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Its a ppt on the disorders of the git tract

1.  ACUTE INFLAMMATORY INTESTINAL DISORDERS Introduction:- Any part of the lower GI tract is susceptible to acute inflammation caused by bacterial, viral, or fungal infection. Two such conditions are appendicitis & diverticulitis , both of which may lead to peritonitis , an inflammation of the lining of the abdominal cavity. 1

2. The appendix is a small, finger-like appendage about 10 cm (4 in) long that is attached to the cecum just below the ileocecal valve. The appendix fills with food and empties regularly into the cecum. Because it empties inefficiently and its lumen is small, the appendix is prone to obstruction and is particularly vulnerable to infection (i.e., appendicitis). Def n :- Is an inflammation of a narrow, blind protrusion located at the tip of the cecum (appendix). 2 1. Appendicitis

3. Can occur at any stage, but more common in 10-30years. It is not common in adult but when it doesn’t occur, rupture is more common About 7% of the population will have appendicitis at some time in their lives; Males are affected more than females . Is the most common reason for emergency abd . - surgery. The most common cause of acute abdomen in the USA Etiology: Appendicitis can be caused by obstruction of the lumen of the appendix by: A fecal mass (fecallith- hardend mass of stool). Tumor or foreign body. Kinking (twisting) of the appendix External occlusion of the bowel by adhesions 3 Incidence of a ppendicitis :

4. When the appendix become obstructed, The intra-luminal pressure increase leading to decrease Venus drainage, thrombosis, edema and bacterial invasion of the bowel wall . Will continue obstruction, perforation will result and the inflamed appendix will fills pus 4 Pathophysiology :

5. Vague epigastric or peri-umblical pain progresses to RLQ. Low grade fever Loss of appetite is common / Anorexia, nausea & sometimes vomiting Local tenderness is elicited at MC - burney’s point (in 50% pts) when pressure is applied.  MC - burney’s point - an area mid way b/n the umbilicus & the right iliac crest) Rebound tenderness may present (i.e. production of pain when pressure is released) Some rigidity of the lower portion of the right rectus muscle may occur. 5 C/M :

6. Rovsing’s sign +ve may be elicited by palpating the left lower quadrants, causes pain in right lower quadrant. Pain becomes steady rather than intermittent and the client often guards the area by lying still & drawing the legs up to relieve tension on abdominal muscles. psoas sign +ve (pain on extension of the right hip) Obturatory sign +ve (pain on internal or external rotation of the hip) Constipation can also occur with appendicitis. Laxatives administered in this instance may result in perforation of the inflamed appendix. In general, a laxative or cathartic should never be given when a person has fever, nausea, and abdominal pain. 6 C/Ms cont’d…

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8. The extent of tenderness depends on the location of the inflamed appendix. Example If its tip in the pelvis, these signs may be elicited by only on rectal examination. Pain on defecation suggests that the tip of the appendix is resting against the rectum. Pain on urination suggests that the tip is near the bladder. If the appendix has ruptured, pain becomes more diffuse, abdominal distension, patients’ condition worsens) 8 C/Ms cont’d…

9. History and physical examination Laboratory examination Complete blood count On laboratory findings :- The complete blood cell count Reveal an elevated white blood cell count. Leukocyte count may exceed 10,000 cells/mm3, Neutrophil count may exceed 75%. Abdominal x-ray films, ultrasound studies, and CT scans may reveal a right lower quadrant density or localized distention of the bowel 9 Diagnostic Assessment

10. Complications The major complication of appendicitis is perforation of the appendix, which can lead to peritonitis or an abscess formation (collection of purulent material) . The incidence of perforation is 10% to 32%. Perforation generally occurs 24 hrs after the onset of pain. Symptoms include a fever of 37.7°C or higher, a toxic appearance &continued abdominal pain or tenderness. Management No medical treatment as such for appendicitis. Surgical Management Appendectomy (removing the appendix). Intravenous fluid (to correct electrolyte and fluid). Antibiotics to prevent infection . 10

