PROBLEM 5

GIT
Aldi Firdaus
405140098
 LEARNING OBJECTIVES
1. Fisiologi Defekasi
2. 3M Etiologi Gangguan GI Tract Bagian Bawah
3. 3M Patofisiologi Gangguan GI Tract Bagian Bawah
4. 3M Tanda & Gejala Gangguan GI Tract Bagian Bawah
5. 3M PF & PP Gangguan GI Tract Bagian Bawah
6. 3M Tata Laksana Gangguan GI Tract Bagian Bawah
7. 3M Komplikasi & Prognosis Gangguan GI Tract Bagian
Bawah
8. 3M KIE & Pencegahan Gangguan GI Tract Bagian
Bawah
LO 1
 Mecanism of defecation
1. Haustra contraction.

– Initiated by autonomous rhythmicity of colonic

smooth muscle.
– These contraction throw the large intestine into
haustra, are similiar to small intestine
segmentation but occur much less frequently.
– These movements are nonpropolsive; they slowly
shuffle the contents in a back-forth mixing
movement that exposes the colonic content to the
absorbtive mucosa.
2. Mass movements
• It is massive contraction that
drive the colonic content into the
distal
After
part of the large
Increase of
Largeintestine,
segments of ascending
and transverse colon
where material storedcontract
meals motility
until simultanously

defecation.
Throw feces one third to
three forth s of the length of
the colon in few seconds
3. Gastrocolic reflex
– Causes of mass movements are
triggered in the colon primarily.
– Mediated from the stomach to the
colon by gastrin and by extrinsic
autonomic nervous.
– This reflex is most evident after the
first meals of the day and is often
followed by the urge to defecate.
 Faeces in colon

delayed defecation
Rectum stretches

Relax sfingter ani rectal wall that

stretch receptor interna stretched to relax
stimulation
Rectum, colon sigmoid
contraction more harder
defecation desire abate
Reflex defecation

feces are pushed more

relax
Sfingter ani into the rectum
defecation
externa

defecation
Reflexes
in Colon
and
Rectum:
 Large intestine

• The colon extracts more water & salt from the contents
 feces
• Primary function  store feces before defecation
• Cellulose & other indigestible substances in the diet 
bulk & help maintain regular bowel movements by
contributing to the volume of the colonic contents

• Colon’s main motility  haustral contractions

(autonomous rhythmicity of colonic smooth muscle
cells)  shuffle the contents back & forth mixing
movement
– Controlled by locally mediated reflexes involving the
intrinsic plexuses
• Massive contractions (mass movements) 
drive the colonic contents into the distal part
of the large intestine  material is stored 
defecation
• Food enters the stomach  gastrocolic reflex
 mediated by gastrin & by the extrinsic
autonomic nerves  first meal often followed
by urge to defecate
 Defecation reflex
• Feces move to the rectum by colon’s mass
movement  distention of rectum  stimulate
stretch receptors on rectum  defecation reflex
 relaxation of internal anal sphincter 
sigmoid colon contracts more vigorously 
relaxation of external anal sphincter 
defecation
• When defecation occur  assited by voluntary
straining movements  increase of intra-
abdominal pressure  helps expel the feces
 Constipation
• Defecation delayed too long  more water
absorbed  feces becomes hard & dry 
constipation
• Causes
– Ignoring urge to defecate
– Decreased colon motility accompanying aging,
emotion, low-bulk diet
– Obstruction of fecal movement in the large bowel
caused by a local tumor or colonic spasm
– Impairment of the defecation reflex (injury of the
nerve pathways)
 Large intestine secretion
• Not secrete any digestive enzymes
• Secrete alkaline (natrium bicarbonate) mucus solution

– Protect the large intestine mucosa from mechanical &
chemical injury
– Provides lubrication
– Neutralzes irritating acids
• Secretions increase in response to mechanical &
chemical stimulation of the colonic mucosa, mediated
by short reflex & parasympathetic innervation
• The colonic bacteria digest some of the cellulose for
their use
 The colon’s beneficial bacteria
• Slow colonic movement  give time for intestinal
bacteria to grow & accumulate
•  beneficial
– Enhance intestinal immunity by competing with potentially
pathogenic microbes
– Promote colonic motility
– Help maintain colonic mucosal integrity
– Make nutritional contributions
– Synthesize absorbable vitamin K & raise colonic acidity
– Promoting the absorption of Ca, Mg, Zn
– Bacterial processing  some glucose  absorbed by colon
 Absorption of colon
• Less absorptive surface area than small intestine
• Normally absorps water & salt
– Sodium is actively absorbed
– Cl- follows passively down the electrical gradient
– Water follows osmotically
• Fecal material normally consists of
– 100 g of water
– 50 g of solid
• Undigested cellulose, bilirubin, bacteria, small amounts of
salt
 Intestinal gases
• ~flatus
• 2 sources
– Swallowed air (500 ml during meal)
– Bacterial fermentation in colon
• The presence of gas percolating through the
luminal contents  borborygmi (gurgling
sound)
• Most gas of the colon  bacterial activity
LO 2
Lower Gastrointestinal Disorders

