MINISTRY OF HELTHCARE OF THE REPUBLIC OF UZBEKISTAN
TASKENT MEDICAL ACADEMY
APPROVED
Vice-rector for studying process
Senior Prof.
Teshaev O.R.
«_________» __________2011y
Uniform tutorial
Theme: Intestinal dyspepsia syndrome.Tumor formation, pain, itching around the anus. Bleeding
from the rectum. Diagnosis, differential diagnosis. Research methods. Clinical management. The
task of the GP. Rehabilitation and prevention. (Lesson 7)
Compiled by: professor
Tashkent - 2011
Ahmedov M.
2
APPROVED
On conference in department of surgical diseases for general practitioners
Head of department___________________senior prof Teshaev O.R.
Text of lecture accepted by CMC for GP of Tashkent Medical Academy
Report №___________from____________2011 y
Moderator
senior professor Rustamova M.T.
3
Exercise: № 7
Subject: tumor formation, pain, itching of the anus. Bleeding from the rectum.Diagnosis,
differential diagnosis. Research methods. Clinical management. The task of the
SPM. Rehabilitation and prevention.
1. Venue activities and equipment:
Hospital, training room, office surgery, dressing room, operating. Case patients, outpatients
medical records, blood tests and urine tests, the results of instrumental studies, guidelines,
training manual on practical exercises, case studies, test questions, algorithms, performance
skills, scripts, interactive teaching methods, standard protocols, handouts from the
Internet slaydoskop, slides, TV-vidio.
2. Duration of training - 327 minutes.
3. Session Purpose:
3.1. Learning Objectives:
- Form the essence of the concept of tumor formation syndromes, pain, itching around the anus
and rectal bleeding;
Disease-master, whose main clinical symptoms of a tumor-like formation, pain and itching of the
anus, rectal bleeding;
- The skills of clinical examination of patients and be able to identify the main symptoms of the
disease perianal area;
- Create the ability to analyze data of laboratory and instrumental methods;
- To form a provisional diagnosis and differential diagnosis;
- Learn basic principles and tactics of treatment of patients;
-Learn the tactics of GPs, principles of treatment and rehabilitation of patients who have tumor
formation, pain and itching around the anus, rectal bleeding;
3.2 The student should know:
• anatomy and physiology of the colon and rectum;
• etiopathogenesis and clinic of the syndrome of "tumor formation, pain, itching around the
anus. Bleeding from rectum "
• conduct a survey of patients who have tumor formation, pain and itching around the anus,
rectal bleeding
• diagnosis and differential diagnosis;
• indications for hospitalization;
• the methods and scope of the survey;
• formulate and justify a clinical diagnosis;
• tactics of treatment of patients;
• carry out preventive measures in individuals at risk for this disease;
3.3 The student should be able to:
• Supervision of patients, professional inspection and inquiries;
• palpation of the abdomen, the colon
• finger rectal examination;
• Conduct rectoscopy;
• interpretation of laboratory data, radiological and instrumental studies;
• if necessary, to provide emergency surgical care.
• conduct regular check-up
• sigmoidoscopy, sfinkterometry
4. Motivation.
Syndrome "tumor formation, pain, itching of the anus. Bleeding from the rectum, "the
widespread pathological condition in which the GP may often encounter in their practice, and
thus should be carried out the correct approach to diagnosis and differential diagnosis. For
example, the causes of bleeding from the rectum could be hemorrhoids, fissures, polyps, cancer
of the rectum, ulcerative colitis, etc. Each of these abnormalities requires an individual approach
to treatment. When choosing the wrong treatment or delayed diagnosis and the correct
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determination of treatment strategies can lead to various complications. In order to prevent such
errors and complications with the syndrome of "tumor formation, pain, itching of the
anus.Bleeding from the rectum, "GPs should be able to diagnose, determine the timing of
planned and emergency hospitalization of patients with these pathologies.
5. Interdisciplinary and inside disciplinary communication.
Anatomy, regional anatomy pathological anatomy, pathophysiology, clinical pharmacology,
gastroenterology, infectious disease, endocrinology, surgery, oncology, anaesthesiology and
resuscitation.
Colon - the distal digestive tubes, which starts from the ileocecal and ends outside of the anal
canal opening. The total length of 1.75 - 2 m. In the colon, there are two main divisions - colon
(length 1.5 - 1.75 m) and straight (length 15 -20 cm) intestine.
For colon cancer is characterized by numerous protrusions haustrum that are not in the small
intestine. Because there is a significantly increased absorptive haustrum and secreting mucosal
surface of the colon, due to the severity of the circular muscle layer at the boundary of each
haustrum is promotion of feces on the colon.Haustration loss, such as the inflammatory process
leads to a gross violation of the motor and evacuation of the colon, resulting in pathological
changes in the secretory and excretory functions of her.
Throughout the colon in radiological and endoscopic study indicated physiological narrowing of
the lumen. The clinical significance of the sphincters of the colon that under certain pathological
conditions comes their spastic contraction, accompanied by severe pain.