11. If appendicitis is suspected :- Prepare the patient for surgery. IV infusion (to replace fluid loss). Antibiotic therapy (to prevent infection). Pain medication should be with held until diagnosis is confirmed Never give enema or a laxative or apply heat (because it can lead to perforation). NPO(Nothing per OS) After Appendectomy Place the patient in a semi fowler’s position. Monitor vital sign, intake and output. Give analgesic, as ordered. Encourage the patient to cough, deep breath, and turn frequently to prevent pulmonary complication Document bowel sounds, Watch closely for possible surgical complications & give Mouth care . 11 Nursing Management

12. Peritonitis : Is an inflammation of the peritoneum. Caused by bacterial or chemical contamination of the peritoneal cavity. Can be primary or secondary peritonitis. Classified as: Acute or chronic peritonitis. Localize or generalized peritonitis Normal bacterial flora of the intestine becomes a source of infection. The most common organism E. coli, streptococci. 12 2. Peritonitis

13. They enter the sterile peritoneal cavity usually this is a result of Perforated appendix. Perforated peptic ulcer disease. Strangulated bowel /bowel perforation. Perforation of a diverticulum Salpingitis Septic abortion Pancreatitis Cholecystitis…..etc. 13 Cont’d…

14. Sharp abdominal pain which worsen with movement. Abdominal distention. Increased pulse rate. Abdomen becomes rigid (muscle guarding). leucocytosis and fever may develop. Decreased or absent bowel sounds. Tenderness/localized or generalized. Respirations may be shallow and rapid. Nausea and vomiting . 14 C/Ms:-

15. History and physical Examination. Lab Ix: shows Elevated WBCs almost always - WBC 20,000 mm3 with high neutrophil count. An abdominal x-ray may show air & fluid levels as well as distended bowel loops or it Shows dilation & edema of the intestine Abdominal ultrasound may reveal abscesses and fluid collections Serum electrolyte studies may reveal altered levels of potassium, sodium, and chloride. A CT scan of the abdomen may show abscess formation. MRI may be used for diagnosis of intra-abdominal abscesses. Culture & sensitivity studies of the aspirated fluid may reveal infection and identify the causative organisms. 15 Diagnosis:

16. Medical Mg't Fluid & electrolyte replacement. Analgesics are prescribed for pain. Antiemetics are administered as prescribed for nausea and vomiting. Intestinal intubations & suctioning – relieve the distension & promote intestinal function 2 therapy Massive broad spectrum antibiotic therapy with early initiation through iv route. Surgical removal of the etiology. 16

17. Nursing Mg't On going assessment of pain, v/s, fluid & electrolyte balance. Report any findings. Administration of analgesics Position the pt is placed on the side with knees flexed, this position decreases tension on the abdominal organs. Accurate record of input & out put. Drainage tube are inserted during the surgical procedure & the nurse should record the character, and amount of the drainage. Signs that indicate the peritonitis is subsiding includes: Decrease in temp - & pulse rate Softening of the abdomen Return of peristaltic sound Passing of flatus & bowel movements 17

18. The inflammation is most commonly not localized, and the entire abdominal cavity shows evidence of widespread infection. There fore possible complications are:- Generalized sepsis – it is the main cause of death Shock - may results from septicemia or hypovolemia. Inflammatory process may cause intestinal obstruction . primarily from the development of bowel adhesions. The two most common postoperative complications are: wound evisceration Abscess formation N.B: Sepsis is the major cause of death from peritonitis. 18 Complications

19. 1. Intestinal Obstructions Definition Failure of normal transit of bowel contents. Or Interruption in the normal flow of intestinal contents. IO is partial or complete blockage of the intestine producing symptoms of vomiting, constipation, distension & abdominal pain Bowel obstruction occurs when the normal propulsion and passage of intestinal contents does not occur. 19 INTESTINAL DISORDERS (Lower)  Selected lower GIT D/ors:- Intestinal (bowel) obstruction Abdominal hernias Hemorrhoids

20. 20 Sites of bowel obstruction 1. Small bowel :- most common site because of its narrow lumen. Duodenum Ileum 2. Large bowel :-can be obstructed at any part of it. But, mostly affected sites :- Left colon – because of its small diameter. Sigmoid – because of its mobility. 3. Both the small and large intestine (generalized ileus).

