GI Bleeding Flashcards
What is the most common cause of upper gastrointestinal bleeding (UGIB)?
A) Esophageal varices
B) Mallory-Weiss tears
C) Gastric cancer
D) Peptic ulcers
Answer: D) Peptic ulcers
Rationale:
Peptic ulcers are the most common cause of UGIB, accounting for approximately 50% of hospitalizations for UGIB. The ulceration leads to erosion of the gastrointestinal mucosa and, in some cases, nearby blood vessels, resulting in bleeding.
What is the recommended intravenous PPI therapy for patients with high-risk peptic ulcers (e.g., active bleeding or nonbleeding visible vessel) after endoscopic intervention?
A) 40-mg bolus every 12 hours
B) 80-mg bolus followed by an 8-mg/hour infusion
C) 20-mg bolus followed by oral PPI
D) 40-mg oral PPI daily
Answer: B) 80-mg bolus followed by an 8-mg/hour infusion
Rationale:
High-dose, constant-infusion IV PPI therapy (80-mg bolus followed by 8-mg/hour infusion) is recommended to sustain an intragastric pH >6, which enhances clot stability and reduces the risk of rebleeding and mortality in patients with high-risk ulcers following endoscopic therapy.
Which of the following statements regarding intermittent PPI therapy for high-risk ulcers is true?
A) It is less effective than constant-infusion PPI therapy.
B) It is equally effective as constant-infusion PPI therapy.
C) It is contraindicated in patients with adherent clots.
D) It should only be used after surgical intervention.
Answer: B) It is equally effective as constant-infusion PPI therapy.
Rationale:
Meta-analyses of randomized trials indicate that high-dose intermittent PPI therapy is noninferior to constant-infusion PPI therapy in preventing rebleeding and reducing mortality in high-risk ulcer patients. It can be substituted based on availability and clinical circumstances.
Which of the following is a classic presentation of Mallory-Weiss tears?
A. Abdominal pain followed by melena
B. Vomiting, retching, or coughing followed by hematemesis
C. Dysphagia followed by regurgitation
D. Chest pain followed by bright red blood in stool
Correct Answer: B. Vomiting, retching, or coughing followed by hematemesis
Rationale: The classic history of Mallory-Weiss tears includes vomiting, retching, or coughing that leads to increased intra-abdominal pressure, causing mucosal lacerations and subsequent hematemesis.
What is the most common location of Mallory-Weiss tears?
A. Esophageal body
B. Gastric fundus
C. Gastric side of the gastroesophageal junction
D. Duodenum
Correct Answer: C. Gastric side of the gastroesophageal junction
Rationale: Mallory-Weiss tears typically occur on the gastric side of the gastroesophageal junction, where the mucosa is more vulnerable to shear forces from retching or vomiting.
What is the appropriate management for a patient with an actively bleeding Mallory-Weiss tear?
A. Discharge the patient after endoscopy
B. Endoscopic therapy with anti-emetics if ongoing nausea
C. Start intensive PPI therapy and monitor
D. Endoscopic ligation
Correct Answer: B. Endoscopic therapy with anti-emetics if ongoing nausea
Rationale: The flowchart shows that endoscopic therapy is indicated for actively bleeding Mallory-Weiss tears. Anti-emetics are helpful in reducing ongoing retching or nausea, which could exacerbate the tear. Endoscopic ligation is not typically used for Mallory-Weiss tears.
For a patient with an ulcer and a flat pigmented spot found during endoscopy, what is the appropriate next step in management?
A. Endoscopic therapy
B. Intensive PPI therapy
C. Once-daily PPI therapy
D. Endoscopic ligation
Correct Answer: C. Once-daily PPI therapy
Rationale: The flowchart indicates that ulcers with a flat pigmented spot do not require endoscopic therapy but should be managed with once-daily PPI therapy.
What is the recommended hospital stay for a patient with an adherent clot on an ulcer after endoscopy?
