General Surgery/GIT / Blood in Stool

Question 1

What are the common causes of lower GI bleeding in newborns?

Answer 1

• Swallowed maternal blood
• anorectal fissures
• necrotizing enterocolitis
• malrotation with volvulus
• Hirschsprung disease
• coagulopathy

Question 2

What diagnosis should you suspect in an infant with nonspecific systemic signs, such as apnea, respiratory failure, lethargy, poor feeding, abdominal distention, vomiting, or diarrhea?

Answer 2

Necrotizing enterocolitis (NEC)

Question 3

What is the hallmark radiographic finding of Necrotizing enterocolitis(NEC)?

Answer 3

• Pneumatosis intestinalis
• gas bubbles in the bowel wall

Question 4

What is the major risk factor for NEC?

Answer 4

Prematurity

Question 5

An infant presents with abdominal distension, bilious emesis, and melena. What is your diagnosis?

Answer 5

Malrotation with midgut volvulus

Question 6

What are the common causes of GI bleeding in infants?

Answer 6

• Allergic colitis
• intussusception
• Meckel diverticulum
• Henoch-Schonlein purpura
• hemolytic uremic syndrome
• lymphonodular hyperplasia

Question 7

What are the classic exam findings in an infant with intussusception?

Answer 7

• Currant-jelly stools
• mass in abdomen
• vomiting

Question 8

What is the diagnostic test of choice for intussusception?

Answer 8

Ultrasonography or contrast enema

Question 9

Guaiac positive stools, cutaneous purpura over buttocks and lower extremities, swelling of feet and joint pains in a child suggest what diagnosis?

Answer 9

Henoch-Schonelin purpura

Question 10

What test can be used to differentiate fetal from maternal blood?

Answer 10

Apt test

Question 11

What are the two major causes of iron deficiency in developed countries?

Answer 11

1. GI blood loss
2. Menstrual blood loss in women

Question 12

What is the differential diagnosis of occult GI bleeding?

Answer 12

• Colon CA
• esophagitis
• peptic ulcer disease
• gastritis
• IBD
• vascular ectasias
• diverticula
• celiac disease
• portal hypertensive gastropathy

Question 13

The presence of occult GI bleeding, epistaxis, and oral telangiectasias suggests what hereditary syndrome?

Answer 13

Osler-Weber-Rendu syndrome (also known as HHT: hereditary hemorrhagic telangiectasia)

Question 14

False positive occult blood tests can result from ingestion of what?

Answer 14

• Red meat
• dietary peroxidases (such as turnips and radishes)

Question 15

False negative results on occult blood tests can result from ingestion of what vitamin?

Answer 15

Vitamin C

Question 16

Minimal bright red bleeding per rectum (BRBPR), or “outlet bleeding” includes what complaints?

Answer 16

• Small amounts of blood on toilet paper after wiping
• few drops of blood in toilet bowl, or
• small amounts of blood on surface of stool

Question 17

Minimal bright red bleeding per rectum in this setting: Painless bleeding with defecation

Answer 17

Internal hemorrhoids

Question 18

Minimal bright red bleeding per rectum in this setting: Sharp pain with bowel movements

Answer 18

• Anal fissure
• rectal CA
• herpes
• recent anal trauma or
• instrumentation

Question 19

Minimal bright red bleeding per rectum in this setting: Passage of mucus, straining with defecation, and sense of incomplete evacuation

Answer 19

Rectal ulcer

Question 20

Minimal bright red bleeding per rectum in this setting: Abdominal pain, change in bowel habits

Answer 20

Colon cancer

Question 21

Maroon stool with intermixed bright red blood (hematochezia) implies bleeding from what part of the GI tract?

Answer 21

Proximal colon or small intestine

Question 22

What test can be done in a patient with hematochezia to rule out an upper GI source proximal to the ligament of Treitz?

Answer 22

Nasogastric tube lavage or endoscopy

Question 23

A history of melena and/or hematemesis suggests bleeding from what source?

Answer 23

Upper GI or slow proximal colon bleeding

Question 24

What are important things to ask for in the history of a patient with rectal bleeding?

Answer 24

• Age
• systemic symptoms
• change in frequency or caliber of stools
• history of inflammatory bowel disease
• family history of colon cancer
• history of anal trauma
• history of pelvic radiation

Question 25

What physical exam is required in the evaluation of rectal bleeding?

Answer 25

* External inspection of anus * digital rectal exam, fecal occult blood testing * office-based anoscopy or proctoscopy

Question 26

What special measures should you take in a person with ongoing rectal bleeding, transfusion requirement greater than two units of packed red blood cells, or signs of hemodynamic instability?

Answer 26

* Admit to ICU * start two large caliber peripheral catheters or central venous line

Question 27

An elderly patient presents with left-sided abdominal pain and rectal bleeding after a recent episode of hypotension after surgery. What is your likely diagnosis?

Answer 27

Ischemic colitis

Question 28

What are indications for additional testing in a patient with BRBPR regardless of age?

Answer 28

* Vital sign abnormalities * constitutional symptoms * change in frequency of stools * anemia * melena * fecal occult blood positive stools * family history of familial polyposis

Question 29

What is the diagnostic test indicated when you cannot find a cause for rectal bleeding in a patient under age 50?

Answer 29

sigmoidoscopy or colononscopy

Question 30

What is the diagnostic test indicated identified for ANY rectal bleeding in a patient OVER age 50?

Answer 30

Colonoscopy

Question 31

What is the recommended evaluation for a patient with occult GI bleeding and anemia or upper GI symptoms?

Answer 31

Upper endoscopy and colonoscopy

Question 32

When should you consider endoscopic evaluation in a premenopausal woman with anemia?

Answer 32

* Positive fecal occult blood test * anemia out of proportion to menstrual blood loss * family history of early GI malignancy

Question 33

What is the grading of internal hemorrhoids?

Answer 33

Grade 1: no prolapse. Grade 2: prolapse with defecation, but reduce spontaneously. Grade 3: prolapse with defecation, require manual reduction. Grade 4: prolapsed and cannot be reduced manually.

Question 34

What is the initial treatment for bleeding and grade 1 or 2 hemorrhoids?

Answer 34

* Adding fiber to diet or using fiber supplement with psyllium or methylcellulose * ensuring adequate fluid intake

Question 35

What is the best initial treatment for irritation and pruritus associated with hemorrhoids?

Answer 35

* Warm sitz baths * hydrocortisone suppositories * analgesic creams

Question 36

What is the treatment of acute thrombosed external hemorrhoids not improving within 24 to 48 hours?

Answer 36

Surgical evacuation of hemorrhoid with excision of skin overlying it

Question 37

What are the nonsurgical treatment options for grade 1-3 internal hemorrhoids refractory to conservative therapy?

Answer 37

* Rubber band ligation * infrared coagulation * laser photocoagulation * sclerotherapy * cryosurgery * bipolar diathermy (Bicap)

Question 38

Operative therapy is indicated for hemorrhoids with what characteristics?

Answer 38

* Failure of medical and nonoperative therapy * concomitant anorectal condition requiring surgery * symptomatic third-degree * fourth-degree, or mixed internal and external hemorrhoids