21. Incidence of bowel obstruction Site of Obstruction Cause Relative Incidences (%) Small intestine [85%] Adhesions 60 Hernia 15 Tumors 15 miscellaneous 10 Large Intestine [15%] CA colon 65 Diverticulitis 20 Volvulus 5 miscellaneous 10 21

22. Incidence cont’d… Most bowel obstructions occur in the small intestine. Adhesions are the most common cause of SBO, followed by hernias and neoplasms. Other causes include intussusceptions, Volvulus (i.e., twisting of the bowel), and paralytic ileus . Most obstructions in the large bowel occur in the sigmoid colon . The most common causes are carcinoma, diverticulitis, inflammatory bowel disorders, and benign tumors . 22

23. 23 Pathophysiologic classification 1. Mechanical (Dynamic) obstruction . Occurred as a result of physical blockage of the intestine. There is continuous peristaltic movement in attempt to over come physical blockage. An Intraluminal obstruction or a mural obstruction from pressure on the intestinal wall occurs. Examples are intussusceptions, polypoid tumors and neoplasms, stenosis, strictures, adhesions, hernias, Volvulus and abscesses .

24. 2. Functional (Adynamic) obstruction The intestinal musculature cannot propel the contents along the bowel. Occurred as a result of impaired intestinal motility. (disorder of propulsive movement) There is no peristalsis Also called paralytic illus Examples are amyloidosis, muscular dystrophy, endocrine disorders such as diabetes mellitus, or neurologic disorders such as Parkinson’s disease. The blockage also can be temporary and the result of the manipulation of the bowel during surgery. The obstruction can be partial or complete. 24

25. Severity of bowel obstruction depends on; Region of obstruction Degree of obstruction Extent of ischemia, especially the degree to which the vascular supply to the bowel wall is disturbed. 25

26. A. Causes of mechanical Bowel Obstruction - In SI I. Intraluminal causes (Causes Inside the Lumen) Intestinal atresia or stenosis, Round worm mass, Foreign body, Gallstone Ileus II. Intramural Causes (With in the wall) Stricture, Neoplasm, Intestinal TB & Intussception 26  Intussception - Invagination of one segment of intestine with in the other. Types Simple E.g., Ileocolic (commonest); Ileoileal; colocolic Compound e.g. -ileoileocolic

27. Causes of mechanical obstruction in SI cont’d… III. In Extramural Causes (outside the wall) Adhesion Volvulus & Hernia Adhesions & Bands - abnormal connective tissue attachments Hernia - abnormal protrusion of an organ through a defect in its containg wall . Volvulus - twisting or rotation o f a bowel about its mesentery. It can involve both Small/Large bowel 27

28. A. Causes of mechanical Bowel Obstruction - In Large Intestine I) Intraluminal causes (Causes Inside the Lumen) Fecal impaction Neoplasms (Left colonic Carcinoma ) II) In Extramural Causes (outside the wall) Sliding Hernia Volvulus (Sigmoid volvulus ) Diverticulitis 28

29. 29 B) Causes of Functional intestinal Obstruction Causes Abdominal Surgeries Medications Anticholinergics Anesthetics Opiates Spinal cord Injury/ Trauma Mechanisms Induce Sympathetic Activation Motility Are anti motility medications. Damage to S2-S4 parasympathetic (Stimulatory) nerves .

