GIT Disorders || Zag Doctors

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Cancer Rectum & Anal Canal | Mersah⛵️ ➡️Most Common Presentation: Bleeding per rectum. ➡️PR Examination: Can detect 90% of cases. ➡️Inv. of Choice (Loco-regional): MRI. ➡️Anal Margin Tumor Type: Most common is Squamous cell Carcinoma. ➡️ Lymphatic Spread (Main Pathway): Pararectal \rightarrow Superior rectal \rightarrow Inferior mesenteric. ➡️Constipation: Presented if the carcinoma is in the Upper 1/3. ➡️Tenesmus: Presented if the carcinoma is in the Lower 1/3. 🔪 Surgery & Therapy 1️⃣ APR (Abdominoperineal Resection of Miles): Most Popular Operation. Ends by a permanent left iliac colostomy. 2️⃣ Hartmann's Abdominal Resection: Indicated in a tumor in the upper one third (> 10 cm from the anus). 3️⃣ Pelvic Exenteration: Operation used when the patient is operable but the tumor infiltrates other pelvic organs. ⚠️ Important Notes: ➡️Enema is NOT used in Anorectal cancer. ➡️Radiotherapy has no role in Distant spread.

Hemorrhoids | Mersah⛵️ ➡️💊 Conservative Treatment: Indicated for 1st Degree primary piles. ➡️🔫 Rubber Band Ligation: Treatment of Choice for non-complicated 2nd Degree hemorrhoids. ➡️💉 Sclerotherapy: Injection is done Submucosally. ➡️✂️ Excision: Best Treatment for External Hemorrhoids. ➡️Reactionary Hemorrhage: Early complication. ➡️Secondary Bleeding: Occurs after hemorrhoidectomy due to Infection. ➡️Urinary Retention: Most common early complication in Males. ➡️Anal Stenosis: Can be caused by surgical treatment. ➡️The pile ligated first in hemorrhoidectomy is the Right Posterior one (at 7 o'clock). ➡️Uncomplicated Hemorrhoids: Most common complaint is Fresh Bleeding. ➡️ External Piles:Present as a Painful Bluish Swelling.

Anal Fissure | Mersah⛵️ Anal Fissure 📍 Sites: ➡️Most Common Site: Midline Posteriorly (90%). ➡️Anterior Fissure: Located at 12 o'clock.(post partum females) ➡️Posterior Fissure: Located at 6 o'clock. 🤕 Clinical Picture: ➡️ Most common cause is Constipation. ➡️ Most common Complaint Severe anal pain ➡️Bleeding: Characterized by Slight bleeding. ➡️PR Examination: Is Contraindicated (CI) in Acute Fissure. 💊 Treatment of Anal Fissure 🔹 Acute Fissure Management: ➡️Most Appropriate Tx: Increased dietary fiber + Sitz baths + Local anesthetic ointment. ➡️Treatment of Choice: GTN Ointment. ➡️Most Effective Tx: Lateral Sphincterotomy. ➡️Chronic Fissure Tx: Forceful dilatation under general anesthesia. ♦️ Chronic fissure ➡️Presence of anal skin tag& Presence of fibro-epithelial polyp& Presence of symptoms >6 weeks.