For all divisions of the colon is characterized by a well-defined network vneorgannyh arterial
and venous anastomoses between the upstream and downstream branches.They form a parallel,
or boundary, the vessel, which is located some distance from the mesenteric edge of the
colon. Vessel boundary is a collection of links vascular arcade I order, which runs the "direct"
the vessels taking part in the blood supply to the wall of the colon. Venous drainage is carried
out in the portal vein and lymph – in around the colon nodes (20-30), arranged in two rows in the
sigmoid mesentery.
The rectum is the distal colon, located in the pelvic cavity and ending in the crotch.Transition
area in the sigmoid colon is located directly below the cape a few of the sacrum and is called
rektosigmoidnogo department. At this level of the sigmoid colon mesentery disappears, and the
longitudinal muscle layer evenly distributed around the circumference of the rectum is it lacks
three lines expressed the muscle (the shadow), typical of the overlying parts of the colon.
There are two main sections of the rectum: a pelvic and perineal, the boundary between them is
in the place of attachment of the muscle that lifts the anus. In the first (pelvic) section, in turn,
secrete a small extent on the site - and the ampullar part has upper ampullar section - the widest
and most long-haul portion of the rectum.Perineal section of the rectum is also called the anal
canal, and 3 / 5 of total length of the colon accounts for the ampullar section, 1 / 5 – upper
ampullar part and the same - in the anal canal.
The rectum has several bends in the frontal and sagittal plane: it follows the course of the sacrum
and coccyx. Most important in practical terms, such as rectoromanoscopy be two bending in the
sagittal and a frontal plane.
Anatomy of the rectum:
1.Seroz membrane (peritoneum), 2 mg of the rectum 3. The anal canal, anus sphincter 4.nutrenny
5. External sphincter anus 6. Anus 7. Anal comb 8. Anal column 9.Anal sinus 10. Muscle lifting
the anus 11. Transverse fold of rectum 12. Mucosa, 13.Muscle membrane.
The upper ampular part of the rectum is covered by peritoneum on three sides, the direction it
gradually loses its peritoneal covering, and at the level of the sacral spinal IY peritoneum
covered only the front surface of the intestine. At this level, the rectum is closely adherent to the
surrounding organs, men - to the rear surface of the bladder, women - to the uterus. Thus, the
lower portion of the rectum ampulla is located under the peritoneum. Outwards from the side
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surfaces of the rectum, between them and the walls of the pelvis, there is deepening, where the
ureters and the branches of the internal iliac vessels. On top of these deeper down loops of small
intestine. Go to the front surface of the rectum in men vials vas deferens and seminal vesicles,
and a few below - the rear surface of the prostate, in women - the rear wall of the vagina.
Anal canal is a transition zone between the outer opening of the anus and rectum. Its length is 24 cm from the skin to the anorectal (dentate) line. The channel is covered by transitional
epithelium, which contains sweat glands and hair follicles. This epithelium thins and ends near
the dentate line. In the passive state of the anal canal lumen is closed by tonic contraction of its
muscles (internal sphincter).
In the anal canal circular fibers expressed particularly strong image of the internal anal sphincter,
whose length is 3-4 cm and a thickness of 1 cm internal sphincter fibers (smooth muscle) are
surrounded by a ring of the external sphincter (striated muscle).
External sphincter is the most superficial of all the muscles of the perineum. It surrounds the
distal segment of the rectum broad muscular ring, the height (width is 2.5 - 3 cm)
External sphincter muscle is composed of three portions. Muscle fibers of the surface portion of
cross anterior to the anus and attached to the skin surrounding the anus.The second, more deeply
situated portion starts from the center of the tendon of the perineum. Muscle fibers of this portion
covering the rectum from all sides and partially attached to the skin, in part to the periosteum
covering the tailbone. The deepest portion of the third external sphincter, which consists of
circular muscle fibers in the form of a cylinder cover internal sphincter of the rectum.
From the top side surfaces between the external sphincter and rectum woven fibers of the three
portions of the muscle that lifts the anus, which is almost circular covering the rectum.
External sphincter is innervated by perineal anus sexual branches (pudendal) nerve stimulation in
isolated which there is a reduction. Internal sphincter is innervated primarily by sympathetic
nerve branches sex, which are postganglionic fibers originating from the sacral sympathetic
ganglia.
The internal sphincter exercises tonic closure anus. The closure of the anus is due to passive
muscle contractions of the internal sphincter. External sphincter, innervated by motor nerves,
that contracts will power. The interaction of these sphincters depends largely on the state of the
nerve ganglia embedded in the wall of the rectum.
Blood supply of the rectum by a single unpaired artery - the upper rectal and two guys - middle
rectal (branches of internal iliac artery) and lower rectal (internal genital branch artery).
The upper rectal artery is a continuation of inferior mesenteric artery - the main arterial vessel of
the rectum.
Venous drainage from the rectum by two venous systems - and the inferior vena portal vein. This
forms three venous plexus - subcutaneous, submucosal, and podfastsialnoe. From 2 / 3 rectal
venous blood flowing through the upper rectal veins in the lower mesenteric (portal vein), and
from the bottom third - a system of inferior vena cava.