COLITIS
Radiation colitis
• Recognized with the title prokitis radiation
• Represents colonic inflammatory diseases as a result of complications of
abdominal and pelvic radiation therapy against cancer, gynecology, urology,
rectum
Factors affecting
• Dosisi received radiation
• Patient's nutritional condition
• Age
• The presence of vascular disease
• There is at least the previous gastrointestinal surgery
Ischemic colitis
Sumber : www.mayoclinic.com
 Ischemic colitis
• Ischemic colitis is a disorder that develops
when blood flow to a part of your large
intestine (colon) is reduced. This can lead to
areas of colon inflammation and, in some
cases, permanent colon damage
Ulcerative colitis
Sumber : www.mayoclinic.com
 Ulcerative colitis
• Ulcerative colitis, an inflammatory bowel
disease (IBD) that causes chronic
inflammation of the digestive tract, is
characterized by abdominal pain and diarrhea
• Ulcerative colitis usually affects only the
innermost lining of your large intestine (colon)
and rectum
• It occurs only through continuous stretches of
your colon, unlike Crohn's disease, which
occurs in patches anywhere in the digestive
tract and often spreads deep into the layers of
affected tissues
Lower Gastrointestinal Disorders

DIVERTICULITIS
 Diverticular Disease
• Diverticula are common in the sigmoid colon.

• Affecting at least 10% of adults in societies

where the diet lacks fibre (low residue)
 Diverticulitis
Risk factor :
1. Increasing age
2. Constipation
3. A diet that is low in dietary fiber content or
high in fat
4. High intake of meat and red meat
Lower Gastrointestinal Disorders

INFLAMMATORY BOWEL DISEASE

(IBD)
 Inflammatory Bowel Disease
• Inflammatory bowel disease (IBD) is an
immune-mediated chronic intestinal
condition.
Inflammatory
bowel
disease

Ulcerative Crohn’s
Colitis Disease
 Ulcerative Colitis (UC)
• Ulcerative colitis  an inflammatory disease
of the rectum extending for a variable
distance proximally in the colon
• Women > men
• Any age  maximum incidence is between
the ages of 20 and 40
 ~ Etiology

Autoimmu
ne
responses
Environme
Genetic
ntal
factors
stimuli
Ulcerat
ive
Colitis
Lower Gastrointestinal Disorders

HEMORRHOID
• Hemorrhoids, often called piles, are
clusters of veins in the anus, just under the
membrane that lines the lowest part of
the rectum and anus. They occur when
veins in your rectum enlarge from
straining or pressure
• Occur : proximal(internal) or distal
(external) to the anal sphincter
• Heavy lifting
• Staying seated for long periods of time
• Straining to have a bowel movement
• Not drinking enough water
• Not eating enough fiber
• Simply aging
• Genetics
• Chronic diarrhea or constipation
• Obesity
• Pregnancy
• Anal intercourse
 Internal •Prolapsed into the anal canal and make the painless anal bleeding
•Internal hemorrhoids originate above the pectinate or dentate line
Hemorrhoids in the anal canal and are covered by a mucous membrane

•Lose the connective tissue support  tend to dilate  blood flow

External through veins tends to slow  thrombosis
•External hemorrhoids are swollen areas of skin and blood vessels
Hemorrhoids around the anus (below the dentate line). They are lined with
squamous epithelium that is highly innervated and sensitive

Internal- •When internal and external hemorrhoids occur simultaneously,

they are referred to as mixed hemorrhoids
External
 First-degree
• do not bulge from the anus
• internal viewed through anoscope

Second-degree
• bulge from the anus during bowel movements but spontaneously
reduce

Third-degree
• bulge from the anus during bowel movements, but they can be
manually reduced

Fourth-degree
• strangulated internal and thrombosed external
• bulge outside the anus all the time (cannot be reduced)
Reference : Sabiston Textbook of Surgery, 18th Edition
Lower Gastrointestinal Disorders

MALIGNANCY
 Colorectal Cancer
• A cancerous growths in
the colon, rectum and appendix.
ADENOKARSINOMA
Lower Gastrointestinal Disorders

PARASIT
Entamoeba histolytica
 Amoebiasis
• Amoebiasis ←protozoan Entamoeba histolytica.
E. histolytica must be differentiated from Entamoeba
dispar, which is a flora normal of the gastrointestinal tract.

