Upper Gastrointestinal Bleeding (UGIB) Quiz
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Upper Gastrointestinal Bleeding (UGIB) Quiz

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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.

<p>False</p> Signup and view all the answers

Preoperative bowel cleansing is necessary before surgery for anal fistula.

<p>True</p> Signup and view all the answers

Fistulotomy is a surgical procedure for high level fistulas.

<p>False</p> Signup and view all the answers

Anal fistula is classified as acute or chronic based on its pathologic features.

<p>False</p> Signup and view all the answers

Digital examination is necessary for diagnosis of anal fissure.

<p>True</p> Signup and view all the answers

A patient with anal fissure usually presents with diarrhea.

<p>False</p> Signup and view all the answers

Big ulcers and fissures can be found in patients with HIV and other viral infections.

<p>True</p> Signup and view all the answers

What is the common feature of pain experienced by a patient with anal fissure?

<p>Sharp, severe pain starting during defecation and lasting an hour or more, ceasing suddenly to reappear during the next bowel motion.</p> Signup and view all the answers

What is the purpose of protective colostomy in the management of high level fistulas?

<p>To prevent infection and facilitate healing.</p> Signup and view all the answers

What is the significance of a sentinel pile in anal fissure examination?

<p>It is a visible skin tag at the anal verge, indicating the presence of an anal fissure.</p> Signup and view all the answers

What is the primary goal of conservative management in anal fissure treatment?

<p>To encourage the passing of soft, bulky stools to aid in healing.</p> Signup and view all the answers

What is the surgical procedure of choice for low level fistulas?

<p>Laying open the entire fistulous tract, also known as fistulotomy.</p> Signup and view all the answers

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.

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