1.

Discussion of Learning Issues

Learning Issue:

a) ​Difference between DIVERTICULITIS and DIVERTICULOSIS?

DIVERTICULITIS DIVERTICULOSIS

Meaning
When one or more of these pouches become Diverticulosis occurs when small, bulging
inflamed or infected, the condition is called pouches (diverticula) develop in your
diverticulitis. digestive tract.

s/s
Patient may feel pain, nausea, f​ ever​ and  They usually don’t cause any symptoms or 
have other symptoms. This is a much more  need to be treated. However, diverticulosis 
serious and potentially dangerous  can lead to diverticulitis. 
condition 

Treatment
● If your diverticulitis is mild, oral diverticulosis, likely don’t have symptoms
antibiotic is given, such as and don’t need treatment. However, since
metronidazole (Flagyl®), diverticulosis could lead to diverticulitis, diet
trimethoprim-sulfamethoxazole high in fiber as a preventive measure is
(Bactrim®), ciprofloxacin (Cipro®) recommended. This means eating more
or amoxicillin and clavulanic acid fruits, vegetables, grains, nuts, seeds,
(Augmentin®). Rest, taking beans, legumes and less red meat.
over-the-counter medications for
pain and following a low-fiber diet
or a liquid diet may be
recommended until the symptoms
improve. Once the symptoms
improve, the patient can slowly
return to soft foods, then a more
normal diet, which should be one
that includes many high-fiber
foods.
● If the diverticulitis is severe, and
have rectal bleeding or are having
a repeat bout of diverticulitis,
hospital admission is
recommended to receive
intravenous (IV) antibiotics, IV
fluids or possibly be considered for
surgery.
 

​b) ​Difference between IRRITABLE BOWEL SYNDROME and INFLAMAMTORY BOWEL DSE?
What are the criteria?-

IBD - is an immune-mediated chronic intestinal condition.

IBS - functional bowel disorder

IBS (IRRITABLE BOWEL SYNDROME) IBD (INFLAMMATORY BOWEL DSE)

Is a syndrome, or group of symptoms, which can cause Is a group of diseases, which include Crohn’s dse and
chronic stomach pain or discomfort, diarrhea, constipation ulcerative colitis
or alternating between both.

IBS is caused by a disturbance in how the brain and gut IBD is caused by an abnormal response from the immune
interact and is aggravated by stress system, mistaking healthy cells and bacteria in the bowel
for harmful foreign substances

Affects mostly women and usually develops in late Can affect males and females equally and tends to run in
adolescence or early adult life families

Can be triggered by emotional or physical stress, food, Often is not associated with any obvious triggers, and is
medications, gaseous detention, and hormonal changes characterized by alternating bouts of flare and remission

IBS does not produce any signs of disease on IBD causes inflammation in the bowel, which can be
colonoscopy or other diagnostic tests and does not detected on a colonoscopy and other diagnostic tests and
increase the risk of colon cancer. may increase the risk of colon cancer

● However anemia, bleeding, weight loss and fever can occur in IBD but not in IBS
● Abdominal pain, changes in bowel movements, constipation and diarrhea both occur in IBD and IBS
 Diagnostic criteria for IBS:

Recurrent abdominal pain or discomfort at least 3 days per month in the last 3 months associated with to or
more of the following:

1. Improvement with defecation

2. Onset associated with a change in frequency of stool
3. Onset associated with a change in form or appearance of stool

​c) ​Other diseases that may present with hematochezia specifically sa blood not sa blood
vessels (ex. Von-Willebrand factor)

​This includes bleeding diatheses such as:

