Credits to Meroshana, Griselda Pearl, Nazrin Asyraf, Haziman Fauzi and Izureen :)

1. PMS 4 – Management of
Colorectal and Anal Diseases and
Lower GIT Bleeding
Haziman Fauzi
Nazrin Asyraf
Izureen Azmar
Meroshana Thaiyalan
Griselda Pearl

2. Case Presentation
Haziman Fauzi

3. Demographics
• Name: Ahmad
• Age: 19 years old
• Occupation: Student
• DOA: 12/8/2015
• DOC: 13/8/2015

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

9. • Provisional diagnosis:
• Anaemia secondary to bleeding haemorrhoids

10. • Plan of management:
• Blood transfusion 2 pints
• IVD 4 pints – 2 pints Normal Saline, 2 pints Dextrose 5%
• Vital sign monitoring
• I/O chart

11. Appendicitis

12. Various positions of the appendix
• Retrocecal (74%)
• Pelvic (21%)
• Paracaecal (2%)
• Subcaecal (1.5%)
• Preileal (1%)
• Postileal (0.5%)
12

13. Symptoms
• Classical sx:
Anorexia, paraumbilical pain -> Nausea and vomiting, diarrhea
• Features of pain:
Migrating pain ( periumbilical -> RLQ pain)
Lie down and flex hips to reduce pain

14. Signs
• Rigidity & guarding
• RLQ tenderness at McBurney’s point
• Rebound tenderness
• Pain on percussion

15. RUQ/ Right flank pain in pregnant women (2nd/3rd trimester)

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

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.

24. 24

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

27. Colorectal Polyps
Slow-growing overgrowth of the colonic
mucosa that carry a small risk of becoming
malignant

28. Types
Inflammatory Inflammatory polyps (pseudopolyps in ulcerative colitis)
Metaplastic Metaplastic or hyperplastic polyps
Harmartomatous Peutz–Jeghers polyp
Juvenile polyp
Neoplastic Adenoma
- Tubular
- Tubulovillous
- Villous
Adenocarcinoma
Carcinoid tumour

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

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

35. Familial Adenomatous Polyposis

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

41. Colorectal cancer and Stoma
Haziman Fauzi
1108 – 2202

42. Anatomic Location of Colorectal ca
• Cecum 14 %
• Ascending colon 10 %
• Transverse colon 12 %
• Descending colon 7%
• Sigmoid colon 25 %
• Rectosigmoid junct.9 %
• Rectum 23 %

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

47. Dietary factors implicated in
colorectal carcinogenesis
Decreased risk
• dietary fiber
• vegetables
• fruits
• antioxidant vitamins
• calcium
• folate (B Vitamin)

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

52. Rectal lesion
• PR bleed
• Haematochezia
• Tenesmus
• Pain

53. Investigations
• Fecal occult blood ( screening, if positive  colonoscopy )
• Full Blood Count
• Colonoscopy with biopsy
• Double contrast barium enema
• CT Scan of thorax, abdomen & pelvis (colonic wall thickening,
enlarged lymph nodes, liver metastases, ascites, lung secondaries )
• Liver function test, Renal Profile, CXR (Mets)
• Carcinoembryonic antigen (CEA)

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.

55. Staging
- Duke’s Staging
- TNM Staging

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

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.

64. Treatment
Nurizdiha Binti Shukor 64

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

69. STOMAS
• A stoma is an opening, either
natural or surgically created,
which connects a portion of the
body cavity to the outside
environment.

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

77. Stoma ischeamia, necrosis

78. Fistula

79. Prolapse

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)

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.

92. Investigations
• FBC :Hb
• ESR: raised
• Folate
• B12
• U&: electrolyte imbalance
• LFTs: albumin reduced
• CRP: Elevated
• Radiographs –AXR: obstruction, perforation, toxic dilatation
• Small bowel enema, barium enema: skip lesions in small bowel, stricture,
‘rosethorn’ ulcers, ‘cobblestone’ mucosa

93. • Sigmoidoscopy and biopsy
• Colonoscopy and biopsy
• USS
• CT: abscess

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.

104. Hemorrhoids
Meroshana Thaiyalan 1108-2123

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

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

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

114. Constipation
(prolonged
lavatory sitting)
Prolonged
Straining
Trauma Diarrhea
Lack of fiber rich
diet
Pregnancy Heredity Aging
Portal
Hypertension and
anorectal varices
Ascites
Uterine/ovarian
neoplasms

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

124. occlude base of hemorrhoid
above dentate line

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

126. Milligan-Morgan (open) Hemorrhoidectomy

127. Ferguson’s (Closed) Hemorrhoidectomy
• Haemorrhoidal tissue excised.
• Mucosal wound and skin sutured
completely with a continuous
absorbable suture.

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

130. Anal Fissure
Meroshana Thaiyalan 1108-2123

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

139. • Surgical procedure of choice lateral internal anal sphintrotomy
• Cure in 95 -98%
• Complications
• - Incontinence to flatus 0 – 18%
• - Soiling 0 – 7%
• - Fecal incontinence 0 – 0.17%

140. Anorectal abscess and
Perianal fistula

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

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

150. Symptoms of Lower GI
Haemorrhage

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

154. Difference between upper
and lower GI bleed

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

156. Type and causes of
Lower Gastrointestinal
Bleeding

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

164. LOWER GI BLEEDING
Discuss the different modality of investigation tools

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.

169. Specific Treatment for Lower
GI Bleed
Haziman Fauzi

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.

174. Therapeutic intervention
• Aim: To stop the bleeding
• Vasopressive

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..

178. Thank you 