Innervation of the rectum by the sympathetic and parasympathetic fibers. Perineal section of the
rectum is innervated by the nerve sexually, which includes motor and sensory fibers.
Outflow of lymph from the rectum is carried out in four main areas. Of the anal canal inguinal
lymph flowing libov or in regional lymph nodes located under their own fascia of the rectum
(Gerota nodes). From the upper rectal lymph enters the sacral lymph nodes along the upper rectal
artery. Thus, lymph drainage - in the inguinal lymph nodes (lower parts of the rectum), the
second - in upper rectal, and the third - in the sacral lymph nodes, and the fourth line - in the
lower iliac arterial collectors.
6. The content of lesson
6.1.Theoretical part
Diseases of the rectum and anal area occur in practice, a family doctor often enough.
Bulk education anus can be divided into true and dropped out of the rectum. Last fall out during
defecation, and then independently reduce a. These include hemorrhoids internal hemorrhoid at
II and stage III, hypertrophied anal papillae, the polyps. May fall wall of the rectum. By the true
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education anus include anal fringe, hemorrhoids with internal hemorrhoids and genital warts.
Anal fringe usually occur after perianal hematoma resorption. Genital warts differentiated with
extensive warts (signs of secondary syphilis).
Many patients with suspected tumor in his, and their complaints should be taken carefully. Colon
and rectal cancer should be suspected if the patient has a surround of education, as well as
bleeding from the anus, even with concomitant hemorrhoids.
Symptoms of anorectal disease: pain in the rectum, three-dimensional formation, discharge from
the anus, bleeding, anal itching.
Pain in the rectum usually occurs during defecation. Pain in the absence of surround formation
observed in anal fissure, ulcerative proctitis rectalgia.
Pain in the presence of the bulk of education observed in anal hematoma, strangulated internal
hemorrhoids, paraproctitis and malignancy.
Hemorrhoids - one of the most common human diseases. This term is found, starting with the
works of Hippocrates, and in Greek means bleeding, reflecting only the most striking feature of
the disease. With modern nosological position to hemorrhoids include all the various clinical
manifestations of pathological changes of hemorrhoids (bleeding, prolapse of internal thrombosis
and swelling of the external nodes, necrosis and purulent fusion of them, maceration,
accompanied by itching, etc.) suffers from hemorrhoids for more than 10 % of the adult
population, and its share of diseases of the rectum is about 40%. The most common cause of
hemorrhoids - chronic constipation due to consumption of foods low in fiber.
Hemorrhoids - this is not the usual pathological changes, and the cavernous veins of the
rectum. Direct arterio-venous anastomoses cavernous rectal cells explain arterial bleeding from
hemorrhoids. In most cases, formed only three major hemorrhoidal node - 3.7 and 11 hours on
the dial (with the position of the body on the back).
Classification and clinical picture. There are many classifications of hemorrhoids - by anatomical
basis (the external and internal), the clinical course (acute and chronic), severity (four degrees).
External hemorrhoids. Hemorrhoids External hemorrhoids are located at the dentate line of the
distal anus and are covered by squamous epithelium. External hemorrhoids may thrombose or
overflow blood clots. Internal hemorrhoids. Hemorrhoids internal hemorrhoid at located
medially (proximal) from the dentate line and covered by transitional and columnar
epithelium. First-degree hemorrhoids are found swollen and bleeding hemorrhoids. Seconddegree hemorrhoids hemorrhoids and reduce a drop on their own. Third-degree hemorrhoids
Hemorrhoids can be precipitated by hand straighten. Finally, the fourth-degree hemorrhoids
hemorrhoids can not straighten.
Acute hemorrhoids. Synonyms - strangulated hemorrhoids, acute hemorrhoidal
thrombosis. Pathogenetic processes that underlie the thrombosis hemorrhoids involve a violation
of the microcirculation, expressed in cochlear dysfunction of the arteries and veins which
discharge, which ultimately leads to a slowing of blood flow, a dramatic expansion of the
cavernous veins and damage the endothelium.
In the clinic of acute hemorrhoids can distinguish four degrees of severity.
I degree. Small subcutaneous, slightly painful education with mild hyperemia of the skin over
them. Complaints of burning, itching, worse after stool, and with an abundant use of alcohol and
spicy food.
Grade II. Anal region sharply painful, hyperemic. A digital examination is almost impossible and
not necessary. No instrumental studies. No straightening fallen and infringed nodes. The only
thing necessary - to differentiate this condition from acute paraproctitis. In acute inflammatory
reaction of hemorrhoids and diffuse hyperemia, takes all the anal skin ring, and when
paraproctitis usually struck some wall and anal canal because finger study possible, and thus
almost always possible to determine the wall of the anal canal concerned, where is the
internal opening the abscess.
