Clinical Science Session

Lower Gastrointestinal Bleeding

Presentan :
Ennok Nisa Islamiati 12100118019

Preseptor :
Hj. Liza Nursanty, dr., Sp. B., M. Kes., FinaCS

PROGRAM PENDIDIKAN PROFESI DOKTER

SMF Ilmu Bedah
Fakultas Kedokteran Universitas Islam Bandung
RS Al-Islam Bandung
2019
Lower Gastrointestinal Bleeding
 Lower gastrointestinal bleeding  bleeding below the ligament of Treitz or
bleeding from the small bowel (jejunum or ileum), colon, or rectum
 Can be caused by :
• polyps,
• inflammatory disease,
• diverticulosis,
• cancer,
• vascular ectasias
• hemorrhoids.
• fissures and rectal ulcers

 Acute, severe gastrointestinal bleeding is life threatening. Mortality depends on

the volume and rate of blood loss, associated disease, age, and effectiveness
of treatment.
LIGAMENT OF TREITZ
Lower Gastrointestinal Bleeding
Adequate Resuscitation

 The principles of ensuring a patent airway, supporting

ventilation, and optimizing hemodynamic parameters apply
and coagulopathy and/or thrombocytopenia should be
corrected.
Source Of Hemorrhage

 Because the most common source of gastrointestinal

hemorrhage is esophageal, gastric, or duodenal, nasogastric
aspiration should always be performed; return of bile suggests
that the source of bleeding is distal to the ligament of Treitz.
 If aspiration reveals blood or nonbile secretions, or if
symptoms suggest an upper intestinal source,
esophagogastroduodenoscopy is performed.
 Anoscopy and/or limited proctoscopy can identify
hemorrhoidal bleeding.
Source Of Hemorrhage

 If the patient is hemodynamically stable, a rapid bowel

preparation (over 4 to 6 hours) can be performed to allow
colonoscopy.
 Colonoscopy may identify the cause of the bleeding, and
cautery or injection of epinephrine into the bleeding site may
be used to control hemorrhage.
Caused Lower Gastrointestinal
Bleeding
 Hematochezia is commonly caused by hemorrhoids or fissure.
 Sharp, knife-like pain and bright-red rectal bleeding with
bowel movements suggest the diagnosis of fissure.
 Painless, bright-red rectal bleeding with bowel movements is
often secondary to a friable internal hemorrhoid that is easily
detected by anoscopy.
 In the absence of a painful, obvious fissure, any patient with
rectal bleeding should undergo a careful digital rectal
examination, anoscopy, and proctosigmoidoscopy.
Failure to diagnose a source in the distal anorectum should
prompt colonoscopy
HEMORROID
 Definition

 Hemorrhoids are cushions of submucosal tissue containing venules,

arterioles, and smooth-muscle fibers that are located in the anal
canal.
 Three hemorrhoidal cushions are found in the left lateral, right
anterior, and right posterior positions.
 Excessive straining, increased abdominal pressure, and hard stools
 increase venous engorgement of the hemorrhoidal plexus 
prolapse of hemorrhoidal tissue.
 Epidemiologi
 Worldwide, the prevalence of symptomatic hemorrhoids is
estimated at 4.4% in the general population.
 In the United States, up to one third of the 10 million people
with hemorrhoids seek medical treatment, resulting in 1.5
million related prescriptions per year.
 Patients presenting with hemorrhoidal disease are more
frequently white, from higher socioeconomic status, and from
rural areas.
 External hemorrhoids occur more commonly in young and
middle-aged adults than in older adults. The prevalence of
hemorrhoids increases with age, with a peak in persons
aged 45-65 years.
 Etiology & Risk Factor
 Decreased venous return  low fiber diet, pregnancy &
abnormal high tension of internal spingter, prolong sitting on
toilet
 Straining and constipation
 Pregnancy
 Anorectal varices
 Familial tendency
 Higher socioeconomic status
 Chronic diarrhea
 Colon malignancy
 Hepatic disease
 Obesity
 Inflammatory bowel disease, including ulcerative colitis, and Crohn
disease
 Pathophysiology & symptoms
 Internal hemorrhoids cannot cause cutaneous pain, because they are
above the dentate line and are not innervated by cutaneous nerves.
 However, they can bleed, prolapse, and, as a result of the deposition of an
irritant onto the sensitive perianal skin, cause perianal itching and
irritation. Internal hemorrhoids can produce perianal pain by prolapsing
and causing spasm of the sphincter complex around the hemorrhoids.
 This spasm results in discomfort while the prolapsed hemorrhoids are
exposed. This muscle discomfort is relieved with reduction.
 Internal hemorrhoids can also cause acute pain when incarcerated and
strangulated.
 Pain is related to the sphincter complex spasm.
 External thrombosis causes acute cutaneous pain.
 Internal hemorrhoids most commonly cause painless bleeding with bowel
movements
 Internal hemorrhoids can deposit mucus onto the perianal tissue with
prolapse. This mucus with microscopic stool contents can cause a localized
dermatitis, which is called pruritus ani.
 Pathophysiology & symptoms
 External hemorrhoids, acute thrombosis of the underlying external
hemorrhoidal vein can occur. Acute thrombosis is usually related to
a specific event, such as physical exertion, straining with
constipation, a bout of diarrhea, or a change in diet. These are
acute, painful events.
 Pain results from rapid distention of innervated skin by the clot
and surrounding edema.
 The pain lasts 7-14 days and resolves with resolution of the
thrombosis. With this resolution, the stretched anoderm persists as
excess skin or skin tags
 External hemorrhoids can also cause hygiene difficulties, with the
excess, redundant skin left after an acute thrombosis (skin tags)
being accountable for these problems.
 Classification