● ​vitamin K deficiency -​ most commonly seen in newborns. Vitamin K deficiency bleeding or VKDB,
occurs when babies cannot stop bleeding because their blood does not have enough Vitamin K to form a
clot. The bleeding can occur anywhere on the inside or outside of the body. Commonly, a baby with
VKDB will bleed into his or her intestines, causing hematochezia or into the brain, which can lead to brain
damage and even death. Infants who do not receive the vitamin K shot at birth can develop VKDB at any
time up to 6 months of age.
● Hemophilia
○ is a genetic bleeding disorder caused by insufficient levels of a blood protein called factor VIII &
9. Factor VIII & 9 is a clotting factors. Clotting factors are specialized proteins that are essential
for proper clotting, the process by which blood clumps together to plug the site of a wound to stop
bleeding.
○ Individuals with the severe form of hemophilia A & B can experience spontaneous bleeding into
any organ system including the kidneys, the gastrointestinal tract, and the brain causing
intracranial bleeding. Genitourinary bleeding may cause hematuria and gastrointestinal bleeding
may cause hematochezia.
● thrombocytopenia
● anti-coagulant toxicity.
 d) ​Picture of patient that have upper GI bleeding that presents with hematochezia and
expected PE findings.

​Picture of patient that have upper GI bleeding Expected PE findings.

Eyes:
Skin changes: ● Pale palpebral conjunctiva
● Palmar erythema ● Anicteric sclera
● Purpura,echymosis ● No cervical lymphadenopathy
● Pale
Heart and lungs:
● Normal heart and lung sounds
Signs of dehydration:
● Apex beat at 6th LICS
● Sunken eyes
● Skin turgor reduced).
Abdomen:
● Hyperactive bowel sounds
● Soft, non-tender, no palpable masses,
no organomegaly

DRE
● Maroon colored stools

2. Staging of internal hemorrhoids:

If i were to stage the hemorrhoids based on patient’s data, i think it is stage 2 because based on
staging the internal hemmorhoids, stage 2 has protrusion with spontaneous reduction and in
the physical examination of the patient it has proturion below the dentate line 4-5 cm from the
anal verge to be specific and base on patient’s history 3 mons PTA patient experienced bloody
stool and pain on defecation esp when constipated and he also complained of on and off
itcheness at the rectum 2-3 mos. So it is safe to assume that the symptoms experienced by the
patient is spontaneously reduced.
 3. Management:

a) Immediate MAnagement-

IV infusion ● Since the patient has difficulty in defecation i think it is essential to hydrate the
patient.

Sitz baths ● which means sitting in warm water to relieve fissures and hemorrhoids.

Injection ● In this procedure, one chemical injection called sclerosant, is injected by the doctor
Sclerotherapy into hemorrhoidal tissue, causing it to sclerise or dry and eventually fall off. Piles that
are not collapsed can be ligated or injected.
● –2 mL of a sclerosant
● sodium tetradecyl sulfate
● injected using a 25-gauge needle into the submucosa of the hemorrhoidal complex
● not to inject the anal canal circumferentially
● stenosis will occur

Banding or Rubber ● (1) Placement of the band caused ischemic necrosis, and the hemorrhoid tissue
Band Ligation became thrombosed and sloughed off about 7–14 days later, resulting in rectal wall
connective scar tissue. (2) in which the hemorrhoids are tied off at its base with
rubber and this will cut off the blood supply.
 Infrared coagulation ● Infrared photocoagulation (also called coagulation therapy) is a medical procedure
used to treat small- and medium-sized hemorrhoids. This treatment is only for
internal hemorrhoids. During the procedure, the doctor uses a device that creates an
intense beam of infrared light. Heat created by the infrared light causes scar tissue,
which cuts off the blood supply to the hemorrhoid. The hemorrhoid dies, and a scar
forms on the wall of the anal canal. The scar tissue holds nearby veins in place so
they don't bulge into the anal canal.

