Different Diagnostic

Hematochezia In
CLINICAL SCIENCE SESSION

Gastrointestinal
Bleeding
Preceptor :
dr. Liza Nursanti, Sp.B, M.Kes., FInaCS

Presented by :
Sarah Nabila Rachmi
Boyke M. Rachman

PROGRAM PENDIDIKAN PROFESI DOKTER

UNIVERSITAS ISLAM BANDUNG
SMF ILMU BEDAH
RS AL ISLAM BANDUNG
2020
 Gastrointestinal Bleeding
0 Hemorrhage may develop from any gut organ.
0 Most commonly :
0 upper GI bleeding presents with melena or hematemesis
0 lower GI bleeding produces passage of bright red or maroon stools.
0 The most common in :
0 Upper GI causes of bleeding are ulcer disease, gastroduodenitis,
and esophagitis.
0 Lower GI sources of hemorrhage include hemorrhoids, anal
fissures, diverticula, ischemic colitis, and arteriovenous
malformations.
0 Other causes include neoplasm, inflammatory bowel disease,
infectious colitis, drug-induced colitis, and other vascular lesions.
DIVERTICULAR
 Diverticula
0 Diverticular disease is a clinical term used to describe
the presence of symptomatic diverticula.
0 Diverticulosis refers to the presence of diverticula
without inflammation.
0 Diverticular bleeding can be massive but usually is
self-limited.
0 True diverticula, which comprise all layers of the
bowel wall, are rare and are usually congenital in
origin.
0 Epidemiology :
0 Diverticulosis is extremely common in the United States and
Europe.
0 It is estimated that half of the population older than age 50
years has colonic diverticula.
0 The sigmoid colon is the most common site of diverticulosis
0 Etiology :
0 Diverticulosis is thought to be an acquired disorder, but
the etiology is poorly understood
0 The most accepted theory is that a lack of dietary fiber
results in smaller stool volume, requiring high
intraluminal pressure and high colonic wall tension for
propulsion.
0 Manfes :
0 Diverticular Bleeding :
0 Hemorrhage from a colonic diverticulum is the most common
cause of hematochezia in patients >60 year
0 Yet only 20% of patients with diverticulosis will have
gastrointestinal bleeding .
0 Diverticulitis :
0 Acute uncomplicated diverticulitis characteristically presents
with fever, anorexia, left lower quadrant abdominal pain, and
obstipation.
0 Evaluation :