30. 30 Causes of Functional intestinal Obstruction cont’d… Causes Infections -Peritonitis -Intra abdominal abscess Electrolyte abnormalities -Hypokalemia -Hyponatremia Mesenteric Ischemia Mechanisms Release of anti motility Substance (Nitric oxide) Leads to impaired excitation &contraction of bowel wall muscles. Necrosis (Death) of Muscles

31. 31 Pathophysiology of intestinal obstruction Obstruction (Mechanical/Functional )  Accumulation of Intestinal contents. The contents include:- Ingested food Fluid ; from swallowed liquids & GI secretions (N.B obstruction stimulates intestinal secretion, but absorption) and, Gas .  Result in the following Local & Systemic Effects.

32. 32 Cont’d…. Local effects   & & Hyper Hypo Peristalsis Peristalisis   Systemic effects Fluid & Electrolyte loss ( 3rd space loss ) in to -Bowel lumen -Bowel wall -Peritoneum & loss via vomiting.  Result In Proximal Bowel Dilatation Distal Bowel Collapse Constipation Abdominal Pain

33. 33 Cont’d…  Distension of proximal bowel  ed Intraluminal Pressure  Compression of vasculatures   Of Veins Of Arteries   Congestion & Ischemia & Edema Necrosis  Of Bowel wall   Electrolyte depletion - Hyponatremia -Hypokalemia Reduced blood volume   ed RBF ed BP   Oliguria Hypotension Dehydration

34. 34 Cont’d…. Necrosis & Gangrenous changes of bowel wall  Proliferation of bacteria  Transmigration of bacteria In to peritoneum  Gen.Peritonitis Septic Shock Death. (un Rxed) Mechanical/Functional Obstruction Vicious cycle Electrolyte Depletion (Hypokalemia) N.B Mechanical obst. Functional obstruction .

35. Cont’d…. N.B Bacterial translocation can occur early in bowel obstruction because of disruption of mucosal barrier resulting in peritonitis even before gangrene formation. 35

36. Clinical Features of Intestinal Obstruction Common Symptoms Colicky and wave like crampy abdominal pain:- due to distension and Hyperperistalisis. Vomiting:- B/C of reverse peristalsis. If the obstruction is in the ileum fecal vomiting takes place Constipation:- B/C of obstruction & Collapse of distal segment. Pass blood and mucus, but no fecal matter & no flatus Abdominal distension - 2 o to accumulated intestinal content. 36

37. 37 Common signs Gen. Appearance :- Acutely Sick Abdominal distension Frequent and high pitched bowel sounds early in the obstructive process Decreased/absent bowel sounds late in the obstructive process Abdominal tenderness and guarding Vital Signs BP-(Hypotension); PR-Tachycardia ,weak pulse Temperature –  in Hypovolumic shock  in Septic shock Signs of Dehydration Sunken Eye, Dry tongue & oral mucosa Decreased skin integrity Increased PR

38. 38 Abdominal Examination Inspection - Distended Abdomen - Visible Peristalsis Auscultation Hyperactive bowel sound  in Mechanical obstruction. Hypoactive bowel sound  in Functional obstruction. Palpation - Guarding - Rebound tenderness Percussion - Hypertympanitic On digital rectal examinations ( DRE) rectal mass, impacted stool, Apex of Intussception

39. 39 Clinical Diagnosis of different Types of Obstruction SBO Central Abdominal pain (initial manifestation)  Bilious vomiting  Minimal central abdominal Distension LBO Constipation (initial manifestation)  Gross abdominal distension & peripheral Pain  Feculent Vomiting

40. 40 Simple Vs Strangulated Presented with all classical symptoms Signs -V/S Stable -Abdomen soft, non tender & distended. Classical symptoms + Fever Signs -GA – ASL -V/S Unstable - PR – tachycardia - T- Fever - Abdomendiffusely tender

41. 41 Investigations Dx: is made based on: Clinical Hx and P/E Laboratory:- ↑ sed WBC count, electrolyte imbalance X-ray studies   shows dilated loop of bowel shows Air-Fluid levels w/c are pathognomonic of intestinal obstruction Used to differentiate SBO from LBO. Abdominal ultrasound - used to see Gall stone, Foreign body & tumors