Humans are the only reservoir, and infection occurs by ingestion

of mature cysts in food or water, or on hands contaminated
by faeces

• Incubation period: 7 days and tissue invasion mostly occurs

during first 4 months of infection.
Lower Gastrointestinal Disorders

ANAL FISSURE
 Definition

• Anal fissure is a disruption in the

lining of the anal canal usually
beginning at or distal of the
pectinate line and extending to or
beyond the anal verge.
 Etiology
1. Trauma to the anus and anal canal.
2. A hard stool or repeated episodes of diarrhea.
3. Insertion of a rectal thermometer, Enema tip, Endoscope, or Ultrasound
probe (for examining the prostate gland)
4. During childbirth, trauma to the perineum (the skin between the
posterior vagina and the anus) may cause a tear that extends into the
anoderm.
5. Anal cancer, Crohn's disease, leukemia as well as many infectious
diseases including tuberculosis, viral infections (CMV or Herpes),
Syphilis, Gonorrhea,Chlamydia , Chancroid (Hemophilus ducreyi), and
(HIV).
• More common causes of anal fissure include:

– Large or hard stools passing through the anal canal

– Constipation and straining during bowel movements

– Chronic diarrhea

– Inflammation of the anorectal area, caused by

Crohn's disease or another inflammatory bowel
disease (IBD)
• Less common causes of anal fissures include:
– Anal sex

– Cancer

– HIV

– Tuberculosis

– Syphilis
Lower Gastrointestinal Disorders

AMEBIASIS
 Amebiasis
• Ex: Entamoeba histolytica
• Invasive & causes disease such as colitis & liver abcess
• Ameba in the stool of a young farmer with dysentery
(Fedor Losch, 1873)
• Morphology  round, pear-shaped / irregular form,
almost continuous motion
• Infective form  cyst form

• Epidemiology
– Children or farmworkers  exposed to human wastewater
used to irrigate crops
 Irritable Bowel Syndrome (IBS)
• Not a disease – syndrome
• Abdominal pain, bloating, abnormal
bowel movements
– Alternating diarrhea, constipation
– Abdominal pain, relieved by defecation
– Bloating w/ feeling of excess flatulence
– Feeling of incomplete evacuation
– Rectal pain, mucus in the stool
 IBS: Etiology
• Increased visceral sensitivity and
motility in response to GI and
environmental stimuli
• React more to:
• Intestinal distention
• Dietary indiscretions
• Psychosocial factors
• Life stressors
• May have psych/social component
(history of physical or sexual abuse)
 DIVERCULITIS
• Diverticulitis is defined as an inflammation of
one or more diverticula, which are small
pouches created by herniation of the mucosa
into the wall of the colon.
• Diverticulitis is generally considered a disease
of the elderly, but as many as 20% of patients
with diverticulitis are younger than 50 years.

http://emedicine.medscape.com/article/17338
8-overview#a1
 Diverticular Disease
Reduced dietary
fibre-low residue in
distal colon

Induces
muscular
hypertrophy

Increased
intraluminal
pressure

Outpouching of
mucosa
 Diverticulitis

Hard stool trapped in diverticula

Lack consumtion of high fibers
food cause diverticula

Vessels overlying a
diverticula are stretched
until they break, causing
bleeding into the colon.
LO 4
Radiation colitis
Acute symptoms:
• Nausea, vomiting, diarrhea
• Tenesmus
• Do within 6 weeks after completion of radiation
• Complaints generally decreases with a reduction in dose or
frequency and disappear within 2-6 months
Chronicles symptoms:
• Occurred in the first two years post-radiation, generally 6-9
months post-radiation
• Hematokezia
• Diarrhea
• Colic
• Tenesmus
Ischemic colitis
Sumber : www.mayoclinic.com
 Symptoms
• Abdominal pain, tenderness or cramping,
usually localized to the lower left side of your
abdomen; the onset can be sudden or gradual
• Bright red or maroon-colored blood in your
stool or, at times, passage of blood alone
without stool
• A feeling of urgency to move your bowels
• Diarrhea
• Nausea
• Vomiting
Ulcerative colitis
Sumber : www.mayoclinic.com
 Symptoms

• Ulcerative proctitis :
– In this form of ulcerative colitis, inflammation is confined to the rectum
and for some people,
– rectal bleeding
– Others may have rectal pain
– a feeling of urgency or an inability to move the bowels in spite of the urge
to do so (tenesmus)
– This form of ulcerative colitis tends to be the mildest.
• Proctosigmoiditis :
– Bloody diarrhea
– abdominal cramps and pain
– tenesmus
• Left-sided colitis :
– inflammation extends from the rectum up the left side through the sigmoid
and descending colon
– bloody diarrhea
– abdominal cramping and pain on the left side
– unintended weight loss.
 Diverticulitis
Sign and Symptoms :
• Usually is an unware changes, but symptoms do appeares at the age of 40.
• The symptoms usually starts when the peristaltis is abnormal and even spasm,
which can cause pain in left abdomen and stool usually accompanied by small
platellets.