1. External hemorrhoids are located distal to the dentate line and

are covered with anoderm.
 A skin tag is redundant fibrotic skin at the anal verge, often
persisting as the residual of a thrombosed external hemorrhoid
 External hemorrhoids and skin tags may cause itching and
difficulty with hygiene if they are large.
 Classification
2. Internal hemorrhoids are located proximal to the dentate line and
covered by insensate anorectal mucosa.
Internal hemorrhoids are graded according to the extent of prolapse.
 First-degree hemorrhoids bulge into the anal canal and may prolapse
beyond the dentate line on straining.
 Second-degree hemorrhoids prolapse through the anus but reduce
spontaneously.
 Third-degree hemorrhoids prolapse through the anal canal and require
manual reduction.
 Fourth-degree hemorrhoids prolapse but cannot be reduced and are at
risk for strangulation.
3. Combined internal and external hemorrhoids straddle the dentate line and
have characteristics of both internal and external hemorrhoids.
 Clinical Manifestation
 any pain, bleeding, protrusion, or change in bowel habits.
 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
 A patient with a thrombosed external hemorrhoid may present with
complaints of an acutely painful mass at the rectum.
 Pain peaks at 48-72 hours
 Clinical Manifestation

 Grade I internal hemorrhoids are usually asymptomatic but, at

times, may cause minimal bleeding.
 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
 visual inspection of the rectum, digital rectal examination, and
anoscopy or proctosigmoidoscopy when appropriate.
The following are external findings that are important to note:
 Redundant tissue

 Skin tags from old thrombosed external hemorrhoids

 Fissures

 Fistulas

 Signs of infection or abscess formation

 Rectal or hemorrhoidal prolapse, appearing as a bluish, tender

perianal mass
 DIAGNOSIS
Digital examination of the anal canal
 ulcerated areas.

 any masses

 tenderness

 mucoid discharge or blood

 rectal tone

 palpate the prostate in all men.

Because internal hemorrhoids are soft vascular

structures, they are usually not palpable unless
thrombosed.
Treatment
TREATMENT
Medical Therapy
Bleeding from first- and second-degree hemorrhoids often
improves with the addition :
 dietary fiber

