44 GI Bleed

Question 1

Most common cause of UGIB? 2nd most common cause?

Answer 1

Most common: ulcer

2nd: varices

Question 2

Most common cause of LGIB? 2nd most common cause?

Answer 2

Most common: Hemorrhoids

2nd: vascular ectasias

Question 3

GI bleeding manifested as hematemesis, coffee-grounds material, melena or hematochezia

Answer 3

Overt GI bleeding

Question 4

GI presenting with symptoms of blood loss or anemia such as light headednes, syncope, angina, iron deficiency anema or positive fecal occult blood tests

Answer 4

Occult GI bleeding

Question 5

What is infusion used to enhance clot stability in PUD and decrease further bleeding

Answer 5

80 mg IV bolus then 8 mg/hr infusion

Question 6

What is the target intragastric pH to enhance clot stability in GI bleed

Answer 6

Intragastric pH of more than 6

Question 7

True or false. High intermittent PPI are non inferior to constant infusion PPI therapy

Answer 7

True.

Question 8

How many days can aspirin be re started in cardiac patient who has GI bleeding

Answer 8

As soon as possible in span of 1-7 days

Question 9

What is classic history of Mallory Weiss tears?

Answer 9

Vomiting or retching or coughing prior to hematemesis especially in an alcoholic patient

Question 10

How soon should endoscopy be done in cirrhotics with UGIB

Answer 10

Urgent endoscopy within 12 hours

Question 11

Vasoactive medications given to esophageal varices and for how long

Answer 11

Ocreotide
Somatostatin
Vapreotide
Terlipressin
For 2-5 days

Question 12

When is TIPS consider in acute variceal bleeding in patients with advanced liver disease

Answer 12

First 1-2 days of hospitalization

Question 13

Most important cause of gastric and duodenal erosion

Answer 13

NSAIDs

Question 14

Endoscopically visualized breaks which are confined to the mucosa and do not cause major bleeding due to the absence of arteries and veins in the mucosa

Answer 14

Erosion

Question 15

Percent small intestinal GIB account for up to what percent of cases?

Answer 15

5-10% of GIB cases

Question 16

Most common cause of small intestinal GIB in adults more than 40 years

Answer 16

Vascular ectasia
Neoplasm
NSAID induced

Question 17

Most common cause of significant small intestinal GIB in children

Answer 17

Meckels diverticulum

Question 18

Which colon often present with diverticular bleeding

Answer 18

Right colon

Question 19

True or false. Diverticular bleeding stop spontaneously in 10% of patients thus endoscopy should be done

Answer 19

False. Resolve spontaneously in 80-90% of patients

Question 20

Syndrome presenting with bleeding vascular ectasias and aortic stenosis

Answer 20

Heyde’a syndrome

Question 21

Best initial assessment of GIB

Answer 21

Heart rate and blood pressure

Question 22

What does melena indicate on the status of GIB

Answer 22

Blood has been present in the GI tract for more than 14 hrs and as long as 3-5 days

Question 23

What is the transfusion threshold in GIB

Answer 23

Hgb below 7 mg/dl

Question 24

True or false. Hemoglobin and hematocrit may be normal in acute GIB due to proportionate reduction in plasma and red cell volume

Answer 24

True

Question 25

How long it may take for the acute GIB blood loss be seen as decrease in hemoglobin count

Answer 25

As as 72 hour before Hgb/Hct drops

Question 26

True or false. When hematochezia is the presenting symptom of UGIB it is associated with hemodynamic instability and dropping hemoglobin

Answer 26

True

Question 27

How is intensive PPI done

Answer 27

IV bolus 80 mg then drip 8 mg/hr x 3 days OR IV bolus 80 mg then IVTT 40-80 mg BID or 40 mg TID x 3 days Then Twice daily PPI for day 4-14 Then once daily PPI

Question 28

``` Ulcer. Active bleeding or visible vessel Endoscopic therapy? Medical therapy? Diet? Hospital stay? ```

Answer 28

``` Active bleeding or visible vessel Endoscopic therapy: Yes Medical therapy: Intensive PPI Diet: clear liquids for 2 days after endoscopy Hospital stay: 3 days after endoscopy ```

Question 29

``` Ulcer: adherent clot Endoscopic therapy? Medical therapy? Diet? Hospital stay? ```

Answer 29

``` Ulcer: adherent clot Endoscopic therapy: may do Medical therapy: Intensive PPI Diet: clear liquids for 2 days after endoscopy Hospital stay: 3 days after endoscopy ```

Question 30

``` Ulcer: flat pigmented spot Endoscopic therapy? Medical therapy? Diet? Hospital stay? ```

Answer 30

``` Ulcer: flat pigmented spot Endoscopic therapy: no Medical therapy: once daily PPI Diet: clear liquids after endoscopy Hospital stay 1-2 days after endoscopy ```

Question 31

``` Esophageal varices Endoscopic therapy? Medical therapy? Diet? Hospital stay ```

Answer 31

Esophageal varices Endoscopic therapy: ligation Medical therapy: Vasoactive drug Diet clear liquids for 2 days after Endoscopic therapy Hospital stay 3-5 days after Endoscopic therapy

Question 32