Stool softeners ● Dulcolax (Docusate) is a stool softener. It works by increasing the amount of water
the stool absorbs in the gut, making the stool softer and easier to pass

Sutured ● Removal of redundant tissue down to the anal verge

hemorrhoidectomy ● Anal skin tags are removed as well

Transhemorrhoidal ● ultrasound guidance to ligate the blood supply to the anal tissue
dearterialization THD

LABS:

Hematologic Significance Px. Results

Tests:

CBC A complete blood cell (CBC) count-​ may be useful as a NORMAL

marker for infection. Anemia due to hemorrhoidal bleeding is
possible, albeit rare (0.5 cases per 100,000 patients), and its
presence should raise suspicion of an alternate diagnosis

Hematocrit Testing if excessive bleeding with concomitant anemia NORMAL

Coagulation is suspected. Are indicated if the history and physical
(Pro-thrombin examination suggest coagulopathy.
time)

DIAGNOSTICS:

Instrumental Significance Px. Results

Examination

Anoscopy Observe the conditions of the anal mucosa ( if inflamed 20 cm from anal verge no
or eroded, or the presence of other diseases), polyp or mass noted.
hemorrhoidal piles (engorgement, possible bleeding, Purplish thrombose 1x2 cm
and tendency to the prolapse under several attempts of protrusion above the dentate
straining, during progressive device retraction), and at 3’oclock with signs of anal
dentate line ( in advanced engorgement it can be bleesing.
disappeared).
Proctosigmoidoscopy Observe the internal structure of the anus from the anal 20 cm from anal verge no
verge up to 30 cm proximally. The anal canal, rectum, and polyp or mass noted.
(Performed) a part of the sigmoid colon can be observed. purplish thrombose 1x2 cm
protrusion above the dentate
at 3 o'clock with signs of
anal bleeding

Colonoscopy Recommended before surgery for patients suffering with

bleeding anal

Medications DOSAGE MODE OF ACTION

Hydrocortisone ● 25mg 2-3 daily ● Hydrocortisone ​suppositories​ help to

acetate (Rectal relieve rectal pain, ​itching​, bloody
suppositories) diarrhea​, and bleeding by reducing
swelling (​inflammation​) directly in the
rectum and anus. Hydrocortisone
belongs to a class of drugs called
corticosteroids.

Daflon ● 500mg (Micronized purified ● Tablet is a flavonoid.

flavonoid fraction) equivalent to
450 mg diosmin and 50 mg
hesperidin) 2 tabs daily for 4 days
● It works by blocking the action of
chemical messengers (prostaglandins,
thromboxane A2) which cause
inflammation (swelling) of the veins. This
improves blood flow in the veins and
restores normal vein function.

(Psyllium/Sucrose)
Oral Powder

● This ​medication​ is used to treat

constipation​. It increases the bulk in
the stool, an effect that helps to
cause movement of the ​intestines​. It
also works by increasing the amount
of water in the stool, making the stool
softer and easier to pass.​Psyllium​,
one type of bulk-forming ​laxative​, has
also been used along with a proper
diet
b) Short-Term Management

● High fiber diet- Increasing the daily intake of dietary fiber​ example vegetable to give bulk and
to soften the stool. ​Foods with little fiber can cause or make constipation (and therefore
hemorrhoids) worse. Limit these foods:
● White bread and bagels
● Milk, cheese, and other dairy
● Meat
● Processed foods such as frozen meals and fast food
● Pramoxine cream - ​This combination medication is used to treat minor pain, itching, swelling,
and discomfort caused by hemorrhoids and other problems of the anal area (e.g., anal fissures,
itching). This medication contains pramoxine, an anesthetic that works by temporarily numbing
the area. This product also contains hydrocortisone, a corticosteroid that reduces redness, itching
and swelling.

c) Long-Term Management

● Dietary and Lifestyle Advices

- Increasing the daily intake of dietary fiber​ example vegetable to give bulk and to
soften the stool. ​Foods with little fiber can cause or make constipation (and therefore
hemorrhoids) worse. Limit these foods:
● White bread and bagels
● Milk, cheese, and other dairy
● Meat
● Processed foods such as frozen meals and fast food
● Other lifestyle modifications​ suggested for patients with hemorrhoidal disease
include engaging in regular exercise ex. jogging
● 8-10 glasses of water​ a day to soften the feces
● Eat fruits​ like ripe papaya because it has an enzyme called papain and vitamin
C w/c soften the stool. Pears may also be eaten because sorbitol gives the
sweet taste to the food and helps soften the stool.