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					Bleeding Per Rectum
      ( lower GI Bleeding )

 Dr. saleh M Al SALAMAH
 Associate Professor of Surgery

           Done by:
        Nawaf al fawaz
       Mansour al nazary
       Majed al mateery
                 Outline
   Definition

   Types

   Causes

   Management
Definition



  Bleeding distal to the ligament of
treitz(4th part of duodenum) to anus
 Common but most patients do not require
  hospital admission.
 Bleeding stop spontaneously in 90% of
  patient before transfusion requirements
  exceed 2 unite.
 Men more than woman.
 The rate of bleeding increases 200-fold from
  the third to ninth decades of life .
 If passing bright red blood but not in shock
  bleeding probably from small intestine or
  colon.
 May be:
     Acute _massive rectal bleeding.
     Chronic.
massive rectal bleeding
 Passage of large volume of red or maroon
  blood through the rectum.
 Hemodynamic instability and shock.
 initial decrease in hematocrit level of 6 g/dl or
  less.
 Transfusion of at least 2 units of packed red
  blood cells.
 bleeding that continues for 3days.
 significant rebleeding in 1week.
Causes of Lower GI Bleeding
 Divericular disease , most common cause.
 Angiodysplasia.
 Colon cancer &other neoplasms.
 Inflammatory bowel disease.
 Anorectal (hemorrhoids & fissure).
 Upper GI source.
 Polyps.
 AIDS-related lesions.
 Meckel’s diverticulum.
 Arteriovenous malformation.
 Aortoenteric fistula.
 Bowel ischemia.
 Postendoscopic bleeding.
DIVERTICLOSIS
 Is asaccular out pouching of mucosa through the
  colonic musculature.

 It can be acquired or congenital.
Acquired divericluta

 Most common type.
 Contain only the mucosa and submucosal
  layers.
 May occur throughout GI tract BUT are most
  common in large bowel, with 95% patients
  having divertcular in Sigmoid colon.
Congenital divertcula
 Contain all layer of bowel wall.
 Predominantly located in the right colon in or
  near the cecum.
 Most common type is Meckel’s diverticulum .
INCIDENCE

 Male = female.
 Age - <5% at 40 years of age ,
   65%in those >85 years old.
 Region- higher in western nations.
Clinical presentation
 80% are Asymptomatic.
 Number of patient present with one or more
  complication like :
     Painful diverticulosis .
     Acute diverticulitis.
     Perforation of diverticulm.
     Obstruction.
 Fistula
 Hemorrhage

   Stop spontaneously in 80% of patients
   If it is massive bleeding , take it as
  life-threatening condition
Ttreatment
 Prevention –high fiber diet decrease
  incidence of symptoms like fruits and
  vegetables.

 Surgery may be required for complications.
Angiodysplasia
Angiodysplasia
 Is arteriovenous malformation located in
  cecum and ascending colon.

 Affected elderly persons older than 60 years.


 The lesion are composed of clusters of
  dilated vessels, mostly Veins.
 Unlike diverticular bleeding, must it is slow
  but repeated episodes of bleeding.

 Patients present with anemia and syncopal
  episodes .
MANEGMANTE
Lower GI Bleeding
History:
        Character and quantity of the blood
        Hx of HTN, CAD, or PVD (ischemic
      colitis)
        Hx of peptic ulcer, liver disease,
      cirrhosis,IBD or coagulopathy.
        Drug Hx like NSAIDs or anticoagulants.
Lower GI Bleeding
Physical Examination:
   look for shock signs (low BP, weak rapid pulse,
    tachycardia, tachypnea , sweating , pallor, cold
     extremities, …etc)
    signs of liver disease (spider nevi, gynecomastia,
     splenomegaly, ascites, …etc)
   look for abdominal masses.
   listen for bruits.
   PR examination (masses , hemorrhoids, fissures)
Lower GI Bleeding
Investigation:
    CBC (but Hb/Hct ,may not reflect true blood volume in patient with acute
    blood loss)
 PT/PTT
 U&E
 LFT
 Radiological studies :
     > CT may show thicking of bowel in cas of mesentric ischemia
     > Diverticulosis usually easily identified
Lower GI Bleeding
Diverticulosis .
Lower GI Bleeding
Rule out upper GI bleeding source:
 up to 12% of patients who are thought to have
  a LGIB are actually bleeding from the UGI tract.
 patient may need UGI endoscopy for
  differentiation.
Lower GI Bleeding
Colonoscopy
 often first maneuver.
 visualization difficulty is usually secondary to
  poor preparation.
Lower GI Bleeding
Tagged RBC scan (nuclear medicine):
 99mTc-pertechnaetate-labeled RBCs,
  Ivinjection.
 demonstrate bleeding source when the rate
  of the bleeding is 0.1- 0.5ml/minute.
 allows repeated evaluation over course of 24
  hours.
 may not exactly localize source and may not
  be able to differentiate colon from small
  bowel.
     typically not used alone for localization.
Lower GI Bleeding
Angiography
 better for specific localization.
 sensitive for bleeding rate 0.5 - 1.5
  ml/minute.
 often require large amount of contras
 (beware of renal insufficiency )
 can be therapeutic (emoblization,
 vasopressin)
Lower GI Bleeding
Capsule Endoscopy:
 may be effective if
 the above methods
 failed.
 may be the only
 way to identify small
 bowel source.
         Treatment of
        Lower GI Bleeding




