GI System

Question 1

What anatomical location defines upper GI bleeding from lower GI bleeding?

Answer 1

Ligament of Treitz in small intestine

Question 2

What are (10) main causes of upper GI bleeds?

Answer 2

1. Peptic ulcer disease
2. Reflux esophagitis
3. Esophageal varices
4. Gastric varices
5. Gastric erosions, duodenitis
6. Mallory-Weiss tear
7. Hemobilia
8. Dieulafoy vascular malformation
9. Aortoenteric fistulas
10. Neoplasms

Question 3

What are the (3) subcategories of peptic ulcer disease and their prevalance?

Answer 3

1. Duodenal ulcer (25%)
2. Gastric ulcer (20%)
3. Gastritis (25%)

Question 4

What is one vascular malformation that may cause massive GI bleeds in the upper GI system and what layer is it located?

Answer 4

Dieulafoy vascular malformation; submucosal dilated arterial lesion

Question 5

What are (8) main causes of lower GI bleeds?

Answer 5

1. Diverticulosis
2. Angiodysplasia
3. IBD
4. Colorectal carcinoma
5. Colorectal adenomatous polyps
6. Ischemic colitis
7. Hemorrhoids, anal fissures
8. Small intestinal bleeding

Question 6

What is the most common cause of lower GI bleeds? What age range does it usually appear? Is it painful or painless?

Answer 6

Diverticulosis in patients >60 yo with painless bleeding

Question 7

What do the following types of bleeding indicate about their origin?

1. Hematemesis
2. “Coffee grounds”
3. Melena
4. Hematochezia

Answer 7

1. Hematemesis - upper GI
2. “Coffee grounds” - upper GI, lower rate of bleeding
3. Melena - upper GI, longer instestinal transport
4. Hematochezia - lower GI, left colon/rectum

Question 8

What (3) medications are important to ask about in a patient reporting GI bleeding?

Answer 8

1. NSAIDs/aspirin
2. Clopidegrel
3. Anticoagulants

Question 9

What (4) diseases might an elevated PT indicate in a patient presenting with a GI bleed?

Answer 9

1. Liver dysfunction
2. Vitamin K deficiency
3. Consumptive coagulopathy
4. Warfarin use

Question 10

What initial tests should be ordered for a patient presenting with:

1. Hematemesis
2. Hematochezia
3. Melena
4. Occult blood

Answer 10

1. Hematemesis - upper GI endoscopy
2. Hematochezia - r/o anorectal cause –> colonoscopy
3. Melena - upper endoscopy; if (-) f/u w/colonoscopy
4. Occult blood - colonoscopy; if (-) f/u w/endoscopy

Question 11

What is the first laboratory value that should be evaluated for with occult blood presentation?

Answer 11

Iron deficiency anemia

Question 12

What size RBC are present with acute bleeding?

Answer 12

Normocytic

Question 13

What happens to the BUN:Cr in upper GI bleeds? What must be assumed for this association to apply?

Answer 13

Elevated in patients with normal renal function

Question 14

What is the most accurate diagnostic test in evaluating upper GI bleeds?

Answer 14

Endoscopy; diagnostic and therapeutic (can coagulate bleeding vessels)

Question 15

What should be performed to exclude anal/rectal source of bleeding if there are no obvious bleeding from hemorrhoids?

Answer 15

Anoscopy or proctosigmoidscopy

Question 16

What is the role of a radionuclide scan when evaluating GI bleeds? What are it’s limitations?

Answer 16

Used to detect bleeding even in low rates of blood loss. Cannot localize lesion // only identifies continued bleeding

Question 17

What imaging study is used to definitively identify origin of bleeding in GI bleeds? When is it used?

Answer 17

Arteriography - normally used in lower GI bleed evaluation when there is active bleeding

Question 18

In upper GI bleeds, what imaging study and medications are started?

Answer 18

EGD - can coagulate bleeding vessel
PPI - increase pH promotes clotting
Octreotide - vasoactive in varices treatment