In stage III of acute severity of hemorrhoid anus whole circle is sharply painful dense
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infiltrate. Ushemlennye purplish-blue hemorrhoids are tense and not vpravlyayutsya.U men
often dysuria, up to anuria. In these patients, there is a sharp constant pain, not certainly worse
during or after stool. The general condition for this is usually mild, fever may not be in a blood
test is almost unchanged, indicating that still the local nature of the process. If such patients do
not receive intensive therapeutic measures, may develop gangrene or septic process (IY stage)
with a melting tissues of the perineum, up to sepsis.
Bleeding is often the only symptom of the disease. Other symptoms - loss of nodes, mucous
discharge, irritation and itching, constipation, and pain.
Hemorrhoids must be distinguished from anal fissures, polyps, paraproctitis, rectalgia,
melanoma, villous tumors, rectal cancer, foreign bodies. It must be remembered about the
possibility of secondary piles in liver cirrhosis, certain diseases of the cardiovascular system of
tumors and in violation of venous outflow.Clinically, secondary hemorrhoids may be
accompanied by dilatation of the rectum, pelvis, anterior abdominal wall, lower extremities.
Acute anal fissure, as well as rectalgia often occurs as a complication of chronic
hemorrhoids. Common symptoms of acute hemorrhoids, and these diseases is a pain. If the anal
fissure and thrombosis, pain is associated with the act of defecation, but it may take a crack is
much longer, and the patients it clearly localize. It is essential to study finger at rectalgia,
coccygodynia, diseases of long duration, with severe pain not related to the act of defecation,
without any external and internal displays. A digital rectal examination to determine the health
and mucosal pain with pressure on the tailbone, a pronounced spasm of the levator muscles of
the anal sphincter and.
Acute paraproctitis, the occurrence of which is not associated with hemorrhoids, usually located
at some distance from the anus. The skin lesion focus in hyperemic, tense and painful. If you
have hemorrhoids, they are in the process is not involved.Defecation painless, was not affected.
Chronic hemorrhoids. This refers to the classic syndrome of hemorrhoidal: Pain in the anus
during and after defecation, minor bleeding intermettiruyuschie also associated with a chair, and
loss of internal nodes. It is often associated with anal itching or burning sensation or moisture in
the perineum, the perianal skin hypersensitivity, etc.
Discharge of blood from the rectum, associated with hemorrhoids, is a classic symptom of this
disease. It is usually a pretty long time and often stop altogether after a temporary or persistent
medical treatment or elective surgery.
Complication is a copious, profuse bleeding, which quickly lead to anemia with a hemoglobin
drop, when you need urgent action.
By proctorrhagia symptom should be taken seriously. If it occurs in older people with severe
disorders of the cardiovascular and pulmonary systems, especially in hypertension and heart
failure, the question of surgical treatment need to decide carefully, carefully defining the
indications and contraindications. If the copious blood from the rectum is not connected with the
chair, observed in "false desires", and the blood is darker, it is necessary to show maximum
onkoostorozhennosti, be sure and thoroughly not only the finger study, but examination with a
speculum, anoscope, proctoscope and complete the survey irrigoscopy.
Treatment. There are four basic methods of hemorrhoid treatment: sclerotherapy, rubber rings
doping sites, cryotherapy, and hemorrhoidectomy. The best remedy for hemorrhoids prevention. You should avoid constipation, eat foods rich in fiber: fresh fruits and vegetables,
whole grains, bran. Patients should try to defecation lasted no more than a few
minutes. Laxatives are not recommended.
Anal itching. A pathological condition characterized by persistent itching of the anus occurs in
practice, quite often, although specific studies the proportion of anal itching in the structure of
proctological diseases was conducted. Anal itching should be clearly divided into primary
(synonyms: true, cryptogenic, idiopathic, neurogenic, essential) and secondary, often
accompanies as a primary symptom of diseases such as hemorrhoids, anal fissure, helminth
infestation, proctosigmoiditis, lack of sphincter anus, constipation, inflammation of the genitals,
exposure to harmful endo-and exogenous substances and factors, fungal skin and sacrococcygeal
8
region.
Anal itching may be an early sign of latent diabetes. Itching is worse at night and with heavy
sweating - in hot weather, emotional and physical stress.
Diagnosis. The first thing to check: 1) whether the itching associated with defecation, 2) whether
increased itching after taking alcohol, spicy foods or Salen: the presence of this feature indicates
the presence of proctosigmoiditis 3) whether the patient at home or on the production of harmful
effects - chemicals, radiation, work in conditions of high temperature, etc. 4) whether there is
close contact with pets (helminthic invasion), 5) the presence of the patient or his relatives of
diabetes, fungal infections, constipation, diarrhea.
Anal fissure - a fairly frequent proctological disease, a separate nosological form.Anatomic
substrate of anal fissure is usually sharply painful ulcer on the border of the longitudinal
transition in the skin lining the anal canal. It is necessary to distinguish between acute and
chronic anal fissure.
Development of anal fissures help constipation and tenesmus. Anal fissure is manifested by pain
during bowel movements and prolonged spasm of the sphincter of the anus. The pain is
excruciating and lasts for hours and irradiruet on the back of the legs. There is bleeding. They are
usually small - in the form of spots of red blood on toilet paper. The typical triad of clinical
symptoms of anal fissure - a pain, spasm of the sphincter and rectal bleeding during bowel
movements.
