GI bleeding

Question 1

_______ is the most common emergency of the GI tract

Answer 1

GI bleeding

Question 2

Mortality from GI bleed is affected strongly by the patient’s _____ factors

Answer 2

comorbid

Question 3

What should be the first step in the approach to a patient with a GI bleed

Answer 3

assess and stabilize hemodynamic status

Question 4

Melena is strongly suggestive of _______ bleeding

Answer 4

upper

rarely right colon

Question 5

Hematemesis is strongly suggestive of _____ bleeding

Answer 5

upper GI

Question 6

Hematochezia is suggestive of ______ bleeding

Answer 6

lower GI

very brisk upper GI

Question 7

What is the purpose of NG lavage?

Answer 7

assess for upper GI bleed
+ for blood- definitely an upper GI bleed
- for blood- cannot definitively rule out upper GI bleed

Question 8

There is evidence to support earlier transfusion of blood in _______ patients with a GI bleed

Answer 8

elderly

coronary artery diseaes

Question 9

______ is used to reverse blood thinning agents like warfarin and normalize the PT/INR more rapidly than Vitamin K

Answer 9

FFP

Question 10

How do you interpret a finding of increased frequency of stools in a patient with suspected GI beed

Answer 10

increased frequency= more active bleeding

blood is cathartic

Question 11

Chronic ______ increases risk for gastritis, gastric ulcers, duodenal ulcers

Answer 11

NSAID

Question 12

If H&P of a patient with suspected GI bleed reveals underlying liver disease, there is increased concern for _______

Answer 12

variceal bleeding, portal hypertension

Question 13

In patients with a history of AAA repair, there is increased concern for ______

Answer 13

aortoenteric fistula

Question 14

Elevated _______ ratio may indicate an upper GI source of bleeding. Why?

Answer 14

BUN:Cr

BUN rises due to the breakdown of blood proteins to urea by intestinal bacteria which is then absorbed

Question 15

_______ may not accurately reflect blood loss if measured acutely after onset of bleeding

Answer 15

hgb/hct

Question 16

Iron deficiency anemia may indicate:

Answer 16

chronic GI bleed

Question 17

Upper GI bleed is defined as proximal to the:

Answer 17

ligament of Trietz

Question 18

List adverse clinical prognostic factors for GI bleeds

Answer 18

shock
varices or cancer as cause of bleeding
comorbid disease
older age
onset in hospital
recurrent bleeding

Question 19

List adverse endoscopic prognostic factors

Answer 19

active bleeding
bleeding from varices
visible vessel
large ulcer

Question 20

The more units of blood that must be transfused, the greater the _____

Answer 20

mortality

Question 21

The _______ travels right behind the duodenal bulb, so an ulcer in the duodenal bulb can erode and cause major bleeding

Answer 21

gastroduodenal artery

Question 22

What is a Mallory-Weiss tear?

Answer 22

tear and GEJ

Question 23

What is the classic presentation of a Mallory-Weiss tear?

Answer 23

history of recurrent retching prior to development of hematemesis

Question 24

Most Mallory- Weiss tears occur on the _____ side

Answer 24

gastric

Question 25

Describe course and treatment of Mallory-Weiss tears

Answer 25

- bleeding usually stops spontaneously | - treat with hemoclips, injection of epinephrine, observation

Question 26

In _______, irritation of the squamous epithelium leads to erosion and ulceration

Answer 26

esophagitis

Question 27

List causes of esophagitis

Answer 27

reflux radiation Candida, CMV pills/ meds

Question 28

What is treatment for GI bleeds due to esophagitis?

Answer 28

acid suppression stop offending medications treat infection

Question 29

How does esophageal cancer cause bleeding?

Answer 29

bleeding can occur from primary as well as metastatic malignancies which ulcerate

Question 30

In esophageal cancer there is often a history of _______ before bleeding occurs

Answer 30

dysphagia to solids

Question 31

What is treatment for bleeds in esophageal cancer?

Answer 31

surgical epinephrine hemoclips

Question 32

_________ can cause life threatening bleeding

Answer 32

esophageal varices distended veins beneath the esophageal mucosa that result from increased portal pressure due to cirrhosis or portal vein thrombosis

Question 33

How is active bleeding from esophageal varices treated?

Answer 33

band ligation sclerotherapy octreotide

Question 34

What temporary procedure can be done for active bleeding from esophageal varices that have not been controlled by band ligation or slcerosants, until more definitive therapy can be performed?

