PROBLEM 5 GIT

IVAN MICHAEL (161)

 ANATOMY
HISTOLOGY
 Histology of the colon
1. Tunica serosa.
2. Tunica muscularis : str. Longitudinale, str.
Circulare.
3. Tunica submucosa : blood vessels, submucosal
plexus, folliculi lymphatici solitarii.
4. Tunica mucosa : have no villi intestinale.
5. Plica semilunaris : submucosal layer, mucosal
layer & stratum circulare tunica muscularis.

Colon have no folliculi lymphatici aggregatii.

 The mucosa (M) is arranged into
tightly-packed straight tubular
glands (G) which consist of cells
specialised for water absorption
and mucus-secreting goblet cells
to aid the passage of faeces.

The large intestine also contains

areas of lymphoid tissue (L); these
can be found in the ileum too
(called Peyer's patches), and they
provide local immunological
protection of potential weak-spots
in the body's defences.

http://www.le.ac.uk/
Rectum
DEFECATION PHYSIOLOGY
Faeces in colon

delayed
Rectum defecation
stretches
Relax sfingter ani
interna rectal wall that
stretch stretched to
receptor Rectum, colon sigmoid relax
stimulation contraction more
harder
defecation desire
Reflex abate
defecation

feces are pushed

relax
Sfingter ani more into the rectum
defecation
externa

defecation
 Mecanism of defecation
1. Haustra contraction.
Initiated by autonomous rhythmicity of colonic
smooth muscle.
These contraction throw the large intestine into
haustra, are similiar to small intestine
segmentation but occur much less frequently.
These movements are nonpropolsive; they slowly
shuffle the contents in a back-forth mixing
movement that exposes the colonic content to the
absorbtive mucosa.
2. Mass movements
It is massive contraction that drive the
colonic content into the distal part of the
large intestine, where material stored until
defecation.
Large segments of
After Increase of ascending and transverse
meals motility colon contract
simultanously

Throw feces one third to

three forth s of the
length of the colon in few
seconds
3. Gastrocolic reflex
Causes of mass movements are triggered in
the colon primarily.
Mediated from the stomach to the colon by
gastrin and by extrinsic autonomic nervous.
This reflex is most evident after the first
meals of the day and is often followed by
the urge to defecate.
GI BLEEDING
 Gastrointestinal (GI) bleeding refers to any bleeding that
starts in the gastrointestinal tract, which extends from the
mouth to the anus.

Bleeding may come from any site along the GI tract, but is
often divided into:
1. Upper GI bleeding: The upper GI tract is located between the
mouth and the upper part of the small intestine.

2. Lower GI bleeding: The lower GI tract is located between the

upper part of the small intestine and the anus. The lower GI
tract includes the small and large bowels.
 Gastrointestinal Bleeding
1. Hematemesis is vomitus of red blood or "coffee-
grounds" material.
2. Melena is black, tarry, foul-smelling stool.
3. Hematochezia is the passage of bright red or
maroon blood from the rectum.
4. Occult GI bleeding (GIB) may be identified in the
absence of overt bleeding by a fecal occult blood
test or the presence of iron deficiency.
http://www.wrongdiagnosis.com/bookimages/14/4791.1.png
Diagnose
Etiology of lower GI bleeding
1. Constipation
2. Ca colon
3. Hemorrhoid
CONSTIPATION
Types of Constipation and Causes
1. Recent onset
Colonic obstruction : Neoplasm, stricture: ischemic, diverticular,
inflammatory
Anal sphincter spasm : Anal fissure, painful hemorrhoids