Symptoms also can consist of :

1.Bloating
2.Changes in bowel movement (constipation or diarrhoea)
3.Abdominal pain
 Symptoms
• The clinical presentation of diverticulitis depends on the
location of the affected diverticulum, the severity of the
inflammatory process, and the presence of complications.
Presenting complaints include the following:
Left lower quadrant pain (70% of patients)
• Change in bowel habits
• Nausea and vomiting
• Constipation
• Diarrhea
• Flatulence
• Bloating

http://emedicine.medscape.com/article/173388-overview#a1
Lower Gastrointestinal Disorders

INFLAMMATORY BOWEL DISEASE

(IBD)
 Clinical Features
• May be fulminant, intermittent or chronic
• Diarrhea, with blood and mucus
• Cramp-like abdominal pains
• Examination  some tenderness in the left iliac fossa
(LIF)
• Rectal examination  blood on the glove of the
examining finger
• Rectal mucosa  oedematous
• Severe attacks  fever, toxemia, severe bleeding, and
risk of perforation
• Acute episodes  anorexia, loss of weight
 Inflammatory Bowel Diseases
(IBD)
• Clinical features
– Food intolerances
– Diarrhea, fever
– Weight loss
– Malnutrition
– Growth failure
– Extraintestinal manifestations
• Arthritic, dermatologic, hepatic
Lower Gastrointestinal Disorders

HEMORRHOID
Internal hemorrhoids
• Bleeding during a bowel movement. As the hard stool passes
through the rectum, the swollen veins will begin to bleed. In most
cases, there is no pain experienced because nerve endings are
lacking in this area. The amount of blood loss is usually small and
bright red in color
• Mucus can be on the toilet tissue or on the bowel movement. Mucus
can drain steadily from the anus.
• Rectal itching and burning symptoms come from the drainage
caused by the hemorrhoids. The skin around the anus can not
handle the irritating fluids as the internal tissue can.
• Leakage of stool from the anus. Stool can escape with the
drainage from this swollen area.
• An internal hemorrhoid can fall down (prolapse) and protrude
outside the anus. Usually, there are two stages associated with
External hemorrhoids
prolapsed hemorrhoids. The first one is when the hemorrhoid will
• fall out ofswelling
A painful the anusorduring
hard a bowel
lump movement,
around the anusbutwhich
then results
it retracts
back
from ainside
bloodafter
clot defecation.
forming in theTheveins.
second stage
These is when theare said
hemorrhoids
prolapsed hemorrhoid
to be thrombosed no longer
because retracts,
the blood andcannot
in them it remains
returnoutside
to
the anus.
circulation in the body and is strangulated. This can be a serious
• A feeling that
condition of rectal
leadsfullness as if you
to gangrene need
(tissue to have a bowel
death).
• movement.
Pain can be severe because of the nerve endings around the
outside of the anus.
• Skin irritation can cause itching, burning and bleeding.
• Drainage of mucus and stool.
Lower Gastrointestinal Disorders

MALIGNANCY
 Sign & Symptoms
• Local:
-change in bowel habit (diarrhea or constipation)
-feeling of incomplete defecation (tenesmus)
-change in stool shape
-Lower gastrointestinal bleeding
-bright red blood in the stool
-abdominal pain, abdominal distension and vomiting.
• Constitutional(If a tumor has caused chronic occult bleeding) :
-iron deficiency anemia
-fatigue
-pale appearance of the skin
-weight loss
• Metastatic (if the tumor spreads):
- jaundice (liver)
-pale stools (bile duct)
Lower Gastrointestinal Disorders

PARASIT
• Symptoms: • DD:
– lower abdominal – infective colitis,
pain – ulcerative colitis,
– diarrhoea and later – colorectal carcinoma
develop dysentery – Crohn's disease,
(with blood and – ileocaecal
mucus in stool). tuberculosis,
– Abdominal – diverticulitis,
tenderness – anorectal
– Abdominal lymphogranuloma
distension venereum
– Fever
Lower Gastrointestinal Disorders

ANAL FISSURE
 Symptoms
• Pain during bowel movements that can be severe
• Pain after bowel movements that can last up to
several hours
• Bright red blood on the stool
• Itching or irritation around the anus
• A visible crack in the skin around the anus
• A small lump or skin tag on the skin near the anal
fissure
Lower Gastrointestinal Disorders

AMEBIASIS
 Clinical features
• Liver abscess
• Asymptomatic
– Ill-defined GI complaints 
most tolerate well
• Dysentery
– Diarrhea that contains visible
or microscopic blood
– Amebic colitis (several weeks)

• abdominal pain,
tenderness, diarrhea &
bloody stools, weight loss, • Cutaneus amebiasis
fever
– Rare
• Acute necrotizing colitis
• Ameboma (granulation – Involving abdominal
tissue in colonic lumen) wall, face, uvula,
vagina, penis
– Occur from fisulous
tract
LO 3
Lower Gastrointestinal Disorders