Most patients are elderly and the bleeding
         usually is not severe and
     frequently stops spontaneously.
Massive Bleeding with Hypovolaemia


Initial resuscitation is needed which include :

secure airway, breathing and circulation.
insert two large bore i.v. cannulae .
insert urinary catheter.
 send bloods for group and cross-match ,full blood
count ,urea and electrolytes , cereatinine

give i.v. fluids: crystalloids to be begin and then
blood if necessary .

monitor pulse, BP ( CVP if the pt is shocked ) ,
pulse oximetry , urinary output .
Assess severity


a- mild : no hypovolaemia

b – moderate : hypovolaemia that responds to
volume replacement , pt remains stable

c- severe : active continued major bleeding
requiring continuous resuscitation or recurrent
bleed .
investigation proceeds with resuscitation

 a- proctoscopy : exclude hemorrhoids.

 b – colonoscopy : often difficult to see anything
 because of blood.

 c - upper gastrointestinal endoscopy : bleeding
  may be from a duodenal ulcer.

 d - mesenteric angiography.

 e - radiolabelled red cell scanning.
Indications for surgery : continued
              bleeding



remove segment of bowel containing ' bleeder ' if
     known from preoperative investigation
if source unknown , perform laparotomy with
intraoperative colonoscopy to try and identify '
bleeder' if source still cannot be found , a total
colectomy may be needed.

Development
    Family/Environment Characteristics-
      continued
   High Parent Education
   Adequate Child Care Resources
   Adequate Financial Resources
   Peers who behave in conventional
    manner
   Cohesive and supportive school
    environment
Protective Factors in Child
Development
    Family/Environment Characteristics-
      continued
   Teachers convey positive attitude
    toward students
   Opportunities for extracurricular
    activities that support conventional
    behavior
   Low Stress
   Rural Environment
Protective Factors in Child
Development
    Parent Characteristics
   Good Psychological Adjustment
   High Intelligence
   More Years of Education
   Mature Mother
   Sensitive/Responsive
   High levels of involvement with their
    children
Protective Factors in Child
Development
    Parent Characteristics - continued
   Availability
   High Self-Esteem
   Good Parenting Models
   Flexible Coping Style
   High Nurturance/Warmth
   Knowledge of Development
    Expectations
   (Benevolent) Authoritative Discipline
Protective Factors in Child
Development
  Parent Characteristics - continued
 Close Supervision
 Good Physical Health
Common Mental Disorders
in Children




   “Tree in Storm” Chrissy 5 y.o. U.S.A.
DSM-IV and Multivariate
Statistical Studies
  _____________________________________________________________
  DSM-III - IV                   Multivariate
  _____________________________________________________________
  Attention Deficit Disorder     Attention Deficit Disorder
  with Hyperactivity             (motor overactivity)
  without Hyperactivity           Attention Deficit Disorder
  Conduct Disorder                Conduct Disorder(s)
  Undersocialized aggressive      Undersocialized aggressive
  Undersocialized nonaggressive
  Socialized aggressive           Socialized aggressive
  socialized nonaggressive
  Anxiety Disorder                Anxiety-Withdrawal-Dysphoria
  Separation Anxiety Disorder
  Avoidance Disorder
  Overanxious Disorder
  Other Disorders
  Reactive Attachment Disorder
  Schizoid Disorder               Schizoid-Unresponsive
  Selective Mutism
  Oppositional Defiant Disorder
  Identity Disorder
  Pervasive Developmental
  Disorder                        Psychotic Disorders
  Infantile Autism
  Pervasive Developmental
   Disorder
Attention Deficit Hyperactivity
Disorder
1. Core Symptoms:
   1. Inattention
   2. Hyperactivity
   3. Impulsivity
2. Prevalence: 1.8% to 3.3% of children
Conduct Disorder


