GROUP 13

GROUP 13
• Tutor : Dr. Sari Dewi/ Dr. Tom Surjadi
• Leader : Feny Chandra Dewi (405090208)
• Secretary : Boe Obet Agung Sanjaya (405100125)
• Scriber : Mieliani (405080191)
• Members :
– Renata C.F. Tjieputri (405080137)
– Charlie (405100005)
– Felicia Faustine Faraday (405100070)
– I Putu Mana Nitia (405100103)
– Adhitia Mahardika (405100124)
– Eva Fauziah (405100132)
– Andy Halim (405100193)
– Rahma Marini Sulwana (405100200)
– Khairunnisa Nugrahenni (405100210)
 Problem
• A 3-year-old boy presented with a large, hard, craggy
abdominal mass arising centrally from the pelvis, was
referred to hospital as a tumor suspected. The Child was
otherwise well and his nutrition was good. He had no pain
and no vomiting. He was described as a fussy eater, but
drank a lot of milk. He was potty trained for bowel and
bladder at 2,5 years of age.

Abdominal examination (confirmed by ultrasound

procedure): there was mass and a hugely distended rectum
filled with faeces.

What can you learn from the problem?

 Unfamiliar Term
• Craggy Abdominal : having hills and crags at
abdomen
• Fussy Eater : Fastidious about one's needs or
requirements; hard to please
 Problems
1. Why was the boy present a large, hard,
craggy abdominal mass arise centrally from
the Pelvis?
2. What’s the relation between drink a lot of
milk, potty trained at 2,5 years old with his
symptoms?
3. What is the intepretation of abdominal
examination from this baby?
 Opinion
1. Children:
– Constipation
– Obstruction of Fecalith
– Hirchsprung’s
– Atresia Ani
Adult:
– Pelvic Tumor
– Constipation
– Hemmorrhoids
– Diverticulitis
– Parasit
 Opinion
2. Milk Formula contain Fat, Protein and no
Lactulose Constipation Abdomen
Distention
– Change habit from diapers to potty lazy
Hold defecation Constipation
3. A mass Tumor
– Hugely distended rectum filled by feces
Constipation, obstruction, anorectal anomaly,
fissura ani, Hirchsprung’s
 Mind Map
Lower GIT Physiology and
Anatomy and Biochemistry of
Histology Defecation

Constipation

Structural: Functional: Anatomy:

- Hirchsprung’s - Habit -Anorectal
- Obstruction of Anomaly
Fecalith -Atresia Ani
-Endocrine Disorder
 Learning Objective
• 1. Able to Learn Anatomy of Lower GIT
• 2. Able to Learn Histology of Lower GIT
• 3. Able to Learn Physiology of Defecation
• 4. Able to Learn Biochemistry of Defecation
• 5. Able to Learn Constipation
Lo. 1. Able to Learn Anatomy of Lower
GIT
Anatomi
Lo. 2. Able to Learn Histology of Lower
GIT
DUODENUM JEJUNUM
ILEUM
 COLON
• There is no villi in colon’s tunica mucosa
• There are plica semilunaris, which contain: tunica mucosa and
circular tunica muscularis
• Surface cells (absorption cells) have striated border
• There are goblet cells between epithelial cells
• Cryptus Lieberkhun: there are smaller epithel than surface epithel,
and most of them contain goblet cells
• There are small amount of Paneth cells and Argentaffin cells

Characterized by:
• solitaire lymphonodules that spread from lamina propria to tunica
submucosa
• Longitudinal tunica muscularis forms 3 longitudinal tape, called
taenia coli
COLON
 APPENDIX VERMIFORMIS
• Appendix veriformis is a
diverticle from caecum
• Its structure looks like
colon’s
• Characterized by:
aggregat lymphonodules
in lamina propria and
spread to tunica
submucosa, stack itself in
ring-shape around the
lumen
• Tunica muscularis mucosa
looks rudimenter
 Histology of Rectum
2 parts of rectum :
1. Upper : colon like structure. Taller cryptus
and walled by goblet cells
2. Lower (anal canal) : Rectal collumn
longitudinal folds in mucosal end about 21/2
inchs from orrificium anal.
The junctional between anal and rectum called
linea pectinata
 Histology of Anus
1. Collumnaris zone
2. Intermedia zone
3. Cutanea zone
Anal gland

Squamous to collumnar
In linea pectinata Thinning squamous epithel

Stratified keratinized squamous epithel

With hair follicle
Lo. 3. Able to Learn Physiology of
Defecation
 Faeces in colon

delayed defecation
Rectum stretches

Relax sfingter ani interna rectal wall that

stretch receptor 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
 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 part of the large intestine,
where material stored until defecation.

