GIB

Question 1

Overt GI bleed manifested as ___

Answer 1

hematemesis or “coffee grounds”

melena
hematochezia

Question 2

Occult GI bleed manifested as ___

Answer 2

symptoms of blood loss or anemia such as lightheadedness, syncope, angina, or dyspnea

Question 3

Occult GI blood tests

Answer 3

Iron deficiency anemia
fecal occult blood test

Question 4

most common gastrointestinal condition leading to hospitalization

Answer 4

GIB

Question 5

The most common cause of upper GIB (UGIB), accounting for ~50% of UGIB hospitalizations.

Answer 5

Peptic ulcer

Question 6

High-dose, constantinfusion IV proton pump inhibitor (PPI) (_____), designed to sustain intragastric pH ____ and enhance clot stability, decreases further bleeding and mortality in patients with high-risk ulcers (active bleeding, nonbleeding visible vessel, adherent clot) when given after endoscopic therapy.

Answer 6

80-mg bolus and 8-mg/h infusion

> 6

Question 7

High-dose intermittent PPIs are noninferior to constant-infusion PPI therapy T/F

Answer 7

T

Question 8

Prevention of recurrent bleeding focuses on the three main factors in ulcer pathogenesis, _____

Answer 8

Helicobacter pylori, nonsteroidal anti-inflammatory drugs (NSAIDs), and acid.

Question 9

If NSAIDs must be given, a _______ is recommended, based on results of a randomized trial.

Answer 9

cyclooxygenase (COX)-2 selective NSAID plus a PPI

Question 10

Patients with established cardiovascular disease who develop bleeding ulcers while taking low-dose aspirin for secondary prevention should restart aspirin as soon as possible after their bleeding episode (_____days).

Answer 10

1–7

Question 11

Aspirin management:

> Restart low-dose aspirin (for primary/secondary? cardiovascular prevention) 1–7 days after bleeding episode.

*Randomized trial: Lower 8-week mortality (1% vs. 13%; hazard ratio, 0.2; 95% CI, 0.1–0.6).

> Discontinue aspirin in most cases of UGIB for primary/secondary? cardiovascular prevention

Answer 11

continue for secondary

discontinue for primary

Question 12

When should low-dose aspirin for secondary cardiovascular prevention be restarted in patients with bleeding ulcers?
A. Immediately after diagnosis
B. Within 1–7 days
C. After 1 month
D. Never

Answer 12

B

Question 13

In patients taking NSAIDs, what is the recommended management if NSAIDs must be continued after a bleeding ulcer?
A. Discontinue NSAIDs permanently
B. Use COX-2 selective NSAIDs plus PPI
C. Use low-dose aspirin only
D. Use acetaminophen instead of NSAIDs

Answer 13

B

Question 14

The classic history of mallory Weiss tears is ____preceding hematemesis, especially in an alcoholic patient.

Answer 14

vomiting, retching, or coughing

Question 15

Bleeding from these tears, which are usually on the ____ side of the gastroesophageal junction

Answer 15

gastric

Question 16

Bleeding from mallory weiss tears stops spontaneously 80-90%

Answer 16

T

Question 17

Esophageal varices are treated with endoscopic ligation and an IV vasoactive medication (octreotide, somatostatin, vapreotide, terlipressin) for____ days.

Answer 17

2–5

Question 18

_____is recommended in patients who have persistent or recurrent bleeding despite endoscopic and medical therapy.

Answer 18

Transjugular intrahepatic portosystemic shunt (TIPS)

Question 19

TIPS also should be considered in the first ___ days of hospitalization for acute variceal bleeding in patients with advanced liver disease (Child-Pugh class B, Child-Pugh class C with score ____)

Answer 19

1–2

10–13

Question 20

Bleeding gastric varices are treated with endoscopic injection of _____, if available; if not, TIPS is performed.

Answer 20

tissue adhesive (e.g., n-butyl cyanoacrylate)

Question 21

What is the recommended long-term management to prevent recurrent esophageal variceal bleeding?
A. Endoscopic ligation only
B. Nonselective beta blockers only
C. Nonselective beta blockers plus endoscopic ligation
D. Surgical ligation

Answer 21

C

“Over the long term, treatment with nonselective beta blockers plus endoscopic ligation is recommended because the combination is more effective than either alone in reduction of recurrent esophageal variceal bleeding.”

