Gastroenterology 2+3.pdf

‫ﺻﻌﻮﺑﮫ ﺑﺎﻟﺒﻠﻊ‬ Dysphagia is defined as difficulty in swallowing. Globus sensation. Upper oesophageal sphincter ‫ﻓﻲ ﻓﺘﺮات اﻟﺘﻲ ﻣﯿﺎﻛﻞ ﺑﯿﮫ ﯾﻨﺴﺪ‬ ‫وﻣﻦ ﯾﺎﻛﻞ رح ﯾﻨﻔﺘﺢ وﻛﻠﺸﻲ ﻣﺎﻛﻮ‬ Odynophagia ‫اﻟﻢ ﺑﺎﻟﺒﻠﻊ‬ Food impaction ‫اﻟﻄ...

‫ﺻﻌﻮﺑﮫ ﺑﺎﻟﺒﻠﻊ‬ Dysphagia is defined as difficulty in swallowing. Globus sensation. Upper oesophageal sphincter ‫ﻓﻲ ﻓﺘﺮات اﻟﺘﻲ ﻣﯿﺎﻛﻞ ﺑﯿﮫ ﯾﻨﺴﺪ‬ ‫وﻣﻦ ﯾﺎﻛﻞ رح ﯾﻨﻔﺘﺢ وﻛﻠﺸﻲ ﻣﺎﻛﻮ‬ Odynophagia ‫اﻟﻢ ﺑﺎﻟﺒﻠﻊ‬ Food impaction ‫اﻟﻄﻌﺎم ﯾﻌﻠﻚ ﺑﺎﻟﻤﺮﯾﺊ وورا ﺷﻮﯾﮫ ﺗﻨﺰل اﻟﻠﻜﻤﮫ‬ initiation of swallowing  ‫اﻟﻔﺤﺺ اﻟﻤﻔﻀﻞ‬ Endoscopy is the investigation ‫ﯾﻮﺳﻊ‬ of choice because it ‫ﯾﺎﺧﺬ ﺧﺰﻋﮫ‬ allows biopsy and dilatation of strictures.‫اﻻﻧﺴﺪاد‬ Even if the appearances are normal, biopsies should ‫ﺳﺎﺋﻞ ﻧﺸﺮﺑﮫ وﻧﻮب ﻧﺼﻮر اﺷﻌﮫ‬ be taken to look for eosinophilic oesophagitis If no abnormality is found, then barium swallow with videofluoroscopic swallowing assessment is indicated to detect major motility disorders. In some cases, dysphagia ‫اﺧﺘﺒﺎرات ﻟﻞ‬ oesophageal manometry is required. ‫ اھﻢ ﺷﻲ‬Endoscopy barium swallow ‫اﺧﺘﺒﺎر ﺣﺮﻛﮫ اﻟﻤﺮﯾﺊ‬ videofluoroscopic swallowing oesophageal manometry  ‫اﺧﺘﻨﺎق‬ ‫ﺻﻌﻮﺑﮫ ﺑﺎﻟﺒﻠﻊ‬ ‫ﺻﻌﻮﺑﮫ ﺑﺎﻟﺒﻠﻊ‬ ‫اول ﺳﺆال ﻻزم اﺳﺌﻠﮫ وﯾﻦ ﺗﻮﻛﻒ اﻟﻠﻘﻤﮫ ‪..‬اذا اﺷﺮ‬ ‫ﺑﺎﻟﻤﺮﯾﺊ‬ ‫ﻋﻠﻰ ﺑﻼﻋﯿﻤﮫ … ادزه ﻛﺒﻞ اﻟﻰ ‪ )ENT‬اذن اﻧﻒ‬ ‫ﺑﺎﻟﺒﻠﻌﻮم‬ ‫ﺣﻨﺠﺮه ( ﻻن ﻣﺸﻜﻠﺘﮫ ‪neuro‬‬ ‫ﻧﺸﻮف ﻣﺮﯾﺊ اﺣﻤﺮ‬ ‫‪Normal‬‬ ‫اﻧﺴﺪاد‬ ‫واﻧﻲ ﺷﺎك ‪susception‬‬ ‫ﻋﻨﺪه ‪dysphagia‬‬ ‫ﻓﻄﺮﯾﺎت‬ ‫ﯾﻌﻨﻲ اﻟﺸﺨﺺ ﻋﻨﺪه ﺧﻠﻞ ﺑﺎﻟﺤﺮﻛﮫ ﻣﺮﯾﺊ‬ ‫وﻧﺴﻮﯾﻠﮫ‬ ‫‪bilateral impairment of‬‬ ‫‪function of the lower cranial‬‬ ‫ﻗﺮﺣﮫ … وﻧﻮب ﯾﺼﯿﺮ اﻟﺘﮭﺎب‬ ‫‪nerves IX, X, XI and XII‬‬ ‫…ﻧﻮب ﯾﺼﯿﺮ ﺗﻠﯿﻒ‬ ‫ﻧﻜﺪر ﻧﻔﺮق اﻟﺤﻤﯿﺪ ﻋﻦ اﻟﺨﺒﯿﺚ ‪..