Tumor of the colon | Mersah⛵️ Tumor of the colon 🍄 Types of Colonic Polyps 1️⃣ Juvenile (Retention) Polyps  ➡️Patient: Children. ➡️Shape: Pedunculated (Rectum). ➡️Features: Bleeding per rectum, rarely prolapse. ➡️Malignancy: Never turns malignant. 2️⃣ Adenomatous Polyps  ➡️ Commonly asymptomatic ➡️Patient: > 21 years. ➡️Shape: Pedunculated (Rectum/Sigmoid). ➡️Features: Bleeding, prolapse, intussusception. ➡️Malignancy: Often turns malignant. ➡️Risk: Flat adenomatous polyps have high risk of malignant transformation.  3️⃣ Villous Adenoma  ➡️Patient: > 45 years. ➡️Shape: Sessile (Rectum/Sigmoid). ➡️Features: Passage of blood or mucous. Causes massive watery diarrhea  ➡️Hypokalemia & Hyponatremia. ➡️Malignancy: Commonly turns malignant. 🔴 FAP (Familial Adenomatous Polyposis) ➡️Genetics: Hereditary (Autosomal Dominant)& Mutation of APC gene ➡️Progression: Puberty (Rectum/Sigmoid) \➡️ Age 21 (Whole colon) \➡️ 5th decade (Carcinomatous change).  ➡️Cancer Risk: 100% risk of adenomatous colorectal cancer.  ➡️Diagnosis: Sigmoidoscopy & biopsy are mandatory.  ➡️Imaging: Barium enema shows "Honey comb appearance".  ♦️Colonic surveillance:6-monthly flexible sigmoidoscopy starting at the age of 13-15 years. ➡️Treatment: Total Colectomy with ileoproctostomy done before 30 years ➡️Note: Sulindac (NSAID) causes regression of rectal polyp after total colectomy.  ♦️Turcot's is a compilation of FAP and CNS tumors 🟣 Peutz-Jeghers Syndrome ➡️Features: Widespread hamartomatous polyps + Mucocutaneous pigmentation.  Carcinoma of the Colon ➡️Commonest Site: Sigmoid & Rectosigmoid.  ➡️Screening: Colonoscopy every 10 years (Greatest effectiveness).  ➡️Barium Enema: Shows "Apple Core appearance" (in Rectum/Colon cancer).  ➡️Tumor Marker: CEA is not diagnostic but Prognostic.  🌍 Spread: ➡️Local: Horizontal spread > Longitudinal.  ➡️Lymphatic: ♦️ First occur to epicoliv lymph nodes ♦️Supraclavicular LN involved by Retrograde spread.  ➡️Blood: Usually late.  ➡️Trans-peritoneal: Occurs specially with Mucoid Carcinoma.  ⬅️ Left Side (Descending/Sigmoid)  ➡️Type: Annular Stenosing (Scirrhous). ➡️Patient: More common in Males. ➡️Symptoms: Obstructive manifestations (Stricture). Constipation interrupted by Spurious Diarrhea. ➡️Acute on top of chronic intestinal obstruction. ➡️Examination: Mass in Lt. Iliac Fossa (Fecal impaction). ➡️Surgery: Left Hemicolectomy.  ➡️ Right Side (Ascending/Caecum)  ➡️Type: Cauliflower (Fungating). ➡️Patient: More common in Females. ➡️Symptoms: Rare intestinal obstruction. ➡️Examination: Palpable tumor mass in Rt. Side. ➡️Surgery: Right Hemicolectomy. ♦️Rare complication of colon cancer ➡️ perforation ♦️Most important prognostic factor in colorectal cancer➡️ hepatic metastasis ♦️Soave like operation ➡️ total colectomy with rectal mucosectomy and ileo anal anastomosis

Diverticular Disease | Mersah⛵️ 🟤 Diverticular Disease 📍 Key Facts: •Site: Sigmoid Colon (Most common). •Pain: Left Iliac Fossa (LIF). •Bleeding: Most common cause of massive colonic bleeding. 🏥 Management: •Investigation of Choice: CT with Contrast. •Complication: Colovaginal Fistula. •Medical Tx: Rifaximin. •Surgical Tx: Hartmann’s Procedure. ♦ etiology of diverticulosis coli ➡️ acquired pulsion diverticula ♦️ Diverticula most commonly herniate through ➡️ weak point of entrance of blood vessels ♦️ Diverticula occur along the mesenteric border of the anti mesenteric taenia ♦️ Most common complication of diverticulosis coli ➡️ inflammation ♦️ Potential complication of multiple jejunoileal Diverticula ➡️ blind loop syndrome and malabsorption ♦️ Multiple globular shadow along the sigmoid colon ➡️ barium filled diverticula ♦️Caecal diverticula ➡️Congenital in origin , (true)

Stomach Surgery | Mersah⛵️ 🔪 Anastomotic Ulcer •Site: Gastric side of stoma. •Pain: Severe, radiates to Left side. •Sign: Hematemesis is common. •Tx: Surgical (Vagotomy). 🟠 Special Gastric Conditions 📍 Zollinger-Ellison Syndrome •Triad: Multiple recurrent ulcers + Non-insulin secreting tumor + Diarrhea. •Tx: Total Gastrectomy. 🚫 Chronic Pyloric Obstruction Duodenal ulcar •Early: Spasm ➡ Temporal. •Late: Fibrosis ➡ Irreversible. •Signs: Non-bilious vomiting, •Succussion splash, "Soup Plate" appearance in Barium.

