Lower GI Bleeding

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my lecture during Surgery II Course

Transcript of Lower GI Bleeding

  • 1.LOWER GI BLEEDING Clinical ConsiderationAli Salah Alkhudair Supervision by Dr. Atef Khan

2. OBJECTIVES

  • By the end of this presentation,we are able to:
  • Defention of Lower GI Hemorrhage .
  • Classification
  • 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.

4. CLASSIFICATION

  • Massive
  • Moderate
  • Mild

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:
  • Fissures
  • 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
  • Causes:
  • carcinoma of the rectum
  • pregnancy:
  • 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.
  • 1-bleeding:
  • -the main and earliest symptom
  • -starts as bright red bleeding on the surface of the stool or on the toilet paper.
  • 2-prolapse:
  • -a much later symptom
  • -starts transiently on defecation, but occurs with increasing frequency
  • until 3 rddegree H. develop.
  • 3-discharge:
  • -a mucous discharge accompanies a prolapsed pile.
  • 4-pruritis
  • 5-pain

15. HEMORRHOIDS (PILES) SIGNS

  • the pt. should be in the left lateral position.
  • INSPECTION:
  • -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

  • Anemia
  • Strangulation:when a prolapsing pile become gripped by the external anal sphincter.
  • Thrombosis
  • Ulceration:superficial ulceration of the exposed mucous membrane.
  • Gangrene
  • Suppuration:uncommon
  • Fibrosis

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.
  • 8-haemorrhoidectomy:
  • 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:
  • papilliferous
  • ulcerating commonest
  • stenosing at rectosigmoid
  • colloid

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.

22.

        • 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.