INFLAMMATORY BOWEL DISEASE

(IBD)
 ~ Pathology
• The rectum and sigmoid colon are principally
affected, but the whole colon may be involved.
• Initially, there is oedema of the mucosa, with
contact bleeding and petechial haemorrhage,
proceeding to ulceration; the ulcers are shallow
and irregular.
• Oedematous islands of mucosa between the
ulcers form pseudopolyps.
• The wall of the colon is oedematous and fibrotic
and is therefore rigid with loss of its normal
haustrations.
• The changes are confluent, with no unaffected
‘skip lesions’ as found in Crohn’s disease.
• The inflamed colon doesn’t become adherent
to its neighbouring intra-abdominal viscera.
• Microscopically, the principal locus of the
disease is mucosal; small abscesses form
within the mucosal crypts.
• The abscesses break down into ulcers whose
base is lined with granulation tissue.
• The walls of the colon are infiltrated with
polymorphs and round cells; there is oedema
and submucosal fibrosis.
• In the chronic, burnt out disease the mucosa
is smooth and atrophic; the bowel wall is
thinned.
Lower Gastrointestinal Disorders

HEMORRHOID
 Constipation or prolonged straining at stools

Stretching or disruption of Treitz’s muscle and venous engorgement

Lax anal mucosa

Sliding
downward

Distal displacement of the anal cushion

Lower Gastrointestinal Disorders

MALIGNANCY
CANCER KOLON
Lower Gastrointestinal Disorders

PARASIT
• Patofisiologi:
The cysts of E. histolytica enter the small intestine
→release trophozoites, which invade the epithelial cells
of the large intestines →flask-shaped ulcers.
Infection can then spread from the intestines to other
organs, e.g. liver, lungs and brain, via the venous
system.

• Invasive amoebiasis most often causes an amoebic liver

abscess but may affect the lung, heart, brain, urinary
tract and skin.
Lower Gastrointestinal Disorders

AMEBIASIS
 Pathogenesis
• Carbohydrate-protein interactions
• Gal/GalNAc-lectin
– Lectin not inhibited by Gal/GalNAc  mediated adherence
& cytolysis activity
– Resistant to C5b-9 complement complexes
• Pore-forming protein  cytolytic activity
• Colagenase  proteolytic activity
• Interaction between the trophozoites & colonic mucins
– Induce secretion of colonic mucins
– Degrading colonic mucins
LO 5
Lower Gastrointestinal Disorders

INFLAMMATORY BOWEL DISEASE

(IBD)
 Special Investigations
• Sigmoidoscopy
– Reveals oedema of the mucosa with contact bleeding
in the early mild cases, proceeding to granularity of
the mucosa and then frank ulceration with pus and
blood in the bowel lumen.
– Biopsy will give confirming histological evidence of the
diagnosis.
• Colonoscopy
– Enables the whole of the large bowel to be inspected,
the proximal extent to be noted and biopsy material
to be obtained.
• Barium enema
– Shows a ragged surface, indicating ulceration.
– Oedema and fibrosis produce loss of haustration.
– In the chronic case the typical smooth, narrow
‘drainpipe’ colon.
• Examination of the stools
– Reveals pus and blood visible to the naked eye or
under the microscope.
– No specific organism has ever been grown.
Lower Gastrointestinal Disorders

HEMORRHOID
Laboratory Studies •Hematocrit testing is suggested if excessive bleeding with
concomitant anemia is suspected.
•Coagulation studies are indicated if the history and
physical examination suggest coagulopathy

Imaging Studies Barium enema study or virtual colonoscopy is suggested if

proximal colonic and intestinal diseases must be excluded
and if endoscopy is not helpful

Diagnostic •Inspection
Procedures •Ask patient to strain as on defecation (valsalva
maneuvers)
•Detect: Skin tags, a thrombosed external plexus or
permanent prolapse
•Palpation
•Detect: areas of thrombosis, hypertrophied anal
papilla, fibrous anal polyp
•Uncomplicated hemorrhoids are impalpable
Diagnostic •Sigmoidoscopy
Procedures •Excluding other disease (inflammatory bowel
disease, hemangioma of the rectum)
•Proctoscopy
•Examine anal cushion for enlargement and
prolapse and squamous ephitelial change

Histologic •Routine histologic examination of hemorrhoidal tissue

Findings is usually unrewarding, especially if it is grossly
examined by an experienced anorectal surgeon.
•Any suspicious tissue must be sent for microscopic
evaluation.
•External hemorrhoids are classified by underlying
pathology and symptoms, which include thrombosed
veins, bleeding from eroded blood clots, and skin
tags causing hygiene problems.
Lower Gastrointestinal Disorders

MALIGNANCY
 Diagnosis
• Rectal toucher
• Fecal occult blood test
• Sigmoidoscopy
• Colonoscopy
*Other screening methods :
-Double contrast barium enema
-Blood tests
Lower Gastrointestinal Disorders

PARASIT
• Investigations:
– Full blood count (leucocytosis), increase ESR, abnormal liver
function tests (increase alkaline phosphatase and
transaminases)
– Stool examination
– Serology: antibody testing is nearly positive 100% of patients
with amoeboma.
– PCR tests (faeces, abscess aspirate or other tissues).
– Barium studies are contraindicated in acute amoebic colitis
because of the risk of perforation.
– Proctoscopy, sigmoidoscopy or colonoscopy: mucosal
scrapings for biopsy and E. histolytica testing.
Lower Gastrointestinal Disorders

ANAL FISSURE
 Examinations
1.Flexible sigmoidoscopy.