Question 22

What is the most common clinical history preceding Mallory-Weiss tears?
A. Persistent diarrhea
B. Vomiting, retching, or coughing
C. Abdominal pain radiating to the back
D. Jaundice and fatigue

Answer 22

B

Question 23

What percentage of Mallory-Weiss tear cases resolve bleeding spontaneously?
A. ~10–20%
B. ~50–60%
C. ~80–90%
D. ~95–100%

Answer 23

C

Question 24

What is the first-line intervention for actively bleeding Mallory-Weiss tears?
A. Transfusion of blood products
B. Endoscopic therapy
C. IV proton pump inhibitors
D. Surgical repair

Answer 24

B

Question 25

Which therapy is most effective for reducing recurrent bleeding in patients with esophageal varices? A. Endoscopic therapy alone B. Medical therapy alone C. Combined endoscopic and medical therapy D. Antibiotic prophylaxis

Answer 25

C

Question 26

When is TIPS (transjugular intrahepatic portosystemic shunt) recommended in patients with esophageal varices? A. Only in patients with no prior treatments B. As the first intervention in all variceal bleeding cases C. For persistent or recurrent bleeding despite standard therapy D. Only for patients without advanced liver disease

Answer 26

C

Question 27

The most important cause of gastric and duodenal erosions is _____

Answer 27

NSAID use ~50% of patients who chronically ingest NSAIDs may have gastric erosions

Question 28

____ are endoscopically visualized breaks that are confined to the mucosa and do not cause major bleeding because arteries and veins are not present in the mucosa.

Answer 28

Erosions

Question 29

Watermelon stomach

Answer 29

Gastric astral vascular ectasia

Question 30

What is the most common cause of gastric and duodenal erosions? A. Alcohol intake B. Stress-related mucosal injury C. Helicobacter pylori infection D. NSAID use

Answer 30

D

Question 31

What is the primary population at risk for stress-related gastric mucosal injury? A. Patients with mild reflux symptoms B. Patients with chronic alcohol use C. Critically ill patients (e.g., ventilator-dependent, coagulopathy) D. Patients on long-term PPI therapy

Answer 31

C

Question 32

What is the likely benefit of PPI prophylaxis in ICU patients with risk factors for gastrointestinal bleeding? A. No reduction in bleeding but improved mortality B. Reduction in clinically important bleeding without impact on mortality C. Significant reduction in both bleeding and infections D. Complete elimination of overt bleeding

Answer 32

B

Question 33

____ is the most common cause of significant small-intestinal GIB in children

Answer 33

Meckel’s diverticulum

Question 34

~75% of GIB previously labeled obscure is now estimated to originate in the _____beyond the extent of a standard upper endoscopic exam.

Answer 34

small intestine

Question 35

[SI GIB] The most common causes in adults include _____

Answer 35

vascular ectasias, neoplasm (e.g., gastrointestinal stromal tumor, carcinoid, adenocarcinoma, lymphoma, metastases), and NSAID-induced erosions and ulcers.

Question 36

Most common cause of lower GIB (LGIB)

Answer 36

Hemorrhoids

Question 37

If these local anal processes, which rarely require hospitalization, are excluded, the most common cause of LGIB in adults is ____

Answer 37

Diverticulosis

Question 38

In children and adolescents, the most common colonic causes of significant GIB are inflammatory bowel disease and juvenile polyps.

Answer 38

inflammatory bowel disease juvenile polyps.

Question 39

_____is abrupt in onset, usually painless, sometimes massive, and often from the ____ colon;

Answer 39

Diverticular bleeding right

Question 40

What is the most common cause of lower gastrointestinal bleeding (LGIB) in adults requiring hospitalization when local anal processes are excluded? A. Hemorrhoids B. Vascular ectasias C. Diverticulosis D. Colitis

Answer 40

C

Question 41

What is a characteristic feature of bleeding due to diverticulosis? A. Chronic and occult bleeding B. Painless and abrupt onset C. Associated with significant pain and hematochezia D. Rarely stops spontaneously

Answer 41

B

Question 42

What is a recommended intervention for persistent or refractory diverticular bleeding? A. Proton pump inhibitors B. Surgical segmental resection C. Antibiotic therapy D. Radiation therapy

