20. Mechanical jaundice, Hemorrhoids and anal fissure & Traumatic injuries of the liver and spleen

What is the definition of MECHANICAL JAUNDICE?

obstructive or post-hepatic icterus. It results from elevated bilirubin (> 2mg/dL)

What is the etiology of MECHANICAL JAUNDICE?

• Choledocholithiasis,

• biliary duct strictures

• malformations of the bile ducts

• Tumours

What is the pathophysiology of MECHANICAL JAUNDICE?

1. Biliary obstruction

2. Backflow of conjugated bilirubin into blood

3. Decreased bilirubin in the intestines

4. Clinical features: jaundice, dark urine, pale stools, pruritus

What is the clinical presentation of MECHANICAL JAUNDICE?

• jaundice,

• pale coloured stool,

• dark urine,

• pruritus

• Fat malabsorption (steatorrhea, weight loss)

What are the diagnostic methods of MECHANICAL JAUNDICE and their positive results?

• LABS:

  increased ALP, GGT, and conj. bilirubin

  increased AST, ALT

• USG

  intrahepatic obstruction = dilated intrahepatic bile ducts

  Extrahepatic ““ = dilated common bile duct

  Stones

• ERCP (Endoscopic retrograde cholangiopancreatography)

• MRI

• CT

What is the surgical treatment of MECHANICAL JAUNDICE?

• surgical excision of the obstruction

• cholecystectomy if stones are present.

What is the definition of HEMORRHOID?

bulging veins or arteriovenous formations within the wall in the rectum, developing due to increased pressure in the rectal veins

What is the classification of HEMORRHOID and their features?

1. Gr. I — No prolapse

2. Gr. II — Prolapse when straining, but spontaneously reduce at rest

3. Gr. III — Prolapse when straining; only reducible manually

4. Gr. IV — Irreducible prolapse

What are the types of HEMORRHOID and their features?

• Internal: painless, bright red hematochezia, perianal mass, pruritus, discharge, ulceration

• external: painful perianal mass, pruritus

What is the etiology of HEMORRHOID?

• Constipation

• chronic diarrhea

• obesity,

• pregnancy,

• low-fiber diet,

• lifting heavy things,

• anal sex.

What are the diagnostic methods of HEMORRHOID and their positive results?

• anoscopy

• proctoscopy

To exclude malignancy:

• Flexible sigmoidoscopy,

• colonoscopy,

• barium enema

What are the measures to ease symptoms of HEMORRHOID?

• Sitz baths (cleanses the perineum)

• ice packs to the anal area, and bed rest.

• High-fibre, high-fluid diet,

• stool softeners,

• topical steroids

What is the treatment of internal HEMORRHOID?

Rubber band ligation

What is the surgical treatment of HEMORRHOID?

• sclerotherapy,

• electrocautery

• laser therapy

• Hemorrhoidectomy = if conservative methods fail or for severe cases like strangulation or large tags.

What is the definition of ANAL FISSURES?

longitudinal tear of the perianal skin distal to the dentate line, often due to increased anal sphincter tone.

What is the classification of ANAL FISSURES and their features?

According to etiology or duration, such as acute or chronic.

What are the primary and secondary etiologies of ANAL FISSURES?

Primary etiologies (local trauma):

• Chronic spasm/increased tone in the internal anal sphincter

• chronic constipation or diarrhea,

• low fiber intake,

• anal sex,

• vaginal delivery.

Secondary:

• Previous anal surgery

• IBD

• Granulomatous disease

• Infections (e.g. chlamydia, HIV)

• Malignancy

What are the clinical features of ANAL FISSURES?

• Sharp, severe pain during defecation

• Rectal bleeding (often bright red and minimal)

• Perianal pruritus

• Chronic constipation

What are the diagnostic methods of ANAL FISSURES and their positive results?

1. Clinical examination

2. Digital rectal examination

3. Anoscopy = Indicated if clinical findings are unclear or if symptoms persist despite adequate treatment-

4. biopsy and histology

What is the conservative treatment of ANAL FISSURES?

• Sitz bath

• Ice packs + bed rest

• Stool softeners

• High-fiber, high-fluid diet

• Topical steroids

What is the surgical treatment of ANAL FISSURES?

• Lateral internal sphincterotomy = decrease sphincter spasming

• Forceful anal dilation

What are the types of TRAUMATIC INJURIES OF THE LIVER AND SPLEEN?

Liver injuries can be caused by blunt or penetrating trauma.

Splenic injuries can include subcapsular hematoma or free rupture.

What is the epidemiology of TRAUMATIC INJURIES OF THE LIVER AND SPLEEN?

The spleen is the most commonly injured intraabdominal organ, especially from non-penetrating injuries.

The liver is the second most injured organ after blunt trauma and the most injured parenchymal organ after penetrating trauma.

What is the etiology of TRAUMATIC INJURIES OF THE LIVER AND SPLEEN?

blunt abdominal trauma and penetrating trauma

What is the clinical presentation of TRAUMATIC INJURIES OF THE LIVER AND SPLEEN?

• hemorrhage

• shock,

• abdominal pain,

• ABD distention

What are the signs of TRAUMATIC INJURIES OF THE LIVER AND SPLEEN?

Clinically obvious signs of major hemorrhage include shock and abdominal distention. Peritonitis may be seen in unstable patients with traumatic splenic rupture.

What are the diagnostic methods of TRAUMATIC INJURIES OF THE LIVER AND SPLEEN and their positive results?

USG or abdominal CT scan.

What is the conservative treatment of TRAUMATIC INJURIES OF THE LIVER AND SPLEEN?

Subcapsular splenic hematoma can be treated conservatively with close observation for 7 days.

What is the surgical treatment of TRAUMATIC INJURIES OF THE LIVER AND SPLEEN?

For liver injury, = suture, drainage, resection, and packing.

For splenic injury = splenectomy and embolisation (blocking off of the hemorrhaging vessels)

What is the definition of POST-TRAUMATIC HEMOPERITONEUM?

Post-traumatic hemoperitoneum is blood accumulating in the abdominal cavity following trauma and is associated with traumatic injuries of the liver and spleen.