Large segments of ascending

Increase of
After meals and transverse colon contract
motility
simultanously

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.
Physiology Defecation
• Composition of Faeces
• 3/4 water
• 1/4 solid matter:
– 30 % dead bacteria
– 10-20 % fat
– 10-20 % inorganic matter
– 2-3 % protein
– 30 % undigested material, including bile pigment
and sloughed epithelial cells
Lo. 4. Able to Learn Biochemistry of
Defecation
• Large-intestine secretion is entirely
protective  NaHCO3  protect
mucosa from mechanical and chemical
injury
• Colonic microorganisms are typically
harmless, but in fact beneficial :
– Enhance intestinal immunity by competing
with pathogenic microorganism
– Promote colonic motility
– Help maintain colonic mucosal integrity
– Make nutritional contributions (vit K, and
raise colonic acidity)
• The large intestine absorbs salt and water,
converting the luminal contents into feces
• Sodium actively absorbed
• Cl- follow passively
• H2O follow osmotically
• Of the 500ml material enter colon  350ml
absorbed  150g of feces to be eliminated
(100g H2O + 50g solid)
• The main waste product excreted 
bilirubin, unabsorbed food residues and
bacteria
 Lactulose
The chemistry
• The disaccharide Lactulose does not occur in
nature but is an isomerisation product from
lactose (galacto-glucose), a natural
component of milk.
• Lactulose is the ketotic analogue of milk sugar
(lactose) and consists of the two
monosaccharides galactose and fructose.
Fig. Chemical structure of Lactulose
 Characteristics of Lactulose
• Lactulose cannot be split by human enzymes
present in the gut.
• Therefore it passes the stomach and small
intestine and reaches the colon unchanged.
 THE EFFECTS OF LACTULOSE
• Lactulose has three major effects:
• It is prebiotic
• It acts as an osmotically active laxative
• It reduces blood ammonia levels
 Prebiotic
• Prebiotics are food ingredients that
beneficially influence the host by selectively
stimulating the growth and/or activity of
health-promoting colonic bacteria.
 Osmotically active laxative
• Lactulose is degraded in the colon by
saccharolytic bacteria, like Lactobacilli, into
SCFA (Short-chain fatty acid) .
• Thus the intestinal content acidifies, the
osmotic pressure rises, and stool volume
increases.
• This leads to the laxative effect of Lactulose
characterised by a shorter colon transit time
and accelerated bowel movement.
 Reducing blood ammonia levels
• Lactulose is split by colonic bacteria promoting their own
growth and increasing biomass.
• For the synthesis of bacterial protein, ammonia and
nitrogen are used.
• Production of ammonia is inhibited by acidifying the
intestinal content.
• This reduces the passage of free ammonia from the
intestine into the blood.
• Furthermore, the residence time of ammonia in the
intestinal lumen is reduced.
• Together with a shortened transit time, the excretion of
ammonia with the stool is accelerated and hence blood
ammonia levels are reduced.
Lo. 5. Able to Learn Constipation
CONSTIPATION
 Definitions
• Definition :
– Constipation is a symptom
– issues of stool consistency (hard, painful stools)
– issues of defecating behavior
• Infrequency (<3x per week)
• Difficulty in defecation
• Straining during defecation (>25% bowel movement)
• Subjective sensation of hard stool
• Incomplete bowel evacuation
• According to Rome III (at least 2 symptoms
over the past 3 months) :
– Less than 3 bowel movements per week
– Straining
– Lumpy/hard stools
– Sensation of anorectal obstruction
– Sensation of incomplete defecation
– Manual maneuvering required to defecate
 Causes
Common causes of constipation are:
• not enough fiber in the diet
• lack of physical activity (especially in the elderly)
• medications
• milk
• irritable bowel syndrome
• changes in life or routine such as pregnancy, aging, and travel
• abuse of laxatives
• ignoring the urge to have a bowel movement
• dehydration
• specific diseases or conditions, such as stroke (most common)
• problems with the colon and rectum
• problems with intestinal function (chronic idiopathic constipation)
 Causes
• 2 main groups :
– Primary Constipation
– Secondary Constipation
 Primary Constipation
• Primary (idiopathic, functional) constipation can
generally be classified into 3 categories:
– Normal-transit constipation (NTC)
• Patients perceive difficulty in evacuating their bowels
– Slow-transit constipation (STC) 
• Infrequent bowel movements, decreased urgency, or straining
to defecate. (mild abdominal distention or palpable stool in
the sigmoid colon)
– Pelvic floor dysfunction (ie, pelvic floor dyssynergia) 
• dysfunction of the pelvic floor or anal sphincter. Patients
often report prolonged or excessive straining, feeling of
incomplete evacuation, or the use of perineal or vaginal
pressure during defecation to allow the passage of stool or
report digital evacuation of stool.
 Secondary Constipation
• Diet and exercise
• Structural
• Endocrinopathic and metabolic
• Drugs
• Neurologic
• Connective-tissue disorders
• Toxicologic
• Psychologic
Types of Constipation and Causes
Recent onset :
- colonic obstruction
- Anal sphincter spasm
- Medications
Chronic
- IBS
- Medications
- colonic pseudo-obstruction
- Disorders of rectal evacuation
- Endocrinopathies
- Psychiatric disorders
- neurologic disease
- generalized muscle disease
Examples
Neoplasm, stricture, ischemic, diverticular,
inflammatory
Anal fissure, painful hemorrhoids
Constipation-predominant, alternating
Ca²⁺ blockers, antidepressants
Slow transit constipation, megacolon (rare
Hirschsprung’s, chagas)
Pelvic floor dysfunction,anismus,descending
perineum syndrom,rectal mucosal prolapse,
rectocele
Hypothyroidism, hypercalcemia, pregnancy
Depression, eating disorders, drugs
Parkinsonism, multiple sclerosis, spinal cord
injury
Progressive systemic sclerosis
 Patophysiology
• Constipation occurs if defecation is delayed for
too long
• The longer colonic contents being retained,
the more amount of H2O is absorbed  hard
& dry in consistency
 Medications that cause constipation