Answer 42

B

Question 43

Which condition involves colonic vascular ectasias and aortic stenosis, and what intervention is beneficial? A. Heyde’s syndrome; aortic valve replacement B. Crohn’s disease; infliximab therapy C. Radiation proctopathy; endoscopic therapy D. Aortocolic fistula; angiographic embolization

Answer 43

A

Question 44

What is the most common cause of significant small-intestinal bleeding in children? A. Crohn’s disease B. Meckel’s diverticulum C. NSAID-induced erosions D. Vascular ectasias

Answer 44

B

Question 45

Which treatment is NOT recommended for prevention of recurrent bleeding from small-intestinal vascular ectasias? A. Octreotide B. Estrogen/progesterone compounds C. Thalidomide D. Endoscopic therapy

Answer 45

B

Question 46

What is the management of small-intestinal tumors causing bleeding? A. Endoscopic therapy B. Radiation therapy C. Surgical resection D. Proton pump inhibitors

Answer 46

C

Question 47

Measurement of the _____ is the best way to initially assess a patient with GIB.

Answer 47

heart rate and blood pressure

Question 48

Thus, hemoglobin may be normal or only minimally decreased at initial presentation of a severe bleeding episode. As extravascular fluid enters the vascular space to restore volume, the hemoglobin falls, but this process may take up to ___ h.

Answer 48

72 (3 days)

Question 49

Melena indicates blood has been present in the gastrointestinal (GI) tract for _____ h and a s long as 3-5 days

Answer 49

≥14

Question 50

Transfusion is recommended when the hemoglobin drops ____g/dL

Answer 50

below 7

Question 51

When _____ is the presenting symptom of UGIB, it is associated with hemodynamic instability and dropping hemoglobin

Answer 51

hematochezia

Question 52

What is the most reliable initial method to assess a patient with gastrointestinal bleeding (GIB)? A. Monitoring hemoglobin levels B. Measuring heart rate and blood pressure C. Performing immediate colonoscopy D. Checking stool for occult blood

Answer 52

B

Question 53

When is transfusion recommended for a patient with acute upper gastrointestinal bleeding (UGIB)? A. Hemoglobin <9 g/dL B. Hemoglobin <8 g/dL C. Hemoglobin <7 g/dL D. Any signs of blood loss

Answer 53

C

Question 54

What does the presence of melena in a patient suggest about the bleeding site and timing? A. Recent LGIB within the last 6 hours B. Proximal GI bleeding, with blood present for ≥14 hours C. Small-bowel bleeding with blood present for ≤12 hours D. Recent UGIB with brisk transit of blood through the bowel

Answer 54

B

Question 55

In a patient with hematochezia, which condition is most likely if it originates from an upper GI source? A. Hemodynamically stable with normal hemoglobin B. Hyperactive bowel sounds with elevated BUN C. Brisk bleeding with hemodynamic instability and dropping hemoglobin D. Chronic anemia with low mean corpuscular volume

Answer 55

C

Question 56

Baseline characteristics predictive of rebleeding and death include _____

Answer 56

hemodynamic compromise (tachycardia or hypotension), increasing age, and comorbidities.

Question 57

Discharge from the emergency room with outpatient m ment has been suggested for patients with a Glasgow-Blatchford score of ____

Answer 57

0–1

Question 58

[Cirrhosis presenting with UGIB] ____ decrease bacterial infections, rebleeding, and mortality, and vasoactive medications may improve control of bleeding in the ____ h after presentation.

Answer 58

Antibiotics 12

Question 59

Upper endoscopy should be performed within ____ h in most patients hospitalized with UGIB

Answer 59

24

Question 60

Even in high-risk patients, more urgent endoscopy (performed within 6 h of gastroenterology consultation) does not improve clinical outcomes T/F

Answer 60

T

Question 61

Patients with hematochezia and hemodynamic instability should have ____ to rule out an upper GI source before evaluation of the lower GI tract.

Answer 61

upper endoscopy

Question 62

_______ is the procedure of choice in most patients admitted with LGIB unless bleeding is too massive, in which case ____ is recommended.