2. Chronic
Irritable bowel syndrome : Constipation-predominant
Medications : Ca2+ blockers, antidepressants.
Colonic pseudo-obstruction : Slow-transit constipation, megacolon
(rare Hirschsprung's, Chagas)
Disorders of rectal evacuation : Pelvic floor dysfunction, anismus,
descending perineum syndrome, rectal mucosal prolapse, rectocele.
Endocrinopathies : Hypothyroidism, hypercalcemia, pregnancy.
Psychiatric disorders : Depression, eating disorders, drugs.
Neurologic disease : Parkinsonism, multiple sclerosis, spinal cord
injury.
Generalized muscle disease : Progressive systemic sclerosis.
 Diet for Constipation and
Diverticulosis
Dietary fiber is important for GI health
Consumption of dieatry fiber, particularly
cellulose, oligofructose, bran, and psyllium
promotes laxation and fecal weight.
For diverticular disease, dietary fiber,
particularly cellulose, and unprocessed bran
gives protective effects
 Diet for Constipation and
Diverticulosis
When the patient need to increase fiber in
their diets, its better to recommend high
fiber foods than fiber supplements, because,
the high fiber foods contains phytonutrients
(thought protective against chronic disease)
and also water.
 Diet for Constipation and
Diverticulosis
Fluid intake is important in treatment of
constipation
Recommended total water intake for adult is
3-4L/day. It can be supplied by any drink (eg.
Water, milk, coffee, juice)
Recommendations for total water intake for
children range from 1-3L and dependeing upon
age.
Medical Treatment for Adults in
Constipation
Fisrt approach : ensure adequate dietary
fiber, fluid, and exercise and to advise the
patient to heed the urge to defecate.
For patient dependent on laxatives :
encaourage to use milder products and reduce
the dose
For patient unable consume adequate amount
of fibrous foods or exercise : substances that
promote regular evacuation of soft stools
(polyethelene glycol, tegaserod, psyllium seed,
lactulose)
 Medical Nutrition Therapy
Primary nutrition therapy for constipation is
adequate amount of soluble and non soluble dietary
fiber.
Adequate fiber : 14g/1000kkal
Woman : 25g
Man : 38g
Children : 19-25g
Function of fiber:
Increases colonic fecal fluid
Increases microbial mass
Increases stool weight and frequency
Increases rate of colonic transit
Softens stools and make them easier to pass
 Medical Nutrition Therapy
Fiber can be provided in the form of:
Whole grains
Fruit
Vegetables
Legumens
Seeds
Nuts
CA COLON
 Risk Factors
1. Genetic risk factors
Family history of colon cancer
Family history of Intestinal polyps
Intestinal polyps
Previous colon cancer
Ulcerative colitis
Crohns disease
2. Lifestyle related risk factors
Chronic constipation
Diet:
High-fat diet
low fiber diet
Obesity
Smoking
 Symptoms
Initial symptoms of colorectal cancer include:
1. Blood in the stool
2. Red stools
3. Black stools
4. Changes in frequency of bowel movements:
Frequent loose stools
Constipation
5. Abnormal appearing stools :
Changes in the size of the stools
Changes in the shape of the stools
Additional symptoms of colorectal cancer
include:
1. Anorexia
2. Abdominal pain
3. Abdominal swelling
4. Excessive fatigue
5. Unintentional weight lost
6. Vomiting
 Stages
Staging colon cancer usually includes some combination
of the following tests:

1. CT scan of the abdomen

2. MRI scan of the abdomen
3. Bone scan
4. Carcinoembryonic antigen blood level
5. Chest x-ray
6. Complete blood count
7. Lymph node biopsy
8. Surgery with tissue biopsy
Colon Cancer Stage 0
Stage 0 cancer is also called carsinoma in situ. In
stage 0, the cancer is found only in the innermost
lining of the colon.

Colon Cancer Stage 1

Stage 1 colon cancer is sometimes called Dukes'
A colon cancer. In stage 1, the cancer has spread
beyond the innermost tissue layer of the colon
wall to the middle layers.
Colon Cancer Stage 2
Stage 2 colon cancer is also called Dukes' B colon
cancer.

Stage 2 colon cancer is divided into stages:

1.Stage 2A: cancer has spread beyond the middle
tissue layers of the colon wall or has spread to
nearby tissues around the colon or rectum.
2.Stage 2B: cancer has spread beyond the colon wall
into nearby organs and/or through the
peritoneum.
Colon Cancer Stage 3
Stage 3 colon cancer is also called Dukes' C colon cancer.
Stage 3 colon cancer is divided into:
1. Stage 3A: cancer has spread from the innermost tissue
layer of the colon wall to the middle layers and has
spread to as many as 3 lymph nodes.
2. Stage 3B: cancer has spread to as many as 3 nearby lymph
nodes and has spread:
beyond the middle tissue layers of the colon wall; or
to nearby tissues around the colon or rectum; or
beyond the colon wall into nearby organs and/or
through the peritoneum.
3. Stage 3C: cancer has spread to 4 or more nearby lymph
nodes and has spread:
to or beyond the middle tissue layers of the colon wall;
or
to nearby tissues around the colon or rectum; or
to nearby organs and/or through the peritoneum.
Colon Cancer Stage 4
Stage 4 colon cancer is also called
Dukes' D colon cancer. In stage
4,cancer may have spread to nearby
lymph nodes and has spread to other
parts of the body, such as the liver or
lungs.
 Imaging studies
Barium enema
CT scanning of the abdomen: an excellent test for
excluding internal injury
MRI scan of the abdomen
Virtual colonoscopy:
Uses a special type of CT scanner that takes many
pictures of the colon in super thin slices. A
computer reassembles the images into a 3-D model
of the colon. The more slices the CT scanner is
capable of taking in rapid succession, the better
the image quality.
Bone scanning
 Laboratory
Stool guaiac:
Testing stools for the presence of blood not
visible to the naked eye
DNA stool testing:
A test that looks for abnormal DNA in a stool
sample.
Complete blood count
Liver profile
Kidney profile
Urinalysis
Anoscopy
Colonoscopy
Sigmoidoscopy
 Treatment
Surgery
Polypectomy
For small tumors that have not spread
Chemotherapy
Radiation therapy
Colorectal cancer clinical trials
 Prevention
Stop smoking
Avoid exposure to secondary smoke.
Eat a healthy heart diet
High fiber diet
Low fat diet
Calcium supplements
Vitamin D may help cut the risk for colon cancer
The Institute of Medicine recommends 200 IU daily for
children and adults up to age 50, and 400 IU for adults aged
51-70; people over age 70 should get 600 IU daily.
Weight loss if overweight
aspirin therapy:
Some studies have shown that it can reduce the risk of colon
polyps in those who have previously had colon cancer.
HEMORRHOID
 What Are Hemorrhoids?
Alternative Names
Rectal Lump
Piles
Lump in the Rectum
Definition:
Dilated or enlarged veins in the lower
portion of the rectum or anus.
 Cont.
Two Types:
Internal- Under the skin
External- Around the anus
Grades:
I- Hemorrhoids only bleed
II- Prolapse and reduce spontaneously
III- Require replacement
!V- Permanently Prolapsed
 Frequency
10 million
Peak ages: 45-65 years
of adults experience hemorrhoids by
age 50
Common among pregnant women
Temporary
 Symptoms
Rectal Bleeding
Bright red blood in stool
Pain during bowel movements
Anal Itching
Rectal Prolapse
Thrombus
 Causes
Pressure
Constipation
Diarrhea
Sitting or standing for long periods of
time
Obesity
Heavy Lifting
Pregnancy
 Signs and Tests
Rectal Examination
Visual
Digital
Tests
Stool test
Sigmoidoscopy
Anoscopy
 Referral
Gastroenterologists
Seek emergency care if :
large amounts of rectal bleeding
Lightheadedness
Weakness
Rapid HR < 100 BPM
Stage and Treatment for Haemorrhoids