• A frequently over-looked cause of constipation is

medications. The most common offending medications
include:
– Narcotic pain medications such as codeine (for example,
Tylenol #3), oxycodone (for example, Percocet), and
hydromorphone (Dilaudid);
– Antidepressants such as amitriptyline (Elavil, Endep) and
imipramine (Tofranil)
– Anticonvulsants such as phenytoin (Dilantin) and
carbamazepine (Tegretol)
– Iron supplements
– Calcium channel blocking drugs such as diltiazem
(Cardizem) and nifedipine (Procardia)
– Aluminum-containing antacids such as aluminum hydroxide
suspension (Amphojel) and aluminum carbonate (Basaljel)
 Other causes of constipation
• Habit
• Bowel movements are under voluntary control. This means
that the normal urge people feel when they need to have a
bowel movement can be suppressed. Although occasionally
it is appropriate to suppress an urge to defecate (for
example, when a bathroom is not available), doing this too
frequently can lead to a disappearance of urges and result
in constipation.
• Diet
• Fiber is important in maintaining a soft, bulky stool. Diets
that are low in fiber can, therefore, cause constipation. The
best natural sources of fiber are fruits, vegetables, and
whole grains.
 Treatment Constipation
• Slow-transit constipation  with bulk, osmotic,
prokinetic, secretory, and stimulant laxatives
including fiber, psyllium, milk of magnesia,
lactulose, polyethylene glycol (colonic lavage
solution), lubiprostone, and bisacodyl
• anismus or pelvic floor dysfunction 
biofeedback management
• spinal cord injuries or other neurologic disorders
 rectal stimulation, enema therapy, and
carefully timed laxative therapy.
 Treatment Constipation
• Patients who have a combined (evacuation
and transit/motility) disorder  pelvic floor
retraining (biofeedback and muscle
relaxation), psychological counseling, and
dietetic advice
• with pelvic floor dysfunction alone,
biofeedback training has a 70–80% success
rate, measured by the acquisition of
comfortable stool habits
 Treatment
• Diet
• drinking enough fluids
• Increase exercise
• Bowel habit training
• Medicine (laxative)
 Hirschsprung's disease
• Hirschsprung's is a disease of the large
intestine.
• Hirschsprung's disease usually occurs in
children. It causes constipation, which means
that bowel movements are difficult.
• Some children with Hirschsprung's disease
can't have bowel movements at all.
The stool creates a blockage in the intestine.
 Why does Hirschsprung's disease
cause constipation?
• Normally, muscles in the intestine
push stool to the anus, where
stool leaves the body. Special
nerve cells in the intestine
called ganglion cells, make the
muscles push.
• A person with Hirschsprung's
disease does not have these
nerve cells in the last part of the
large intestine.
 Symptoms
• Symptoms in Newborns
– Newborns with Hirschsprung's disease don't have
their first bowel movement when they should.
These babies may also throw up a green liquid
called bile after eating and their abdomens may
swell. Discomfort from gas or constipation might
make them fussy. Sometimes, babies with
Hirschsprung's disease develop infections in their
intestines.
• Symptoms in Young Children
– constipation
– diarrhea
– anemia
– Also, many babies with Hirschsprung's disease grow
and develop more slowly than they should.
• Symptoms in Teenagers and Adults
• Like younger children, teenagers and adults with
Hirschsprung's disease usually have had severe
constipation all their lives. They might also have
anemia.
 Diagnostic evaluation
• Barium enema x ray
– For a barium enema x ray, the doctor puts barium through the
anus into the intestine before taking the picture. Barium is a
liquid that makes the intestine show up better on the x ray.
– In places where the nerve cells are missing, the intestine looks
too narrow.
• Manometry
The doctor inflates a small balloon inside the rectum.
Normally, the analmuscle will relax.