‬اﻧﻮ‬ ‫اﻟﺤﻤﯿﺪ ﯾﺤﺘﺎج وﻗﺖ وﯾﺼﯿﺮ ﺻﻌﻮﺑﮫ‬ ‫ﺑﺎﻟﺒﻠﻊ ) ﯾﻌﻨﻲ ﻣﺮﯾﺾ ﯾﻜﻮل ﺻﺎرﻟﻲ ﺳﻨﮫ‬ ‫وﺷﻮﯾﮫ ﺷﻮﯾﮫ دﯾﺰداد اﻟﺼﻌﻮﺑﮫ (‬ ‫ﺑﯿﻨﻤﺎ اﻟﺨﺒﯿﺚ ﻓﺠﺄ ﺻﺎر ﺻﻌﻮﺑﮫ‬ ‫ﺿﻐﻂ ﻣﻦ ﺧﺎرج‬ ‫اﻟﻤﺮﯾﺊ ) ﻣﺜﻼ ﻗﻠﺐ(‬  Barium swallow = oesophageal ‫ﻣﻮﺿﻮع ﻣﺎﻟﮫ ﻋﻼﻗﮫ‬ Barium meal = stomach ‫ﻋﺪم ارﺗﯿﺎح ﺑﻌﺪ اﻛﻞ‬ Barium follow through = small intestinal ‫ﺑﺲ اﻗﺮا ﻣﮭﻢ‬.. ‫ﺑﺎﻟﻤﻠﺰﻣﮫ‬ Barium enema = colon endoscopy ‫ ﻛﺒﻞ ﻧﺪز ﻣﺮﯾﺾ‬55 ‫ھﻲ ﻋﺮض ﺳﺨﯿﻒ ﻣﻮ ﻣﮭﻢ ﺑﺲ اذا ﺗﺼﯿﺮ ورا ﺳﻦ‬ ‫واﻟﺘﻲ ﯾﻌﺘﻘﺪ‬ discomfort, bloating and nausea, which are thought to originate from the upper gastrointestinal tract. ( amprazol ‫ﺷﺎب اذا ﯾﺎﻛﻞ ﺑﺎﺟﮫ وﺑﻄﻨﮫ وﺟﻌﺘﮫ اﻛﻠﮫ روح‬ ‫ﻻھﻠﻚ وﻛﻠﺸﻲ ﻣﺎﺑﯿﻚ ) او ﻧﻨﻄﻲ‬ ‫اﻧﮭﺎ ﺗﻨﺸﺄ‬ ‫ ﻛﺒﻞ ﻧﺪزه ﻧﺎظﻮر‬55 ‫ﺑﺲ اذا ﻛﺎن ﺷﺨﺺ ورا‬ %100 ‫او‬ Dyspepsia affects up to 80% of the population at some time in life and most patients have no serious underlying disease. ‫ﯾﻌﺎﻧﻮن‬ People who present with new dyspepsia at an age of more ‫ﻻ ﯾﺴﺘﺠﯿﺒﻮن‬ than 55 years and younger patients unresponsive to empirical treatment require investigation to exclude serious ‫ﻻﺳﺘﺒﻌﺎد‬ disease. ‫أي واﺣﺪ ﯾﻜﻠﻮﻟﻚ ﻋﻨﺪي ‪ Dyspepsia‬ﻓﻼزم أﺳﺄل ﻛﻞ اﻷﺳﺌﻠﺔ ھﺎي‬ ‫ﻣﯿﺰات ﻣﮭﻤﮫ‬  ‫اﻗﻞ‬ ‫اﻛﺒﺮ‬ ‫ﻋﺎﺟﻞ‬ ‫ﻋﻨﺪه‬ ‫ﻗﻀﺎء‬ ‫ﻧﺤﻠﺖ‬  ‫ارﺗﺠﺎع‬ Heartburn describes retrosternal, burning discomfort, often rising up into the chest and sometimes accompanied by regurgitation of acidic or bitter fluid into the throat. ‫ﯾﺴﺘﻠﻘﻲ‬ These symptoms often occur after meals, on lying down or with ‫ﯾﻨﺤﻨﻲ‬ bending, straining or heavy lifting.