Podcast
Questions and Answers
An anal fissure is a small tear in the upper anal canal.
False
A sentinel pile is a small ulcer at the anal verge.
False
Lateral anal sphincterotomy is a surgical procedure for anal fistula.
False
A high fiber diet is recommended for patients with anal fistula.
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Preoperative bowel cleansing is necessary before surgery for anal fistula.
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Fistulotomy is a surgical procedure for high level fistulas.
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Anal fistula is classified as acute or chronic based on its pathologic features.
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Digital examination is necessary for diagnosis of anal fissure.
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A patient with anal fissure usually presents with diarrhea.
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Big ulcers and fissures can be found in patients with HIV and other viral infections.
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What is the common feature of pain experienced by a patient with anal fissure?
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What is the purpose of protective colostomy in the management of high level fistulas?
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What is the significance of a sentinel pile in anal fissure examination?
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What is the primary goal of conservative management in anal fissure treatment?
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What is the surgical procedure of choice for low level fistulas?
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Study Notes
Gastrointestinal Bleeding
Upper Gastrointestinal Bleeding (UGIB)
- Defined as blood loss originating from a site in the GIT proximal to the ligament of Treitz
- Etiology:
- Peptic ulcer (commonest cause, with duodenal ulcer bleeding four times more common than gastric ulcer)
- Varices
- Gastritis (acute mucosal erosions)
- Gastric neoplasms (carcinoma of the stomach, adenoma, angioma, lymphoma, etc.)
- Stress ulcer
- Mallory-Weiss tears (longitudinal mucosal tears extending across the esophagogastric junction)
- Others (esophagitis, vascular malformations, systemic diseases leading to bleeding and coagulation abnormalities)
Signs and Symptoms of UGIB
- Hematemesis (vomiting of blood, which may be a coffee ground material, fresh blood, or blood clots)
- Melena (passage of black tar-like stool due to mixing with altered blood)
- Hematochezia (passage of liquid blood or blood clots per rectum)
Work-up and Management of UGIB
- Initial evaluation: assessment of clinical features, identification of patients who need immediate intervention, and suspicion of the possible site of bleeding and cause
- History: inquiries about scoiodemagraphic variables, PUD history, ingestion of drugs implicated as causes of GI bleeding, liver diseases, co-morbid diseases, and symptoms of bleeding diathesis
- Urgent examination: signs suggestive of seriously depleted blood volume and probably continuing blood loss
- Management:
- Resuscitation: restoration of blood volume with rapid crystalloid infusion, blood transfusion, and monitoring response to resuscitation measures
- Alleviating anxiety and pain
- Placing nasogastric tube to monitor rate of bleeding and for saline lavage
- Diagnostic evaluation: esophago-gastro-duodenoscopy, other studies performed based on endoscopy findings and availability of facilities
- Further management: depending on the underlying cause, including medical therapy, endoscopic therapy, and surgical therapy
Lower Gastrointestinal Bleeding (LGIB)
Types of LGIB
- Small intestinal bleeding
- Colorectal bleeding
- Anorectal bleeding
Causes of Colorectal Bleeding
- Neoplasms and polyps
- Diverticulosis/diverticulitis
- Vascular malformations
- Inflammatory causes (intestinal tuberculosis, inflammatory bowel diseases)
Clinical Evaluation of LGIB
- History: note the presence of hematochezia, chronic bleeding, and symptoms related to causes of UGIB
- Physical examination: assessment of hemodynamic status, clinical diagnosis of the possible underlying cause and site of bleeding, and signs of chronic blood loss
Management of LGIB