2.Colonoscopy

3.Anal manometry.
Lower Gastrointestinal Disorders

AMEBIASIS
 Diagnosis
• Microscopy
– Examination of stools for cysts and trophozoites  ineffective
• Antigen detection
– A stool antigen detection  rapid, has improved sensitivity compared
to microscopy
– Detection of Gal/GalNAc-lectin in stool
• PCR
• Serology
– Indirect hemagglutination  anti amebic antibody 99% sensitive for
amebic liver abscess, 88% sensitive for amebic colitis
• Colonoscopy
– Amebic colitis  granular, friable, diffusely ulcerated mucosa, large
geographic ulcers, pseudomembranes
• Imaging
 IBS: Diagnosis
• Symptoms for 3 months or longer
• Positive family history
• Rule out other med/surg conditions
 Diverticulosis: Diagnosis
• Often found incidentally during evaluation for
another condition or during a screening exam for
polyps.
• Using: sigmoidoscopy (only rectum and lower colon),
colonoscopy (entire colon).
• Other imaging tests: computed tomography (CT) scan
or barium x-rays.

http://www.asge.org/patients/patients.aspx?id=6818
 Laboratory test
• The white blood cell count may show leukocytosis and a left shift,
but may be normal in immunocompromised, elderly, or less
severely ill patients
• A hemoglobin level is important in patients who report
hematochezia
• Electrolyte assays may be helpful in the patient who is vomiting or
has diarrhea
• Renal function is assessed prior to the administration of most
intravenous contrast material
• Liver enzyme and lipase levels may help to exclude other causes of
abdominal pain
• A urine culture may distinguish sterile pyuria due to inflammation
from polymicrobial infection due to fistula
• Blood cultures should be obtained prior to the administration of
empiric parenteral antimicrobial therapy in patients who are
severely ill or in those with complicated disease

http://emedicine.medscape.com/article/173388-overview#a1
LO 6
Lower Gastrointestinal Disorders

INFLAMMATORY BOWEL DISEASE

(IBD)
 Treatment
• Medical treatment  uncomplicated case
• Surgery  when medical treatment fails or
when complications supervene.
• A high protein diet is prescribed with vitamin
supplements, iron and potassium
• Blood transfusion  severely anemic
• Codeine phosphate or loperamide  diarrhea
• Corticosteroids  given systemically, by rectal infusion
or in combination, produce remission in an acute
attack.
• Salicylates (mesalazine or sulfasalazine)  maintain a
remission.
• Patients with ulcerative colitis are often highly
intelligent, tense and anxious  should be
supplemented with sympathy and reassurance.
• The indications for surgery:
– Fulminating disease not responding to medical
treatment (defined as the passage of more than 6
bloody motions per day, with fever, tachycardia
and hypoalbuminaemia)
– Chronic disease not responding to medical
treatment.
– Prophylaxis against malignant change with long-
standing disease.
– Complications of colitis already listed.
• The procedure usually comprises total removal of the colon
and rectum with either a permanent ileostomy or an ileo-
anal anastomosis with an interposed pouch of ileum.
• Occasionally, the disease of the rectum is relatively mild
and the anal sphincter can be preserved with anastomosis
between the ileum and rectum (colectomy with ileorectal
anastomosis).
• Most patients requiring surgery for ulcerative colitis are
either on corticosteroids or have recently received them.
Surgical procedures must therefore be covered by
increased dosage of corticosteroids, which can then be
tailed off gradually in the postoperative period.
 IBD Medical Management
• To induce and maintain remission
• To maintain nutritional status
• During acute stages:
• Corticosteroids
• Anti-inflammatory agents
• Immunosuppressive agents
• Antibiotics
 IBD Nutritional Management
(acute)
• Low-residue, low-fiber liquid diet
• “Bowel rest” with parenteral nutrition
• Enteral nutrition may have better
success at inducing remission
• Diet tailored to individual pt:
• Minimal residue for reducing diarrhea
• Limited fiber to prevent obstruction
• Small, frequent feedings
• Supplements , MCT with fat malabsorption
IBD Nutritional Management (chronic)

• High protein, high calorie diet with oral

supplements
• Monitor vitamin-mineral status of iron,
calcium, selenium, folate, thiamin,
riboflavin, pyridoxine, vitamin B12, zinc,
magnesium, vitamins A, D, E
• High fiber diet as tolerated
• Avoid unnecessary restrictions
Lower Gastrointestinal Disorders