Survey: when viewed from anal fissure is an ulcer as an oval, located on the midline (for 6 or 12
hours). When multiple cracks should be suspected Crohn's disease. With long-term existence of
the cracks in its inner edge formed a guard mound, represented by scar tissue, there are fistulas,
stenosis develops the anus.
Treatment: prevention of constipation, in particular the appointment of foods rich in fiber, can
lead to complete recovery. Apply stretching the sphincter anus - under general anesthesia. With
recurrent fractures and stenosis anus effective surgical treatment.
Anococcygeal pain - coccygodynia and in the anal canal and rectum - rectalgia practice can be
combined under the name "anakopchikovy pain." We should also consider the presence of
traumatic coccygodynia obvious bone pathology in the sacrum - coccyx vertebrae. In the
symptom syndrome leading symptom - pain, often sharp and short, rarely dull and persistent, not
associated with the act of defecation, irradiated the perineum, buttocks and thighs. In this case,
the pain does not appear as a symptom, a diagnosis, for a purely functional in nature, they are not
caused by any organic lesions of the rectum, sacrum, or tailbone, genitalia in female urinary
tract. In adults, mostly middle-aged men. The attacks often occur at night disturbs sleep. The
reasons described pain is still not fully understood. Presumably, here plays the role of pathology
of the nervous system sacrococcygeal plexus, etc.
Examination of the patient with pain anokopchikovym includes finger rectal examination,
radiographs rectoscopy sacrococcygeal spine, sfinkterometriyu, ballaonografiyu, seeding, fecal
flora, scatological study. With appropriate complaints mandatory consultation urologist,
gynecologist, neurologist, trauma.
Treatment. First, you need to treat all of the identified related, especially proctological
disease. But even if we found out etiological factors of pain, in addition to etiotropic treatment
focuses doctor should give it pain therapy
Bleeding from the rectum. Amount of bleeding can be different. The causes of bleeding can be
anal fissure, haemorrhoids, single ulcer of the rectum, colon cancer, ulcerative colitis, polyps and
polyposis, colon diverticula, colon cancer, colon angiodysplasia etc. The color of blood (red,
black, black) nature of the bleeding (drop of blood on the strip surface feces, blood, mixed with
feces, massive hemorrhage) helps to determine the source of bleeding. Bleeding hemorrhoids
occur, usually from a small hemorrhoid and is characterized by the release of red blood. Isolation
of blood with mucus observed in colorectal cancer proctitis. When bleeding from the rectum
clarify all associated symptoms: pain, diarrhea, constipation, the presence of space-occupying
9
lesions, false desires, feelings of incomplete emptying. Survey of bleeding from the rectum in
addition to measuring overall inspection includes anal area, rectal examination, colonoscopy, etc.
For this class applies the following new educational technology:
Students in the form of lots selected issues and prepare for 3 minutes, then everyone is
responsible for their selected question, if necessary, complementary, or response is
complemented by a teacher.
Control questions:
1. The concept of hemorrhoids.
2. Factors of development of hemorrhoids.
3. Clinical characteristics of hemorrhoids
4. Methods of diagnosis of the syndrome of "tumor formation, pain, itching around the
anus. Bleeding from the rectum. "
5. Complications of hemorrhoids.
The answers to these questions:
1. Hemorrhoids - in Greek means bleeding. Violation of blood outflow from the cavernous
venules of cells, which are located in the rectal wall, which wall is damaged cavernous bodies is
bleeding.
2. Mechanical factors (constipation), inactive lifestyle, pregnancy, alcohol, spicy food, the
infectious factor in cryptogenic infection, an allergic factor.
3. sensation in the anus easy itching, difficulty during defecation, bleeding, loss of nodes. When
inflammation sites - increasing them, feeling strong, throbbing pain.
4. Inspection of the perianal area, digital research, rectoscopy.
5. Bleeding, thrombosis node loss.
Teacher offers to disassemble management of patients with the syndrome of "tumor formation,
pain, itching around the anus. Bleeding from the rectum. "
The teacher divides the group into 2 subgroups, the rate of 1, 2.
Drawn by lot by the task 1. "Clinical supervision of patients with the syndrome of" tumor
formation, pain, itching around the anus. Bleeding from the rectum. "
Then given time to prepare for writing answers in workbooks. Then read the answer, one
participant subgroups. At this time, the rival group, together with the teacher are expert.
Briefing - 3 min, the division of 2 minutes preparation time - 10 minutes, the performance of
groups of 10 min (30 min).
Card number 1. Clinical supervision of patients with diseases of the rectum.
Clinical examination of the patient:
1) Pain in the anal area.
2) Isolation of blood during defecation.