Stomach Surgery | Mersah⛵️ ●Parietal Cell secrete (oxyntic cell)➡️ Hydrochloric acid (HCl) & Intrinsic Factor (IF). ●Chief Cell secrete ➡️ Pepsinogen. ●G Cell (located at Pyloric antrum) ➡️ Secretes Gastrin ➡️ Stimulate acid production. ●D Cell secrete ➡️ Somatostatin ➡️ Inhibits acid production. ●Main source of protective bicarbonate-rich mucus gel layer ➡️ Surface mucous cells. ●Normal gastric emptying time ➡️ 2 - 4 hours. 🦀 Gastric Carcinoma (Cancer) Risk Factors & Pre-cancerous Conditions: ●Predisposing factors ➡️ Urban areas, Japanese, Spirits, Hydrocarbons, (+) family history, Blood group A. ●Pre-cancerous conditions: Achlorhydria & Adenomatous polyps & Atrophic gastritis. Peptic ulcer, Pernicious anemia & Post-gastrectomy. Types & Pathology: ●Most common malignancy of GIT ➡️ Gastric carcinoma. ●Most common site ➡️ Pylorus (65%). Microscopic (MIC) types: ●Adenocarcinoma (95%): Columnar (acini), Spheroidal (loss of acini), Mucoid (Signet Ring appearance). Macroscopic types: ●Fungating (40%): Body & Fundus ➡️ Irregular filling defect. ●Ulcerative (40%): Pylorus ➡️ Most malignant ➡️ Carman’s Meniscus Sign. ●Diffuse (20%): Pylorus (no mass) ➡️ Linitis Plastica (Leather bottle stomach). ●Intestinal gastric cancer (80%) ➡️ On top of intestinal metaplasia (Fundus & body). Spread & Signs: ●Spread types: Direct, Lymphatic (Most important), Blood, Transperitoneal. ●Krukenberg’s tumor ➡️ Ovary (Female). ●Rectal shelf (Blumer's shelf) ➡️ Male. ●Virchow’s gland (enlarged supraclavicular node) ➡️ Troisier Sign. ●Sister Mary Joseph nodule ➡️ Metastasis to Umbilicus. Diagnosis: ●Most valuable investigation ➡️ Gastroscope. ●To detect degree of infiltration ➡️ Endoscopic Ultrasound. 🔪 Surgical Operations & Management Resection Rules: ●Relative Curative Resection ➡️ R = N. Gastric Operation Margins: ●Proximal Cut ➡️ 3 inches above the palpable edge of the tumor. ●Distal Cut ➡️ Beyond the prepyloric vein of Mayo. Type of Surgery by Location: ●Carcinoma of Pylorus & Antrum ➡️ Radical Subtotal Gastrectomy. ●Carcinoma of Body ➡️ Total Gastrectomy. ●Carcinoma of Fundus ➡️ Esophagogastrectomy. ●Early gastric cancer most common type ➡️ Ulcerating type. ⚠️ Post-Gastrectomy Complications Dumping Syndrome: ●Early Dumping: •Occurs immediately after food. •Leads to ➡️ Hypovolemia. •common follow partial gastrectomy ●Late Dumping: •Occurs 1 or 2 hours after food. •Cause ➡️ Temporary Hyperglycemia followed by Hypoglycemia. •Relieved by ➡️ Carbohydrate ingestion. Other Syndromes: ●Afferent Loop Syndrome: •Occurs after ➡️ Billroth II. •Cause of obstruction ➡️ Twisting or Kinking. •Treatment ➡️ Converting anastomosis to Roux-en-Y loop. ● Fullness & epigastric pain relived spontaneously with Bilious vomiting after surgery ➡️ Kink at the point of anastomosis. Alkaline Gastritis: ●Primary cause ➡️ Duodeno-gastric reflux of alkaline content. ●Symptoms similar to ➡️ Recurrent peptic ulcer. ●Essential diagnostic procedure ➡️ Endoscopy. 💊 Ulcers, ZES & Obstructions Anastomotic Ulcer: ●Primary etiology ➡️ Inadequate Vagotomy. ●Most common site ➡️ Gastrojejunal anastomosis (after Roux-en-Y gastric bypass). ●Gold standard for diagnosis ➡️ Upper Endoscopy. Zollinger-Ellison Syndrome (ZES): ●Caused by ➡️ Gastrin secretion tumor. ●Common symptoms ➡️ Watery diarrhea. ●Definitive Treatment ➡️ Removal of pancreatic tumor. Gastric Obstruction & Deformities: ●Meniscus Sign ➡️ Malignant gastric ulcer. Hourglass Stomach: ●Primary cause ➡️ Gastric ulcer with associated fibrosis. ●Best test reveals deformity ➡️ Barium meal. ●Preferred surgical treatment ➡️ Partial gastrectomy. Chronic Pyloric Obstruction: ●Radiological appearance ➡️ Soup plate appearance. ●Metabolic disturbance in long-standing obstruction ➡️ Alkalosis. ●Duodenal obstruction with marked fibrosis ➡️ Vagotomy and Gastrojejunostomy.