- Resuscitation: initiation while assessing the patient and monitoring progress closely
- Diagnostic evaluation: further clinical assessment and investigations performed after the patient is hemodynamically stable
- Specific treatment: depending on the underlying cause, including medical therapy, operative therapy, or endoscopic therapy
Colorectal Tumors
Clinical Features of Colorectal Carcinoma
- Nonspecific symptoms: anemia, loss of appetite, weight loss, generalized body weakness
- Local effects of the tumor: palpable lump, features of appendiceal mass, change in bowel habit, passage of mucus, tenesmus, sense of incomplete defecation
- Investigation: stool examination, sigmoidoscopy, colonoscopy, barium enema, biopsy under endoscopic guide
- Management: depending on mode of presentation, stage of the disease, site of the primary lesion, and presence or absence of multiple lesions
Anorectal Abscesses
Clinical Features
- Pain (usually severe), fever, constitutional symptoms, features of proctitis, and constipation
- Physical findings: lump visible and palpable at the anal margin/anal canal or ischiorectal fossa, tenderness, and rectal tender mass
Management
- Abscess drainage as soon as diagnosed, followed by irrigation, packing with saline-soaked gauze, and Sitz bath twice daily till wound healing
- Antibiotics used together with surgical treatment, especially in immunocompromised patients
Perianal Fistulas (Fistula in Ano)
Definition
- A track lined by granulation tissue, connecting the anal canal or rectum internally with the skin around the anus externally
Causes
- Usually an untreated or inadequately treated anorectal abscess
- Granulomatous infections and inflammatory bowel diseases
Clinical Features
- Seropurulent discharge with perianal irritation
- External opening seen as a small elevated opening on the skin around the anus with a granulation
- Internal opening felt as a nodule on digital rectal examination
- Signs of underlying/associated diseases
Anal Fissure (Fissure in Ano)
Definition
- An elongated tear (ulcer) in the lower anal canal, which lies along the long axis of the canal
Etiology
- Passage of hard fecal mass precipitates and aggravates the condition
Clinical Features
- Pain (commonest feature)
- Characteristic sharp, severe pain starting during defecation and lasting an hour or more, ceasing suddenly to reappear during the next bowel motion
- Constipation: patient tends to be constipated for fear of the pain on defecation### Symptoms of Anal Fissure
- Bright streaks of blood on the stool surface or toilet paper indicate bleeding
- Discharge is common in chronic cases
- Manifestations of underlying diseases and/or complications may also occur
Physical Examination
- Tightly closed anus due to sphincter spasm may be observed
- Sentinel pile (skin tag) may be visible at the anal verge
- Lower end of the fissure can be seen on gentle parting of the buttocks
- Digital examination may not detect the fissure in early cases
- In fully established cases, the fissure may feel like a vertical crack in the anal canal
- Patients with HIV and other viral infections may have big ulcers and fissures
Conservative Management
- Recommended for small, acute, and superficial fissures that may heal spontaneously
- Includes a high fiber diet, high fluid intake, and a mild laxative to encourage soft, bulky stools
- Local anesthetic ointment or suppository may be administered
Surgical Measures
- Needed when conservative management fails, or in cases of chronic fissures with fibrosis, skin tag, or mucous polyp, or recurrent anal fissures
- Procedures include lateral anal sphincterotomy, fissurectomy, and sphincterotomy
- Requires an experienced operator to reduce complications such as hematoma formation, incontinence, and mucosal prolapse
- After-care includes bowel care, daily baths, and stool softening until wound healing occurs
Gastrointestinal Bleeding
Upper Gastrointestinal Bleeding (UGIB)
- Defined as blood loss originating from a site in the GIT proximal to the ligament of Treitz
- Etiology:
- Peptic ulcer (commonest cause, with duodenal ulcer bleeding four times more common than gastric ulcer)
- Varices
- Gastritis (acute mucosal erosions)
- Gastric neoplasms (carcinoma of the stomach, adenoma, angioma, lymphoma, etc.)