 stool softeners

 increased fluid intake

 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.
Rubber Band Ligation
 Persistent bleeding from first-, second-, and selected third-degree
hemorrhoids may be treated by rubber band ligation.
 Mucosa located 1 to 2 cm proximal to the dentate line is grasped and
pulled into a rubber band applier.
 After firing the ligator, the rubber band strangulates the underlying tissue,
causing scarring and preventing further bleeding or prolapse.
 Other complications of rubber band ligation include infection, and bleeding.
Necrotizing infection is an uncommon, but life-threatening complication.
 Severe pain, fever, and urinary retention are early signs of infection and
should prompt immediate evaluation of the patient usually with an exam
under anesthesia.
 Treatment includes débridement of necrotic tissue, drainage of associated
abscesses, and broad-spectrum antibiotics.
 Bleeding may occur approximately 7 to 10 days after rubber band
ligation, at the time when the ligated pedicle necroses and sloughs.
Infrared Photocoagulation
Infrared photocoagulation is an effective office treatment for small first- and
second-degree hemorrhoids.
 The instrument is applied to the apex of each hemorrhoid to coagulate the
underlying plexus.
 All three quadrants may be treated during the same visit.
 Larger hemorrhoids and hemorrhoids with a significant amount of prolapse are
not effectively treated with this technique.
Sclerotherapy
 The injection of bleeding internal hemorrhoids with sclerosing agents is another
effective office technique for treatment of first-, second-, and some third-
degree hemorrhoids.
 One to 3 mL of a sclerosing solution (5-phenol in olive oil, sodium morrhuate, or
quinine urea) are injected into the submucosa of each hemorrhoid.
 complications are associated with sclerotherapy, but infection and fibrosis have
been reported.
Excision of Thrombosed External Hemorrhoids
Acutely thrombosed external hemorrhoids generally cause intense pain and a
palpable perianal mass during the first 24 to 72 hours after thrombosis.
 The thrombosis can be effectively treated with an elliptical excision performed in
the office under local anesthesia. Because the clot is usually loculated, simple
incision and drainage is rarely effective. After 72 hours, the clot begins to resorb,
and the pain resolves spontaneously. Excision is unnecessary, but sitz baths and
analgesics are often helpful.
Excision of Thrombosed External
Hemorrhoids
OPERATIVE HEMORRHOIDECTOMY
Closed Submucosal Hemorrhoidectomy
The Parks or Ferguson hemorrhoidectomy involves resection of hemorrhoidal
tissue and closure of the wounds with absorbable suture.
 The procedure may be performed in the prone or lithotomy position under
local, regional, or general anesthesia.
 The anal canal is examined and an anal speculum inserted. The hemorrhoid
cushions and associated redundant mucosa are identified and excised using
an elliptical incision starting just distal to the anal verge and extending
proximally to the anorectal ring.
 The apex of the hemorrhoidal plexus is then ligated and the hemorrhoid
excised. The wound is then closed with a running absorbable suture.
 All three hemorrhoidal cushions may be removed using this technique;
however, care should be taken to avoid resecting a large area of perianal
skin in order to avoid postoperative anal stenosis
Closed Submucosal
Hemorrhoidectomy
Open Hemorrhoidectomy
 This technique, often called the Milligan and Morgan
hemorrhoidectomy, follows the same principles of excision
described, but the wounds are left open and allowed to
heal by secondary intention.
Stapled Hemorrhoidectomy
Instead, stapled hemorrhoidectomy removes a short
circumferential segment of rectal mucosa proximal to the
dentate line using a circular stapler. This effectively ligates
the venules feeding the hemorrhoidal plexus and fixes
redundant mucosa higher in the anal canal.
 Critics suggest that this technique is only appropriate for
patients with large, bleeding, internal hemorrhoids, and is
ineffective in management of external or combined
hemorrhoids.
Open and Closed Hemorrhoidectomy
 Fig. 1.Optimal treatment of symptomatic hemorrhoids. BHC, bipolar
hyperthermic coagulation; IRC, infrared photocoagulation; ALTA,
aluminum potassium sulfate and tannic acid; RBL, rubber band
J Korean Soc Coloproctol. 2011
Dec;27(6):277-281.
ligation; THD, transanal hemorrhoidal dearterialization; PPH,
https://doi.org/10.3393/jksc.2011.27.6.277 procedure for prolapsed hemorrhoid.
© 2011 The Korean Society of
Coloproctology
ANAL FISSURE
 Definition

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
 Characteristic symptoms include tearing pain with
defecation and hematochezia (usually described as
blood on the toilet paper).
 Patients may also complain of a sensation of intense
and painful anal spasm lasting for several hours
after a bowel movement.
 On physical examination, the fissure can often be
seen in the anoderm by gently separating the
buttocks.
 An acute fissure is a superficial tear of the distal anoderm and
almost always heals with medical management.
 Chronic fissures develop ulceration and heaped-up edges with
the white fibers of the internal anal sphincter visible at the base
of the ulcer.
 There is often an associated external skin tag and/or a
hypertrophied anal papilla internally.
 These fissures are more challenging to treat and may require
surgery.
 A lateral location of a chronic anal fissure may be evidence of
an underlying disease such as Crohn's disease, human
immunodeficiency virus, syphilis, tuberculosis, or leukemia.
 If the diagnosis is in doubt or there is suspicion of another cause
for the perianal pain such as abscess or fistula, an examination
under anesthesia may be necessary.
 Treatment
 First-line therapy to minimize anal trauma includes bulk agents,
stool softeners, and warm sitz baths.
 The addition of 2% lidocaine jelly or other analgesic creams
can provide additional symptomatic relief.
 Nitroglycerin ointment (0.2%) has been used locally to improve
blood flow but often causes severe headaches.
 Both oral and topical diltiazem have also been used to heal
fissures and may have fewer side effects than topical nitrates.
 Newer agents, such as arginine (a nitric oxide donor) and
topical bethanechol (a muscarinic agonist), have also been used
to treat fissures.
 Medical therapy is effective in most acute fissures, but will heal
only approximately 50 to 60% of chronic fissures.
 Treatment
 Botulinum toxin causes temporary muscle paralysis by
preventing acetylcholine release from presynaptic
nerve terminals.
 Injection of botulinum toxin has been proposed as an
alternative to surgical sphincterotomy for chronic
fissure.
 Although there is limited experience with this
approach, results appear to be superior to other
medical therapy, and complications such as
incontinence are rare. However, healing is slower than
after sphincterotomy and recurrence may be more
common.
 Treatment
 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.
 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.
 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