Gastrointestinal Bleeding Flashcards
How is gastrointestinal bleeding classified?
Gastrointestinal bleeding (GIB) is broadly divided into upper and lower GIB.
Upper GIB arises from the esophagus, stomach or duodenum, proximal to the ligament of Treitz, while lower GIB arises distally in the small bowel, colon and rectum.
Though there are many commonalities, it is useful to consider the etiology, presentation, diagnosis and treatment of upper and lower GIB separately.
What are the signs and symptoms of gastrointestinal bleeding?
Gastrointestinal bleeding may present in a variety of ways depending on the location, underlying cause, and pace of the bleeding.
Common terminology used to describe GIB includes hematemesis, vomitus containing frank blood; coffee ground emesis, vomitus containing black or dark brown material representing digested blood; melena, dark, tarry stools containing blood from a proximal source; and hematochezia, the passage of frank blood from the rectum [1, 3].
Depending on the underlying etiology, other symptoms such as abdominal pain, nausea and vomiting may accompany bleeding and help to guide the diagnostic workup [2].
Obscure GIB refers to bleeding without an identifiable source despite thorough workup [1].
Slow bleeding from any location in the GI tract may present as anemia without overt signs of bleeding, and is termed occult.
How does upper gastrointestinal bleeding present?
Upper GIB most commonly presents with hematemesis, followed by melena and finally coffee ground emesis [2, 4].
Uncommonly, brisk upper GIB may present with hematochezia [2, 3].
How does lower gastrointestinal bleeding present?
Lower GIB characteristically presents with hematochezia, but slower, more proximal sources of lower GIB may also present with melena [2, 3].
How common is gastrointestinal bleeding in children?
Data describing the incidence of GIB in children are sparse.
In a review of emergency department admissions from a nationally representative sample of US-based pediatric hospitals from 2006 to 2011, GIB accounted for approximately 1.5% of all ED visits.
Upper GIB accounted for 20% of these visits, lower GIB for 30%, and the location of bleeding was not specified in the remaining 50%.
Over the time period studied, the rate of GIB-associated ED visits increased from 82.2 to 93.9 per 100,000 children per year [5].
What are the most common causes of upper gastrointestinal bleeding?
The differential diagnosis in children presenting with upper GIB is broad and depends on age, as shown in Table 1.
The most common etiologies include gastritis, peptic ulcers (often H.pylori related), and vomiting induced hematemesis, which includes Mallory-Weiss tears and prolapse gastropathy syndrome [1, 2, 4].
What are the most common causes of lower gastrointestinal bleeding?
As with upper GIB, the differential diagnosis for children presenting with lower GIB depends on age and is shown in Table 2.
The most common etiologies include colorectal polyps, inflammatory bowel disease (IBD) and both infectious and non-infectious colitis [1–3].
What are the initial priorities in children with gastrointestinal bleeding?
Prior to embarking on an extensive diagnostic workup, patients should be rapidly assessed for hemodynamic stability.
Hemodynamically unstable patients may present with tachycardia, tachypnea, orthostatic hypotension, or altered mental status.
In these patients, prompt resuscitation with isotonic fluid and/ or blood products is the first priority.
Initial laboratory studies should include a complete blood count, electrolytes, liver function panel, and coagulation tests to help quantify the severity of blood loss, clarify comorbid conditions and identify bleeding diathesis. Severe ongoing blood loss or persistent hypotension necessitates urgent surgical, angiographic, or endoscopic intervention to control the bleeding [1–3].
Does acid suppression benefit children with gastrointestinal bleeding?
Medical therapy for pediatric GIB should be directed by the suspected etiology of the bleeding.
For patients with upper GIB, treatment with proton pump inhibitors (PPIs) has been shown to reduce the rate of re-bleeding, transfusion requirement, and need for surgery [1].
In addition, administration of a PPI in the first 48 h is associated with lower mortality [6].
What is the medical treatment for patients with portal hypertension and gastrointestinal bleeding?
In patients with portal hypertension and GIB, treatment with somatostatin or the somatostatin analog octreotide, vasopressin, or non-selective beta-blockers reduces portal venous pressure, decreasing variceal bleeding [1].
Endoscopy can be used prophylactically to prevent progression to variceal bleeding.
What is the role of endoscopy in the diagnosis of gastrointestinal bleeding?