• Biopsy
– This is the most accurate test for Hirschsprung's disease. The
doctor removes and looks at a tiny piece of the intestine under a
microscope
 Dx
• The radiographic diagnosis of Hirschsprung
disease is based on the presence of a
transition zone between normal dilated
proximal colon and a smaller-caliber
obstructed distal colon caused by the
nonrelaxation of the aganglionic bowel
 Treatment
• operative intervention
• There are three basic surgical options
– excise the aganglionic segment and anastomose the
normal proximal bowel to the rectum 1-2 cm above
the dentate line
– procedure to create a neorectum, bringing down
normally innervated bowel behind the aganglionic
rectum
– stripping the mucosa from the aganglionic rectum and
bringing normally innervated colon through the
residual muscular cuff, thus bypassing the abnormal
bowel from within
 Diet and Nutrition
• Drinking plenty of liquids is important after
surgery for Hirschsprung's disease.
– .Since your child's intestine is shorter now, it
absorbs less. Your child will need to drink more to
make sure his body gets enough fluids.
• Eating high-fiber foods can help reduce
constipation and diarrhea.
 Fecal Impaction
• A fecal impaction is a large lump of dry, hard
stool that remains stuck in the rectum. It is
most often seen in patients with long-
term constipation
• Fecal impaction is often seen in people who have had constipation
for a long time and have been using laxatives. Impaction is even
more likely when the laxatives are stopped suddenly. The muscles of
the intestines forget how to move stool or feces on their own.
• Persons at risk for chronic constipation and fecal impaction include
those who:
– Do not move around much and spend most of their time in a chair or
bed
– Have diseases of the brain or nervous system that damage the nerves
that go to the muscles of the intestines
– Certain drugs slow the passage of stool through the bowels:
– Anticholinergics, which affect the interaction between nerves and
muscles of the bowel
– Medicines used to treat diarrhea, if they are taken too often
• Common symptoms include:
– Abdominal cramping and bloating
– Leakage of liquid or sudden episodes of watery diarrhea in
someone who has chronic constipation
– Rectal bleeding
– Small, semi-formed stools
– Straining when trying to pass stools
– Other possible symptoms include:
– Bladder pressure or loss of bladder control
– Lower back pain
– Rapid heartbeat or light-headedness from straining to pass
stool
 Hypothyroidism
• When newborns do have problems with
hypothyroidism, they may include:
Yellowing of the skin and whites of the eyes
(jaundice). In most cases, this occurs when a
baby's liver can't metabolize a substance called
bilirubin.
Frequent choking.
A large, protruding tongue.
A puffy appearance to the face.
• As the disease progresses, infants are likely to have
trouble feeding and may fail to grow and develop
normally.

• They may also have:

Constipation
Poor muscle tone
• In general, children and teens who develop
hypothyroidism have the same signs and symptoms
as adults do, but they may also experience:
Poor growth, resulting in short stature
Delayed development of permanent teeth
Delayed puberty
Poor mental development
• The reason constipation as a side effect of
hypothyroidism is because of the fact that the under
active thyroid is not able to keep the digestive
process going as well as it should be.