42. Components of Conservative Mg’t:- Fluid resuscitation Early preoperative preparation Electrolyte & acid-base correction NG tube- to decompress distension NG-Tube insertion, also used:- For Aspiration of gastric content.  Will  Intraluminal pressure & gangrenous progression. For prevention of vomiting. Keep NPO Early operation (laparatomy) when there is strangulation Post operative care Monitor response of Mg't - with V/S chart & Input-output record. 42

43. 43 Signs of success of conservative Mg’t Passage of flatus Reduced nasogastric aspirate Reduced abdominal distension Return of normal bowel sound Surgical Mg’t Definitive mode of Mg’t for complicated obstruction. Components of surgical Mg’t Pre-op prophylactic antibiotics Definitive surgery (Laparatomy) Adhesion – Release Band – Divide Gallstone – Remove Stricture – Resection Hernia – Resection Intussception – Reduce/Resection. Gangrene – Resection Volvulus – Derotate /Untwist (if viable) Resection & Anastamosis - (if Bowel is Gangrenous)

44. NURSING INTERVENTION Monitor vital signs for changes. Assess abdomen for bowel sounds, tenderness. Monitor intravenous access site for irritation, redness, swelling. Keep patient NPO. Monitor intake and output. Replace fluids lost from all sources 44

45. 2. Abdominal hernias Hernia - is the abnormal protrusion of an organ or structure through weak abdominal wall. Etiology - Abdominal hernias are caused by a combination of:- Weakening or defect in the muscle wall Increased intra abdominal pressure Obesity, coughing, COPD, Straining on micturation / defecation Intra-abdominal malignancies, Pregnancy, Ascites & Heavy lifting Due to congenital defect or acquired muscles wall weakness may develop as result of trauma or with aging. Abnormal embryogenesis, Age (extreme ages), Sex, Occupation, Congenital connective tissue disorders, defective collagen synthesis Due to previous surgical intervention 45

46. Classification Abdominal hernias may be classified according to the anatomic location and the severity of protrusion. The more commonly occurring location are Hiatal (Diaphragmatic) = 1% incisional ( ventral ) (10%) Umbilical (3%) inguinal ( direct or indirect ) = (75%), and femoral (6%) 46

47. 1. Inguinal hernia Abnormal protrusion of abdominal contents (omentum & intestines) into inguinal region through a weak abdominal wall. More common in males (90% of all the cases) than in females b/c of the passage of the spermatic cord through the inguinal canal. Two types :-  Direct and indirect inguinal hernias The boundary between them being the lateral umbilical fold containing the inferior epigastric vessels. 47

48. Sites of inguinal hernias 48

49. Contents of the inguinal canal Contents: 1. Male – spermatic cord 2. Female – round ligament of uterus 3. Ilioinguinal nerve (both sexes) 4. a fat pad and the artery of the round ligament 49

50. Constituents of the spermatic cord: Within the layers of the spermatic cord indicated above run the following structures. Ductus deferens Testicular artery Artery of the ductus deferens Cremasteric artery Pampiniform plexus of veins Sympathetic nerve fibers Genital br. of genitofemoral N Lymphatic vessels 50

51. A. Direct inguinal hernia (DIH) It is less common than the indirect (15 - 25% of the cases) and is usually acquired. Believed to be hereditary or r/t a defect in the synthesis of collagen It usually occurs in older age groups when the abdominal musculature and the conjoint tendon become atrophied. Usually bilateral & typically caused by increased abdominal pressure Technically more difficult to repair & often recurs after surgery Passes through the posterior inguinal wall at a point of muscle weakness Therefore, it rarely descends as far as the scrotum or labia majora . 51

52. B. Indirect inguinal hernia (IIH) Is the most common type of hernia with high incidence in male . Is more common than the direct constituting 75 - 85% of all the cases. IIH = can be congenital or acquired . Usually unilateral and occurs in young adults. Indirect protrusion of viscus through the inguinal ring, hernia sac follows the spermatic cord (male) or round ligaments( female ) through the inguinal canal and often on into scrotum or labia . 52