Endoscopy, including esophagogastroduodenoscopy (EGD) and colonoscopy is the diagnostic test of choice in children with GIB, with the patient’s presentation determining the initial test [2–4].
Those presenting with hematochezia, suggesting a lower GIB should undergo colonoscopy first, while those presenting with melena or hematemesis, suggesting a proximal source, should undergo EGD [2].
What are the next steps in patients with a negative EGD and colonoscopy?
The diagnostic yield of repeat colonoscopy or EGD is low in these patients, and there is no established algorithm which can be applied to all patients [2, 3].
In patients with painless lower GIB, technetium-99 pertechnetate disodium scintigraphy (Meckel scan) can be used to diagnose Meckel’s diverticulum with a sensitiv- ity of 89.7% and specificity of 97.1% [7].
Cross sectional imaging, including CT and MRI, can also be used to located a Meckel’s diverticulum or bleeding tumor, and double-balloon enteroscopy or video capsule enteroscopy can identify luminal bleeding inaccessible by EGD or colonoscopy [3].
Due to the risk of capsule retention, the latter technique should not be used when there is suspicion for an stricture or tumor.
A technetium labeled red blood cell scan, or angiography may also be used to localize GIB, but both of these techniques require relatively brisk bleeding [3].
Ultimately, the source of GIB will not be identified in 10–20% of patients who present with GIB [2, 4].
What is the role of endoscopy in the treatment of gastrointestinal bleeding?
Endoscopy is employed both diagnostically and therapeutically in pediatric GIB.
Hemostasis can be achieved endoscopically using injection of epinephrine or sclerosants, electrocautery, argon beam coagulation, or application of clips [1, 3].
What is the role of interventional radiology in gastrointestinal bleeding?
For patients who present with brisk, arterial GIB, mesenteric angiography can be
used both to identify the site, and to embolize the offending vessel [1, 3].
When is surgery indicated for pediatric gastrointestinal bleeding?
Surgical intervention is generally reserved for patients with significant ongoing bleeding refractory to endoscopic treatment, hemodynamic instability, signs of peritonitis, bleeding tumor, or Meckel’s diverticulum [2, 7].
What is a Meckel’s diverticulum?
A Meckel’s diverticulum is a remnant of the vitelline duct which manifests as an outpouching of the distal small bowel.
According to the approximately correct and easily remembered “rule of 2’s” which states that they occur in 2% of the population, within 2 feet of the ileocecal valve, are 2 inches in length, with 2 possible types of heterotopic tissue (gastric and pancreatic), and present before the age of 2 [7].
How often does a Meckel’s diverticulum present with bleeding?
Meckel’s diverticula most commonly present with painless lower GIB, intestinal obstruction, or local inflammation which may mimic appendicitis. Roughly 25% of symptomatic Meckel’s diverticula in children will present with GIB [7].
How is a bleeding Meckel’s diverticulum managed?
A Meckel scan will reveal the diverticulum due to uptake of the radiotracer in heterotopic gastric mucosa, though false positives and negatives are possible, and other modalities including cross sectional imaging or angiography identifying the vitelline artery as the source of GIB can be used to make the diagnosis.
The treatment of a bleeding Meckel’s diverticula is surgical resection, either via a laparo- scopic or open approach [7].
What is the prognosis for children with gastrointestinal bleeding?
The prognosis for pediatric patients with GIB is generally excellent.
Roughly 80% of pediatric ED visits for GIB are discharged from the ED, suggesting that the majority of children with GIB have a relatively benign course [5].
In a nationally representative database study of children with GIB, the overall mortality was 2.07%.
However among patients whose principal diagnosis was GIB, the mortality was only 0.37%, demonstrating the favorable prognosis of isolated GIB compared to GIB in the setting of other significant illness [6].
A previously well 3-year-old presented with an upper respiratory tract infection and had been retching and vomiting small amounts of blood. She is growing well and has a normal examination. The most likely diagnosis is:
A non-steroidal anti-inflammatory drug gastropathy
B Mallory–Weiss’s tear
C haemorrhagic gastritis
D peptic ulcer
E vascular malformation
B
A mallory–Weiss’s tear is an acute mucosal laceration of the gastric cardia or gastro-oesophageal junction.
The classic presentation is haematemesis following repeated retching or vomiting.
Abdominal pain is uncommon and is most likely to be musculoskeletal in origin because of the forceful retching.