• The slower the digestive process goes the more

chance there is that the items that are in the
digestive tract will start to dry out and become
harder to move through.
 Tests and Diagnosis
• Blood tests
A low level of thyroxine and high level of TSH(
Thyroid Stimulating Hormon) indicate an
underactive thyroid.
 Treatment
• Standard treatment for hypothyroidism
involves daily use of the synthetic thyroid
hormone levothyroxine.
• This oral medication restores adequate
hormone levels, shifting your body back into
normal gear.
Definition
–An anal fissure is a small split or
tear in the thin moist tissue
(mucosa) lining the lower rectum
(anus).
 Causes
•Anal fissures are extremely common in young infants
but may occur at any age. Studies suggest 80% of infants
will have had an anal fissure by the end of the first year.
The rate of anal fissures decreases rapidly with age.
Fissures are much less common among school-aged
children than infants.
•In adults, fissures may be caused by constipation, the
passing of large, hard stools, or by prolonged diarrhea. In
older adults, anal fissures may be caused by decreased
blood flow to the area.
•Anal fissures are also common in women after
childbirth and persons with Crohn's disease
Symptoms
•Anal fissures may cause painful bowel movements and
bleeding. There may be blood on the outside of the stool
or on the toilet tissue (or baby wipes) following a bowel
movement.
•Other symptoms may include:
– A crack in the skin that can be seen when the area
is stretched slightly (the fissure is almost always in
the middle)
– Constipation
Exams and Tests
•The health care provider will perform a rectal exam and
look at a sample of the rectal (anal) tissue.
Treatment
•Most fissures heal on their own and do not require treatment, aside
from good diaper hygiene in babies.
•However, some fissures may require treatment. The following home
care methods usually heal most anal fissures.
– Cleansing more gently
– Diet changes -- eating more bulk, substances that
absorb water while in the intestinal tract
– Muscle relaxants applied to the skin
– Numbing cream, if pain interferes with normal bowel
movement
– Petroleum jelly applied to the area
– Sitz bath
– Stool softeners
•If the anal fissures do not go away with
home care methods, treatment may
involve:
–Botox injections into muscle in the
anus (anal sphincter)
–Minor surgery to relax the anal muscle
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
 Atresia Ani
(Imperforate anus)
• Abnormalitis from imperforate anus to
complete absence of anus and rectum
• Result of failure breakdown of the septum
between the hindgut and the invagination
ectoderm of the proctodeum
 symptoms
• If your baby has anal atresia, he/she may have:
– No anal opening present at birth
– Anal opening in the wrong location
– No stool within 24-48 hours after birth
– Stool being excreted through the vagina, penis,
scrotum, or urethra
– Tight, swollen stomach
• Milder anal atresia may not be apparent until
later in life. It may show as a lack of bowel control
by age 3.
Surgery
• Surgery may be an option to correct the anal
atresia. The exact surgery will depend on the
defects that are present. One type of surgery
may help to connect the anus and intestine.
• Another type of surgery is anoplasty. This is
done to move the anus to the correct location.
It will also make sure that the muscles that
control bowel movements are in place.
Colostomy
• A colostomy is done if your baby needs a new way for
waste to pass from the body. During this surgery, a part
of the intestine is attached to an opening in the wall of
the abdomen. Waste can pass out of this opening into a
bag outside the body.
• A colostomy may be needed if the birth defect does not
allow waste to pass from the body. It may also be done
after surgery to the rectum. The colostomy will give the
anal area time to heal before waste passes through. The
colostomy will be closed once the anus is fully healed.
 Temporary Colostomy of an Infant
Copyright © Nucleus Medical Media, Inc
• Radiographic features
• Plain film / Abdominal radiograph
• can be variable depending on the site of atresia (e.g high or low) ,
level of impaction with meconium and physiological effects such as
straining.
• may show multiple dilated bowel loops with with absence of rectal
gas
• Ultrasound
• the anus may be seen as an echogenic spot at the level of the
perineum and in an atresia this echogenic spot may be absent 4.
• may show bowel dilatation
• an infra coccygeal or transperineal approach may allow
differentiation between a high or low sub-type 4.
 treatment
• if the septum is thin,it is divided with suture of
the edges of the defect to the skin
• If there is an extensive gap between the blind end
and the anal verge , a colostomy is fashioned
• If vaginal fistula is present, operation is not
urgent, and elective surgery is performed when
the girl is older
• If a rectourethral or vesical fistula is present,
fistula must be close urgently with colostomy or
reconstruction.
 prognosis
• The recovery from anal atresia is very good,
especially in milder cases. Surgery generally
solves all issues related to the condition
although constipation could be a frequent
problem for the patient. In some cases
medication will be prescribed to help promote
proper bowel function, and certain dietary
guidelines might need to be followed.
 Hemorrhoid
• Definition:
–Dilated or enlarged veins in the lower portion
of the rectum or anus.

• Alternative Names
–Rectal Lump
–Piles
–Lump in the Rectum
 Epidemiology
• Symptomatic hemorrhoids affect at least 50% of
the American population at some time during their
lives, with around 5% of the population suffering at
any given time
• Both sexes experiencing the same incidence of
the condition.
• They are more common in Caucasians.
 Etiology
Factors may lead to the formations of hemorrhoids including
• irregular bowel habits (constipation or diarrhea)
• Lack of exercise
• nutrition (low-fiber diet and high fat)
• increased intra-abdominal pressure (prolonged straining)
• absence of valves within the hemorrhoidal veins
• Other factors that can increase the rectal vein pressure
resulting in hemorrhoids include obesity and sitting for long
periods of time.
• Pregnancy. During pregnancy, pressure from the fetus on the
abdomen and hormonal changes cause the hemorrhoidal
vessels to enlarge. Delivery also leads to increased intra
abdominal pressures. Surgical treatment is rarely needed, as
symptoms usually resolve post delivery.
 Pathogenesis
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

 Symptom

• Anal itching
• Anal ache or pain, especially while sitting
• Pain during bowel movements
• One or more hard tender lumps near the anus
• Painless Bleeding
bright red blood on the outside of the stools, on the
toilet paper, or dripping into the toilet. The bleeding
usually is self-limiting.
 Classifications
External
• External hemorrhoids are those that occur
outside the anal verge (the distal end of the anal
canal). Specifically they are varicosities of the
veins draining the territory of the inferior rectal
arteries
• They are sometimes painful, and often
accompanied by swelling and irritation. Itching,
although often thought to be a symptom of
external hemorrhoids, is more commonly due to
skin irritation.
• External hemorrhoids are prone to thrombosis: if
the vein ruptures and/or a blood clot develops,
the hemorrhoid becomes a thrombosed
hemorrhoid.
Internal
• Internal hemorrhoids are those that occur
inside the rectum. Specifically they are
varicosities of veins draining the territory of
branches of the superior rectal arteries.
• Internal hemorrhoids are usually not painful
and most people are not aware that they have
them.
• Untreated internal hemorrhoids can lead to
two severe forms of hemorrhoids: prolapsed
and strangulated hemorrhoids.
• Prolapsed hemorrhoids are internal
hemorrhoids that are so distended that they
Classical appearance of an external
hemorrhoid
 Classification & degree
a. Interna hemoroid

