GI Bleed

Question 1

what is the most common location of an aortic-enteric fistula?

Answer 1

3rd part of the duodenum

Question 2

do mild elevations in INR (1.3 to 2.5) increase the risk of re-bleeding after endoscopy?

Answer 2

No

Question 3

in what two scenarios should bleeding patients be intubated?

Answer 3

1. Hematemesis
   2, AMS

Question 4

What is the classification system used to classify peptic ulcers?

Answer 4

Forrest classifcations system

Question 5

How does a Forest class 3 ulcer appear and what endoscopic therapy is needed?

Answer 5

Clean based ulcer and no endoscopic intervention needed, just PPI

Question 6

How does a Forest class 2c ulcer appear and what endoscopic therapy is needed?

Answer 6

Flat pigmented spot, no endoscopic intervention needed, just PPI

Question 7

In terms of ACTIVE bleeding, recent bleeding or no bleed, what is the difference between forest class 1, 2, and 3

Answer 7

1. active bleed
2. recent bleed
3. no bleed

Question 8

what is the difference between forest class 1a and 1b ulcers and their treatment?

Answer 8

1. 1a is an active and spurting lesions, treat with dual therapy (epi injection + thermal or clips) and IV PPI
2. 1b is active but oozing

Question 9

What is the different between forest class 2 and 2b ulcers and treatment?

Answer 9

1. 2a is visible vessel treat with dual therapy (epi injection + thermal or clips) and IV PPI
2. 2b is adherent clot treat with dual therapy (epi injection + thermal or clips) and IV PPI

Question 10

How long do you treat with IV PPI forest class 1 and 2 ulcers

Answer 10

72 hours

Question 11

what are the 5 techniques used to achieve hemostasis on bleeding lesions?

Answer 11

1. Thermocoagulation
2. Endoclips
3. Epi injection
   4.Hemospray
4. Over the scope clips

Question 12

when to restart Aspirin after achieving hemostasis in a bleeding ulcer patient with CVD history?

Answer 12

when ulcer hemostasis is achieved

Question 13

in pts with peptic ulcer bleeds, when does rebleeding occur most often>

Answer 13

within 72 hrs

Question 14

in patients with severe ulcer bleed, that cant be fixed with endo, what are the two salvage therapies>

Answer 14

1. Surgery
2. radiographic embolization

Question 15

which type of ulcer results in the setting of multi-organ failure?

Answer 15

gastric stress ulcer

Question 16

what is the cause of gastric stress ulcers?

Answer 16

gastric mucosal hypoperfusion

Question 17

in pts with gastric stress ulcers, what is seen on endoscopy

Answer 17

multiple shallow erosions in the proximal stomach

Question 18

what can be given for gastric stress ulcer prophylaxis

Answer 18

IV H2 blockers or IV PPI

Question 19

whats the time frame for EGD in pts with cirrhosis and bleeding

Answer 19

12 hours EGD

Question 20

in cirrhotic patients, hepatic venous gradients greater than what number are associated with higher risk of rebleeed and treatment failure?

Answer 20

HVPG greater than 20

Question 21

in variceal bleed patients who fail endoscopic therapy what is there last resort for treatment?

Answer 21

TIPS

Question 22

whaT is the main complication of TIPS

Answer 22

ENCEPHALOPATHY

Question 23

For isolated gastric varices in the fundus, what is the treatment?

Answer 23

splenectomy

Question 24

in which gastric varices can you attempt EVL? which ones cant you attempt it?

Answer 24

EVL can be attempted in EGV1. If the fundus is involved at all, have to do TIPS

Question 25

EGD should be performed in all patients with decompensated cirrhosis to screen for varices. However, In patients with clinically compensated cirrhosis, what patients should receive an EGD for variceal screening?

Answer 25

1. 2. 3. 4.

Question 26

In DEcompensated cirrhosis pts, who should get EGD?

Answer 26

EGD should be performed in all patients with decompensated cirrhosis to screen for varices.