- Stress ulcer
- Mallory-Weiss tears (longitudinal mucosal tears extending across the esophagogastric junction)
- Others (esophagitis, vascular malformations, systemic diseases leading to bleeding and coagulation abnormalities)
Signs and Symptoms of UGIB
- Hematemesis (vomiting of blood, which may be a coffee ground material, fresh blood, or blood clots)
- Melena (passage of black tar-like stool due to mixing with altered blood)
- Hematochezia (passage of liquid blood or blood clots per rectum)
Work-up and Management of UGIB
- Initial evaluation: assessment of clinical features, identification of patients who need immediate intervention, and suspicion of the possible site of bleeding and cause
- History: inquiries about scoiodemagraphic variables, PUD history, ingestion of drugs implicated as causes of GI bleeding, liver diseases, co-morbid diseases, and symptoms of bleeding diathesis
- Urgent examination: signs suggestive of seriously depleted blood volume and probably continuing blood loss
- Management:
- Resuscitation: restoration of blood volume with rapid crystalloid infusion, blood transfusion, and monitoring response to resuscitation measures
- Alleviating anxiety and pain
- Placing nasogastric tube to monitor rate of bleeding and for saline lavage
- Diagnostic evaluation: esophago-gastro-duodenoscopy, other studies performed based on endoscopy findings and availability of facilities
- Further management: depending on the underlying cause, including medical therapy, endoscopic therapy, and surgical therapy
Lower Gastrointestinal Bleeding (LGIB)
Types of LGIB
- Small intestinal bleeding
- Colorectal bleeding
- Anorectal bleeding
Causes of Colorectal Bleeding
- Neoplasms and polyps
- Diverticulosis/diverticulitis
- Vascular malformations
- Inflammatory causes (intestinal tuberculosis, inflammatory bowel diseases)
Clinical Evaluation of LGIB
- History: note the presence of hematochezia, chronic bleeding, and symptoms related to causes of UGIB
- Physical examination: assessment of hemodynamic status, clinical diagnosis of the possible underlying cause and site of bleeding, and signs of chronic blood loss
Management of LGIB
- Resuscitation: initiation while assessing the patient and monitoring progress closely
- Diagnostic evaluation: further clinical assessment and investigations performed after the patient is hemodynamically stable
- Specific treatment: depending on the underlying cause, including medical therapy, operative therapy, or endoscopic therapy
Colorectal Tumors
Clinical Features of Colorectal Carcinoma
- Nonspecific symptoms: anemia, loss of appetite, weight loss, generalized body weakness
- Local effects of the tumor: palpable lump, features of appendiceal mass, change in bowel habit, passage of mucus, tenesmus, sense of incomplete defecation
- Investigation: stool examination, sigmoidoscopy, colonoscopy, barium enema, biopsy under endoscopic guide
- Management: depending on mode of presentation, stage of the disease, site of the primary lesion, and presence or absence of multiple lesions
Anorectal Abscesses
Clinical Features
- Pain (usually severe), fever, constitutional symptoms, features of proctitis, and constipation
- Physical findings: lump visible and palpable at the anal margin/anal canal or ischiorectal fossa, tenderness, and rectal tender mass
Management
- Abscess drainage as soon as diagnosed, followed by irrigation, packing with saline-soaked gauze, and Sitz bath twice daily till wound healing
- Antibiotics used together with surgical treatment, especially in immunocompromised patients
Perianal Fistulas (Fistula in Ano)
Definition
- A track lined by granulation tissue, connecting the anal canal or rectum internally with the skin around the anus externally
Causes
- Usually an untreated or inadequately treated anorectal abscess
- Granulomatous infections and inflammatory bowel diseases
Clinical Features
- Seropurulent discharge with perianal irritation
- External opening seen as a small elevated opening on the skin around the anus with a granulation
- Internal opening felt as a nodule on digital rectal examination
- Signs of underlying/associated diseases
Anal Fissure (Fissure in Ano)
Definition
- An elongated tear (ulcer) in the lower anal canal, which lies along the long axis of the canal
Etiology
- Passage of hard fecal mass precipitates and aggravates the condition
Clinical Features
- Pain (commonest feature)
- Characteristic sharp, severe pain starting during defecation and lasting an hour or more, ceasing suddenly to reappear during the next bowel motion
- Constipation: patient tends to be constipated for fear of the pain on defecation### Symptoms of Anal Fissure
- Bright streaks of blood on the stool surface or toilet paper indicate bleeding
- Discharge is common in chronic cases
- Manifestations of underlying diseases and/or complications may also occur
Physical Examination
- Tightly closed anus due to sphincter spasm may be observed
- Sentinel pile (skin tag) may be visible at the anal verge
- Lower end of the fissure can be seen on gentle parting of the buttocks
- Digital examination may not detect the fissure in early cases
- In fully established cases, the fissure may feel like a vertical crack in the anal canal
- Patients with HIV and other viral infections may have big ulcers and fissures
Conservative Management
- Recommended for small, acute, and superficial fissures that may heal spontaneously
- Includes a high fiber diet, high fluid intake, and a mild laxative to encourage soft, bulky stools
- Local anesthetic ointment or suppository may be administered
Surgical Measures
- Needed when conservative management fails, or in cases of chronic fissures with fibrosis, skin tag, or mucous polyp, or recurrent anal fissures
- Procedures include lateral anal sphincterotomy, fissurectomy, and sphincterotomy
- Requires an experienced operator to reduce complications such as hematoma formation, incontinence, and mucosal prolapse
- After-care includes bowel care, daily baths, and stool softening until wound healing occurs
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Test your knowledge on Upper Gastrointestinal Bleeding, its definition, symptoms, and management. Learn about the mortality and morbidity rates, especially in the elderly.