Esophagus | Mersah⛵️ ♦️Auerbach's plexus is situated ➡️ between the outer longitudinal and inner circular muscles of the esophagus. ♦️Meissner's plexus is located in ➡️ the submucosa. ♦️Cervical esophagus blood supply ➡️ primarily received from the inferior thyroid artery. ♦️Esophageal opening in the diaphragm ➡️ occurs at the level of T10. ♦️Achalasia ➡️ characterized by high LES (Lower Esophageal Sphincter) pressure and dysphagia to solids and fluids (more difficulty with fluids). ♦️Drug used for cardiac achalasia ➡️ Ca channel blockers. ♦️Corkscrew esophagus ➡️ diagnostic appearance for diffuse esophageal spasm. ♦️Commonest diaphragmatic hernia in adults ➡️ sliding hiatus hernia. ♦️Sliding hernia ➡️ typically occurs on the left side of the esophagus. ♦️Para-esophageal hiatus hernia ➡️ treatment is essentially surgical correction, especially if complicated by strangulation. ♦️Plummer-Vinson syndrome ➡️ increases the risk of cervical esophageal cancer. ♦️Chronic gastric reflux ➡️ a major risk factor for the development of adenocarcinoma of the esophagus. ♦️Barrett's esophagus ➡️ associated with the most common type of malignancy, Adenocarcinoma. ♦️Risk of carcinoma in Barrett's esophagus ➡️ is 0.5\% per year. ♦️Squamous cell carcinoma ➡️ most commonly occurs in the cervical and upper thoracic esophagus. ♦️Most common site for esophageal carcinoma ➡️ the lower third of the thoracic esophagus. Diagnosis & Staging: ♦️Locoregional staging ➡️ Endoscopic ultrasonography has high sensitivity and specificity for this. ♦️Nodal and distant metastasis ➡️ detected using a PET-CT scan. ♦️Cervical esophageal cancer treatment ➡️ the most effective and preferred treatment is chemo-radiotherapy. ♦️Esophagectomy complication ➡️ pneumonia is the most common complication following this surgery. ♦️Best esophageal conduit ➡️ the stomach is considered the best replacement. ♦️Transhiatal approach ➡️ this surgical method is less stressful from a physiological standpoint.

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Liver Cirrhosis | Mersah⛵️ 🧪 Lab Findings of Decompensation: ➡️Enzymes: \increase AST > ALT. Proteins: \decrease Serum Albumin & \increase Gamma-globulin. Bilirubin: \increase Bilirubin. ⚠️ Clinical Signs: ➡️Jaundice: is a Late sign in liver cirrhosis. ➡️Ascites: Fluid accumulation due to \increase pressure in the Portal Vein. ➡️Liver Size: Decreases as cirrhosis progresses. ➡️Cutaneous: Spider Angioma (Note: Spider man appearance) is present. ➡️Anemia: Prevalence is 75%. Classification: ➡️Micronodular: Occurs in Alcohol or Biliary Tract Disease. ➡️Macronodular: Occurs in Chronic Viral Hepatitis. ➡️The Hallmark: Development of Scar Tissue. 🚫 What does NOT cause Cirrhosis? ➡️HAV (Hepatitis A Virus). ➡️Bilharziasis (Schistosomiasis). Prevention & Treatment: ➡️General Measure: Abstinence of Alcohol is the most important step. ➡️Hepatic Encephalopathy: Requires Protein Restriction (up to 60/80 g/d). ➡️HCC Screening: Alpha Fetoprotein is used for detection; Done every 6 months. ➡️Survival: 5-year survival rate is 50%. ➡️Electrolytes: Associated with Hyponatremia.