3) Itching in the anal and perianal
4) Pale skin color - a sign of anemia
Collect history:
• The cause of the disease
• duration of illness
• received treatment, the types of drugs
• the effect of treatment
• the frequency of exacerbations
Laboratory studies:
• full blood and urine
Conducting research methods:
• Inspection of the perianal and anal area
• Definition of skin-anal reflex
• A digital study
• Sfinkterometriya
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• rectoscopy
The tactics of a doctor depends on the shape and form of the disease complications.
- In the presence of enlarged hemorrhoids, without any complications given preventive
recommendations.
- In the presence of complications of hemorrhoids - bleeding, thrombosis, loss of sending
patients to a specialized agency.
- Acute anal fissure appoint conservative treatment.
- For chronic anal fissure with complications - pektenoz, education "watchdog tubercle" strong
anal itching, difficult defecation send patients to a specialized agency.
Interactive game "question ball"
Write questions about the little pieces of paper and stick on the ball with a ribbon molding so
that it is possible to read the questions completely and remove the following response.
Throws the ball to one of the students. The student received the ball detaches one of the
questions and answers the question written on a piece of paper. If the answer is correct the game
continues and the student who answered the question, throws the ball to another student. Thus,
the game continues until you have answers to all questions.
Questions and answers:
1. Etiological factors of hemorrhoids?
- Congenital insufficiency of the venous system anorectal region, the mechanical theory,
endogenous and exogenous intoxication, infection, neurovascular.
2. Stage of deposition of hemorrhoids?
- There are three stages of loss: 1-stage - nodes drop out during defecation and independently
reduce a 2-step - to reduce a drop-down units, 3-phase nodes fall at the slightest exertion.
3. Extent of thrombosis hemorrhoids?
- 1-degree. A small increase in units, easy flushing of the skin, 2-stepeng. Edema and congestion,
severe pain. 3 - a sharp painful tumor formation in the anus, bluish-purple visible internal
components fell, with areas of necrosis.
4. The causes of anal fissure?
- Constipation, diarrhea, injury, foreign bodies, colitis, enterocolitis, hemorrhoids, etc.
5. Clinical symptoms of anal fissure?
- Itching and burning sensation in the anus, tonic spasms anus, extreme pain during bowel
movements, sometimes associated dysuria, intestinal colic, dysmenorrhea, angina.
6. The main methods of diagnosing the syndrome of "pain and swelling of the anal region?"
- Visual inspection of the perianal area, digital rectal examination, sfinkterometriya, rectoscopy.
6. What are the surgical interventions for the treatment of chronic anal fissures? Open or
closed lateral internal sphincterotomy, excision of the crack (the so-called ultserektomiya),
excision of the crack and YV or any other kind of anoplasty or stretching the anal canal.
6.2.Analytical part.
Situational problem. Enrolled 35 patients with complaints of pain in the anus, worse after
defecation, presence of structures on the anal area. History of sick for three days. OBJECTIVE:
general condition is satisfactory. When viewed in the anus indicated the formation of size 3x2
cm, bluish color, plotnoelasticheskoy consistency, painful on palpation. A digital rectal
examination is not possible to carry out the strong pain.
Questions:
1 Your first diagnosis
2 Which survey should be carried out?
3 Differential diagnosis
4. Tactics GPs
№
answers
Max.ball
Full answer
Unsatisfactor
y
answer
11
1
2
3
4
The patient has an acute thrombosis of
hemorrhoids
Necessary to carry
out rectal finger examination
The differential diagnosis should be
conducted acute paraproctitis, genital
warts,epithelial coccygeal festering course
and teratomatous cyst.
The patient was shown a course of antiinflammatory therapy with
subsequentoperations
5
5
0
5
5
0
5
5
0
5
5
0
Situational problem. Received 40 patient complained of severe pain in the anus, which
appear after defecation, presence of blood in the act of defecation. Anamnesis: ill for
three years. Objective: the overall condition of the patient is satisfactory. On examination
of the anus at the back of the anal canal is a flaw size of 1.5 x0, 5 cmkalleznymi edges.
questions:
1.Vash diagnosis
2.Plan survey
3 Differential diagnosis
4. Tactics treatment
№
1
2
3
4
answers
Max.ball
The patient has a chronic anal
fissure with back pain
Necessary to carry
out rectal finger examination under local
anesthesia andsigmoidoscopy
The differential diagnosis should be
conducted acute paraproctitis, genital
warts,epithelial coccygeal festering course
and teratomatous cyst.
The patient showed rapid treatment excision of anal fissure with
measured backsphincterotomy.
Full answer
Unsatisfactor
y
answer
0
5
5
5
5
0
5
5
0
5
5
0
6.3. Practical part.
Determination of the symptoms of anorectal disease
№
steps
1
2
3
4
5
Laying the patient Bozeman's position or on an
examination table.
Careful examination of the anus
Finger research proyamoy intestine
Determining the tone of the sphincter (sfinkterometriya)
Definitions of state adrectal tissue and lymph nodes in her
Not
Fully implem
fulfilled (0 poi ented correctl
nts)
y
(10 points)
0
10
0
0
0
0
10
10
10
15
12
6
7
8
Rectoromanoscopy
Anoscopy
Colonoscopy
In all:
0
0
0
15
15
15
100
Sygmoidoscopy
Indications: Disorders of the colon and intestines, various inflammatory diseases and tumors
of the colon and rectum, paraproctium.