HEMORRHOID
Pharmacologic Non pharmacologic
•Improve defecation •Bowel managment program (BMP)
•Fiber supplement  psyllium, improve diet, fluid, fiber, stools softener,
isphagula husk the way of defecation
•Stools softener  natrium dioctyl •The way of defecation  squatting
•Soak anus in the water for 10-15
sulfosuccinat minutes (2-4 times/day)
•Symptomatic •More exercise
•Local anesthesia  reduce pain •Drink water (30-40ml/kgBB/day)
•Corticosteroid  reduce •High fiber (vegetables, fruits, cereal,
inflammation fiber supplement)
•Stop bleeding
•Psyllium, daflon
•Healing and preventing hemorrhoid
•Diosminthespridin  improve
symptom of inflammation, congestion,
edema, and prolapse
• Minimally invasive procedures
– Rubber band ligation
Places one or two tiny rubber bands around the base of an
internal hemorrhoid to cut off its circulation. The hemorrhoid
withers and falls off within a few days. This procedure is
effective for many people
– Injection (sclerotherapy)
Injects a chemical solution into the hemorrhoid tissue to shrink
it. While the injection causes little or no pain, it may be less
effective than rubber band ligation.
– Coagulation (infrared, laser or bipolar)
These techniques use laser or infrared light or heat. While
coagulation has few side effects, it's associated with a
higher rate of hemorrhoids coming back (recurrence) than is
the rubber band treatment.
• Surgical procedures
If other procedures haven't been successful or you have large hemorrhoids

– Hemorrhoidectomy
• Removes excessive tissue that causes bleeding
• The surgery may be done with a local anesthetic combined with sedation, a spinal anesthetic or a
general anesthetic
• Hemorrhoidectomy is the most effective and complete way to remove hemorrhoids, but it also has the
highest rate of complications
• Most people experience some pain after the procedure
• Medications can be used to relieve your pain. Soaking in a warm bath also helps

– Stapled hemorrhoidectomy or stapled

hemorrhoidopexy
• Blocks blood flow to hemorrhoidal tissue
• Stapling generally involves less pain than hemorrhoidectomy
• Stapling has been associated with a greater risk of recurrence and rectal prolapse, in which part of
the rectum protrudes from the anus
Lower Gastrointestinal Disorders

PARASIT
• Management :
– blood transfusion
– Diloxanide furoate : std.kista
– Metronidazole and tinidazole : tropozoit
Lower Gastrointestinal Disorders

ANAL FISSURE
 NonSurgical Treatment
1. Fiber supplements.
2. Sitz baths.
Soaking in warm water for 10 to 20 minutes several times a day, especially
after bowel movements, will help relax the sphincter and promote healing.
3. Medicated creams
(Anusol-HC, zinc oxide, others) to help relieve discomfort from a mild fissure.
4. Nitrogylcerin.
Applying nitroglycerin ointment to the anus widens blood vessels and
increases blood flow to the fissure, promoting healing
5. Botox.
Injecting a small dose of onabotulinumtoxinA (Botox) into the anal sphincter
paralyzes the muscle for several months, causing the spasm to relax. Possible
side effects include pain at the injection site or temporary, mild leakage of
gas or stool (anal incontinence).
6. Calcium channel blockers.
The blood pressure medications nifedipine (Adalat) and diltiazem (Cardizem),
taken orally or ground into a gel and applied to the fissure, also may help.
Lower Gastrointestinal Disorders

AMEBIASIS
 Treatment

• Interruption of the fecal-oral spread of the

infectious cyst stage  improved hygiene,
sanitation, water treatment
 IBS: Medications
• Antispasmodics
• Anticholinergics
• Antidiarrheals
• Prokinetics
• Antidepressants
 IBS: Nutritional Care
• ID individual food intolerances
• Keep food record, include symptoms, time they
occur in relation to meals
• Avoid offending foods, substances
• Milk, milk products (lactose) only in presence of
lactose deficiency
• Fatty foods
• Gas-forming foods, beverages
• Caffeine, alcohol
• Foods w/  fructose or sorbitol
 IBS: Nutritional Care
• Eat small frequent meals at relaxed
pace, regular times
• Gradually add dietary fiber to diet
– 20 – 30 g
– Fiber supplements may help (psyllium)
• Fluids – 2 – 3 qts w/ fiber supp.
• Regular physical activity to reduce stress
 Diverticulosis: Treatment
• When accompanied by abdominal pain, bloating or
constipation  high-fiber diet to help make stools
softer and easier to pass (20 to 35 g daily)
• The easiest way to increase fiber intake is to eat more
fruits, vegetables or grains: Apples, pears, broccoli,
carrots, squash, baked beans, kidney beans, and lima
beans are a few
• Prescription of medications to help relax spasms in the
colon that cause abdominal cramping or discomfort.

