GI bleeding

Question 1

Top differentials for hematemesis in patient with pneumonia on Abx

Answer 1

ulcer and gastritis

Question 2

How do you differentiate between melena and iron supplements

Answer 2

melena smells

Question 3

Occult GI bleeding positive = think …

Answer 3

colon cancer

Question 4

Top differential in alcoholic with haematemesis

Answer 4

varices secondary to liver disease

Question 5

Differences in the presentation of oesophageal vs gastric tumour

Answer 5

oesophageal tumour more likely to cause haematemesis at a later stage after dysphagia, whereas gastric tumour will have necrosis in ulcer so first presentation is often haematemesis

Question 6

Mechanism of stress ulcers

Answer 6

Vagal stimulation due to acid hyper secretion, systemic acidosis causes mucosal injury, splanchnic vasoconstriction - hypoxia due to reduction of blood flow

Question 7

Mallory weiss tears are common in

Answer 7

alcoholics (often also have oesophagitis) and bulimics

Question 8

2 causes of peptic ulcer disease

Answer 8

Increased acid: zollinger Ellison syndrome, hyperparathyroidism, chronic renal failure

Reduced mucosal defence: H pylori (most common), NSAIDs, cigarettes, corticosteroids

Question 9

How does H pylori weaken mucosal defence

Answer 9

Mucous is rich is carbs, H pylori digests carbs and exposes mucosa to action of acid

Question 10

Functions of paracetamol

Answer 10

1 = redue temperature
2= painkiller

Question 11

How does codeine cause constipation

Answer 11

Inhibits peristalsis of bowels, contents become more dehydrated, vicious cycle

Question 12

Pain killers for colic

Answer 12

Buscopan > paracetamol/NSAIDs

Question 13

Mechanism behind gastroesophageal varices

Answer 13

Resistance to portal blood flow, angiogenic factors and increased nitrous oxide production in splanchnic vascular bed, splanchnic arteriolar vasodilation and increased portal outflow

Question 14

Varices temporary fix

Answer 14

balloon can be used to compress

Question 15

Uncommon causes of haematemesis

Answer 15

Dieulafoy’s lesion- dilated aberrant submucosal vessel that erodes overlying epithelium not associated with ulcer (endoscopy reveals active arterial pumping from a site)
◦ Watermelon stomach or gastric antral vascular ectasia
◦ Aorta-enteric fistula (often infected prosthetic aortic graft eroding into intestine), some present with back/abdo pain, others with fever associated with sepsis

Question 16

Benign lesions of oesophagus or stomach

Answer 16

Lipomas, polyps, blue rubber bleb Nevus syndrome

Question 17

What type of cancer is most common in oesophagus

Answer 17

adenocarcinoma more than Squamous cell carcinoma (look at barrets oesophagus)

Question 18

Points to remember when diagnosing GI bleed

Answer 18

where is blood loss, colour/smell/consistency, amount, history of PUD, signs of chronic liver disease, recent negation of NSAIDs/aspirin/warfarin, history of retching

Question 19

Diverticulitis vs cancer

Answer 19

Cancer more common cause of bleeding in over 50, diverticulitis could present with abdominal pain too

Question 20

Fissure and piles gender distribution

Answer 20

Piles more common in men, fissures more common in women

Question 21

What is always indicated with PR bleeding

Answer 21

DRE/PR

Question 22

Rectal cancer order of symptoms usually

Answer 22

pain and then bleeding

Question 23

Angiodysplasia leads to bleeding in presence of

Answer 23

constipation or blood thinners

Question 24

When to think about inflammatory/ischaemic colitis or UC

Answer 24

Abdo pain, raised inflammatory markers, haematochezia

Question 25

Bleeding in ischaemic colitis

Answer 25

Jelly, dark, mucous-like bleeding

Question 26

Why is it important not to miss ischaemic colitis

Answer 26

necrosis and perforation requiring surgery can occur

Question 27

Features of colonic diverticula

Answer 27

often psychiatric patients due to reduced bowel motility from medications, painless/painful haematochezia,

herniation of colonic mucosa and submucosa through the muscular layers of the colon, colonic tissue is pushed by the intra-luminal pressure,

common location is left colon (most common cause of benign lower GI bleed in adults) (more common in women due to constipation and distension, in men the more common cause of haematochezia is perforation)

Question 28

Colonoscopy is often indicated in

Answer 28

haematochezia from haemorrhoids just to rule out cancer and check piles is actual cause

Question 29

Which type of haemorrhoids is more common

Answer 29

Internal

Question 30

Classic presentation of colon cancer

Answer 30

recent change in bowel habits, can have palpable mass on abdo/PR exam, painless occult bleed is most common manifestation, iron deficiency anaemia

Question 31

features of colon cancer genetics

Answer 31

• Colon cancer has a strong genetic component, can present young, more common in young men, young patients often have a very aggressive cancer leading to worse outcomes

Question 32

What is IBD

Answer 32

inappropriate immune response to endogenous commensal microbiota within the intestines, intestinal epithelial dysfunction with or without some component of autoimmunity

Question 33

major UC symptoms

Answer 33

diarrhoea, rectal bleeding, tenesmus, crampy abdo pain, look for extra intestinal manifestations

Question 34

Ischaemic colitis is associated with

Answer 34

atherosclerosis/vasculitis, segmental due to collateral circulation

Question 35

Points to remember in blood PR

Answer 35

amount of bleed and colour of blood, blood on toilet paper, blood coated in stool pattern, diarrhoea and mucus PR, FH of colorectal cancer, Age (children - Meckel’s diverticulum)

Question 36

Is admission warranted in melena

Answer 36

• Admission warranted in malaena due to suspicion of internal bleed- give colonoscopy if OGD unremarkable

Question 37

What divides upper and lower GI

Answer 37

ligament of treitz

Question 38

Treatment of upper GI bleed

Answer 38

• Treatment of GI bleed: clinical assessment, blood test, aggressive resuscitation, diagnostic tests (endoscopy/radiology), transfusion
• Must keep perfusion of vital organs, assess bp and urine output/kidney function to assess success of fluid resuscitation

Question 39

Appearance and source of PR bleeding

Answer 39