Answer 34

Sengstaken blakemore tube | definitive therapy is TIPS

Question 35

List possible etiologies of gastric ulcers

Answer 35

NSAIDs H pylori malignancy

Question 36

List treatments of gastric ulcers

Answer 36

``` hemoclips thermal-coaptiv therapy bicap cautery epinephrine injection acid suppression ```

Question 37

In cases of gastric ulcers, you should get biopsies to assess for ______ and test for and treat ______

Answer 37

malignancy | H pylori

Question 38

List the stigmata of bleeding for gastric ulcers in order of most likely to rebleed

Answer 38

``` active bleeding non bleeding visible vessel clot dot clean base ```

Question 39

_______ can reduce rebleeding, surgery, and death in patients with stigmata of bleeding in gastric ulcers

Answer 39

omeprazole PPIs are good but not H2 blockers

Question 40

_______ is often caused by alcohol, NSAIDs, or H pylori and bleeding is usually minor

Answer 40

gastritis

Question 41

Define portal gastrophathy

Answer 41

vascular congestion of the stomach lining from increased portal pressure - bleeding can be chronic as well as acute

Question 42

What is a Dieulafoy's vessel?

Answer 42

abnormally large submucosal artery that can rupture and bleed, surrounded by normal mucosa - moderate to severe bleed - majority occur in the stomach

Question 43

What is treatment for a Dieulafoy's vessel?

Answer 43

hemoclips, epinephrine injection, surgery, angioembolization

Question 44

What is duodenitis?

Answer 44

irritation of the duodenal mucosa, most often due to NSAIDs, but can also be caused by bile acids - mostly chronic bleeding, but can be acute

Question 45

How is duodenitis treated?

Answer 45

Eradicate H pylori stop NSAIDs cholestyramine for bile acids

Question 46

What are common causes of duodenal ulcers?

Answer 46

NSAIDs, H pylori

Question 47

How are duodenal ulcers treated?

Answer 47

Hemoclip, cautery, epinephrine injection, surgery

Question 48

What is a serious complication of duodenal ulcers?

Answer 48

erosion into gastroduodenal artery

Question 49

What is an aortoenteric fistula?

Answer 49

communication between the aorta and the GI tract - 75% occur in the third portion of the duodenum - usually develop after AAA graft repair

Question 50

_______ are angioectasias that can occur anywhere in the GI tract but are most common in the small intestine

Answer 50

arteriovenous malformations

Question 51

What are AVMs associated with?

Answer 51

chronic renal failure aortic stenosis radiation can be acute or chronic bleeding

Question 52

What is treatment for AVMs

Answer 52

argon plasma coagulation

Question 53

What steps are important to prevent recurrence of upper GI bleeding

Answer 53

eradicate H pylori acid suppression avoid NSAIDs surgery- Billroth I or II

Question 54

Lower GI bleeding often presents with _______

Answer 54

hematochezia

Question 55

What is diverticulosis?

Answer 55

small pouches in the colon that bulge outward at weak spots in the colon wall, can bleed

Question 56

What is the normal course of bleeding with diverticulosis?

Answer 56

spontaneously stops in 75% of people

Question 57

How is diverticulosis localized?

Answer 57

tagged RBC scan

Question 58

How is diverticulosis treated?

Answer 58

endoscopy is difficult, use epi and hemoclips, angiography with embolization surgery- hemicolectomy

Question 59

______ usually presents with bloody diarrhea and can have a variety of underlying causes

Answer 59

colitis

Question 60

List causes of colitis

Answer 60

Crohn's, ulcerative infectious, C diff Ischemic

Question 61

How is bleeding due to colitis treated?

Answer 61

treat underlying cause

Question 62

AVMs can be found in the colon and are treated with _______

Answer 62

argon plasma coagulation | stop anticoagulation

Question 63

List signs and symptoms of colon cancer

Answer 63

``` occult GI bleed or hematochezia iron deficiency anemia abdominal pain or masses weight loss change in caliber of stool ```

Question 64

What is a common history at presentation with hemorrhoids?

Answer 64

recent constipation with straining and then passage of brown stool with bright red blood

Question 65

What is treatment for hemorrhoids?

Answer 65

observation, stool softeners, banding if repeat bleeding

Question 66

What is evidence for occult bleeding?

Answer 66

iron deficiency anemia and/or recurrent guaiac positive

Question 67

The focus of the workup for occult bleeding is detection of _______

Answer 67

colorectal cancer

Question 68

What is the most common cause of obscure bleeding?

Answer 68

AVMs/ angioectasias

Question 69

What techniques can be used to evaluate the small intestine in the workup of obscure/ occult bleeding?

Answer 69

Push Enteroscopy: using a enteroscope for an upper endoscope and pushing as far as possible into the small intestine - Double balloon enteroscopy - capsule endoscopy - small bowel follow through x-rays - CT enteroclysis: double contrast imaging of the small bowel