Gastrointestinal Bleeding

Question 1

What is the dividing point between the upper and lower GI

Answer 1

the ligament of Treitz. Bleeds beyond this point are unlikely to be vomited up

Question 2

What is a sign of occult GI bleed

Answer 2

anemia, which is why every case of anemia must be worked up thoroughly

Question 3

What are signs of instability in blood loss

Answer 3

tachycardia, low BP, dizziness

Question 4

What is appropriate course of action if an upper GI bleed is suspected

Answer 4

at least call the ER to consult if the patient is stable. Upper GI bleeds are considered medical emergencies

Question 5

What is endoscopy preferred over barium for visualizing upper GI bleed

Answer 5

You can visualize, treat, and biopsy all in one fell swoop

Question 6

What is a ddx for upper GI bleed

Answer 6

PUD, bleeding esophageal varices, Mallory-Weiss tears, esophageal rupture, Boerhaave’s syndrome, bleeding gastric varices, angiodysplasia and cancer

Question 7

What most often causes esophageal varices

Answer 7

liver cirrhosis (alcohol and Hep C)

Question 8

How doe boerhaave’s syndrome and mallory-weiss tears differ

Answer 8

Boerhaave’s is transmural esophageal perforation, generally worse and hurts way more, and the blood leaks anywhere. Mallory-Weiss is a partial thickness tear near the LES and the blood stays local within the GI tract.

Question 9

What is angiodysplasia

Answer 9

AV malformation, artery meets up with a vein without capillaries to buffer the pressure difference (happens in >70 yo)

Question 10

What are the ssx of AV malformation

Answer 10

chronic, slow forming bleed, painless. usually iron deficiency anemia

Question 11

what are complicating factors in bleeding esophageal varices

Answer 11

liver cirrhosis means the patient has poor clotting ability; infix by gram neg bug often concomitant or precipitant. Often require transfusion

Question 12

What are the main treatments for esophageal varices

Answer 12

variceal ligation (banding), or sclerotherapy (hypertonic saline, tetracycline). Acutely, it is fixed with endoscopy

Question 13

What is the presentation of bleeding PUD

Answer 13

hematemesis, coffee ground vomiting, melena, or hematochezia (maroon colored stool if the hemorrhage is severe)
Patients may also present with complications of anemia, including fatigue, chest pain, syncope and shortness of breath

Question 14

What common substances can turn stool black

Answer 14

Besides an upper GI bleed, bismuth (found in antacids), activated charcoal. Melena will be sticky and smell intensely foul

Question 15

What does bright red blood in the stool mean

Answer 15

Normally it is an indication of a lower GI bleed, but an arterial/intense upper GI bleed could go rapidly through transit and cause bright red blood in the stool

Question 16

What are the most common causes of PUD bleeds

Answer 16

H. pylori, NSAID use, ASA; to a lesser extent SSRIs, corticosteroids, and anticoagulants.

Question 17

What parameters are checked in the Glasgow-Blasford scoring

Answer 17

Hemoglobin level >12.9 g/dL (men) or >11.9 g/dL (women)
Systolic blood pressure >109mm Hg
Pulse

Question 18

What is the Rockall scoring system

Answer 18

used to determine whether an upper GI bleed should be scoped and risk of adverse outcome

Question 19

what are common causes of lower GI bleed

Answer 19

Diverticulosis, diverticulitis
Crohn’s disease
Ulcerative colitis
Ischemic colitis 
Infectious colitis esp. E. coli O157:H7, Shigella, Salmonella, Campylobacter jejunai
Angiodysplasia
Neoplasm, polyps, cancer
Hemorrhoids, anal fissures

Question 20

What is hematochezia

Answer 20

blood in the stool that is not melenic. It will be red or maroon in color, with the blood being darker the longer it is in the GI tract

Question 21

What is a true diverticulum

Answer 21

An out pouching that involves all layers of the bowel wall

Question 22

What is are potential outcomes of diveticulosis

Answer 22

diverticulitis, perforation (blood in the peritoneum is exquisitely painful)

Question 23

What are the ssx of UC

Answer 23

bloody diarrhea, hemorrhage (more common in UC than in Crohn’s)

Question 24

What are signs of massive lower GI bleeds

Answer 24

Normally in patients over 65:
Systolic blood pressure of less than 90 mm
Hemoglobin levels of

Question 25

What are indications for surgery

Answer 25

Persistent hemodynamic instability with active bleeding.
Persistent, recurrent bleeding.
Transfusion of more than 4 units packed red bloods cells in a 24-hour period, with active or recurrent bleeding.

Question 26

What is the work up of choice for lower GI bleed

Answer 26

Colonoscopy. If that fails to find source of bleeding, followed by angiography