Melana and Hemoxhezia

Question 1

Symptoms of UGIB and LGIB

Answer 1

• UPPER (can present with melena, if rapid can present as hematochezia)
• LOWER (typically present as hematochezia)

Question 2

DDx for UGIB

Answer 2

1. Peptic Ulcer Disease
2. Varices (esophageal)
3. Hemorrhagic/erosive gastritis
4. Mallory-Weiss tear
5. Boerhaavesyndrome
6. Erosive esophagitis
7. Aortoentericfistula
8. Arteriovenous malformations/angioectasias
9. Cancer (Esophagus, Gastric)
10. Swallowed blood (nosebleed aka epistaxis)
11. Anticoagulant and fibrinolytic therapy

Question 3

DDx for UGIB

Answer 3

LOWER (typically present as hematochezia)

1. Inflammatory Bowel Disease
2. Ischemic colitis
3. Diverticulosis bleed
4. Anal fissures
5. Hemorrhoids
6. Polyps
7. Cancer (Colon)
8. Infectious colitis
9. Arteriovenous malformations/angioectasias
10. Varices (Colon)
11. Radiation colitis
12. NSAID-induced ulcers
13. Rectal ulcer
14. Intussusception

Question 4

DDx for LGIB depends on the age of the patient and severity of the bleed.

DDx UNDER 50:

Answer 4

1. Infectious colitis
2. Anorectal disease
   
   1. Anal fissures, hemorrhoids
3. IBD
4. Meckel diverticulum

Question 5

DDx for LGIB depends on the age of the patient and severity of the bleed.

DDx OVER 50:

Answer 5

1. Cancer
2. Diverticulosis
3. Angectasias
4. Ischemic Colitis

Question 6

____ of hematochezia due to upper gastrointestinal source

Answer 6

10%

Question 7

There is an increased risk of LGIB in patients taking _______________.

Answer 7

aspirin, non-aspirin antiplatelet agents, and NSAIDs.

Question 8

2 weird things that can cause hematochezia and make doc think LGIB

Answer 8

1. Liquid meds with red dye, as well as
2. certain foods, such as red Kool-aid™ and beets

Question 9

Diagnostics in ppl with LGIB

Answer 9

Evaluation with colonoscopy in stable patients

Question 10

UGIB = melana or if rapid, hematochezia. What medications can cause this?

Answer 10

Medications with iron or bismuth

• MVI with iron, Peptobismol

Question 11

DIFFERENTIAL DX CONSIDERATIONS: HEMATOCHEZIA/MELENA

Answer 11

1 Diverticulosis bleed

2. IBD

3. Ischemic colitis

4. Anorectal disease
5. Polyps
6. Cancer (Colon)
7. Arteriovenous malformations/angioectasias
8. Upper GIB

• 1.PUD
• 2.Varices

Question 12

_______ is the most common cause of major lower tract bleeding, most commonly occuring in the ________.

Answer 12

Diverticulosis

Sigmoid Colon

Question 13

Will all patients with diverticulosis be symptomatic?

Answer 13

No, 90% will have uncomplicated diverticulosis = asymptomatic

Question 14

Diveritulosis

• Sx
• Diagnostics

Answer 14

1. Acute, PAINLESS, large ovlume red poop
2. Hemorrage, without diverticulitis, from the ascending colon.

•Evaluation with colonoscopy in stable patients, once bleeding subsides typically

Question 15

_______ is a CD (Crohns Disaese) related gene on Chr16.

Answer 15

CARD15/NOD2

Question 16

If patient has primary sclerosing cholangitis, think _____

Answer 16

UC

Question 17

Appendectomy for confirmed appendicitis (before age 20) may protect against developing ____

Answer 17

UC

Question 18

Crohns disease symptoms vs Chrohns

• Type of diarrhea
• Tx

Answer 18

• Diarhea (w or w/o blood)
• Pain can micmic appendicits (acute ileitis)
• Treat
  
  • corticosteroids, immunomodulating agents, biologic angents, ABX

Bloody diarrhea + testmus/fecal urgency ask if stopped smokung

corticosteroids, immunomodulating agents, biologic angents, surgery = cure

Question 19

Ischemic Colitis

• Sx
  
  • CC in older patients vs young patients
• Imaging
• Treatment

Answer 19

• Acute vascular obstruction => sudden onset of cramping LLQ pain, desire to defecate, passage of blood or bloody diarrhea (hematochezia or BRB per rectum)
• CC in older people = atherosclerotic disease
• CC in younger = cocain
• Imaging
  
  • Abdominal XR = thumb print
  • Sigmoidoscopy
• Tx
  
  • NPO, IV, blood
  • Surgical resection

Question 20

ACUTE MESENTERIC ISCHEMIA

Sx

Imaging

Treatment

Answer 20

Periumbilical pain out of proportion to tenderness that worsens when we eat food “food fear”

• => so they are writhing in pain, but physical exam isn’t impressive, maybe mild tenderness)don’t just think they are malingering!