• Degree one (early): if there is enlargement of

hemorrhoids that do not prolapse outside the
anal canal. can only be seen with anorektoskop
• Degree two: enlargement of the prolapsed
hemorrhoids and disappear or go alone into the
anus
• Degree three: enlargement of the prolapsed
hemorrhoid can go back into the anus with a
finger push aid
• Degree four: prolapsed hemorrhoids permanent
vulnerable and prone to thrombosis and infarc
 Diagnosis
• A visual examination of the anus and surrounding area may
be able to diagnose external or prolapsed hemorrhoids.
• A rectal exam may be performed to detect possible rectal
tumors, polyps, an enlarged prostate, or abscesses.
• Visual confirmation (inspection) of internal hemorrhoids is via
anoscopy. This device is basically a hollow tube with a light
attached at one end that allows one to see the internal
hemorrhoids, as well possible polyps in the rectum.
 Diagnosis
• If there is the potential that the bleeding source originated
above the rectum from other parts of the colon,
sigmoidoscopy or colonoscopy by a gastroenterologist may
be recommended.
• If there is concern that significant bleeding has occurred, a
CBC (complete blood count) to measure hemoglobin and
hematocrit levels is obtained.
• If the patient is on warfarin (Coumadin), a prothrombin time
(PT) or INR may be done to measure the blood clotting levels.
Direct view of a hemorrhoid as seen by
sigmoidoscopy
Endoscopic image of internal hemorrhoids
seen on retroflexion of the
flexible sigmoidoscope at the ano-rectal
junction
 Treatment
• Non pharmacologic
– Bowel management program (BMP) improve
diet, fluid, fiber, stools softener, the way of
defecation
• The way of defecation  squatting
• Drown anus in the water for 10-15 minutes (2-4
times/day)
• More exercise
• Drink water (30-40ml/kgBB/day)
• High fiber (vegetables, fruits, cereal, fiber supplement)
 Treatment
• Pharmacologic
– Improve defecation
• Fiber supplement  psyllium, isphagula husk
• Stools softener  natrium dioctyl sulfosuccinat
– Symptomatic
• Local anesthesia  reduce pain
• Corticosteroid  reduce inflammation
– Stop bleeding
• Psyllium, daflon
– Healing and preventing hemorrhoid
• Diosminthespridin  improve symptom of inflammation,
congestion, edema, and prolapse
 Treatment
• Minimal invasive treatment
– If non pharmacologic and pharmacologic don’t
give improvement
– Treatment: Injection sclerotherapy, elastic band
ligation, laser therapy
• Hemorrhoidectomy
– Criteria:
• Those who have large prolapsing hemorrhoids with areas of
squamous ephitelial change
• Those who symptoms have not responded to other treatment
• Those who have recurrent episodes of thrombosis
 Treatment
– Principle
• Removal of the 3 primary hemorrhoids
• Taking care not to damage either of the underlying
sphincters
• Preserve the bridge of mucosa and skin between each
wound to ensure healing without stenosis
Stapled Hemorrhoidectomy
 Differential diagnose
Many anorectal problems, including:
- anal fissures
- anal fistulae
- abscesses
- colorectal cancer
- rectal varices
have similar symptoms and may be incorrectly referred to
as hemorrhoids.
 Complication
• Fissure
• Prolapsing anal polyp
• Hypertrophied anal papilla
• Clotted venous saccule
• 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).
Complication
• 1st bowel movement and dressing on the 1st few
postoperative days are painful  analgesics
• Retention of urine
• Fecal impaction
• Secondary hemorrhage
 CIE
• 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
 CIE
• 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
 Prognosis
• 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.
 Prevention
• Decreased constipation and straining at stools
with:
– More exercise (walking, etc)
– Increase fiber consumption
 IBS
(Irritable Bowel Syndrome )
 Definition
• Irritable bowel syndrome (IBS) is a chronic
gastrointestinal disorder of unknown cause.
• Common symptoms include abdominal
cramping or pain, bloating and gassiness, and
altered bowel habits. Irritable bowel
syndrome has been called spastic colon,
functional bowel disease, and mucous colitis
 Causes
• The cause of irritable bowel syndrome is currently
unknown. IBS is thought to result from an
interplay of abnormal gastrointestinal (GI) tract
movements, increased awareness of normal
bodily functions, and a change in the nervous
system communication between the brain and GI
tract
• Abnormal movements of the colon, whether too
fast or too slow, are seen in some, but not all,
people who have IBS.
 ETIOLOGY
• Motility disorders
• Food intolerance
• Sensory abnormalities
• Axis abnormalities of brain-gut interactions
• Visceral hypersensitivity
• Intestinal post-infection
 CRYTERIA OF IBS
• Based on Rome III Criteria:
– Pain or discomfort in the abdomen are repeated
at least three days per month during the last three
months with the following symptoms:
• Improve with defecation
• Onset associated with change in frequency of
defecation
• Onset associated changes in the form of faecal
 SUBGROUP IBS
• Predominant IBS pain
– In the iliac fossa pain, can not explicitly show the
location of the pain.
– Pain is felt more than six months
– Pain disappeared after defecation
– Increase if the stress and pain during
menstruation
– Persistent pain is felt even more sick if relapse
• Diarrhea predominant IBS
– Diarrhoea in the morning, often with urgency
– Usually accompanied by pain and loss in meals
• Constipation predominant IBS
– Especially women
– Defecation did not
– Usually accompanied by mucus, without blood
stool
• IBS alternating pattern
– Defecation patterns changing: diarrhea and
constipation
– Stool is often hard in the morning followed by a
couple of times defecate, and liquid faeces into
the afternoon
 Symptomps
• Abdominal cramping and pain that are relieved
after bowel movements
• Alternating periods of diarrhea and constipation
• Chance in the stool frequency or consistency
• Passing mucus from the rectum
• Bloating
• Abdominal distension
• Flatulence
 MANAGEMENT
• Diet
– Avoid foods that sparked IBSgandum, milk, caffeine, onions,
chocolate and some vegetables.
• Psychotherapy
• Drugs
– Pain abdomenantispasmodik: mebeverine, hiosin N-
butilbromida, chlordiazepoksid / klidinium, alverine
– IBS constipationlaksatif osmotic: lactulose, magnesium
hydroxide
– IBS type diarrhealoperamid
 Medication
• Antispasmodic (dicyclomine, hyoscyamine)
– are sometimes used to treat symptoms of irritable bowel
syndrome. Antispasmodic medicines help slow the action of
the digestive tract and reduce the chance of spasms.
• Antidiarrheal (loperamide, kaopectate, lomotil)
– are sometimes used when diarrhea is a major feature of
IBS. Do not take these on a long-term basis without first
consulting a doctor.
• Antidepressants
– are some commonly used medicines that may
alleviate irritable bowel syndrome symptoms. Some other
antidepressants are more commonly prescribed when
depression and IBS coexist.
 DIFFERENTIAL DIAGNOSIS
• Lactase deficiency
• Colorectal Cancer
• Diverticulitis
• IBD
• Mechanical obstruction in the small intestine
and colon
• Intestinal infection
• Ischemia
• Maldigesty and malabsorption
• Endometriosis
 PROGNOSYS
• IBS disease will not increase mortality,
patients with IBS symptoms will usually
improve and disappear after 12 months on
50% of cases and only less than 5%, which will
worsen and the rest with persistent
symptoms.
 Prevention
• Maintaining good physical fitness improves
bowel function and helps reduce stress.
• Stopping smoking is important for overall
good health.
• Avoiding coffee, gas-producing foods, and
spicy foods may help.
• Reducing or eliminating alcohol consumption
may help.
 UC CD
Definition Is a chronic inflammatory Is an idiopathic inflammatory
disease that causes ulceration disorder that affects any part
of the colonic mucosa and of GIT from the mouth to the
extends proximally from the anus
rectum into the colon
Etiology  dietary  Mutations gene
 infectious genetic CARD15/NOD2
 immunologic factor  smoking / tobacco use
 commensal / pathogenic
enteric microorganisms with
increased mucosal adherence
and invasion and persistent
activation of T cells
 UC CD
Pathophysiolo  limited to the mucosa Inflammatory begins in the
gy  not transmural intestinal submucosa 
 the mucous layer thinner mucosa and serosa
than normal
 impairment of the
epithelial barrier
 Features UC CD
Age of Onset Any Age; 10-40 years Any Age; 10-30 years most
most common common
Family History Less Common More Common