0 Diverticular Bleeding
0 Initial localization of diverticular bleeding may include
colonoscopy, multiplanar computed tomography (CT)
angiogram, or nuclear medicine tagged red cell scan.
0 Long-term results (40 months) indicate that more than 50%
of patients with acute diverticular bleeds treated with highly
selective angiography have had definitive treatment
0 If the patient is unstable or has had a 6-unit bleed within 24
h, current recommendations are that surgery should be
performed.
0 Diverculitis :
0 The diagnosis of diverticulitis is best made on CT with the
following findings:
0 Sigmoid diverticula, thickened colonic wall >4 mm, and
inflammation within the periodic fat ± the collection of
contrast material or fluid.
 Medical Management
0 Asymptomatic diverticular disease discovered on
imaging studies or at the time of colonoscopy is best
managed by diet alterations.
0 Patients should be instructed to eat a fiber-enriched
diet that includes 30 g of fiber each day.
Supplementary fiber products such as Metamucil,
Fibercon, or Citrucel are useful.
0 Symptomatic uncomplicated diverticular disease with
confirmation of inflammation and infection within the
colon should be treated initially with antibiotics and
bowel rest
0 The current recommended antimicrobial coverage is
trimethoprim/ sulfamethoxazole or ciprofloxacin and
metronidazole targeting aerobic gram-negative rods
and anaerobic bacteria.
0 The usual course of antibiotics is 7–10 days
 Surgical Management
0 The goals of surgical management of diverticular
disease include
0 controlling sepsis,
0 eliminating complications such as fistula or obstruction,
0 removing the diseased colonic segment,
0 and restoring intestinal continuity.
0 lists the opera- tions most commonly indicated based
on the Hinchey classification and the predicted
morbidity and mortality rates :
0 The options for the surgical management of complicated
diverticular disease include the following:
1. proximal diversion of the fecal stream with an ileostomy
or colostomy and sutured omental patch with drainage
2. resection with colostomy and mucous fistula or closure
of distal bowel with formation of a Hartmann’s pouch,
3. resection with anastomosis (coloproctos- tomy), or
4. resection with anastomosis and diversion (coloproctos-
tomy with loop ileostomy or colostomy). Laparoscopic
techniques have been used for complicated diverticular
disease.
Hemorroid
 HEMORROID
0 Definition :
0 Hemorrhoids are cushions of submucosal tissue containing
venules, arterioles, and smooth-muscle fibers that are located
in the anal canal.
0 Three hemorrhoidal cushions are found in the left lateral,
right anterior, and right posterior positions.
0 Excessive straining, increased abdominal pressure, and hard stools
 increase venous engorgement of the hemorrhoidal plexus 
prolapse of hemorrhoidal tissue.
0 Epidemiology :
0 Worldwide, the prevalence of symptomatic hemorrhoids is estimated at 4.4% in
the general population.
0 The prevalence of hemorrhoids increases with age, with a peak in persons
aged 45-65 years.
0 Etiology and Risk Factor :
0 Decreased venous return  low fiber diet, pregnancy & abnormal
high tension of internal spingter, prolong sitting on toilet
0 Straining and constipation
0 Pregnancy
0 Anorectal varices
0 Familial tendency
0 Higher socioeconomic status
0 Chronic diarrhea
0 Colon malignancy
0 Hepatic disease
0 Obesity
0 Inflammatory bowel disease, including ulcerative colitis, and Crohn disease
 External Hemorroid
0 External hemorrhoids are located distal to the dentate line and are
covered with anoderm.
0 Because the anoderm is richly innervated, thrombosis of an external
hemorrhoid may cause significant pain.
0 A skin tag is redundant fibrotic skin at the anal verge, often
persisting as the residual of a thrombosed external hemorrhoid
0 External hemorrhoids and skin tags may cause itching and difficulty
with hygiene if they are large.
0 Treatment of external hemorrhoids and skin tags is only indicated
for symptomatic relief.
 Internal Hemmroid
0 Internal hemorrhoids are located proximal to the
dentate line and covered by insensate anorectal
mucosa.
0 Internal hemorrhoids are graded according to the
extent of prolapse :
1. First-degree hemorrhoids bulge into the anal canal
and may prolapse beyond the dentate line on
straining.
2. Second-degree hemorrhoids prolapse through the
anus but reduce spontaneously.
3. Third-degree hemorrhoids prolapse through the anal canal and require manual
reduction.
4. Fourth-degree hemorrhoids prolapse but cannot be reduced and are at risk for
strangulation.
5. . Combined internal and external hemorrhoids straddle the dentate line and have
characteristics of both internal and external hemorrhoids.
 Clinical Manifestation
0 any pain, bleeding, protrusion, or change in bowel habits.
0 Rectal bleeding is the most common presenting symptom.

The blood is usually bright red and may drip, squirt into the toilet
bowl, or appear as streaks on the toilet paper. The physician should
inquire about the quantity, color, and timing of any rectal bleeding
0 A patient with a thrombosed external hemorrhoid may present

with complaints of an acutely painful mass at the rectum.

0 Pain peaks at 48-72 hours
0 Grade I internal hemorrhoids are usually
asymptomatic but, at times, may cause minimal
bleeding.
0 Grades II, III, or IV internal hemorrhoids usually
present with painless bleeding but also may present
with complaints of a dull aching pain, pruritus, or
other symptoms due to prolapse
 Diagnosis
0 visual inspection of the rectum, digital rectal examination,
and anoscopy or proctosigmoidoscopy when appropriate.
The following are external findings that are important to note:
0 Redundant tissue
0 Skin tags from old thrombosed external hemorrhoids
0 Fissures
0 Fistulas
0 Signs of infection or abscess formation
0 Rectal or hemorrhoidal prolapse, appearing as a bluish,
tender perianal mass
 Diagnosis
Digital examination of the anal canal
0 ulcerated areas.
0 any masses
0 tenderness
0 mucoid discharge or blood
0 rectal tone
0 palpate the prostate in all men.
Because internal hemorrhoids are soft vascular structures,
they are usually not palpable unless thrombosed.
 Treatment
0 Medical Therapy :
0 Bleeding from first- and second-degree hemorrhoids often
improves with the addition :
0 dietary fiber
0 stool softeners
0 increased fluid intake
0 and avoidance of straining.
Associated pruritus may often improve with improved
hygiene. Many over-the-counter topical medications are
desiccants and are relatively ineffective for treating
hemorrhoidal symptoms.
 Operative Hemorroid
0 Rubber Band Ligation
0 Infrared Photocoagulation
0 Sclerotherapy
Excision of Thrombosed
External Hemorrhoids
0 OPERATIVE HEMORRHOIDECTOMY
 ANAL FISSURE