Required tools: proctoscope, transformer, glycerin or petrolatum. Position of the
patient Bozeman.
Student assignment: Explain indications, the necessary tools, training methods andtechniques of
production sigmoidoscopy. Tell semiotics of disease and the possibility of additional research.
Information Teachers: Assess the knowledge and skills of students through the stepsseparately.
№
steps
1
Prepare the patient siphon enema or
testimony fortrans before the survey.
Lubricate rectoromanoscope glycerine or petroleum jelly.
0
10
End of the tube with an
0
10
olive obturator carried through the anal canal to a depth
of 4-5 cm and obturator removed.
Promotion tube to a depth of 10 - 12 cm under the control
0
10
of the eye.
When collapsed the walls of the intestine, with a
0
10
closed end of the
peripheral ballooninflate tubosa intestine and gradually pr
omote proctoscope to the end.
You should not force the tube to promote, if it rests on
0
10
the mucus - may damage thelatter. The physician
must see gut lumen
Mucosa of the colon in catarrhal proctosigmoiditis dark red, long-term,
0
swollen,covered
10
with slime;
When purulent catarrhal proctosigmoiditis are focal accumulations of pus in the mucus;
In hemorrhagic proctosigmoiditis diffuse redness with hemorrhage in tolschu in the lumen
of slime and blood, contact bleeding.
Ulcerative proctosigmoiditis detected ulcers with irregular edges
and saped fibrinouscoating on the bottom.
When polypous0
10
ulcerative proktoigmoidite islets revealed normal
mucosa betweenpolypoid formations. In the lumen
of muco-purulent masses of blood.
In Crohn's disease mucosal polypoid protrusion in the
0
form of "cobbles".
During a sigmoidoscopy on the testimony of a
0
10
diagnostic biopsy is done, the printsmucosal smears tests.
100
2
3
4
5
6
7
8
9
10
7. Control methods used in class:
• Oral response
Not
fulfilled (0 poin
ts)
0
Fully implement
ed correctly
(10 points)
10
13
• Written response
• Solving case studies
• implementation of practical skills
8. Сriteria assessment of the current control
№
1
%
96-100
mark
Very well «5»
2
91-95
Very well «5»
3
86-94
Very well «5»
4
81-85%
Well “4”
Criteria
In full view of a syndrome of tumor formation, pain,
itching in the anal area, bleedingfrom the
rectum. Classification of pathology, diagnosis,
differential. Diagnosis andtreatment methods. The
questions gives a correct and comprehensive answer. To
think independently and draw conclusions. Selfsupervised patients and skillfullyapplies the practical
skills. Interprets the data of clinical and instrumental
studies.Independently, with knowledge of the
facts involved in the choice of treatment. Actively
involved in conducting intraktivnyh games. In solving
the situational
problems appliesunconventional approaches grounded i
n the responses.
In full view of a syndrome of tumor formation, pain and
itching around the anus.Bleeding from the
rectum. Classification of pathology, diagnosis,
differential.Diagnosis and treatment methods. The
questions gives a correct and comprehensiveanswer. To
think independently and draw conclusions. Selfsupervised patients andskillfully applies the practical
skills. Interprets the data of clinical and instrumental
studies. Independently, with knowledge of the
facts involved in the choice of treatment.Actively
involved in conducting intraktivnyh games. In solving
the situational
problemsapplies unconventional approaches grounded i
n the responses. When interpreting the data of
laboratory tests made one mistake.
The full syndrome has an idea about the volume of
education, pain, itching of the anus.Classification of
pathology, diagnosis, differential. Diagnosis
and treatment methods.The questions gives a
correct and comprehensive answer. To think
independently anddraw conclusions. Selfsupervised patients and skillfully applies the practical
skills.Interprets the data of clinical and instrumental
studies. Independently, with knowledge of the
facts involved in the choice of treatment. Actively
involved in conductingintraktivnyh games. In solving
the situational problems made 2.1 ko inaccuracies.
A student in full view of a syndrome
of tumor formation, pain, itching of
the anus.Bleeding from the rectum. Classification,
diagnosis, differential diagnosis andtreatments. The
14
5
76-80%
Well “4”
6
71-75%
7
66-70%
Well “4”
Satisfactory “3”
8
61-65%
9
55-60%
Satisfactory “3”
Satisfactory “3”
questions gives the correct answer. Selfsupervised patients andskillfully applies the practical
skills. Interprets the data of clinical and instrumental
studies, but not fully aware of the value of
individual data. Knowingly involved in the choice of
treatment. Actively involved in
conducting intraktivnyh games. Case solvedthe
problem correctly, but the rationale for not fully answer.