53. 2. Femoral hernia Is the protrusion through the femoral ring found behind the medial part of the inguinal ligament. Femoral hernia accounts for about (6%) Develops when a loop of intestine passes through the femoral ring and moves down the femoral canal Creates a round bulge below the inguinal ligament Femoral hernia is more common in females than in males. This is due to the relatively wide pelvis in females. Within females, because of the loosening of the femoral septum, it is commoner in those who have had repeated deliveries. 53

54. Bulges of Hernias 54

55. 3. Umbilical hernia - It accounts for about (3%) Is the protrusion of the mid gut through the umbilical opening. Results from failure of the umbilical orifice to close Is not common in adults. It is common in obese persons & those with ascites and cirrhosis or when bronchitis and asthma. Also seen in increased intra- abdominal pressure as with cirrhosis and Ascites 4. Incisional hernia - Incisional hernia accounts for about (10%) (Ventral ) Protrusion occurs through weakness in abdominal wall at site of previous surgery/ operative incision . It occurs most often when impaired healing ( infection, poor nutrition, multiple surgical in same location ) and in obese person. 55

56. The severity of hernia may be described with one of four terms (i.e., according to its clinical features) Reducible, irreducible, incarcerated or strangulated Reducible - the protruding viscus, recedes in to the abdomen mechanically when the client is supine or can be manually replace by gently pushing the mass back in to the cavity. May occur when the pt lies back or it may require manual reduction Irreducible It cannot be replaced in to the abdominal cavity by any method. Incarcerated Intestinal flow may be obstructed completely An incarcerated hernia is one in which the protruding viscus is both irreducible and obstructed. Strangulated hernia The blood & intestinal flow through the intestine in the hernia ceases completely Reductions impossible 56

57. Clinical presentations Appearance of Swelling on the Abdomen / Bulging of different sizes and shapes When instructed to cough or bear down, if hernia is presents the protrusion is more obvious Some times swelling is painful, but the pain disappears when the hernia is reduced Incarcerated hernias cause sever pain, and if not treated they may become strangulated. If strangulated hernia occurs, the client suffer extreme abdominal pain, and sever pressure on the loop of intestine protruding out the abdominal cavity causes intestinal obstruction. 57

58. Complications of hernias Strangulation (irreducible with vasc.compromisation) Incarceration (irreducible w/o vasc. Compromisation) Inflammation Irreducibility (chronically) 58

59. Medical, surgical & Nursing managements May wear a truss, which is an apparatus that passes over the hernia and prevents protrusion of the bowel though the defect. A herniorraphy , the surgical repair of a hernia is the recommended treatments Recurrence of hernia can be managed by heriaplasty . Nursing Mgt Teach the pt methods for avoiding constipation Controlling a cough & performing proper body mechanics Complications of hernia operations  Reactionary bleeding, hematoma & abscess  Recurrence  s permatic cord division, testicular ischemia & atrophy.  Other postop. complications 59

60. 3. Hemorrhoids Def n :- Are dilated veins out side/inside the anal sphincter. Or Is a dilated portion of veins in the anal canal. Hemorrhoids is also types of ano-rectal disorders They are very common; by 50 years of age, about 50% of people have hemorrhoids. Classification s Based on location/site - Hemorrhoids are classified as :- Those occurring above the internal anal sphincter are called internal hemorrhoid ; and Those appearing out side the external anal sphincter is called external hemorrhoids . Thromboses hemorrhoids are veins that contain clots. 60

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62. Cont’d…  Internal haemorrhoids Occurs above the internal anal sphincter Are usually asymptomatic Prolapse may occur Painless rectal bleeding is their most common feature Haemorrhoids of both types are basically asymptomatic unless complications occur Routinely painful defecation with rectal bleeding Constipation may develop in an effort to limit defecation when there is pain & bleeding. 62