Vomiting episodes are usually related to a concurrent viral illness, and occur in previously well children with normal growth patterns and with no history of vomiting or loose stools.
SPSE 1
Most gastrointestinal (GI) stromal tumours are found in the
A mesentery
B stomach
C retroperitoneum
D omentum
E duodenum.
B
GI stromal tumours are mesenchymal tumours arising from the GI wall, mesentery, omentum and retroperitoneum.
most GI stromal tumours are found in the stomach (60%–70%) and should be considered in a patient with neurofibromatosis.
SPSE 1
The investigation of choice for evaluating haematemesis is:
A barium swallow
B upper GI endoscopy
C pH study
D Helicobacter pylori antigen in stool
E breath test for H. pylori.
B
upper GI endoscopy is the test of choice for evaluating haematemesis.
The aims of endoscopy are to identify the site of bleeding and to initiate therapeutic interventions as and when necessary.
Emergency endoscopy is only indicated when the bleed is ongoing and life-threatening.
most centres use general anaesthesia and control of the upper airways in children.
SPSE 1
The most likely diagnosis in a 18-month-old baby with an antecedent viral illness followed by sudden onset of colicky abdominal pain, tenderness and passage of ‘redcurrant jelly’ in stools is:
A Meckel’s diverticulum
B intussusception
C irritable bowel syndrome
D portal hypertension
E von Willebrand’s disease.
B
Idiopathic intussusception should be the working diagnosis for any child younger than 2 years of age who presents with abdominal pain or tenderness associated with lower GI blood loss.
The sudden onset of colicky abdominal pain and vomiting with antecedent viral illness, followed by redcurrant jelly stool is intussusception until proved otherwise.
Beyond 2 years, intussusception is most likely to be associated with a lead point such as meckel’s diverticulum, polyp, lymphoid nodular hyperplasia, foreign body, intramural haematoma, lymphoma or bowel wall oedema in relation to Henoch–Schönlein’s purpura.
SPSE 1
A previously well 2-year-old has painless rectal bleeding. She has normal growth and a normal examination. She also has soft stools and opens her bowels once every day. She is haemodynamically stable. The investigation that would help make the diagnosis is:
A colonoscopy
B Technetium-99m (99m Tc) scan
C abdominal X-ray
D cow’s-milk-free trial
E all of the above.
B
In any child who presents with painless, frank bleeding per rectum, the possible diagnosis are meckel’s diverticulum, polyp, intestinal duplication, intestinal submucosal mass or angiodysplasia. meckel’s diverticulum is a vestigial remnant of the omphalomesenteric duct located on the antimesenteric border in the distal ileum that occurs in 1.5%–2% of the general population.
A meckel’s diverticulum that contains gastric mucosa may present as painless acute lower GI bleed.
After exclusion of an intussusception, the next step in evaluation of haematochezia is a99m Tc pertechnetate scan. The radionuclide binds strongly to gastric mucosa in the meckel’s diverticulum, which forms a focus in the right lower quadrant. The radionuclide may also be taken up by the gastric heterotopias in the small-bowel mucosa or enteric duplications.
SPSE 1
Which of the following is true about Meckel’s diverticulum?
A It is found in 2% of the population.
B In children who are less than 4 years old, the commonest presentation is with obstruction or bleeding.
C The commonest ectopic tissue found histologically is gastric.
D Symptomatic diverticula are more common in males.
E All of the above.
E
Among paediatric patients, the most common presentations of symptomatic meckel’s diverticula are obstruction, intussusception, volvulus, bleeding and diverticulitis.
It is more common in males; up to 50% of those requiring surgery occur under the age of 2 years, and 80% by 10 years of age.
It classically presents as massive painless frank blood loss per rectum, often requiring blood transfusion, in an otherwise healthy child.
Bleeding is due to ectopic gastric mucosa, which may ulcerate, in 90% of cases.
Diagnosis is made by 99m Tc pertechnetate abdominal scintigraphy to detect heterotopic gastric mucosa.
The scan is positive in around 85% of cases. Treatment is prompt surgical removal.
SPSE 1
Which of the following is not true about juvenile polyposis syndrome?
A It is an autosomal dominant condition.
B Diagnosis requires the presence of at least three polyps.
C Surveillance endoscopy is required every 2 years.
D Malignant change is mostly in the first and second decades.
E It usually presents in the first decade with bleeding, rectal prolapse and anaemia.
D
Juvenile polyposis syndrome is autosomal dominant, with multiple polyps anywhere in the GI tract, especially the colon.
It presents around the age of 9 years with bleeding, rectal prolapse or anaemia.
Diagnosis requires the presence of between three and five polyps.
malignant change and colorectal carcinoma occur in 15% of cases under the age of 35 years.
Surveillance endoscopy is required every 2 years.
First-degree relatives should be screened using colonoscopy from the age of 12 years as they may be asymptomatic.
SPSE 1
Which of the following is not true of Peutz–Jeghers’s syndrome?
A Polyps mainly arise in the colon.
B It is an autosomal dominant condition.
C It is associated with melanin pigmentation of buccal mucosa, hands, feet and eyelids.
D The family should be counselled regarding intussusceptions.
E Screening for malignancy should start in adolescence.
A
Peutz–Jehgers’ syndrome is an autosomal dominant inherited condition, with the mutated gene on chromosome 19p13.3.
It is associated with mucocutaneous melanin pigmentation of lips, buccal mucosa and, occasionally, more peripheral sites including hands, feet and eyelids.
Children present with melanin pigmentation of their mucosa, and rectal bleeding.
Polyps mainly arise in the small intestine, but also in the stomach and colon.
management includes removal of larger midgut polyps, and counselling the family regarding the high risk of intussusceptions.
Young adults may develop malignancy in the GI tract, pancreas or ovaries/testes. Screening for malignancy should commence after adolescence.
SPSE 1
A 6-month-old baby has presented to the outpatient clinics with failure to thrive. He has crossed 2 centiles on his growth charts, and suffered from loose stools since birth, occasionally mixed with blood. He suffers from eczema and has episodes of vomiting. Which of the following interventions would help him most?
A endoscopy to rule out varices
B cow’s milk exclusion diet
C colonoscopy to look for causes of lower GI bleed
D bloods to rule out inflammatory bowel disease and coeliac disease
E all of the above
B
This condition should be suspected in infants who present with rectal bleeding, even those who are exclusively breast fed as antigens may be passed down via the breast milk.
GI manifestations may occur with skin (eczema) and respiratory manifestations (wheeze).
Acute watery diarrhoea may occur with vomiting or abdominal cramps.
Chronic diarrhoea and failure to thrive may follow after the ingestion of the milk because it induces a patchy villous atrophy in the small intestine.
Excessive intestinal protein and blood loss may lead to hypoproteinaemia and iron deficiency anaemia.
Peripheral blood eosinophilia may be present.
Stools may contain eosinophils and biopsy specimens from colon, oesophagus and small intestine contains eosinophils predominantly.
SPSE 1
Which of the following is true about Henoch–Schönlein’s purpura?
A Lower GI bleeding occurs in 25% of the cases.
B Endoscopic examination may show patchy erythema, mucosal oedema and erosions.
C These lesions are most prominent in the duodenal bulb and second part of duodenum.
D Biopsy findings may include neutrophilic infiltration in the lamina propria around blood vessels.
E All the above.
E
Henoch–Schönlein’s purpura is a multisystem disorder characterised by purpura, colicky abdominal pain, haematuria and obscure GI bleeding.
lower GI bleeding occurs in 25% of the cases.
Endoscopic examination may show mucosal oedema, patchy erythema and multiple gastric erosions.
The lesions are more severe in the duodenal bulb and the second part of the duodenum.
Biopsies show neutrophilic infiltrates especially in the lamina propria.
SPSE 1
The treatment of choice for an acute variceal bleed that is not controlled by conservative measures in children is:
A endoscopic sclerotherapy
B endoscopic variceal ligation
C portosystemic shunts
D octreotide
E propanolol.
B
Where there are known varices, prompt resuscitation followed by intravenous octreotide may provide time for the child to be transferred to a paediatric liver unit where therapeutic endoscopy can be performed safely.
octreotide is a somatostatin analogue that decreases pressure within varices by decreasing splanchnic blood flow. It is safe, has few side effects and stops bleeding completely in approximately 70%–80% of patients.
Endoscopically large or bleeding varices can be injected or, preferably, ligated using an endoscopic variceal ligator (EVl). EVl was first described in 1989 and is now considered to be first-line treatment for variceal haemorrhage.
It is both safe and effective, even in small children, and results in less stricture formation than sclerotherapy.
Regular endoscopy with banding should be performed until varices are minimal or ablated.
SPSE 1
A 12-year-old presented with abdominal pain when passing stools, rectal bleeding and mucus in stools. He may have any of the following except:
A salmonella
B shigella
C ischaemic colitis
D inflammatory bowel disease
E Meckel’s diverticulum.
E
Symptoms of colitis include acute bloody diarrhoea, tenesmus and abdominal pain.
Beyond infancy, the two main causes of colitis are infectious colitis and inflammatory bowel disease.
Bacterial colitis is self-limiting and usually resolves in 2 weeks; if bloody diarrhoea persists for more than 2 weeks in any patient, a paediatric gastroenterologist referral is required to rule out inflammatory bowel disease.
The presence of fever, fatigue, weight loss, arthritis or arthralgia supports the diagnosis of inflammatory bowel disease.
Ischaemic colitis should be considered in any child with collagen vascular disease, a recent history of anaesthesia, cardiac failure, uraemia, or history of taking medication for birth control or taking digitalis.
SPSE 1
In children with obscure GI bleed, with normal endoscopic and colonoscopic findings, which of the following investigation may help in reaching a diagnosis?
A wireless capsule endoscopy (WCE) on its own
B double-balloon enteroscopy (DBE) on its own
C capsule endoscopy followed by DBE
D laparotomy with peroperative endoscopy
E none of the above
A
WCE is a useful tool for diagnosing small-bowel lesions in patients with obscure GI bleeding, with a yield rate of 38%–93%.
Flexible GI endoscopy is sufficient for diagnostic and therapeutic procedures in the vast majority of paediatric cases, and in adult patients with obscure GI bleeding the procedure determines the source in up to 90% of cases.
However, in the small number of cases where the pathology is confined to the small bowel beyond the reach of conventional endoscopy, WCE and DBE have been recently employed.
WCE has been compared favourably with intraoperative enteroscopy for the diagnosis of obscure bleeding in adults, with 95% sensitivity and 75% specificity.
WCE has been found to be diagnostically superior to endoscopy and barium follow-through/CT scan in obscure GI bleeding, and has been recently evaluated in children.
WCE is, however, non-therapeutic by its nature, and since the imperative in paediatric gastroenterology is the drive to diagnosis by mucosal histology, this is a shortcoming of WCE.
SPSE 1
Dieulafoy’s lesion is best described by which one of the following?
A A submucosal artery that protrudes through a minute defect in the gastric mucosa.
B A GI stromal tumour that arises from the stomach.
C Oesophageal varices in the lower end of the oesophagus.
D Another name for hiatus hernia.
E None of the above.
A
Among the mucosal lesions that may be a cause for haematemesis, a Dieulafoy lesion is a submucosal artery that aberrantly protrudes through a minute defect in the mucosa.
It is a very rare cause for haematemesis.
SPSE 1
The main disadvantage in wireless capsule endoscopy is:
A the time taken for transit through the small bowel
B the inability to get tissue for diagnosis
C that the bowel needs preparation
D that the child has to be nil by mouth for 6–8 hours
E that it can be used for treatment of lesions found during examination.
B
WCE has recently become the investigation of first choice for such diagnoses, while intraoperative enteroscopy, despite its invasive quality, has been the mainstay in the subsequent treatment of obscure GI bleeding in children and adults.
WCE is, however, non-therapeutic by its nature, and since the imperative in paediatric gastroenterology is the drive to diagnosis by mucosal histology, this is a shortcoming of WCE.
SPSE 1
A 26-weeker who is 8 weeks old was feeding and growing in the transitional care area. Over a couple of days he developed diarrhoea, which was initially thought to be due to breast feeding. Over the next couple of days, he became lethargic and had one episode of blood in stools. Which of the following interventions will help him most?
A vitamin K as intramuscular injection
B septic screen, abdominal X-rays and triple antibiotics
C fresh frozen plasma
D reassure parents that it is due to breast feeding
E change the milk, as this could be cow’s milk protein allergy
B
Ex-prems are prone to develop necrotising enterocolitis.
Any loose stools in an ex-prem, especially when they are establishing feeds, should be viewed with suspicion.
Blood in stools is a late presentation. Any suspicion of necrotising enterocolitis warrants a septic screen and abdominal X-rays and starting triple antibiotics.
Fresh frozen plasma is of help only in those with known coagulation defects.
Cow’s milk protein allergy presents as a chronic problem with vomiting and failure to thrive, rather than as an acute presentation.
SPSE 1
Which of the following is not a cause of GI bleeding in a neonate?
A necrotising enterocolitis
B swallowed maternal blood
C vitamin K deficiency
D hypertrophic pyloric stenosis
E Hirschsprung’s enterocolitis
D
All of the causes present with GI bleed except hypertrophic pyloric stenosis, which presents with vomiting at 3–8 weeks of life.
Swallowed maternal blood may arise from the mother’s nipple or may have been swallowed during delivery, and can be proved to be maternal in origin by Apt Downey test, where, on mixing with alkali, maternal blood turns brown because of formation of haematin, whereas there is no change in colour with fetal haemoglobin, which is alkali resistant.
All neonates who present with haematemesis should also be given vitamin K, as they may have missed the prophylaxis post delivery.
SPSE 1
Intussusception is common among which age group?
A. Neonates.
B. Infants.
C. Toddlers.
D. Preschool.
E. Teenagers.
B
Intussusception is common in infants. Common causes of bleeding per rectum in neonate are swallowed maternal blood, haemorrhagic disease of newborns, and anal fissure.
Other causes in neonates include necrotising enterocolitis, malrotation, and volvulus.
Common causes of bleeding per rectum in infants are anal fissures, intussusception, internal volvulus, duplication, and gastroenteritis.
In toddlers and preschool children’s, common causes of bleeding per rectum are anal fissure, rectal prolapse, gastroenteritis, Meckel’s diverticulum, juvenile polyp, and trauma.
Common causes in teenagers are polypoid disease, ulcerative colitis, haemorrhoids, and Meckel’s diverticulum.
Syed/MCQ
Regarding Peutz–Jeghers syndrome, which is false?
A. Polyps from the stomach to rectum.
B. Most of the polyps are in the small intestine.
C. Autosomal dominant.
D. If not treated becomes malignant in 20 per cent of cases.
E. Sometimes has isolated juvenile polyp.
E
If isolated juvenile polyp, it will not come in category of Peutz-Jeghers syndrome.
Syed/MCQ
Regarding familial adenomatous polyposis, which of the following is false?
A. Autosomal recessive.
B. Mutation at long arm of chromosome number 5.
C. Nearly all untreated becomes malignant.
D. Total colectomy with rectal mucosectomy and endorectal ileal pull trough is technique of choice.
E. Familial adenomatous polyposis is called spare type when polyps are in the hundreds.
A
Familial adenomatous polyposis (FAP) is an autosomal dominant disorder.
FAP is called the “spare” type, when polyps are in hundreds, and it is called the “profuse” type when polyps are in the thousands.
Syed/MCQ
Features of Gardner syndrome include all except:
A. Autosomal dominant condition.
B. Associated with familial adenomatous polyposis.
C. Multiple osteoma.
D. Epidermal cyst.
E. Intracranial tumour.
E
Intracranial tumours (glioblastoma and meduloblastoma) are features of Turcot’s syndrome.
Syed/MCQ
What is false for Peutz–Jeghers syndrome?
A. Polyps most commonly occur in colon.
B. Thirty per cent of patients have signs and symptoms in first year of life.
C. Histologically polyps of Peutz–Jeghers syndrome are hamartoma of muscularis mucosa.
D. Excise polyps more than 5 mm preoperatively and more than 15 mm endoscopically.
E. The risk of cancer is 13 times greater than in the general population.
A
The polyp of Peutz–Jeghers syndrome most commonly occurs in the small intestine (55 percent) but are also found in stomach, duodenum (30 per cent), and colon/rectum (15 percent).
Syed/MCQ
Intussusception lead point occurs in what percentage of cases?
A. Fewer than 1 percent of cases.
B. 1–2 percent of cases.
C. 2–6 percent of cases.
D. 6–12 percent of cases.
E. 12–20 percent of cases.
C
2–6 percent of cases.
Syed/MCQ
About intussusception, which is false?
A. Recurrence is seen in first 48 hours.
B. Success with no operative therapy is widely variable.
C. Young children has more likely pathological lead point especially 3 months to 3 years.
D. Recurrence is more common in children treated by nonoperative ways.
E. Pressure of 80 torr, 100 torr, and then 120 torr (each for 5 minutes), applied in air reduction.
C
Explanation. Older children are more likely to have pathological lead point.
Syed/MCQ