Correct, but incomplete coverage of the issue of tumor
formation syndrome, pain,itching of the anus, rectal
bleeding, classification, diagnosis, differential
diagnosis andtreatments. The questions gives the
correct answer. To think independently.Selfsupervised patients and skillfully applies the practical
skills. Interprets the data of clinical and instrumental
studies, but not fully aware of the value of
individual data.Knowingly involved in the choice of
treatment. Actively involved in
conductingintraktivnyh games. In solving
the situational tasks and practical skills made
02.03inaccuracies.
A student in full view of a syndrome of tumor
formation, pain and itching of the perianal
region. Bleeding from the rectum. Know the
classification, diagnosis, differential.Diagnosis
and treatment methods. The questions gives the correct
answer. To think independently and draw
conclusions. Selfsupervised patients and skillfully applies thepractical
skills. Independently, with knowledge of the
facts involved in the choice oftreatment tactics, but
admits mistakes. In carrying out the practical
skills makes a grave error. Situational problems decides
not to complete.
The student is responsible for half of the
questions, but is aware of
the syndrome,tumor formation, pain, itching around
the anus. Bleeding from the rectum. Not fully aware
of the classification, diagnosis, differential
diagnosis and treatment. The answers
are not confident. Practical skills and case
studies serves correctly.
At half the questions gives the correct answer. . Poor
knowledge of the classification, diagnosis
and differential diagnosis of tumor formation, pain and
itching around theanus ischemia. To individual
questions knows the answers, but to present
their ideacan not. Incorrectly decided case studies
Half the questions asked gave the correct answer. In
presenting the essence of thesyndrome,
diagnosis, diff. Diagnostic algorithm for the
interpretation of medicalmistakes. Uncertain poses a
15
10
54% and
below
Unsatisfactory “2”
problem. Practical skills are difficult
to perform.Situational tasks executes correctly.
The student has no idea about the syndrome,
classification, diagnosis, differential diagnosis does not
know the treatment policy and is not able to
perform skills
9. Chronological map of classes.
№
stages of training
1
2
3
4
5
6
7
8
Opening remarks of the teacher.
Justification of topics.
Discussion of homework. Interactive
game "lottery"
Supervision of patients in the hospital.
The study of history
Improvement of practical skills,
interpretation of laboratory and
instrumental studies.
break
Discussion of the practical lessons with
a teacher
Hearing the report of the student's
abstract and discussion of the report of
the entire group
Group discussion as interactive games.
The solution of case problems on the
topic: the syndrome of "tumor
formation, pain, itching of the anus.
Bleeding from the rectum. "
Consolidation of student
Conclusion of the teacher on the subject.
Evaluation of each student on a 100
ballnoy system and announces it.
Distributes tasks for self-training.
Form classes
Duration of training
(327 min)
10
Poll. Debate
(Appendix № 1)
Reception. Questions.
Examination of
patients. Medical
history. Test results.
The algorithm of
(desktop application
programs): data from
laboratory and
instrumental studies
45
Poll. Debate
60
60
30
22
Review the message.
discussion Topics
25
Working in small
groups, interactive
game (Annex № 2,3)
65
Magazine. Work
Program. Questions
for self-preparation
(see rotation)
10
10. Quiz Questions
1. What are hemorrhoids?
2.Raskazhite classification of hemorrhoids.
3. Tell us about the etiology of hemorrhoids.
4.Kakie symptoms of hemorrhoids you know?
5.What conservative treatments for hemorrhoids?
6.How treatment in thrombosis of hemorrhoids?
7.Kakie clinical symptoms may occur if the anal fissure?
8.Pri detected cracks in the side walls of the anal canal of which diseases should first think about
the doctor?
9. What causes anal itching?
16
10.O which diseases should think a doctor for bleeding from the rectum?
11. Literature
General:
1. Karimov SH.I. Surgical diseases. 2004
2. Navruzov S.N. Surgical diseases. 2004
4. Kuzin MI et al. Surgical diseases M.1987
5. R. Conde and L. Nayhusa. Clinical Surgery. M.1998
6. Oripov U.O. Karimov SH.I. Қorin bўshliғi azolarining ўtkir oshiғich zharrohligi.T.1991
7. John Murtha. Directory of GP. M. 1998.
8. 2000 kasallik Adan Hgacha Amaliet shifokorlari uchun қўllanma. M.2000.
9. Nurmukhamedov RM Қorin bўshligi azolarini ўtkir zharrohlik hastaliklari. T.1991.Қўllanma
techniques.
10. Fedorov VD, Dultsev Y. Proctology. M. 1984.
10. Situational problems.
11. Standard protocols.
12. Test questions
13.Algoritm diagnosis and treatment of surgical. Tashkent. 2003.g. Ed. Acad.Karimov SH.I.
14.Uchebnoe allowance for the development of surgical skills profile. Tashkent. 2003.Edited by
prof. Atalieva AE
MORE:
1. Saveliev VS Guide to Emergency Surgery of the abdominal cavity. Triad - M.2004
2. Clinical guidelines for practitioners, evidence-based medicine. M. 2002.
3. Briskin BS, Vertkin AL, Vovk EI Prehospital care and other surgical diseases of the
abdominal cavity. Acute abdominal pain. Lechashy doctor. № 6, 2002, CPT. 72-77.