‫ﯾﺸﯿﻞ ﺣﻤﻞ‬ They are classical symptoms of gastro-oesophageal reflux but up to 50% of patients present with other symptoms (atypical), such as chest pain, belching, halitosis, chronic cough or sore throats. ‫ﯾﺘﺮﯾﻊ‬ ‫رﯾﺤﮫ ﺣﻠﻜﮫ ﻣﻄﯿﺒﮫ‬ In young patients with typical symptoms and a good response to dietary changes, antacids or acid suppression investigation is not required, but in patients over 55 years of age and those with alarm symptoms or atypical features urgent endoscopy is necessary. ‫ﺷﺨﺺ ﺷﺎب وﻋﻨﺪه ھﺬا ﺣﺮﻗﮫ ﻓﻮاﺋﺪ اﻧﻄﻲ ﻋﻼج‬.. ‫ﻧﻔﺲ اﻟﺸﻲ‬ ‫ ﺳﻨﮫ اﺳﻮﯾﻠﮫ ﻧﺎظﻮر‬55 ‫ﺑﺲ اذا ﺷﺨﺺ ورا‬  ‫اﺳﺒﺎب ھﻮاي‬ ‫اذن ﺗﺸﺨﯿﺼﮫ ﺻﻌﺐ‬ It is important to distinguish true vomiting from regurgitation and to elicit whether the vomiting is acute or chronic (recurrent), as the underlying causes may differ. ‫ﻣﻦ ﯾﺠﻮك ﻟﻼﺳﺘﺸﺎرﯾﺔ ﯾﻮﺻﻒ اﻟﺘﻘﻲء ﺑﮭﻞ ﻣﻌﺎﻧﻲ‬ ‫ارد على راسي‬ ‫ازوع‬ ‫استفرغ‬ ‫اهوع‬ ‫اجدف‬ ‫اتقيأ‬ ‫اتقيد‬  most common gastrointestinal emergency. ‫ ﻣﺮات ﺑﺎﻟﯿﻮم‬or 5,4 ‫ﺗﺸﻮﻓﮭﺎ ﺑﺎﻟﯿﻮم‬ Mortality 10% ‫ﯾﻤﻮﺗﻮن ﺑﯿﮭﺎ ھﻢ ھﻮاي‬ Blatchford score ١٤ ‫ﻣﻮﺟﻮد ب ﺳﻼﯾﺪ‬  ‫اﺧﺬﻧﺎ ﺑﺎﻟﻤﺮﺣﻠﮫ ﺛﺎﻟﺜﮫ‪..‬ﺷﺨﺺ ﻣﻦ ﯾﺸﺮب ﻋﺮك رح‬ ‫ﯾﺰوع ھﻮاي وﯾﻨﺸﻚ اﻟﻤﺮﯾﺊ وﯾﺰوع دم … ھﺬا ﺣﻠﻮ‬ ‫ﺑﺎﻟﺘﺸﺨﯿﺺ ‪..‬ﻻن اي ﺳﺒﺐ ﻋﺪا ھﺬا ﻣﻦ ﯾﺰوع دم اول‬ ‫ﻣﺮا ﯾﻜﻮن ھﻮاي وﺛﺎﻧﻲ ﺗﺰوﯾﻌﮫ ﯾﻘﻞ اﻟﺪم‬ ‫ﺑﺲ ھﺬا ﺑﺎﻟﻌﻜﺲ ﻣﻦ ﯾﺰوع اول ﻣﺮا دم ﻗﻠﯿﻞ او ﻣﺎﻛﻮ ‪..‬‬ ‫وﺛﺎﻧﻲ ﺗﺰوﯾﮫ ﯾﻄﻠﻊ دم ھﻮاي‬  ‫ھﺬا اﻟﺠﺪول ﻣﺎدري اذا ﻣﻄﻠﻮب او ﻻ … ﺑﺲ اﻟﺪﻛﺘﻮر ﻛﺎل‬ ‫ھﺬا ﺣﯿﺘﻮزع ﺑﺎﻟﻄﻮارئ وﯾﺒﻘﻰ ﯾﻤﻚ ‪..‬اﻟﻤﮭﻢ ﺧﻠﻨﺤﺠﻲ ﻋﻠﯿﮫ‬ ‫اﺟﺎك ﺷﺨﺺ ﺑﺎﻟﻄﻮارئ ﻋﻨﺪه ﻣﺮض ‪ A‬وﯾﺰوع دم‬ ‫واﺟﺎك ﺷﺨﺺ ﺛﺎﻧﻲ ﻋﻨﺪه ﻣﺮض ‪ B‬وﯾﺰوع دم‬ ‫ﻣﻨﻮ رح ﺗﻌﺎﻟﺞ اول ﺷﻲ ؟‬ ‫رح ﻧﻌﺎﻟﺞ ﺣﺴﺐ اﻟﺠﺪول ) اﻟﻌﻨﺪه ‪ score‬اﻋﻠﻰ ﯾﺘﻌﺎﻟﺞ اوﻻ(‬ ‫زﯾﻦ وﯾﻦ ال ‪ score‬؟