Gastrointestinal Bleeding Answers 307If not excised, symptoms will most often resolve within several days when
the hemorrhoid ulcerates and leaks the dark accumulated blood. Residual
skin tags may persist. Excision provides both immediate and long-term
relief and prevents the formation of skin tags.
(a)The symptoms of nonthrombosed external and nonprolapsing internal
hemorrhoids can be improved by the WASHregimen. Warm water,via sitz
baths or by directing a shower stream at the affected area for several minutes,
reduces anal pressures; mild oral analgesicsrelieve pain; stool softeners
ease the passage of stool to avoid straining; and a high-fiber dietproduces
stool that passes more easily. (b) Incisionof a hemorrhoid (as opposed to
excision) leads to incomplete clot evacuation, subsequent rebleeding, and
swelling of lacerated vessels. (c)This patient has a thrombosed external
hemorrhoid. The need for further evaluation of the rectal bleeding has not been
established.(e)Hemorrhoids rarely require immediate operative management,
unless there is evidence of thrombus formation with progression to gangrene.
277.The answer is a.(Tintinalli, pp 547-555.)IBDis a chronic inflammatory
disease of the GI tract. There are two major types: CD and UC. CDcan
involve any part of the GI tract, from mouth to anus, and is characterized
by segmental involvement. The distal ileum is involved in the majority of
cases; therefore, acute presentations can mimic appendicitis. CD spares the
rectum in 50% of cases. There is a bimodal age distribution, with the first
peak occurring in patients 15 to 22 years of age, and a second in patients
55 to 60 years of age. Definitive diagnosis is by upper GI series, air-contrast
barium enema, and colonoscopy. Segmental involvement of the colon with
rectal sparing is the most characteristic feature. Other findings on colonoscopy
include involvement of all bowel wall layers, skip lesions(ie, interspersed
normal and diseased bowel), aphthous ulcers,andcobblestoneappearance
from submucosal thickening interspersed with mucosal ulceration. Extrain-
testinal manifestations are seen in 25% to 30% of patients with CD.
(b)UC primarily involves the mucosa only with formation of crypt
abscesses, epithelial necrosis, and mucosal ulceration. Rectal pain and bloody
diarrhea are more common in UC than in CD. UC begins in the rectum, and
fails to progress beyond this point in one-third of patients. Colonoscopy
demonstrates inflammation of the mucosa only and continuous lesions of
the GI tract. Although blood loss from sustained bleeding may be the most
common complication, toxic megacolon must not be missed. (c)While
appendicitis may be in the differential diagnosis, the acute on chronic nature
of this disease and a normal-appearing appendix on abdominal CT rules it out.