Question 27

In patients with clinically compensated cirrhosis, what two clinical values can be used to predict the need for EGD?

Answer 27

1. Transient elastography (liver stiffness (KPA>20 2. Platelet count (less than 150)

Question 28

if a patient with compensated cirrhosis has a platelet count above 150 and a liver stiffness kpa less than 20, if you defer EGD, what you should be done next to stratify risk of varices?

Answer 28

Defer EGD and repeat transient elastography in 1 year

Question 29

What pressure gradient and/or liver stiffness measurement are considered CLINICALLY SIGNIFICANT PORTAL hypertension?

Answer 29

1. Hepatic venous pressure gradient > 10mm hg 2. Liver stiffness measurement >25kpa

Question 30

In patients with CLINICALLY SIGNIFICANT PORTAL hypertension, what treatment is recommended?

Answer 30

NSBB (coreg preferred), If started EGD can deferred

Question 31

In performing an EGD to screen for varices, if NO varices are seen on EGD, when should the next EGD screening be for patients in which the liver insult has resolved? vs the liver insult is ongoing (untreated hep c, alcohol)?

Answer 31

If insult resolved, EGD q3 years, and if ongoing insult, EGD q2 years

Question 32

In performing an EGD to screen for varices, if SMALL varices are seen on EGD, what should be done next for patients with HIGH RISK FEATURES on EGD (red wales sign, advanced cirrhosis)? What should be done for patients with no high risk features?

Answer 32

1. If high risk features, start a NSBB 2. If low risk or no risk features, repeat EGD in 1 year for those with ongoing liver injury and 2 years for those without ongoing liver injury

Question 33

In performing an EGD to screen for varices, if MEDIUM to LARGE NON BLEEDING varices are seen on EGD, what should be done next?

Answer 33

Start a NSBB or EVL for primary prophylaxis

Question 34

Is there any benefit to doing a NSBB and EVL in patients with varices who have never bled for PRIMARY PROHPLAXIS?

Answer 34

No. Studies dont support

Question 35

if cirrhotic patients with varices on EGD are started on NSBB, do they still need follow up EGD?

Answer 35

No, just titrate to a HR fo 55-60

Question 36

In cirrhotic pts with varices, and can not tolerate NSBB, who can be done next?

Answer 36

EVL

Question 37

In cirrhotic pts with varices who get banded, how often should banding be performed?

Answer 37

repeat every 2 to 4 weeks untul varices gione, then 6 monthsn then 1 year

Question 38

How do NSBB decrease portal pressure?

Answer 38

decreased cardiac output (b1 blocked) and causes splanchnic vasoconstriction

Question 39

Can cirrhotic patients with refractory ascites receive NSBB?

Answer 39

Yes but avoid high doses. if they get hepatorenal syndrome stop the medsa

Question 40

can you use TIPS as a means of primary prophylaxis in patients with cirrhosis and non bleeding varices

Answer 40

No, not for primary prophylaxis

Question 41

for cirrhotic patients with varices, when is it ideal to use both NSBB and EVL?

Answer 41

after an acute bleed. if they never bleed do one or the other

Question 42

In cirrhotic patients with varices who get a tips, do they need EGD or EVL ny more?

Answer 42

No need for EVL or NSBB if they get a TIPS

Question 43

In patients with obscure bleed, when should you do a anterograde deep enteroscopy (upper) vs retrograde (colon)?

Answer 43

If a capsule showed bleeding in the proximal 2/3 small bowel do upper/anterograde. If in the lower 1/2. do retro/lower.

Question 44

How is diarrhea defined?

Answer 44

Decrease in the consistency of stool or increase in the frequency of stool >3/day more than 4 weeks

Question 45

What are the 4 main categories of diarrhea ?

Answer 45

1 Inflammatory diarrhea 2 Watery diarrhea 3 Fatty diarrhea (steatorrhea) 4 Medication-induced diarrhea: