocks are separated or piles may prolapse when the pt. strains.
- -3 rddegree H. shows the red anal mucosa in their position (3,7,11)
- DIGITAL EXAMINATION:internal H. cant be felt unless they are thrombosed or in the long standing thickened piles.
- And should not apply PR
16. HEMORRHOIDS (PILES) INVESTIGATION
- 1-sigmoidscopy: essential to exclude co-exclude rectal pathology as carcinoma or polyps.
- 2-barium enema:indicated when sigmoidscopy and protoscopy cant explain the symptoms.
- 3-CBC: anemia, rarely happen in longstanding piles.
17. HEMORRHOIDS (PILES) D.D.
- Anal or rectal cancer.
- Redunculated polyps.
- Rectal prolapse.
- Anal fissures or fistula or hematoma if painful-
18. HEMORRHOIDS (PILES) COMPLICATION
- Strangulation:when a prolapsing pile become gripped by the external anal sphincter.
- Ulceration:superficial ulceration of the exposed mucous membrane.
19. HEMORRHOIDS (PILES) TREATMENT
- 1-first degree H.:bulk laxatives and high dietary fibers maybe enough to decrease the constipation
- 2-injection therapy (sclerotherapy):-for the 1 stdegree and early 2 nddegree H.
- 3-5 ml of 5% phenol in almond oil is injectedthrough a special syring to the base of the pile or just above the anorectal ring.
- 4- Rubber band ligation:
- -effective with 1 stand 2 nddegree H.
- -a small o-ring rubber band applied to constrict the mucosa at the base. This will lead to strangulation of the pile and subsequent sloughing of the pile over a period of 10 days or so.
- 5-infra-red photocoagulation.
- 6-cryotherapy:a cryoprope is applied to the overlying mucosa.
- 7-stretching of the anal sphincter : it improves venous drainage and decrease the need for straining. Overstretching may lead to anal incontinence.
- Necessary for the 3 rddegree H. or in prolapsed thrombosis.
- Complications of the procedure:Anal stenosis, acute urinary retention, post-operative haemorrhage.
20. CARCINOMA OF THE RECTUM
- 75% occur in the lower part of the rectal ampulla papilliferous or a simple ulcer with everted edges.
- 25% in the upper part of the rectum annular in shape.
- 90% or rectal cancers can be felt with a finger during PR.
- MACROSCOPIC APPEARANCE:
- It may be as follows:
- ulcerating commonest
- stenosing at rectosigmoid
21. CARCINOMA OF THE RECTUM
- MICROSCOPIC APPEARANCE:
- *90% are adenocarcinoma
- *9% are colloid adenocarcinoma with mucous production-
- *1% highly anaplastic carcinoma simplex
- *at the anus, sq. cc occur but, a malignant tumour protruding through the anal canal is more likely to be an adenocarcinoma of the rectum invading the anal skin.
- Rectal ca is common in middle and old age (50-70 yrs) but can occur in young adults.
- It is equally common in both sexes.
- Rectal bleeding:small dark red streak on the stool. If a lot ofblood accumulates it can pass as such but this is uncommon.
- The surface of the tumour produces mucous which is expressed in a more liquid motion diarrhea like-but if it pools it can be passed as liquid faeces.
- There may bechange in bowel habitusually towards constipation.
- High annular cancers at the rectosigmoid junction maycause partial obstructionpresenting as alternating constipation and diarrhoea.
- Tenesmustumour in the lower part of the rectum is large to fool the sensory mechanisims into thinking it is faeces.
- Wight loss:this is common even if there isnt any metastasis.
- Small primary lesions maybe symptom less but associated with multiple metastasis especially to the liver. Here the pt. has upper abdominal pain, malaise and a palpable mass.
- Pain is an uncommon symptom.