http://www.asge.org/patients/patients.aspx?id=6818
 Treatment
Single-agent or multiple-agent antibiotic regimens
for outpatient therapy are equally effective,
provided that they provide both anaerobic and
aerobic coverage. Potential regimens include the
following:
• Ciprofloxacin and metronidazole
• Trimethoprim-sulfamethoxazole and
metronidazole
• Moxifloxacin
• Amoxicillin/clavulanic acid

http://emedicine.medscape.com/article/173388-overview#a1
LO 7
Lower Gastrointestinal Disorders

INFLAMMATORY BOWEL DISEASE

(IBD)
 Complications
• Local
– Toxic dilatation, where the colon dilates in a fulminant
colitis, leading to perforation
– Haemorrhage
– Stricture
– Malignant change
– Perianal disease
• Anal fissures (common)
• Fistula-in-ano, fistula into the vagina and perianal abscesses
do occur, but are less common than in Crohn’s disease
• General
– Toxemia
– Weight loss and anemia
– Arthritis and uveitis
– Dermatological manifestations: pyoderma
gangrenosum, skin rashes and ulceration of the
legs
– Primary sclerosing cholangitis
 ~ Malignant change
• Patient with ulcerative colitis who have had
chronic total colitis, particularly if the first attack
was in childhood, have a high risk of developing
carcinoma of the colon.
• 5-12% of patients with colitis of 20 years’
duration will develop malignant change.
• Patients should therefore be offered annual or
biannual colonoscopy with multiple biopsies to
seek the dysplasia that heralds malignant change.
• Even in the absence of a total, or pan-colitis,
patients with ulcerative colitis are at far greater
risk of developing carcinoma of the large bowel
than a normal individu.
• The tumor occurring in the colitis are more likely
to affect a younger age group, be anaplastic and
be multiple.
• Often, the condition is only diagnosed late, as
both the patient and doctor attribute the
symptoms (bleeding, diarrhea, and pus) to the
colitis.
Lower Gastrointestinal Disorders

HEMORRHOID
• Anemia
Chronic blood loss from hemorrhoids may cause
anemia, in which you don't have enough healthy
red blood cells, resulting in fatigue and
weakness.
• Strangulated hemorrhoid
If blood supply to an internal hemorrhoid is cut
off, the hemorrhoid may be "strangulated,"
which can cause extreme pain and lead to
tissue death (gangrene).
• The outcome is usually very good for most
people
• Eating a high-fiber diet, and avoiding
constipation may help to prevent hemorrhoids
from coming back
• However, you may still develop new
hemorrhoids.
Lower Gastrointestinal Disorders

PARASIT
• Complications:
– Amoebic colitis may lead tonecrotising colitis,
toxic megacolon, amoeboma or a rectovaginal
fistula.
• Prognosis
– In uncomplicated disease, mortality rate is less
than 1%. But is much higher in complicated
severe disease, e.g. fulminant amoebic colitis,
chest involvement or cerebral amoebiasis.
– More severe illness occurs in children (especially
neonates), the immunosuppressed,
malnourished, pregnancy and post-partum.
Lower Gastrointestinal Disorders

ANAL FISSURE
 Complications
1. become chronic, meaning it lasts for more than six weeks.

2. increased risk of another anal fissure.

3. extend into the ring of muscle that holds your anus closed (internal anal

sphincter).
Lower Gastrointestinal Disorders

DIVERTICULOSIS
 Complications
• Abscess
• Intestinal fistula
• Intestinal perforation
• Intestinal obstruction
• Peritonitis
• Sepsis and septic shock
• Diverticular bleeding (more common in
diverticulosis than diverticulitis)

http://emedicine.medscape.com/article/173388-overview#a1
LO 8
Lower Gastrointestinal Disorders

HEMORRHOID
• Give the patient and the caregiver verbal and written instruction. Provide them with the
name and telephone number of a physician or nurse to call if question arise
• Review any explanation about treatment and specific follow-up care
• Explain and discuss the development of hemorrhoids, causes or contributing factors, care,
treatment, and potential for recurrence
• Diets : high fiber  promote regular bowel movements and soft stools
• Drink plenty of fluids (2-3L/day), unless contraindicated
• Use stool softeners and laxatives prevent constipation
• Defecate promptly after the urge  pressure in the rectum prevented
• Avoid prolonged sitting , squatting, or standing
• Avoid straining during defecation
• Advise the patient to abstain from anal intercourse until healing is complete
• Advise the patient to use topical anesthetics, astringents, and prescribed antiinflammatory
preparations
Dietary Fibres
Lower Gastrointestinal Disorders

PARASIT
• Prevention
– adequate sanitation, safe food and
water, and good personal hygiene of
the population.
Lower Gastrointestinal Disorders

ANAL FISSURE
 Prevention
• To prevent anal fissures in infants, be sure to
change diapers frequently.
• To prevent fissures at any age:
* Keep the anal area dry
* Wipe with soft materials or a moistened
cloth or cotton pad
* Promptly treat any constipation or diarrhea
* Avoid irritating the rectum