 Core Symptoms:
  – Aggression to people and animals
  – Destruction of property
  – Deceitfulness, lying, stealing
  – Serious violation of rules
 Prevalence: 1%-4% of 9-17 year olds
             Anxiety Disorders




 Separation Anxiety Disorder
 Core Symptoms:
    –   An excessive and unrealistic fear of separation from an
        attachment figure, usually a parent. In particular,
        children worry about harm to either the attachment
        figure or to themselves that would result in separation.
    Prevalence: 2% to 4% of children
Anxiety Disorders- continued

 Generalized Anxiety Disorder
 Core Symptoms:
  – Involves worry of a general nature. These
    children show excessive and unrealistic worry
    about the future, the past, and their own
    competence.
 Prevalence: 3% of children
Anxiety Disorders- continued

 Childhood-Onset Social Phobia
 Core Symptoms:
  – Involves a persistent fear of one or more social
    situations in which the person is exposed to
    possible scrutiny by others and fears that he
    may do something or act in a way that will be
    humiliating or embarrassing. Can also involve
    social avoidance in which the child shrinks
    from contact with unfamiliar people.
 Prevalence: 1% of children
Anxiety Disorders- continued

 Simple Phobias
 Core Symptoms:
  – Characterized by a persistent fear of a
    circumscribed object or event, leading to
    avoidance of that object of event. The fear is
    excessive and out of proportion to the demands
    of the situation, cannot be reasoned away, are
    beyond voluntary control, persistent over time,
    and are maladaptive.
 Prevalence: 2%-3% of children
Anxiety Disorders- continued

 Post-Traumatic Stress Disorder
 Core Symptoms:
  – This diagnosis requires exposure to an event
    outside the realm of usual human experience
    that would distress anyone, intrusive
    reexperiencing of the event, avoidance of
    stimuli associated with the trauma or numbing
    of general responsiveness, and persistent
    symptoms of increased arousal.
 Prevalence: Unknown
Anxiety Disorders- continued
 Obsessive-Compulsive Disorder
 Core Symptoms:
    –   Characterized by recurrent obsessions or
        compulsions that are distressful or interfere in one’s
        life. Obsessions are defined as persistent thoughts,
        images, or impulses that are ego-dystonic, intrusive,
        and, for the most part, senseless. Compulsions are
        repetitive, purposeful, and intentional behaviors that
        are performed in response to an obsession, according
        to certain rules, or in a stereotyped fashion.
    Prevalence: 0.3% to 0.4% for children and
     1% for adolescents
Depression
 Core Symptoms:
  – Affective Symptoms - dysphoric mood,
    diminished pleasure.
  – Cognitive Symptoms - negative self-
    evaluations, hopelessness
  – Motivation - suicidality
  – Physical Symptoms - sleep disturbance,
    somatic complaints
 Prevalence:0.4% to 2.5% for children and
  0.4% to 8.3% for adolescents
Bipolar Disorder
 Core Symptoms:
  – Episodes of depressed mood
  – Episodes of hypomanic or irritable mood
    involving inflated self-esteem or grandiosity,
    decreased need for sleep, pressured speech,
    flight of ideas or racing thoughts, distractibility,
    increased goal-directed activity, or excessive
    involvement in activities with the potential for
    painful consequences
 Prevalence: Unknown
Other Common Disorders
 Drug/Alcohol Abuse
 Eating Disorders
 Learning Disorders
 Pervasive Developmental Disorders
  Problems/Disorders presenting
  by Age
Age Common Transient Problem                    Low Frequency Serious Disorder
0 – 3 Concern about monsters under the bed      Sleep Behavior Disorder
                                                Separation Anxiety Disorder (crying &
3 – 5 Anxious about separating from parent
                                                clinging)
       Shy and anxious with peers
5–8                                             Reactive Attachment Disorder
       (sometimes with somatic complaints)
                                                Conduct Disorder
5 – 8 Disobedient, temper outbursts
                                                Oppositional Defiant Disorder
5 – 8 Very active and doesn't follow directions Attention Deficit Hyperactivity Disorder
5 – 8 Has trouble learning at school            Learning Disabilities
8 - 12 Low self-esteem                          Depression
12 - 15 Defiant/reactive                        Oppositional Defiant Disorder
12 - 15 Worries a lot                           Depression
15 - 18 Experimental substance abuse            Substance Abuse
What Causes Mental Disorders