Gender Women = Men Women = Men

Cancer Risk Increased Increased

Location Colon and Rectum, no All of GIT; “skip” lesion

“skip” lesions common
Granulomas Rare Common

Friable Mucosa Common Common

Fistula & Abcesses Rare Common

Stricture & Possible Rare Common

Obstruction
 Features UC CD

Abdominal Pain Occasional Common

Diarrhea Common Common

Bloody Stools Common Les Common

Abdominal Mass Rare Common

Small Intestine Rare Common

Malabsorption

Steatorrhea Rare Common

Potential of Common Common

Malignancy
 Features UC CD
Antineutrophil Common Rare
Cytoplasmic Ab
AntiSaccharomyces Rare Common
cerevisiae Ab
Clinical Course Remissions and Remissions and
exacerbations exacerbations
CA COLON
 Risk Factors
1. Genetic risk factors
• Family history of colon cancer
• Family history of Intestinal polyps
• Intestinal polyps
• Previous colon cancer
• Ulcerative colitis
• Crohn’s disease
2. Lifestyle related risk factors
• Chronic constipation
• Diet:
–High-fat diet
–low fiber diet
• Obesity
• Smoking
 Symptoms
Initial symptoms of colorectal cancer include:
1. Blood in the stool
2. Red stools
3. Black stools
4. Changes in frequency of bowel movements:
– Frequent loose stools
– Constipation
5. Abnormal appearing stools :
– Changes in the size of the stools
– Changes in the shape of the stools
Additional symptoms of colorectal cancer include:
1. Anoreksia
2. Abdominal pain
3. Abdominal swelling
4. Excessive fatigue
5. Unintentional weight lost
6. Vomiting
 Stages
Staging colon cancer usually includes some combination of the
following tests:

1. CT scan of the abdomen

2. MRI scan of the abdomen
3. Bone scan
4. Carcinoembryonic antigen blood level
5. Chest x-ray
6. Complete blood count
7. Lymph node biopsy
8. Surgery with tissue biopsy
Colon Cancer Stage 0
Stage 0 cancer is also called carsinoma in
situ. In stage 0, the cancer is found only in
the innermost lining of the colon.

Colon Cancer Stage 1

Stage 1 colon cancer is sometimes called
Dukes' A colon cancer. In stage 1, the
cancer has spread beyond the innermost
tissue layer of the colon wall to the middle
layers.
Colon Cancer Stage 2
Stage 2 colon cancer is also called Dukes'
B colon cancer.

Stage 2 colon cancer is divided into stages:

1. Stage 2A: cancer has spread beyond the
middle tissue layers of the colon wall or
has spread to nearby tissues around the
colon or rectum.
2. Stage 2B: cancer has spread beyond the
colon wall into nearby organs and/or
Colon Cancer Stage 3
Stage 3 colon cancer is also called Dukes' C colon cancer.

Stage 3 colon cancer is divided into:

1. Stage 3A: cancer has spread from the innermost tissue
layer of the colon wall to the middle layers and has spread
to as many as 3 lymph nodes.
2. Stage 3B: cancer has spread to as many as 3 nearby lymph
nodes and has spread:
– beyond the middle tissue layers of the colon
wall; or
– to nearby tissues around the colon or rectum; or
– beyond the colon wall into nearby organs and/or
Stage 3C: cancer has spread to 4 or more nearby
lymph nodes and has spread:
–to or beyond the middle tissue layers of the
colon wall; or
–to nearby tissues around the colon or rectum;
or
–to nearby organs and/or through the
peritoneum.
Colon Cancer Stage 4
Stage 4 colon cancer is also called
Dukes' D colon cancer. In stage
4,cancer may have spread to nearby
lymph nodes and has spread to
other parts of the body, such as the
liver or lungs.
 Imaging studies
• Barium enema
• CT scanning of the abdomen: an excellent test for
excluding internal injury
• MRI scan of the abdomen
• Virtual colonoscopy:
– Uses a special type of CT scanner that takes many
pictures of the colon in super thin slices. A
computer reassembles the images into a 3-D
model of the colon. The more slices the CT
scanner is capable of taking in rapid succession,
the better the image quality.
• Bone scanning
 Laboratory
• Stool guaiac:
– Testing stools for the presence of blood not visible
to the naked eye
• DNA stool testing:
– A test that looks for abnormal DNA in a stool
sample.
• Complete blood count
• Liver profile
• Kidney profile
• Urinalysis
• Anoscopy
• Colonoscopy
• Sigmoidoscopy
 Treatment
• Surgery
• Polypectomy
– For small tumors that have not spread
• Chemotherapy
• Radiation therapy
• Colorectal cancer clinical trials
 Prevention
• Stop smoking
• Avoid exposure to secondary smoke.
• Eat a healthy heart diet
– High fiber diet
– Low fat diet
• Calcium supplements
• Vitamin D may help cut the risk for colon cancer
– The Institute of Medicine recommends 200 IU daily for children and
adults up to age 50, and 400 IU for adults aged 51-70; people over age
70 should get 600 IU daily.
• Weight loss if overweight
• aspirin therapy:
– Some studies have shown that it can reduce the risk of colon polyps in
those who have previously had colon cancer.
 Conclusion
• We had studied learning objective :
– Anatomy, histology lower GIT
– Physiology, biochemistry defecation
– Constipation
 Suggestion
• Patient should eat high Fiber and low fat,
drink a lot of water, do exercise.
 REFERENCES
• Sherwood L. Human physiology. 5thed. Belmont: Thomson
Learning,2004.
• Fauci AS, Braunwald E, Kasper DL, Hauser SL, Longo DL,
Jameson JL, et al, editors. Harrison’s principle of internal
medicine. 17 th ed. USA : McGrawHill medical, 2008.
• Kliegman RM, Berhman RE, Jenson HB, Stanton BF.
Nelson’s Textbook of Pediatrics. 18th ed. Philadelphia: WB
Saunders Co, 2007.
• http://www.ncbi.nlm.nih.gov/pmc/articles/PMC314308
6/http://www.cdc.gov
• http://www.mayoclinic.com
• http://www.lactulose.eu