63. Cont’d…  External haemorrhoids Seen most often in young and middle - aged adults Bulging of the haemorrhoid form a '' skin tag'' Rarely bleed May be thrombosed and raptures subcutaneously with hematoma formation- then become truly symptomatic- intense pain. Become quite large and may encompass the entire anus. 63

64. Based on the size internal haemorrhoids are further classified as:- First degree The haemorrhoid bulges into the lumen of the Anorectal canal but does not protrude through the anus Second degree The haemorrhoid prolapsed out of the anus with defecation or on straining but spontaneously returns to its normal anatomic position Third degree The haemorrhoid prolepses out or the anus with defecation or straining and requires manual reduction to return to its normal position . Fourth degree The haemorrhoid prolepses out of the anus & is irreducible is at risk of strangulation Perineal aching may occur with higher -degree haemorrhoid 64

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66. Etiology and Pathophysiology The valves of the vain are not incompetent, but rather that the veins become displaced downward from their natural location, due to a loss of supporting tissue . With out adequate connective tissue and smooth muscle support, the veins become dilated and filled with blood . As dry stool passes by the engorged hemorrhoids the mucosa is stretched and irritated giving rise to the localized symptoms of burning, itching and pain . Passing dry, constipated stool may cause the hemorrhoids to bleed. Increased pressure in the hemorrhoidal tissue due to pregnancy may initiate hemorrhoids or aggravate existing ones. 66

67. Etiology & Predisposing factors Constipation  causes excessive straining Carcinoma of rectum  by blocking veins Pregnancy - is a common initiating factor  w/c is due to compression on superior rectal veins or due to progesterone w/c relaxes smooth muscles in the wall of the veins. Obesity Congestive heart failure & Chronic liver disease with portal hypertension Prolonged sitting or standing 67

68. C/Ms:- External hemorrhoid may cause few symptoms, pain, itching and soreness of the anal area . It appears as small, reddish blue lumps at the edge of the anus. It is associated with severe pain b/c of inflammation & edema caused by thrombosis  This may lead to ischemia of the area & eventual necrosis . Internal hemorrhoid may cause bleeding but are less likely to cause pain , unless protrude through the anus. It is not usually painful until they bleed or prolapse when they become enlarged. It usually protrude each time the client defecates but retract after defecation. As the mass growth larger, they remain outside the sphincter . N.B:  Hemorrhoids cause itching & pain & are the most common cause of bright-red bleeding with defecation . 68

69. Diagnostics evaluations History P/E – perirectal examination done to rule out carcinoma of rectum or other causes of bleeding of rectum; But haemorrhoid can not be felt by rectal examination unless they are thrombosis. Anoscope, Proctosigmodoscope & colonoscopy - to rule out proximal cancer if the patient experience rectal bleeding Complications of hemorrhoids Chronic anemia – due to the bleeding Prolapse outside with sever pain Ulceration and secondary infection Thrombosis 69

70. Medical management Conservative Mg't if the symptoms are not present (both for external and internal) which includes - High - fibber diet Bulk forming laxatives Warm sits baths Gentle cleansing/good personal hygiene Avoiding excessive straining during defecation Small external hemorrhoid may disappear with out treatment 70

71. Mg’t cont’d… A variety of Mg't options are available when symptoms occur; Hemorrhoid symptoms & discomfort can be relieved by Good personal hygiene and by avoiding excessive straining during defecation. A high-residue diet that contains fruit and with an increased fluid intake - to promote the passage of soft, bulky stools to prevent straining. If this treatment is not successful, Warm compresses, sitz baths, analgesic ointments and suppositories Application of an ointments that contains a local anesthetic for the relief of pain and itching Topical astringent pads to relive swelling & bed rest reduce engorgement. A diet that correct constipation and stool softener Hemorrhoid may be legated (tied off) - Rubber band legation for:- Grade 2 & 3 haemorrhoid First and second degree small bleeding haemorrhoids A conservative surgical treatment of internal hemorrhoids is the rubber-band ligation procedure.   71