Acute and Chronic GI Bleeding

Question 1

What are the cardinal features of acute upper GI bleeding?

Answer 1

Haematemesis

Malaena

Question 2

What is malaena?

Answer 2

The passage of black tarry stools

Question 3

What is the passage of dark blood and clots without shock almost always due to?

Answer 3

Lower GI bleeding

Question 4

What is the most common cause of serious GI bleeding?

Answer 4

Peptic ulceration

Question 5

What are the GI side effects of aspirin and NSAIDs?

Answer 5

Ulcers and erosions

GI haemorrhage from duodenal and gastric ulcers

Question 6

What are the common causes of acute upper GI bleeding?

Answer 6

Drugs
Alcohol
Reflux oesophagitis
Varices (gastric and oesophageal)
Mallory-Weiss syndrome
Gastric adenocarcinoma
Hemorrhagic gastropathy and erosions

Question 7

Which factors affect the risk of re-bleeding and death?

Answer 7

Age
Evidence of co-morbidity
Presence of the classical clinical features of shock
Endoscopic diagnosis
Endoscopic stigmata of recent bleeding
Clinical signs of chronic liver disease

Question 8

What are the classical clinical features of shock?

Answer 8

Pallor
Cold peripheries
Tachycardia
Low blood pressure

Question 9

What is the immediate management for acute GI bleeding?

Answer 9

Take blood for Hb, U&Es, LFTs, coagulation screen, group and crossmatching
Establish IV access and give blood transfusion if in shock or Hb<100 g/L
Give oxygen therapy
Perform urgent endoscopy in shocked patients or liver disease
Continue to monitor pulse and Bp, re-endoscope if bleeding continues, arrange surgery if bleeding persists

Question 10

In management of acute GI bleeding, how may medication need to be altered?

Answer 10

Stop NSAIDs, aspirin, clopidogrel and warfarin

Question 11

What pieces of information are guides to the adequacy of a blood transfusion?

Answer 11

Pulse rate

Venous pressure

Question 12

What are the stigmata of recent bleeding that can be seen on endoscopy?

Answer 12

Spurting vessel
Active oozing
Fresh or organised blood clot or black spots

Question 13

How are varices treated?

Answer 13

Usually banding

Stenting can also be used but is not widely available

Question 14

How are bleeding ulcers and those with the stigmata of recent bleeding treated?

Answer 14

Two or three haemostatic measures:

Injection with adrenaline and thermal coagulation or endoscopic clipping

Question 15

What drug therapy should be given to patients with actively bleeding ulcers or ulcers with a visible vessel?

Answer 15

PPIs

Question 16

What is a Mallory-Weiss tear?

Answer 16

A tear in the gastro-oesophageal junction produced by a sudden increase in intra-abdominal pressure

Question 17

How is a chronic peptic ulcer treated?

Answer 17

Eradication of H. pylori
PPI for 4 weeks
if eradication not achieved - long term acid suppression
If bleeding not controlled - angiography and embolisation or surgery

Question 18

What is acute lower GI bleeding usually due to?

Answer 18

Diverticular disease or ischaemic colitis

Question 19

What are common causes of small acute lower GI bleeds?

Answer 19

Haemorrhoids

Anal fissures

Question 20

What are the causes of acute lower GI bleeding?

Answer 20

Meckel's diverticulum
Carcinoma
Diverticula
Angiodysplasia
Ischaemic colitis
Polyps
IBD
Haemorrhoids

Question 21

What are the main investigations for acute lower GI bleeding?

Answer 21

Proctoscopy
Flexible sigmoidoscopy or colonoscopy
Video capsule endoscopy
Angiography

Question 22

What is a proctoscopy used to diagnose?

Answer 22

Anorectal disuse, particularly haemorrhoids

Question 23

What is a flexible sigmoidoscopy or colonoscopy used to diagnose?

Answer 23

IBD
Cancer
Ischaemic colitis
Diverticular disease
Angiodysplasia

Question 24

What is an angiography used to diagnose?

Answer 24

Vascular abnormality

Yield is low so usually a last resort

Question 25

What do isolated bleedings in the young usually require?

Answer 25

Rectal exam and flexible sigmoidoscopy

Question 26

What do patients with chronic GI bleeding usually present with?

Answer 26

Iron deficiency anaemia

Question 27

What is the primary concern in chronic GI bleeding?

Answer 27

To exclude carcinoma

Question 28

What is the most common worldwide cause of chronic GI blood loss?

Answer 28

Hookworm

Question 29

What are the usual investigations for chronic GI blood loss?

Answer 29

Upper GI endoscopy
Colonoscopy
Unprepared CT
CT colonoscopy

Question 30

When is an upper GU endoscopy used in chronic GI blood loss?

Answer 30

Usually first

Take duodenal biopsy for coeliac disease, even if serology already performed

Question 31

When is a colonoscopy used in chronic GI blood loss?

Answer 31

The next investigation after upper GI endoscopy

Any lesion should be biopsied or removed

Question 32

When is an un prepared CT used in chronic GI blood loss?

Answer 32

As a reasonable test to look for colon cancer in frail patients

Question 33

When is a CT colonoscopy used in chronic GI blood loss?

Answer 33

Can be used as an alternative to colonoscopy

Question 34

What is the investigation of choice to examine the small bowel in chronic GI blood loss?

Answer 34

Capsule endoscopy

Question 35

How can bleeding lesions in the small bowel be treated?

Answer 35

Balloon-assisted enteroscopy

Question 36

What may be used to demonstrate a potential bleeding site in a Meckel’s diverticulum?

Answer 36

IV technetium-labelled colloid