Answer 62

Colonoscopy after an oral lavage solution angiography

Question 63

_____ is often suggested prior to angiography to document evidence and location of active bleeding.

Answer 63

Computed tomography (CT) angiography

Question 64

Sigmoidoscopy is used primarily in patients ____ years old with minor bleeding.

Answer 64

<40

Question 65

What is the initial step for a patient presenting with hematochezia and hemodynamic instability? A. Perform colonoscopy B. Perform sigmoidoscopy C. Perform upper endoscopy D. Proceed directly to angiography

Answer 65

C

Question 66

What is the procedure of choice for most patients admitted with lower gastrointestinal bleeding (LGIB)? A. Colonoscopy after oral lavage B. Sigmoidoscopy C. CT angiography D. 99m Tc-labeled red cell scan

Answer 66

A

Question 67

Which imaging modality is increasingly preferred over 99m Tc-labeled red cell scanning in patients with LGIB? A. Magnetic resonance angiography (MRA) B. Positron emission tomography (PET) scan C. CT angiography D. Duplex ultrasonography

Answer 67

C

Question 68

When is sigmoidoscopy most appropriately used in the evaluation of LGIB? A. In patients with massive bleeding and hemodynamic instability B. In patients with hematochezia and suspected upper GI source C. In patients <40 years old with minor bleeding D. In patients with no source identified after colonoscopy

Answer 68

C

Question 69

What therapeutic option is available for active LGIB detected during angiography? A. Endoscopic therapy with clipping B. IV vasopressin infusion C. Transcatheter arterial embolization D. Surgical bowel resection

Answer 69

C

Question 70

A positive test necessitates colonoscopy.

Answer 70

FOBT

Question 71

____testing is recommended only for colorectal cancer screening, beginning at age 45–50 years in average-risk adults.

Answer 71

Fecal occult blood

Question 72

What is the recommended initial diagnostic test for patients with massive bleeding suspected to originate from the small intestine? A. Video capsule endoscopy B. CT enterography C. Angiography D. Push enteroscopy

Answer 72

C “In patients with massive bleeding suspected to be from the small intestine, current guidelines suggest angiography as the initial test.”

Question 73

What is the next step if video capsule endoscopy is negative in a clinically stable patient with suspected small-intestinal bleeding? A. Deep enteroscopy B. Observation and treatment with iron C. CT angiography D. Second capsule endoscopy

Answer 73

B

Question 74

What is the recommended hospital stay for a patient with Mallory-Weiss tear and active bleeding who underwent endoscopic therapy? A. Discharge after endoscopy B. ~1–2 days hospitalization C. ~3 days hospitalization D. ~3–5 days hospitalization

Answer 74

B

Question 75

What is the dietary recommendation for a patient with erosions and no active bleeding following endoscopy? A. Regular diet B. Clear liquids for ~2 days C. Clear liquids for ~1 day D. NPO (nothing by mouth)

Answer 75

A

Question 76

What is the recommended next step for a patient with an ulcer showing a clean base during endoscopy? A. Intensive PPI therapy B. Endoscopic therapy C. Once-daily PPI therapy D. Vasoactive therapy

Answer 76

C

Question 77

What is the first diagnostic step in a patient with hematochezia and hemodynamic instability? A. Colonoscopy B. Upper endoscopy C. CT angiography D. Flexible sigmoidoscopy

Answer 77

B

Question 78

What diagnostic procedure is recommended for a stable patient aged <40 years with minimal rectal bleeding? A. Colonoscopy B. Flexible sigmoidoscopy C. Angiography D. CT angiography

Answer 78

B

Question 79

For patients aged ≥40 years with no hemodynamic instability, what is the initial diagnostic procedure? A. Flexible sigmoidoscopy B. Colonoscopy C. CT angiography D. Surgery

Answer 79

B

Question 80

What is the next step if colonoscopy fails to identify a bleeding site in a patient with acute LGIB? A. Repeat colonoscopy B. Workup for small-intestinal or obscure bleeding site C. Immediate surgery D. Endoscopic therapy

Answer 80

B

Question 81

What is the appropriate management for a patient with acute LGIB who is too unstable to undergo bowel preparation? A. Surgery B. Flexible sigmoidoscopy C. Angiography (or CT angiography first) D. Workup for small-intestinal bleeding

Answer 81

C