‬  Clinical assessment Upper git bleeding Red? Black? Syncope? Symptoms of anaemia? Melaena? Lower git bleeding ‫ وﻣﻦ ھﻠﻜﺪ ﻣﺎ ھﻮاي ﺣﯿﻨﺰل اﻟﺪم‬upper ‫اﺣﺘﻤﺎل‬ ‫ﻟﻼﻣﻌﺎء وﯾﻄﻠﻊ اﺣﻤﺮ ﺑﺎﻟﺨﺮوج‬ coffee ground ‫ﯾﺸﺒﮭ‬ ‫ﺗﺴﻠﺴﻞ ﻣﮭﻢ ‪Management‬‬ ‫اي ﺧﻄﺎ ﺑﺎﻟﺘﺴﻠﺴﻞ … رح ﯾﻘﺘﻞ ﺑﺸﺮ‬ ‫‪1. Intravenous access‬‬ ‫ﻧﺸﺪﻟﮫ ﻛﺎﻧﻮﻧﺘﯿﻦ وﯾﻔﻀﻞ ﺗﻜﻮن ‪wide‬‬ ‫‪2. Initial clinical assessment:‬‬ ‫ﻧﻘﯿﺲ ﺿﻐﻂ ‪a) Define circulatory status,‬‬ ‫ﺗﺴﺎﻟﮭ ھﻞ ﻋﻨﺪك اﻣﺮاض ﺑﺎﻟﻜﺒﺪ ‪b) Seek evidence of liver disease,‬‬ ‫اﻟﺤﺎﻻت اﻟﻤﺮﺿﯿﺔ اﻟﻤﺰﻣﻨﮭ ﺗﺴﺎﻟﮭ ﺷﻌﻨﺪه ﻣﺎﻋﻨﺪه ‪c) Identify comorbidity‬‬ ‫‪3. Basic investigations:‬‬ ‫ﻟﯿﺶ ﻧﺴﻞ ﻋﻦ ﻛﺒﺪ اول ﺷﻲ ؟ ﻧﻮب اﺷﻮف ال ‪score‬‬ ‫‪1. Full blood count‬‬ ‫ﻻن ﺷﻜﻮ ﺳﺒﺐ ﻟﻠﺰواع اﻟﺪم ﯾﺘﻌﺎﻟﺞ ب ‪Amprazol‬‬ ‫ف اﻧﻄﻲ ﻛﺒﻞ ھﺬا ﻋﻼج وﯾﺼﯿﺮ زﯾﻦ‬ ‫‪2. Urea and electrolytes‬‬ ‫‪3. Liver function tests‬‬ ‫ﺑﺲ دواﻟﻲ ﻣﺮﯾﺊ ) اﻟﻲ ﺳﺒﺒﮫ ﺧﻠﻞ ﺑﺎﻟﻜﺒﺪ ( ﻣﯿﺘﻌﺎﻟﺞ ب ‪amprazol‬‬ ‫ف اﻧﻲ اﺳﺌﻠﮫ اذا ﻣﺎﻋﻨﺪه ﺧﻠﻞ ﺑﺎﻟﻜﺒﺪ ﯾﻌﻨﻲ ال‪ amprazol‬ﯾﻔﯿﺪ‬ ‫‪4. Prothrombin time.‬‬ ‫اﻟﻤﺮﯾﺾ ﺑﻜﻞ ﺣﺎﻻﺗﮫ‬ ‫‪5. Cross-matching‬‬ Management 4. Resuscitation ‫اﻧﻌﺎش‬ 5. Oxygen ( ‫اﻧﻄﻲ ﻋﻤﯿﻮاي )ﺑﺪون ﻣﺘﻘﯿﺲ اوﻛﺴﺠﯿﻦ ﻣﺎﻟﺘﮫ‬ 6. Endoscopy: I. heater probe ‫ﯾﺠﻮي ﻟﻠﺸﻖ وﯾﺴﺪه‬ II. endoscopic clips ‫ﻛﻠﺒﺴﺎت ﺗﺴﺪ اﻟﺸﻖ‬ III. dilute adrenaline ‫ وﯾﺴﺬ اﻟﺸﻖ‬vasoconstriction ‫ﺣﺘﮫ ﯾﺴﻮي‬ IV. Haemospray ‫ﺑﺨﺎخ ﯾﺘﻔﺎﻋﻞ وﯾﮫ دم وﯾﺴﻮي ﺧﺜﺮه وﯾﺴﺪ ﻣﻜﺎن اﻟﺸﻖ‬ V. band ligation VI. balloon tamponade VII.transjugular intrahepatic portosystemic shunt  ? ‫ورا ﻣﺎ ﺳﻮﯾﺘﮭ وﻛﺪرت ﺗﺨﻠﻲ ع ﻗﯿﺪ اﻟﺤﯿﺎة ﺷﻨﻮ ﺗﺴﻮي وراھﺎ‬ 7. Monitoring ‫ﺗﺒﻘﻰ ﺗﺮاﻗﺒﮭ‬ 8. Surgery: If available, angiographic embolisation is an ‫اﻟﻀﻌﻔﺎء‬ effective alternative to surgery in frail patients. 9. Eradication. ‫اذا ﻣﺎ ﻓﺎد اﻟﻌﻼج ﺑﺎﻟﻨﺎظﻮر … ﻧﺴﻮﯾﻠﮫ ﺟﺮاﺣﮫ‬ ‫‪This may be caused by haemorrhage from the colon, anal canal‬‬ ‫‪or small bowel.‬‬ ‫واﺣﺪ ﻣﻦ ﯾﻄﻠﻊ دم ﻣﻦ ﺧﺮوﺟﮫ ﺣﻔﻜﺮ ب ‪ 3‬ﺣﺎﻻت‬ ‫‪Upper git bleeding‬‬ ‫‪ -‬ﻧﺰﯾﻒ ﻣﻦ ﻣﻌﺪﺗﮫ‬ ‫‪-‬ﻧﺰﯾﻒ ﻣﻦ ‪rectum‬‬ ‫‪-‬ﻧﺰﯾﻒ ﻣﻦ ‪anal‬‬ ‫ﯾﻌﻨﻲ اذا اﺟﮫ اﻟﻤﺮﯾﺾ وﻛﺎل ﺧﺮوﺟﻲ ﺑﻲ دم ﻻزم اﺳﺘﺒﻌﺪ‬ ‫‪upper git bleeding‬‬ ‫اﻟﺸﺨﺺ اﻟﻲ ‪ upper git bleeding‬واﻟﺪم دﯾﻄﻠﻊ ﻣﻦ ﻣﺨﺮج ﻣﺎﻟﺘﮫ ﻻزم ﺑﺠﻲ اﻟﺸﺨﺺ ﻣﻨﺘﮭﻲ )ﻓﺎﻗﺪ وﻋﯿﮫ(‬ ‫ﺑﻮاﺳﯿﺮ ‪) hemorrhoids‬ﯾﺤﺲ اﻛﻮ ﻟﺤﻢ زﯾﺎد ﺑﺎﻟﻤﺨﺮج(وﻣﻦ ﯾﻠﻌﺐ ﺑﯿﮫ ﺗﻨﺰف دم‬ ‫ﻣﻦ اﺷﻮﻓﮭﻢ اﻛﻮل ‪anal bleeding‬‬ ‫‪Anal bleeding‬‬ ‫ﺑﺲ ﺻﺮاﺣﮫ ﻣﻮ ﻛﺒﻞ اﻛﻮ ‪anal bleeding‬‬ ‫ﺷﻖ ‪ fissure‬ﻋﻨﺪه ﻗﺒﺾ وﯾﻌﺼﺮ ﻗﻮي وﯾﻄﻠﻊ ﺑﻌﺮور واﻟﻢ ﻗﻮي ﻛﻠﺶ وﯾﺬب دم‬ ‫ﻻن اﺣﺘﻤﺎل اﻛﻮ ‪ fissure‬و‪cancer‬‬ ‫وﺳﺒﺐ اﻟﻨﺰﯾﻒ ھﻮ ‪cancer‬‬ ‫ھﺎي اﻓﺮق ﺑﯿﮫ ﻣﻦ ﺧﻼل اﻟﻌﻤﺮ… اذا ﺷﺨﺺ ﺷﺎب وﯾﻨﺰف دم واﺷﻮف ﻋﻨﺪه ‪ fissure‬او‪.‬ﺑﻮاﺳﯿﺮ‬ ‫اطﻤﺌﻦ واﻛﻮل ﺳﺒﺐ ﻧﺰﯾﻒ ھﻮ ‪ fissure‬او ﺑﻮاﺳﯿﺮ‬ ‫ﻋﻤﺮه ‪ 70‬ﺳﻨﮫ‬ ‫اذا ﺷﺨﺺ ﻛﺒﯿﺮ ﻋﻨﺪه ﻧﺰﯾﻒ واﻓﺤﺼﮫ اﻟﻜﮫ ﻋﻨﺪه ﺑﻮاﺳﯿﺮ او ‪fissure‬‬ ‫ﺑﻄﻨﮫ ﻗﺒﺾ‬ ‫ﺷﺨﺺ ﻋﻤﺮه ﻓﻮق ‪ 40‬ﺳﻨﮫ ﺗﻘﺮﯾﺒﺎ‬ ‫ﺑﮭﻞ ﺣﺎﻟﮫ ﻣﺎ اﻛﻮل ﺳﺒﺐ ﻧﺰﯾﻒ ھﻮ ﺑﻮاﺳﯿﺮ او ‪fissure‬‬ ‫وﯾﻨﺰف دم ﻣﻦ ﻣﺨﺮﺟﮫ‬ ‫ﻻزم اﺳﻮﯾﻠﮫ ‪colonoscopy‬‬ ‫ﺑﻮاﺳﯿﺮ ‪fissure /‬‬ ‫ﯾﺼﯿﺮ ﺑﺎﻟﺸﺒﺎب طﺒﯿﻌﻲ‬ ‫ﺗﺸﺨﯿﺼﮫ ‪/‬ﺣﻔﻜﺮ ﺑﺤﺎﻻت اﻻﺗﯿﮫ‬ ‫‪Most common‬‬ ‫‪Diverticulosis‬‬ ‫ﺑﺲ ﻻزم ﻧﺪور ﺧﺎف اﻛﻮ ‪ cancer‬ﻣﻦ ﺧﻼل ﻧﺴﻮﯾﻠﮫ ‪colonoscopy‬‬ ‫‪Cancer‬‬ ‫ﻻن ‪ Diverticulosis‬ﻧﺸﺨﺼﮫ ﻣﻦ وﻗﺖ او ﻣﺘﺎﺧﺮﯾﻦ ﻣﺎ ﯾﻀﺮ اﻟﻤﺮﯾﺾ‬ ‫ﺑﻮاﺳﯿﺮ‪fissure/‬‬ ‫‪Angiodysplasia‬‬  Severe acute lower gastrointestinal bleeding Diverticular disease is the most common cause and is often due to ‫ﺗﺂﻛﻞ‬ erosion of an artery within the mouth of a diverticulum ‫ﻣﻦ ﺗﻠﻘﺎء ﻧﻔﺴﮫ‬ Bleeding almost always stops spontaneously, but if it does not, the (diverticular ‫اﻟﻘﻄﻌﮫ اﻟﻤﺼﺎﺑﮫ ﻣﻦ اﻻﻣﻌﺎء) اﻟﻲ طﺎﻟﻊ ﺑﯿﮫ‬ ‫ازاﻟﺘﮭﺎ‬ ‫ﺑﻌﺪ ﺗﺄﻛﺪ‬ diseased segment of colon should be resected after confirmation of the site by angiography or colonoscopy. abnormal, tortuous, dilated small Angiodysplasia blood vessel in the mucosal and submucosal layers of the GI tract ‫ ﺳﻨﮫ‬70-80 ‫واﺣﺪ ﻋﻤﺮه‬ anemia ‫وﻋﻨﺪه‬ Bowel ischaemia skin‫وﻋﻨﺪه ﻣﻈﺎھﺮ ﻣﺎل اوﻋﯿﮫ ﺑﻞ‬ Meckel’s diverticulum most common congenital anomaly of the Diverticular gastrointestinal tract ‫ﺷﺨﺺ ﺑﻜﺪﻧﺎ وﻓﺠﺄه ﯾﻨﺰف دم‬ ‫وﻣﯿﻠﺤﻚ ﻋﻠﻰ ﻧﻔﺴﮫ‬ ‫ﺧﻔﯿﻒ‬  Proctoscopy Subacute or chronic lower gastrointestinal bleeding ‫ﺟﻤﯿﻊ اﻋﻤﺎر‬ ‫ﺑﻮاﺳﯿﺮ‬ All ages: haemorrhoids, anal fissure. ‫اﺣﻤﺮ ﻓﺎﺗﺢ‬ Haemorrhoidal bleeding is bright red and occurs during or ‫ﺗﻐﻮظ‬ after defecation. Proctoscopy can be used to make the diagnosis, but subjects who have altered bowel habit and those who present over the age of 40 years should undergo colonoscopy to exclude coexisting colorectal ‫ﻻﺳﺘﺒﻌﺎد‬ ‫وﺟﻮد‬ cancer. ‫طﺎزج‬ Anal fissure should be suspected when fresh rectal bleeding and anal pain occur during defecation ‫اھﻢ ﺷﻲ‬  ‫‪Terminology‬‬ ‫داﺷﻮﻓﮫ ﺑﻌﯿﻮﻧﻲ ‪Overt‬‬ ‫ﻣﺪا اﺷﻮف ﺑﻌﯿﻮﻧﻲ ‪Occult‬‬ ‫ﺑﺲ ﻣﺎﺷﻮف دم‬ ‫ﻣﺎﻋﺮف ﻣﺼﺪره ﻣﻨﯿﻦ ‪Obscured‬‬  ‫ﻏﯿﺮ ﻣﻌﻠﻮم اﻟﺴﺒﺐ‬ ‫ﺣﺎﻟﮫ ﺧﻄﺮه‬ ‫‪In some patients who present with major gastrointestinal bleeding,‬‬ ‫‪upper endoscopy and colonoscopy fail to reveal a diagnosis.‬‬ ‫ﯾﻔﺸﻠﻮن ﻓﻲ اظﮭﺎر اﻟﺘﺸﺨﯿﺺ‬ ‫‪In some patients‬‬ ‫‪who‬‬ ‫ﻧﺎظﻮر‬ ‫‪present‬‬ ‫ﻧﺴﻮﯾﻠﮫ‬ ‫‪with‬‬ ‫ﺷﺪﯾﺪ وﻣﻨﻠﺤﻚ‬ ‫‪major‬‬ ‫دﯾﻨﺰف‬ ‫‪gastrointestinal‬‬ ‫اﻟﺸﺨﺺ‬ ‫اﻛﯿﺪ‬ ‫‪bleeding,‬‬ ‫‪upper endoscopy and colonoscopy‬‬ ‫ﯾﻄﺐ ب‬ ‫‪shock fail‬‬ ‫واﺣﺘﻤﺎل ‪to‬‬ ‫‪reveal a diagnosis.