Melena, Hematochezia, Occult GIB

Question 1

Name Ddx’s for an UGIB

Answer 1

PUD
Esophageal Varices
Mallory-Weiss Syndrome
Boerhaave Syndrome
Arteriovenous Malformations/Angioectasias

Question 2

Name Ddx’s for a LGIB

Answer 2

IBD
Ischemic Colitis
Diverticulosis 
Anal Fissures
Hemorrhoids 
Cancer
Infectious Colitis

Question 3

What is Occult GI bleeding, and what is the most common cause?

Answer 3

Bleeding that is not apparent. 
Most common cause include: 
1) Neoplasm
2) Angioectasias
3) Crohn's

Question 4

Who is iron deficiency anemia a normal finding?

Answer 4

Premenopausal, menstrating women.

Pregnant woman

Question 5

What is an automatic differential if a person has occult bleeding as over the age of 45?

Answer 5

Colon Cancer

Question 6

Ddx list for patients under 50

Answer 6

1. Infectious Colitis
2. Anorectal problem (fissure, hemorrhoid)
3. IBD
4. Meckel’s Diverticulum

Question 7

Ddx list for patients over 50

Answer 7

1. Malignancy
2. Diverticulosis
3. Angiectasias
4. Ischemic Colitis

Question 8

A 30 year old male presents panicking because his stool is bright red. He has no family history of cancer, eats a fibrous diet, and exercises regularly. After interviewing him, you smile and tell him this is not an emergency. What is the most likely cause of his red stool?

Answer 8

The beet smoothie he colored red and mixed with koolaid… OH YEAAAH

Question 9

Describe a Diverticulosis

Answer 9

Herniation of the mucosa through the muscularis, creating a pouch that could become impacted/perforate. Most common in Sigmoid Colon
Can have bright red stool, often asymptomatic
Evaluate with Colonoscopy

Question 10

Dr. Shnyra bursts through the door during your exam waiving an AK-47 and asks you point blank “what immune cell is implicated in the development of IBD?” Answer wrong and you die.

Answer 10

T-regulatory Cells

Question 11

You got Shnyra’s question right, but now Mcgowen walks in and asks you how to differentiate UC from CD using serum testing. What is your answer?

Answer 11

UC: +ANCA, -ASCA
CD: +ASCA, -ANCA (ASCA= Saccharomyces Cerevisiae)

Question 12

God, damnit Mcgowen put you in a breakout room with just the two of you and she shows you CT and says this is a “string sign”. What is disease process is she referring too?

Answer 12

CD

Lead pipe= UC

Question 13

Describe Crohn’s Disease

Answer 13

RLQ pain (mimics Appendicitis)
ASCA + 
Diarrhea
Skip lesions 
Can spare the rectum 
Risk of gallstone/kidney stones

Question 14

How are fistulas named?

Answer 14

Where they started to wear they end (Colovesical= Colon –> bladder)

Question 15

Describe Ulcerative Colitis

Answer 15

Diffuse Abd pain (left-sided) 
ANCA + 
ALWAYS INVOLVE THE RECTUM (my personal motto)
Dysentery (bloody diarrhea) 
Bright red blood on DRE
Complications: Toxic MC, perf, cancer

Question 16

What are three other findings associated with UC?

Answer 16

Pyoderma Gangernosum
Aphthous Ulcers
Erythema Nodosum

Question 17

A patient has pseudo polyps on colonoscopy, and you’re asked what this rules out?

Answer 17

Crohn’s (cobblestoning) think both start with C

Question 18

A patient walks into the ER panicking, clutching their stomach, and runs into the bathroom. You walk in and it looks like Tanner/Christian’s murder suicide by dull knife (very bloody). The patient does a line of cocaine and reports ULQ. What is a likely diagnosis?

Answer 18

Ischemic Colitis

• Sudden onset of defecation, hematochezia, thumb-printing on XR.
• Old people= atherosclerosis
• Young people= vaso-occlusive drug use (cocaine)
• Happens at splenic flexure because it has poor perfusion

Question 19

What are the two diseases that show thumb printing on XR?

Answer 19

Ischemic Colitis

Mesenteric Ischemia

Question 20

What disease process is associated with Retinal Hypertrophy?

Answer 20

Familial Adenomatous Polyposis (FAP)

Question 21

What is the recommended treatment for FAP?

Answer 21

Complete proctocolectomy with ileoanal anastomsis before age 20.

Question 22

Describe Lynch Syndrome

Answer 22

aka: HNPCC
Early onset colon cancer that is INHERITED and ASSOCIATED with multiple cancers
MLH1, MSH2 defects

Question 23

What is the oral presentation difference between Peutz-Jeghers and Cowden Dz?

Answer 23

Both are hamartomatous polyposis syndromes
PJS: telangiectasis on lips
Cowden: Trichilemmomas on lips (uglier because Cows are ugly)

Question 24

When do you recommend screening for colorectal cancer in an individual with no family history, and when can you stop screening?

Answer 24

45-75

Question 25

At what age is a colonoscopy contraindicated?

Answer 25

85

Question 26

What is the rule of screening for people with first degree relatives who have/had colorectal cancer?

Answer 26

Begin at age 40 OR 10 years prior to the age of the youngest person diagnosed.
Ex: Father was diagnosed at 45, son would start at 35; Father diagnosed at 65, son would start at 40.

Question 27

Common Infection associated with Adenocarcinoma

Answer 27

Strep Bovis (gallolyticus)

Question 28

Angioectasias

Answer 28

form of occult bleeding caused by dilated vessels in the GI tract
Painless bleeding common in patients >70 with chronic renal failure or aortic stenosis

Question 29

What PE do you perform for all suspected anorectal diseases?

Answer 29

DRE (yay)

Question 30

Which hemorrhoids are painful?

Answer 30

External
Bright red blood per the rectum
Treat: Bulk laxative or stool softener

Question 31

What is an anal fissure?

Answer 31

Tear/Ulceration due to trauma during defecation. Confirmed by visual inspection