Viral hepatitis | Mersah⛵️ Hepatitis B: 🧪 Diagnosis Markers: ➡️Acute Infection: HBsAg + Anti-HBc IgM. ➡️Chronic Active (Replication): HBsAg (> 6 months) + HBeAg (+) + High HBV DNA. ➡️Previous Exposure (Immunity): Anti-HBc IgG + Anti-HBs (HBs Ab). ➡️Window Period: The time between HBsAg and Anti-HBs positivity. 🔬 Key Signs: ➡️Replication Sign: Presence of HBeAg indicates ongoing viral replication. ➡️Histology: "Ground Glass" appearance is the diagnostic hallmark of Chronic Hepatitis B. Core Antigen: Hep B core antigen can be detected in liver tissue only. 🔹 Hepatitis D (Delta): ➡️Defective Virus: A satellite virus that is Essential for infection. ➡️Dependency: Virus is essential for Hepatitis D infection ➡️ Hepatitis B. ➡️Treatment: First line option for chronic Hep D is Bulevirtide. 🔸 Hepatitis A & E: ➡️Transmission: Feco-oral route. ➡️Hepatitis A: Never causes chronic hepatitis. ➡️Hepatitis E: Most likely to cause Fulminant Hepatitis in Pregnant Women. 🩸 Hepatitis C (HCV): ➡️Enzymes: Shows an episodic pattern of aminotransferase elevation. ➡️Extra-hepatic (HCV): Associated with Sjogren's syndrome, Lichen planus, and Porphyria cutanea tarda. ➡️Treatment: Directly Acting Antivirals (DAAs) are effective in treating acute HCV. ⚡ Hepatitis B Extra-hepatic: Polyarteritis nodosa, Essential mixed cryoglobulinemia, Guillain-Barre syndrome. 🦀 Malignancy (HCC): ➡️Hepatocellular Carcinoma (HCC) is caused by Hepatitis C or Hepatitis B. 🧬 Virus Characteristics: ➡️DNA Virus: Hepatitis B (Double stranded DNA). Transmission: ➡️Vertical: Hepatitis B & C& D ➡️HBV Specimens: Blood, Semen, Saliva. 💉 Treatment & Prevention: ➡️Vaccine: Active immunization available for Hepatitis A & B. ➡️Interferon: Effective in chronic infection of Hep B. ➡️Goal: Primary goal of pegylated therapy Sustained suppression of HBV. 📊 Labs: ➡️Acute Liver Failure: ALT & AST elevation > 10-20x. ➡️Chronic Active vs. Persistent: Most reliably distinguished by Liver Histology.