I Enlargement with bleeding

Fiber supplementation
Cortisone suppository
Sclerotherapy

II Protrusion with spontaneous reduction

Fiber supplementation
Cortisone suppository
III Protrusion requiring manual reduction
Fiber supplementation
Cortisone suppository
Banding
Operative hemorrhoidectomy (stapled or
traditional)

IV Irreducible protrusion
Fiber supplementation
Cortisone suppository
Operative hemorrhoidectomy
 Treatment
Non pharmacology : improvement of lifestyle, eating and
drinking patterns, the pattern / way of defecation (diet,
fluids, additional fiber, changes in bowel behavior)
Pharmacology:
drugs improve defecation: fiber supplement (psilium,
isphagula), laxans, sodium dioctyl sulfosucsina
symptomatic medications: anusol, boraginol,
corticosteroids
medication to stop the bleeding: psilium, citrus
bioflavanoids, diosmin and hesperidin mixture
cure and prevention hemorrhoid attack: ardium
minimal invasive: hemorrhoids sclerotherapy, ligation
hemorrhoids, hemorrhoids treatment with laser
therapy
 Treatments
For painful or persistant hemorrhoids:
Tying off a hemorrhoid
Sclerotherapy
Infered Light
Laser Therapy
Freezing
Electrical Current
Surgery
 Treatment Non-surgical
Mild cases are controlled by:
Preventing constipation
Drinking Fluids
High-fiber diet
Use of Fiber supplements
Stool softeners
 Cont.
Apply and OTC cream or suppository
containing hydrocortisone
Keep anal area clean
Soak in a warm bath
Apply ice packs or compresses x 10min
 Cont.
If prolapses, gently push back into anal
canal
Use a sitz bath with warm water
Use moist towelettes or wet toilet
paper instead of dry toilet paper.
 To remove a hemorrhoid using rubber band ligation,
your surgeon inserts a small tool called a ligator
through a lighted tube (scope) in the anal canal and
grasps the hemorrhoid with forceps.
Sliding the ligator's cylinder upward releases rubber
bands around the base of the hemorrhoid.
Rubber bands cut off the hemorrhoid's blood supply,
causing it to wither and drop off.
 Hemorrhoid Surgery
Alternative Name: Hemorrhoidectomy
Hemorrhoid surgery is the removal of
enlarged veins around the anus
 Cont.
Indications
Persistent itching
Anal bleeding
Pain
Blood clots
Infection
 Cont.
Risks
Reactions to medications of anestesia
Bleeding
Infection
Narrowing of the anus

*The outcome is usually very good in

the majority of cases.
 Complications
The blood in the enlarged veins may
form clots and the tissue surrounding
the hemorrhoids can die (Necrosis)
This causes painful lumps in the anal
area.
Severe bleeding can occur causing iron
deficiency anemia.
 Prevention
Eat high fiber diet
Drink Plenty of Liquids
Fiber Supplements
Exercise
Avoid long periods of standing or sitting
Dont Strain
Go as soon as you feel the urge