A. 1–2 days
B. 2–3 days
C. 3 days
D. Discharge immediately
Correct Answer: C. 3 days
Rationale: For ulcers with adherent clots, the flowchart suggests hospitalization for 3 days, coupled with intensive PPI therapy, to reduce the risk of rebleeding and monitor for complications.
Which treatment is indicated for a patient with active esophageal variceal bleeding?
A. Endoscopic therapy and anti-emetics
B. Endoscopic ligation and vasoactive drugs
C. Intensive PPI therapy only
D. Once-daily PPI therapy
Correct Answer: B. Endoscopic ligation and vasoactive drugs
Rationale: The flowchart highlights that active bleeding from esophageal varices requires endoscopic ligation and adjunctive therapy with vasoactive drugs (e.g., octreotide) to control portal hypertension and reduce bleeding.
What is the management for a patient with a clean-based ulcer identified during endoscopy?
A. Endoscopic therapy and hospitalization
B. Once-daily PPI therapy and discharge
C. Intensive PPI therapy and 3-day hospitalization
D. Endoscopic ligation and clear liquids for ~2 days
Correct Answer: B. Once-daily PPI therapy and discharge
Rationale: Clean-based ulcers do not require endoscopic therapy or prolonged hospitalization. The patient can be discharged after endoscopy with once-daily PPI therapy.
What is the best initial method to assess a patient with gastrointestinal bleeding (GIB)?
A. Measurement of hemoglobin levels
B. Measurement of heart rate and blood pressure
C. Abdominal ultrasound
D. Stool guaiac test
Correct Answer: B. Measurement of heart rate and blood pressure
Rationale: Heart rate and blood pressure are the best initial assessments for determining hemodynamic stability in GIB. Postural changes, tachycardia, and hypotension are reliable indicators of significant blood loss. Hemoglobin levels may not reflect the severity of acute blood loss immediately.
Why does hemoglobin not fall immediately in a patient with acute GIB?
A. Hemoglobin is produced rapidly to compensate for blood loss
B. Acute blood loss reduces plasma and red cell volumes proportionately
C. Hemoglobin is only affected by chronic blood loss
D. Blood loss triggers increased hemoglobin binding
Correct Answer: B. Acute blood loss reduces plasma and red cell volumes proportionately
Rationale: In acute GIB, hemoglobin does not fall immediately because the loss of plasma and red cell volumes occurs proportionately. Only after extravascular fluid shifts into the vascular space to restore volume will hemoglobin levels drop, which can take up to 72 hours.
When is a red blood cell transfusion recommended in a patient with GIB?
A. When hemoglobin falls below 9 g/dL
B. When hemoglobin falls below 8 g/dL
C. When hemoglobin falls below 7 g/dL
D. When hemoglobin falls below 6 g/dL
Correct Answer: C. When hemoglobin falls below 7 g/dL
Rationale: Current guidelines recommend red blood cell transfusion when hemoglobin levels drop below 7 g/dL in most patients with acute GIB, as this threshold balances the need for oxygen delivery with the risks associated with transfusion.
How long must blood be present in the GI tract to result in melena?
A. 4–6 hours
B. ≥14 hours
C. 24–48 hours
D. 3–5 days
Correct Answer: B. ≥14 hours
Rationale: Melena occurs when blood remains in the gastrointestinal tract for at least 14 hours. This allows time for bacterial degradation of hemoglobin, producing the characteristic black, tarry stool. Melena may persist for up to 3–5 days after the bleeding episode.
What does hematochezia as a presenting symptom of UGIB typically indicate?
A. Slow bleeding without hemodynamic instability
B. A lower GI source of bleeding
C. Brisk upper GI bleeding with hemodynamic instability
D. Small bowel lesion
Correct Answer: C. Brisk upper GI bleeding with hemodynamic instability
Rationale: Hematochezia in the setting of upper GI bleeding (UGIB) suggests brisk bleeding, allowing blood to transit through the bowel before it can be digested into melena. This is often associated with hemodynamic instability and a rapidly dropping hemoglobin.