A fissure in ano is a tear in the

anoderm distal to the dentate line.
 Patophysiology
The pathophysiology of anal fissure is thought to be related to
trauma from either the passage of hard stool or prolonged
diarrhea.
A tear in the anoderm  spasm of the internal anal sphincter 
results in pain, increased tearing, and decreased blood supply to
the anoderm.
This cycle of pain, spasm, and ischemia contributes to
development of a poorly healing wound that becomes a chronic
fissure.
The vast majority of anal fissures occur in the posterior midline.
Ten to 15% occur in the anterior midline. Less than 1% of
fissures occur off midline.
 Symptoms and Findings
0 Characteristic symptoms include tearing pain with defecation
and hematochezia (usually described as blood on the toilet
paper).
0 On physical examination, the fissure can often be seen in the
anoderm by gently separating the buttocks. Patients are often
too tender to tolerate digital rectal examination, anoscopy, or
proctoscopy
0 An acute fissure is a superficial tear of the distal anoderm and
almost always heals with medical management
0 Chronic fissures develop ulceration and heaped-up edges with
the white fibers of the internal anal sphincter visible at the base
of the ulcer.
 Treatment
0 First-line therapy to minimize anal trauma includes bulk agents, stool
softeners, and warm sitz baths.

0 The addition of 2% lidocaine jelly or other analgesic creams can provide

additional symptomatic relief

0 Nitroglycerin ointment has been used locally to improve blood flow but often
causes severe headaches.

0 Newer agents, such as arginine (a nitric oxide donor) and topical bethanechol
(a muscarinic agonist), have also been used to treat fissures.

0 Medical therapy is effective in most acute fissures, but will heal only
approximately 50% of chronic fissures.
 Treatment
0 Surgical therapy has traditionally been recommended for
chronic fissures that have failed medical therapy, and lateral
internal sphincterotomy is the procedure of choice for most
surgeons.
0 The aim of this procedure is to decrease spasm of the internal
sphincter by dividing a portion of the muscle. Approximately
30% of the internal sphincter fibers are divided laterally by
using either an open or closed) technique.
0 Healing is achieved in more than 95% of patients by using this
technique and most patients experience immediate pain relief.
Recurrence occurs in less than 10% of patients and the risk of
incontinence (usually to flatus) ranges from 5 to 15%.
 Treatment
Open Technique Closed Technique
 Ischemic Colitis
0 Intestinal ischemia occurs most commonly in the
colon
0 Instead, most colonic ischemia appears to result from
low flow and/or small vessel occlusion
0 Risk factors include vascular disease, diabetes
mellitus, vasculitis, hypotension, and tobacco use. In
addition, ligation of the inferior mesenteric artery
during aortic surgery predisposes to colonic ischemia.
 Sign and Symptom
0 Signs and symptoms of ischemic colitis reflect the
extent of bowel ischemia.
0 In mild cases, patients may have diarrhea (usually
bloody) without abdominal pain.
0 With more severe ischemia, intense abdominal pain
(often out of proportion to the clinical examination),
tenderness, fever, and leukocytosis are present.
Peritonitis and/or systemic toxicity are signs of full-
thickness necrosis and perforation.
 Diagnosis
0 The diagnosis of ischemic colitis is often based on the
clinical history and physical examination.
0 Plain films may reveal thumb printing, which results from
mucosal edema and submucosal hemorrhage.
0 CT often shows nonspecific colonic wall thickening and
pericolic fat stranding.
0 sigmoidoscopy is relatively contraindicated in any patient
with significant abdominal tenderness. Contrast studies
(Gastrografin or barium enema) are similarly
contraindicated during the acute phase of ischemic colitis.
 Treatment
0 Treatment of ischemic colitis depends on clinical severity.
0 Unlike ischemia of the small bowel, the majority of
patients with ischemic colitis can be treated medically.
0 Bowel rest and broad-spectrum antibiotics are the
mainstay of therapy, and 80% of patients will recover with
this regimen.
0 Failure to improve after 2 to 3 days of medical
management, progression of symptoms, and deterioration
in clinical condition are indications for surgical
exploration.