Imaging

• Abdominal XR = thumb printing = submucosal edema
• ***** CT Angiography
• Early celiac and mesenteric arteriography is rec

Treat

• Laparatomy

Question 21

For EVERY anorectal disease, wht do you perform

Answer 21

DRE

Question 22

Hemorrhoids sx

complications

Answer 22

Bright red blood per rectum (BRBPR)-usually only drops on tissue or in toilet

Thrombosed external hemorrhoid are VERY painful

Question 23

Anal fissures

Sx

Answer 23

• Patients complain of severe, tearing pain during defecation followed by throbbing that may lead to constipation due to fear of recurrent pain.
• There may be mild associated hematochezia, with blood on the stool or toilet paper

Question 24

]ANORECTAL INFECTIONS cause ________,, which are mostly transmitted __________.

It is important to dinshuish these from ________/

Answer 24

Proctitisis characterized by:

• anorectal discomfort, tenesmus, constipation, and mucus or bloody discharge

sexually transmitted, especially by anal sex

must be distinguished from noninfectious causes

Question 25

* How do you test for **N. Gonnarhea** * **Trepemona Pallidium?** * **chlamydia**

Answer 25

1. Rectal swab for during anoscopy for culture + pharynx + urethra/cervix 2. Scrape chancer/condylomas and use **dark-field microscopy** or **flurorecent Ab testing** =\> requires proper eqiupment and trained ppl 3. Serology, culure or PCR testing of rectal discharge or rectal biopsy

Question 26

MCC of **Anorectal infection i**s \_\_\_\_\_\_\_, how do we diagnose?

Answer 26

**HSV2** * Get **vesicle** fluid and do [**viral culture, PCR or antigen detection assays]**

Question 27

In **Condylomata acuminate-anal conylomas (genital warts),** what is the most important?

Answer 27

* Warts must be distinguihsed from conyloma lata (secondary syphillus) o**r anal cancer**; thus, **bipsy** large or suspiosus lesions! * **HPV vaccines,** especially for MSM

Question 28

\_\_\_\_\_\_\_\_ is a common etiology for anal cancer

Answer 28

HPV

Question 29

PERIANAL PRURITUS (PRURITUS ANI) does not necesarrily present as hemotachezia , but it is \_\_\_\_

Answer 29

**perianal itching** and **discomfort**

Question 30

What types of polyps have the most signifiant implication

Answer 30

Adenomatous polyps and serrated polyps

Question 31

It is important to consider HEREDITARY COLORECTAL CANCER & POLYPOSIS SYNDROMES in whom

Answer 31

* 1. FHx of colorectal cancer that has affected \>1 family member * 2. Personal or fmaily Hx of colorectal cancer deveoping early (before 50) * 3. FHx or multuple polpys (\>20) * 4. FHx of multiple extracolonic cancers

Question 32

FAP (Review deck on H&P, how to treat) Lynch Sndruome Nonfamilial adenenmouts and serated (review card) Harmatomatous polpyposos sundrome (Review card)

Question 33

Colorectal cancer screen should be down when?

Answer 33

* Start regular screening from **45- 75.** * **From 76-85;** only do it based on persons prefercence, life expentancy, overal health and prior screen * **Over 85**= do not screen *

Question 34

Above average risks for Colorectal cancer include:

Answer 34

* 1. 1st degree relative with cancer before 60 or 2 first degree relatives at any age: screen starting at 40 for ever 5 years or 10 years ebfore youngest age was affected. * **2. Inherited FAP:** genetic testing/anual screening by sigmoidoscopy starting at 10-12 * **3. Inhereited HNPCC:** genetic testing or colonoscopy every 1-2 yrats begning at ages 20-25 or 10 years younger than younger age of person w colorectal cancer.

Question 35

How do wetest and screen for colorectal cancer?

Answer 35

* 1. Fecal occult blood test * **2. FIT (Fecal immunochemical test) =\> MORE sensitive**

Question 36

review AVM UGI Bleeds: PUD

Question 37

\_\_\_\_\_\_\_ is commonly due to **portal HTN** and found in 50% of patients with \_\_\_\_\_, causing UGI bleeds.

Answer 37

* **Espohageal varices** * **Cirrhosis**

Question 38

Symptoms of esophageal varices Treat?

Answer 38

* Asx, but can cause acute GI hemorrhage =\> melena, hematoxhezia, and hematemisis. * Treat * **Acute resucuitaiton** * 1. (rapidly access and resuccistate with IV fluids and blood) * 2. Fresh frozen plasma and platemants and IV Vit K because most have coagulopathy due to underlying conitions * **EMERGENT EGD + variceal banding**

Question 39

Other tx of esophageal varices

Answer 39

1. ABX propgylaxis 2. Somatostatin and octreotide 3. Lactulose 4. Baloon tampomade 5. Travenous intrahepatic portosystemic shint (TIPS) 6. Liver transplant

Question 40

* Diagnose Meckles Diverticulim, which can cause rectal bleeding * Treatment

Answer 40

**1. Technetium 99-scan** Treat with **surgical resection**