   Environment




                    Person
Identifying Troubled Children
Identifying Troubled Children
Domains of Functioning
 Physical Development and Health
 Sleep
 Eating weight
 Cognitive Functioning
 Interpersonal Relationships
 Mood-Internal States
 Behavioral Regulation
Identify children that are
members of high-risk groups
 Subnormal intelligence or specific learning
  disabilities.
 Chronic Health Problems
 Living in conditions of poverty/overcrowding
 Obese
 Incarcerated or having legal charges before age
  12
 Bisexual or homosexual
 Admitted into psychiatric inpatient service
Identify children experiencing
high-risk situations
 Death of a close family member or friend
  (particularly if a suicide death)
 Family instability involving frequent moves
 Family violence/abuse or break-up
 Serious school failure or discipline incident
 Legal problems or incarceration
 An episode of public humiliation
 Sexual trauma
Identify children exhibiting
high-risk behaviors
 Inattention and/or hyperactivity
 Impulsive and/or aggressive behaviors
  resulting in discipline problems at home or in
  school.
 Persistent disobedience or aggression (longer
  than 6 months) and provocative opposition to
  authority figures.
 Uncharacteristic delinquent behavior such as
  theft, vandalism, other forms of rule violations
Identify children exhibiting
high-risk behaviors - continued
 Affiliation with “delinquent peers.”
 Social withdrawal or isolation
 Threats of self-harm or harm to others
 Evidence of self-harm (e.g., marks on body
  suggesting self-mutilation)
 Evidence of excessive interest in sexual activity
  as noted by frequent comments regarding
  sexual interest or acting out
 Strong interests in counter-cultural clothing
  and music
Identify children exhibiting
high-risk behaviors - continued
 Troubled by school failure, frequent absences,
  and school dropout
 Substance Abuse (including cigarette and
  alcohol use)
 Strange thoughts and feelings (e.g., beliefs that
  others are plotting against them); and unusual
  behaviors (e.g., talking to themselves,
  appearing to be seeing or hearing things)
Identify children exhibiting
mood disturbance
 Frequent sadness, tearfulness, crying
 Decreased interest in activities; or inability to
  enjoy previously favorite activities
 Unusual neglect of personal appearance
 Persistent boredom; low energy
 Social isolation, poor communication
 Extreme sensitivity to rejection or failure
 Increased irritability, anger, or hostility
 Difficulty with relationships
Identify children exhibiting
mood disturbance-continued
 Frequent complaints of physical illnesses such
  as headaches and stomachaches
 Frequent absences from school or poor
  performance in school
 A major change in eating and/or sleeping
  patterns
 Refusal to go to school
 Talk of or efforts to run away from home
 Panic or agitation
Identifying children exhibiting
suicidal interests or self-harm
behavior
 Talk of not being present in the near future.
  (E.g., I won’t be a problem for you much longer.”)
 Giving away or throwing away favored
  possessions.
 Having suicidal themes in literature or art
  class.
 Questions about suicide.
 Open talk of suicide.
 Self-mutilation
Identifying children exhibiting
the potential for violence- Signs
over a period of time:
 A history of violent or aggressive behavior
 Serious drug or alcohol use
 Gang membership or strong desire to be in a gang
 Access to or fascination with weapons, especially guns
 Threatening others regularly
 Trouble controlling feelings like anger
 Withdrawal from friends and usual activities
 Feeling rejected or alone
 Having been a victim of bullying

 Poor school performance
Identifying children exhibiting
the potential for violence- Signs
over a period of time: continued

 History of discipline problems or frequent run-
  ins with authority
 Feeling constantly disrespected
 Failing to acknowledge the feelings or rights of
  others
Identifying children exhibiting
the potential for violence-
Immediate Warning Signs:
 Loss of temper on a daily basis
 Frequent physical fighting
 Significant vandalism or property damage
 Increase in use of drugs or alcohol
 Increase in risk-taking behavior
 Detailed plans to commit acts of violence
 Announcing threats or plans for hurting others
 Enjoying hurting animals
 Carrying a weapon
Schools Support Mental Health
in Children in Three Ways

 Environmental


 Programmatic


 Individual
Building Protective Factors in
the School
 Good instruction
 Emphasis on intelligence as malleable
 Develop a sense of belonging
 Effective structure and discipline
 Give a sense of vision
Teddy Stoddard’s Story

				
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