``` Mallory Weiss Tears. Active bleeding Endoscopic therapy? Medical therapy? Diet? Hospital stay ```

Answer 32

``` Mallory Weiss Tears. Active bleeding Endoscopic therapy Yes Medical therapy: anti emetic if ongoing nausea Diet clear liquids for 1 day endoscopy Hospital stay 1-2 days after endoscopy ```

Question 33

``` Mallory Weiss Tears. No active bleeding Endoscopic therapy? Medical therapy? Diet? Hospital stay ```

Answer 33

``` Mallory Weiss Tears. No active bleeding Endoscopic therapy No Medical therapy: anti emetic if ongoing nausea Diet regular diet after endoscopy Hospital stay discharge after endoscopy ```

Question 34

``` Erosion. Endoscopic therapy? Medical therapy? Diet? Hospital stay ```

Answer 34

``` Erosion Endoscopic therapy. No Medical therapy. Once daily PPI Diet: regular diet after endoscopy Hospital stay: discharge after endoscopy ```

Question 35

How is vasoactive drug ocreotide given?

Answer 35

Intravenous 50 ug bolus then 50 ug/h infusion for 2-5 days

Question 36

What promotility agent may be given before endoscopy to improve visualization

Answer 36

Erythromycin 250 mg IV before endoscopy

Question 37

When should upper endoscopy be done in most patients with UGIB

Answer 37

Within 24 hours

Question 38

True or false. Cirrhotics patients with UGIB should be antibiotics and vasoactive drug prior to endoscopy

Answer 38

True. Antibiotics to decrease infection and vasoactive drug to control bleeding

Question 39

True or false. In patients with hematochezia and hemodynamic instability and upper endoscopy may be done first to ry le out an UGIB before LGIB

Answer 39

True

Question 40

What is procedure of choice for most patients admitted for LGIB

Answer 40

Colonoscopy after oral lavage

Question 41

What procedure to do if LGIB is massive

Answer 41

CT angiography

Question 42

If no bleeding found on colonoscopy what is the next procedure

Answer 42

99Tc labeled red cell scan

Question 43

What is the initial test if patients with massive bleeding is suspected from the small intestines

Answer 43

CT angiography or 99Tc red blood cell scan prior to angiography Others repeat EGD and colonoscopy as second look can detect 25% or bleeding

Question 44

Other clues to UGIB

Answer 44

Hyperactive bowel sounds | Elevated BUN

Question 45

What is included in the Glasgow Blatchford score

Answer 45

``` BUN Hgb SBP HR Other markers Melena Syncope Hepatice disease Cardiac failure ```

Question 46

Algorithm for LGIB. No hemodynamic instability. Age more than 40 yrs old.

Answer 46

Colonoscopy

Question 47

Algorithm for LGIB. No hemodynamic instability. Age less than 40 yrs old. Minimal bleeding

Answer 47

Flexible sigmoidoscopy

Question 48

Algorithm for LGIB. No hemodynamic instability. Age less than 40 yrs old. Copious bleeding

Answer 48

Colonoscopy

Question 49

Algorithm for LGIB. No hemodynamic instability. Colonoscopy identified bleeding site. Bleeding persists.

Answer 49

Angiography then surgery if bleeding persists

Question 50

Algorithm for LGIB. No hemodynamic instability. Colonoscopy didn't identify site.

Answer 50

Workup for small intestinal/ obscure bleeding site

Question 51

Algorithm for LGIB. Hemodynamic instability.

Answer 51

Upper endoscopy

Question 52

Algorithm for LGIB. Hemodynamic instability. Upper endoscopy done. No upper GI source. Able to bowel prep

Answer 52

Colonoscopy

Question 53

Algorithm for LGIB. Hemodynamic instability. Upper endoscopy done. No upper GI source. Not able to bowel prep

Answer 53

Angiography or CT angiography first.

Question 54

Algorithm for LGIB. Hemodynamic instability. Upper endoscopy done. Angiography done. Bleeding persists. Able to bowel prep.

Answer 54

Colonoscopy

Question 55

Algorithm for LGIB. Hemodynamic instability. Upper endoscopy done. Angiography done. Bleeding persists. Instability persist.

Answer 55

Surgeru with intra operative endoscopy

Question 56

Recommended for colorectal cancer screening at age 50 in average risk adults

Answer 56

Fecal occult blood testing

Question 57

At what age is fecal occult blood testing recommended

Answer 57

Age 50 years old

Question 58

Next step if second look procedure are negative

Answer 58

Video capsule endoscopy

Question 59

What is the disadvantage of video capsule endoscopy

Answer 59

Does not allow full visualization of the small intestines No tissue sampling Cannot apply therapy

Question 60

Used instead of video capsule endoscopy in patients with possible small bowel narrowing

Answer 60

CT enterography

Question 61

Nest step if video capsule endoscopy turned out negative

Answer 61

Deep enteroscopy