GIT Bleeding | Mersah⛵️ 📉 Tilt Test Positive: HR increase > 20/min & Systolic BP drop 10-20 mmHg (standing) = approx 700 ml loss. 🩸 Hematocrit: A 2-3% drop reflects ~500 ml blood loss. 2. Important Labs 🧪 BUN/Creatinine Ratio > 35: Strongly suggests Upper GI Bleeding (due to digestion of blood). ➡️ Packed RBCs usually required if Hemoglobin < 8 g/dL. ➡️ Tagged RBC Scan: Detects bleeding rate > 0.1 ml/min. ➡️Colonoscopy: The test of choice (finds source in 70% of cases). 🌑 Melena: Loose, black, tarry, foul-smelling stool. ➡️📍 Source: Proximal to Ligament of Treitz (DJ flexure). 2. Lower GI Signs 🚽 Blood mixed with stool: Originates above the Sigmoid Colon. 🧻 Blood streaking stool/paper: Suggests Anus or Rectum. 🚿 Blood separate (after defecation): Typical of Anal conditions. 3. Special Case (Elderly) 👴 Painless abrupt maroon/bright red blood: Most common cause is Diverticulosis. Upper GI Causes 🏆 Most Common: Peptic Ulcer Disease. ➡️ Mallory-Weiss Tear: Mucous membrane tear at lower esophagus. Trigger: Forceful vomiting/retching (often Alcoholism 🍷). ✅ Self-limited in 95% of cases. Lower GI Causes 📉 Most Common (<50 yrs): Hemorrhoids. ☢️ Radiation Proctitis: Main sign is rectal bleeding. 🔥 Colitis: Causes lower GIT bleeding. ⚠️ Note: Chronic Alcohol + Cirrhosis = Portal Hypertension. Variceal Bleeding 💀 Mortality Rate: 15–40%. 🚑 Prevention: Prophylactic Antibiotic (Ceftriaxone 1g/24h). Drug Therapy: Octreotide ⚙️ Mechanism: Vasoconstriction of splanchnic circulation. 💉 Dose: 50 µg bolus ➡️ then 25-50 µg/hr. Procedures (If drugs fail) 🎈 Sengstaken-Blakemore tube: Temporary measure only. 🛣️ TIPSS: Used if medical/endoscopic therapy fails. ➡️Risk: Worsened Hepatic Encephalopathy 🧠. Interventions 1. Peptic Ulcer 💊 80% respond to medical treatment alone. 2. Dieulafoy Lesion 📎 Best Therapy: Endoscopic Hemoclips (best combined with injection). 3. Portal Hypertensive Gastropathy (PHG) ⚡ Preferred: Argon Plasma Coagulation. 4. Upper GI bleeding Stop 📹 Procedure: Esophagogastroduodenoscopy (EGD).

IBS | Mersah⛵️ ➡️ IBS is the Most Common GI disorder in the community. ➡️Current Diagnostic criterion: Rome IV Criteria. ➡️ Key Symptom: Abdominal pain is Relieved with defecation. ➡️ Pain may also be temporarily relieved by the passage of flatus or stool. ➡️IBS commonly presents with mucous diarrhoea or pencil-like pasty stools. ➡️ First Line: Reassurance alone may lead to the resolution of symptoms. ➡️ Dietary Recommendation: Low FODMAP diet. ➡️Antibiotics (IBS-D): Rifaximin has the strongest evidence for Diarrhea-predominant IBS. ➡️(Colonoscopy Indicated) Colonoscopy is required in IBS patients who present with any of the following "red flags": •Age > 45 years •Rectal bleeding •Unintentional weight loss •Iron deficiency anemia •Positive FOBT (Fecal Occult Blood Test)

Peptic Ulcer Disease | Mersah⛵️ ⚖️ Prevalence: Duodenal Ulcer (DU) > Gastric Ulcer (GU). ⚠️ Risk Factors: •H. Pylori Infection (Major Cause). ♦️best triple therapy regimen for eradication➡️Omeprazole + Clarithromycin + Amoxicillin •NSAIDs: Especially COX-1 inhibitors. •Genetics: Blood Group O ➡ associated with DU. •Stress, Smoking & •Hypersecretory states. 🔥 Complications: •Bleeding: (Most Common). •Perforation & Penetration. •Obstruction: Relative ➡ Edema. Fixed ➡ Fibrosis ➡ Surgery. 🔬 PUD Investigations 1️⃣ Endoscopy: Most sensitive & specific test. 2️⃣ Barium Meal: Diagnostic but less sensitive. 3️⃣ H. Pylori Detection: Stool Antigen: 🌟 The Best method. Urea Breath Test: Can give False (-ve) results., best tool to assess for success of treatment Serology: Not useful for follow-up. ♦️optimal initial management of a patient hospitalized for a bleeding peptic ulcer➡️ Intravenous PPIs ♦️H. pylori is present in 50-70% of patients with DUs. ♦️free air under diaphragm ➡️ perforation ♦️Zollinger-Ellison syndrome ➡️ hypersecretory state ♦️In developing parts of the world, 80% of the population may be infected by the age of 20