‬‬ ‫‪There is no emergency colonoscopy‬‬ ‫ﻻن اذا اﺳﻮﯾﻠﮫ ‪ colonoscopy‬ﻻزم اﺣﻀﺮ ﻟﻠﻌﻤﻠﯿﮫ ) ﻣﺜﻼ ﻻزم اﻧﻄﻲ ﻟﻠﻤﺮﯾﺾ دواء ﻣﻠﯿﻦ‬ ‫ﻛﺘﮫ ﯾﻄﻠﻊ ‪ stool‬وادﺧﻞ ﻧﺎظﻮر ﺑﺮاﺣﺘﻲ( ﺑﺲ ھﻮ ﻣﺮﯾﺾ ﺟﺎي ﺑﻠﯿﻞ و‪sever bleeding‬‬ ‫واﻧﻲ اﺳﻮﯾﻠﮫ اﺳﮭﺎل ﺣﯿﻄﺐ ب ‪shock‬‬ ‫ﻓﺮﺿﺎ ﺳﻮﯾﻠﻨﺎ ﺗﺤﻀﯿﺮ ﺑﻐﺾ ﻧﻈﺮ ﻋﻦ ‪ shock‬ودﺧﻠﻨﺎ ﻧﺎظﻮر ﺷﻨﻮ ﺣﻨﺸﻮف ؟‬ ‫‪ Angiodysplasia‬ﺻﻌﺐ ﺟﺪا ﺗﻨﺸﺎف) ﺣﺠﻤﮫ ﺻﻐﯿﺮ(‬ ‫ﺣﺘﻠﻮ ﺷﻔﻨﺎه ﻣﺎﻧﻜﺪر ﻧﻜﺪر ﻧﺴﻮي ﺷﻲ) ﻻن ھﻲ ﺗﻄﯿﺐ ﻣﻦ وﺣﺪه(‬ ‫‪Diverticular disease‬‬ ‫ﺣﺎﻻت ﻋﺎﺟﻠﮫ‬ ‫ﯾﻌﻨﻲ ﺑﺨﺘﺼﺎر ﻣﺎﻛﺪر اﺳﺘﺨﺪم ‪ colonoscopy‬ﺑﺤﺎﻻت ‪urgent‬‬ ‫واﻟﻤﺮﯾﺾ اﻛﯿﺪ ﺣﯿﺠﻲ ﺿﻐﻄﮫ ﻗﻠﯿﻞ وﻋﻨﺪه ﻣﺸﺎﻛﻞ ﺑﺎﻟﻜﻠﻰ ‪..‬اذا ادزه ‪ … CT‬ﻣﯿﺼﯿﺮ ﻻن ﺷﺨﺺ ﻋﻨﺪه ‪shock‬‬ ‫واذا اﺻﯿﺢ ﺟﺮاح ﺣﯿﻔﺘﺢ ﺑﻄﻨﮫ ﻣﺮح ﯾﻮف ﺷﻲ ﻻن اﻟﻨﺰف ﺻﺎﯾﺮ ﻣﻦ داﺧﻞ اﻻﻣﻌﺎء‬ ‫ف اﺳﻮﯾﻠﮫ ھﺎي اﻟﺸﻐﻼت اﻻﺗﯿﮫ‬  special X-ray of the blood vessels (arteries) in the abdomen in order to show where the artery is blocked or bleeding ‫اﻟﻌﺎﺟﻞ‬ When severe‫اوﻋﯿﮫ‬ life-threatening ‫ﺗﺼﻮﯾﺮ‬ bleeding continues, urgent CT mesenteric angiography is indicated. ‫ﯾﺘﺠﺎوز‬ This will usually identify the site if the bleeding rate exceeds 1 mL/min and then formal ‫اﻟﻌﺎدي‬ angiographic embolization ‫وﺿﻊ ﻏﺜﺮه ﻟﺴﺪ اﻟﻨﺰﯾﻒ‬ can often stop the bleeding. ‫اذا ﻣﺎﺷﻔﻨﮫ ﻧﺰﯾﻒ‬ If angiography is negative or bleeding is less severe, push or double ‫ﺗﺼﻮﯾﺮ‬ balloon enteroscopy can visualise the small intestine. Wireless capsule endoscopy is often used to define a source of bleeding prior ‫ﻗﺒﻞ‬ to enteroscopy. nonsurgical procedure that finds and treats problems deep inside the small bowel ‫ﻋﻤﻠﯿﮫ ﺑﺤﯿﺚ ﻧﺼﻐﺮ طﻮل اﻻﻣﻌﺎء ﻣﻦ ﺧﻼل ﺗﻘﺮﯾﺐ اﻻﻣﻌﺎء‬ ‫ﺑﻮاﺳﻄﮫ ﺑﺎﻟﻮﻧﺎت ﺗﻜﻤﺶ ﺑﺎﻻﻣﻌﺎء‬  ‫اھﻞ اﻟﻨﻮاظﯿﺮ ﯾﻮﻛﻔﻮن ﺳﻮﯾﮫ ﻋﻠﻰ ﻣﺮﯾﺾ وﯾﺪورون ﻋﻠﻰ اﻟﻌﻠﮫ‬ When all else fails, laparotomy with on-table endoscopy is indicated  ‫اﺷﺘﺒﺎه‬ ‫ﻣﺎﺷﻮف