GI Bleeding

The most common cause of intrinsic lower gastrointestinal (GI) bleeding in an adult is: A. Polyps B. Inflammatory bowel disease C. Diverticulosis D. Cancer

The answer is C. Diverticulosis and angiodysplasia account for 80% of lower GI bleeds. In approximately 10% of all patients with GI bleeding, no source of bleeding will be found.

Regarding gastrointestinal bleeding, which of the following is TRUE? A. The majority of bleeding from diverticula occurs from the right side of the colon B. The most common cause of upper gastrointestinal bleeding in both adults and children is peptic ulcer disease C. The mortality of lower gastrointestinal bleeding is higher than the mortality of upper gastrointestinal bleeding D. Patients with a history of gastrointestinal bleeding almost always bleed again from the same site

The answer is A. There are many specific etiologies that cause gastrointestinal bleeding. In general, however, the mortality of upper gastrointestinal bleeding is higher than lower gastrointestinal bleeding. In adults, the most common cause of upper gastrointestinal bleeding is peptic ulcer disease. In children, it is esophagitis. Unfortunately, it can be difficult to diagnose the source of gastrointestinal bleeding as the bleeding may often stop and start spontaneously or from different sites.

Which of the following bacteria does NOT produce bloody diarrhea? A. Yersinia enterocolitica B. Clostridium perfringens C. Campylobacter enteritis D. Escherichia coli 0157

The answer is B. Clostridium perfringens is the most common cause of food poisoning in the United States. Patients ingest heat-resistant spores of C. pergringens which produce an enterotoxin in the GI tract. Campylobacter, E. coli 0157, Salmonella and Yersinia are all invasive bacteria that can cause bloody enteritis.

The most common cause of adult upper gastrointestinal (GI) bleeding is: A. Varices B. Peptic ulcer disease (PUD) C. Mallory-Weiss tears D. Esophagitis

The answer is B. The most common causes of upper GI bleeding are (in descending order of frequency): PUD, gastric erosions, varices, Mallory-Weiss tears, esophagitis, and duodenitis.

A 67 year old man with a history of peptic ulcer disease presents to the emergency department complaining of feeling light-headed. On ROS he acknowledges having had black tarry stools for the past 2-3 days. On exam he is noted to be pale with the following vital signs: T 97.3 F, HR 126, BP 92/64, RR 22, and melena is noted on rectal exam. Which of the following is an INCORRECT recommendation regarding the initial management of this patient? A. Type and cross two units of packed red blood cells. B. Place two intravenous lines that are 22-gauge. C. Place the patient on cardiac and oxygen saturation monitors. D. Apply supplemental oxygen. E. Administer normal saline intravenously in 10mg/kg boluses.

The answer is B. The patient is having gastrointestinal bleeding most likely from a peptic ulcer given his history. Urgent first steps in management include placement of two intravenous lines that are larger-bore than 22-gauge (18 gauge or larger size preferred) to enable rapid volume resuscitation, in addition to the oxygen, monitoring, intravenous fluids and preparation of blood products. Patients with an upper GI bleed who remain hemodynamically unstable require urgent consultation with gastroenterology.

A 20 year old man presents to the emergency department with 1 week of intermittent bloody bowel movements associated with crampy abdominal pain, tenesmus, and fecal urgency. He is previously healthy. He is not on medications; nor has he recently traveled. What test will most likely confirm his diagnosis? A. a workup for a bleeding diathesis B. colonoscopy to rule out inflammatory bowel disease C. barium enema to rule out intussusception D. stool culture to rule out invasive bacterial diarrhea

The answer is B. This patient will need a colonoscopy with intestinal biopsy to evaluate for inflammatory bowel disease such as ulcerative colitis and Crohn's disease or other causes of colitis. Appendicitis usually presents with periumbilical pain migrating to the right lower quadrant with associated anorexia, not bloody bowel movements. Intussusception is uncommon after the age of 6. A stool culture should be obtained to rule out bacterial colitis, but his history is less suggestive of this.

You are treating an 80 you male in whom you suspect a lower GI bleed. Which of these following statements is TRUE regarding the guaiac test? A. A false positive may be caused by ingestion of magnesium-containing antacids B. A false negative may be caused by the presence of chlorophyll C. A false positive may be caused by the presence of methylene blue D. A false negative may be caused by the presence of bromide preparations

The answer is C. Red fruits or meats, methylene blue, chlorophyll, iodide, cupric sulfate and bromide preparations can cause a false positive guaiac test. A false negative guaiac test can be caused by bile or ingestion of magnesium-containing antacids or ascorbic acid. Red Jell-O, tomato sauce, wine, iron therapy and Pepto-Bismol may cause the stool to look bloody when it is not.

A 49 year old presents complaining of 1 day of painful bright red blood per rectum. He has painful bowel movements and streaks of blood appear on the toilet paper. He has had hard stools for two weeks after starting opiate pain medication for a broken arm. He has never had these symptoms before. Based on the patient's history, the physician examining the patient will likely find: A. An internal hemorrhoid B. A nonthrombosed external hemorrhoid C. An anal fissure D. A thrombosed external hemorrhoid

The answer is C. Sudden sharp pain after defecation along with blood on toilet tissue characterizes anal fissures. A thrombosed external hemorrhoid causes painful bleeding on defecation. Usually there is a history of external hemorrhoids and associated itching, swelling, and mucoid drainage. Internal hemorrhoids usually exhibit painless bleeding that may drip into the toilet after defecation. Rectal cancers also have painless bleeding but usually are associated with a change in bowel movement character and other signs and symptoms of malignancy.

An 85 year old woman presents with acute lower abdominal pain and bloody diarrhea for 1 day. On exam her abdomen is slightly distended with diffuse tenderness. Her vital signs are stable. A plain film X-ray shows "thumbprinting" suggesting the diagnosis of: A. Volvulus B. Intussusception C. Invasive gastroenteritis D. Ischemic colitis

The answer is D. Thumbprinting represents local areas of swelling in the bowel mucosa caused by submucosal edema and hemorrhage and suggests ischemic colitis.

The most common cause of lower GI bleeding is: A. Angiodysplasia B. Cancer C. Peptic ulcer disease D. Esophageal varices E. Diverticulosis

The answer is E. Diverticulosis is the most common cause of lower GI bleeding. Angiodysplasia is the more common in young people.