دم‬ ‫اﺷﻮف دم‬ ‫ﯾﻌﺎﻟﺞ وﻓﻘﺎ ﻟﺤﺎﻟﺘﮫ )ﺣﺴﺐ اﻟﻤﺮض(‬ ‫ﻟﻜﯿﻨﺎ ﻣﻮﻗﻊ اﻟﻨﺰف‬ ‫ﻛﺮر‬ ‫ﺑﺨﺘﺼﺎر دﯾﻜﻠﻚ ﻋﯿﺪ اﻟﻨﺎظﻮر ﻋﻠﻤﻮد ﺗﺘﺎﻛﺪ اﻧﺖ ﻣﻦ ﻣﻮﻗﻊ‬ ‫اﻟﻨﺰﯾﻒ)ﯾﻌﻨﻲ اﺑﻮ ﻧﺎظﻮر ﻣﯿﻔﺘﮭﻢ ﺷﻲ وﻣﯿﻌﺮف ﯾﺸﺘﻐﻞ ﻋﺪل (‬ ‫اذا ﻟﺰم اﻻﻣﺮ‬ ‫ﻣﺎ ﻟﻜﯿﻨﺎ ﻣﻮﻗﻊ اﻟﻨﺰف‬ ‫اﻣﻀﻲ ﻗﺪم ﻟﻔﺤﺺ )‪ ( Small intestine‬ﺑﻌﺘﺒﺎر ﺳﻮﯾﻨﺎ ﻓﺤﺺ ال‪ colon‬ﻋﻦ طﺮﯾﻖ اﻟﻨﺎظﻮر وﻣﺎ ﺷﻔﻨﺎ ﺷﻲ‬ ‫‪VCE = Video capsule endoscopy‬‬ ‫‪MRE = MRI enterography‬‬ ‫‪CTE = computed tomographic enterography‬‬ ‫ھﺎي ﺷﻐﻼت ﻛﻠﮫ ﺗﻔﺤﺺ ‪small intestine‬‬ ‫ﺑﺲ اﻟﻔﺮق ﺷﻨﻮ ﺷﻮﻛﺖ اﺳﺘﺨﺪﻣﮭﻢ ‪..‬‬ ‫‪VCE‬‬ ‫‪Small intestine non-obstruction‬‬ ‫‪MRE‬‬ ‫‪Small intestine obstruction‬‬ ‫‪CTE‬‬ ‫ﻣﻦ ﻧﺸﻮف اﻟﻨﺰﯾﻒ‬ ‫ﻣﻦ ﻣﻨﺸﻮف ﻧﺰﯾﻒ‬ ‫اﻓﺤﺺ ﻣﻦ ﺟﺪﯾﺪ‬ ‫ﻋﻼج دواﺋﻲ‬  ‫ﻧﺰﯾﻒ ھﻮاي ﺑﺲ ﻣﺨﻔﻲ‬ ‫وﺣﺪﯾﺪ‬/‫ف اﻧﻲ ﺣﻀﻞ اﻧﻄﻲ ﻋﻼج‬ Occult bleeding may reach 200 mL per day and cause iron deficiency anaemia. colorectal cancer, particularly carcinoma of the caecum. In clinical practice, investigation of the upper and lower gastrointestinal tract should be considered.‫ﻧﺨﻠﻲ ﺑﺎﻟﻨﺎ‬  ‫ﻏﯿﺮ ﺿﺮوري‬ testing the stool for‫ﻟﻮ ﻻ‬the presence of blood ‫وﯾﺠﺐ ان ﻻ ﯾﺆﺛﺮ اذا ﻛﺎن ﺳﯿﺘﻢ ﺗﺼﻮﯾﺮ ﺟﮭﺎز ھﻀﻤﻲ‬ is unnecessary and should not influence whether or not the gastrointestinal ‫ﻣﺘﻘﻄﻊ‬ tract is imaged because bleeding from tumours is often intermittent and a negative faecal occult blood (FOB) test does not exclude the ‫ ﻟﻮ ﻻ‬stool‫اﺧﺘﺒﺎر ﻋﻠﻤﻮد اﺷﻮف اﻛﻮ دم ﺑﺎل‬ ‫ﻻ ﯾﺴﺘﺒﻌﺪ‬ diagnosis. (‫اﻟﻘﯿﻤﮫ اﻟﻮﺣﯿﺪه)ﻓﺎﺋﺪه‬ ‫ﻛﻮﺳﯿﻠﮫ ﻓﺤﺺ‬ ‫ﻟﻠﺴﻜﺎن‬ ‫ﻟﻠﺒﺤﺚ‬ The only value of FOB testing is as a means of population screening for colonic neoplasia in asymptomatic individuals. ‫اﻟﻲ ﻣﺎﺑﯿﮭﻢ اﻋﺮاض‬ ‫ ھﻲ ﯾﻨﺰف دم ﺷﻮﯾﮫ ﺷﻮﯾﮫ‬cancer ‫ﻻن اﺣﺪ اﺷﯿﺎء اﻟﻲ ﯾﺴﻮﯾﮫ ھﺬا‬