S2: Ch 3 Gi 2-6

Front 1

421. What does coffee grounds emesis suggest?

Back 1

a. Upper GI bleeding as well as a lower rate of bleeding (enough time for vomitus to transform into coffee grounds).

Front 2

422. Melena?

Back 2

a. Black, tarry, liquid, foul-smelling stool
b. Caused by degradation of hemoglobin by bacteria in the colon; presence of melena indicates that blood has remained in GI tract for several hours.
c. The further the bleeding site is from rectum, the most likely melena will occur.

Front 3

423. What does Melena suggest?

Back 3

a. Upper GI bleeding (oesophagus, stomach, or duodenum). Occasionally, the jejunum or ileum is the source. It is unusual for melena to be caused by colonic lesion, but if it is, the ascending colon is the most likely site.

Front 4

424. What 5 other things can dark stools result from?

Back 4

1. Bismuth
2. Iron
3. Spinach
4. Charcoal
5. Licorice

Front 5

425. Hematochezia?

Back 5

a. Bright red blood per rectum
b. Usually represents a lower GI source (typically left colon or rectum).

Front 6

426. What etiologies should you consider w/hematochezia?

Back 6

a. Diverticulosis
b. AV malformations
c. Haemorrhoids
d. Colon cancers.
e. May result from an upper GI source that is bleeding very briskly (so that blood does not remain in colon to turn into melena). Indicates heavy bleeding and likely hemodynamic instability.

Front 7

427. Other Clinical features of GI bleeds?

Back 7

a. Signs of volume depletion (depending on rate and severity)
b. S/S of anaemia (e.g., fatigue, pallor, exertional dyspnea).

Front 8

428. Note: a lower GI bleed (or positive occult blood test of stool) in pts over 40 is colon cancer until proven otherwise.

Back 8

428. Note: a lower GI bleed (or positive occult blood test of stool) in pts over 40 is colon cancer until proven otherwise.

Front 9

429. What should be your first question in people w/GI bleeding?

Back 9

a. Do they take NSAIDs/Aspirin or anticoagulants.

Front 10

430. Factors that increase mortality in GI bleeding?

Back 10

a. Age >65.
b. Severity of initial bleed
c. Extensive comorbid illnesses.
d. Onset or recurrence of bleeding while hospitalized for another condition.
e. Need for emergency surgery
f. Significant transfusion requirements
g. Diagnosis (oesophageal varices have a 30% mortality rate).
h. Endoscopic stigmata of recent haemorrhage.

Front 11

431. 6 lab tests to order for GI bleed?

Back 11

1. Stool guaiac for occult blood
2. H/H level (may not be decreased in acute bleeds).
3. A low MCV is suggestive or iron deficiency anaemia (chronic blood loss).
4. Coagulation profile (platelet count, PT, PTT, INR)
5. LFTs, renal function
6. BUN-Creatinine ratio is elevated w/upper GI bleeding. This is suggestive of upper GI bleeding If pts has no renal insufficiency.

Front 12

432. What hemoglobin level is acceptable for young people vs. for older adults?

Back 12

a. Young, healthy pts w/o active bleeding >7 to 8.
b. Most elderly pts, esp those w/cardiac disease, should have a hemoglobin >10 g/dl.

Front 13

433. In addition to Lab tests, 6 more invasive tests to determine the etiology of GI bleeding?

Back 13

1. Upper endoscopy
2. Nasogastric tube
3. Anoscopy or proctosigmoidoscopy
4. A bleeding scan (radionuclide scanning)
5. Arteriography definitively locates point of bleeding
6. Exploratory laparotomy (last resort).

Front 14

434. Most accurate test in evaluation of upper GI bleed?

Back 14

a. Upper endoscopy
b. Both diagnostic and potentially therapeutic (coagulate bleeding vessel).

Front 15

435. Utility of nasogastric tube for GI bleed?

Back 15

a. Often the initial procedure for determining whether GI bleeding is due to an upper or lower GI source
b. Use the nasogastric tube to empty the stomach to prevent aspiration
c. False-negative findings are possible if upper GI bleeding is intermittent or from a lesion in the duodenum

Front 16

436. Utility of bleeding scan (radionuclide scanning)?

Back 16

a. Reveals bleeding even w/a low rate of blood loss.
b. It does not localize the lesion; it only identifies continued bleeding.
c. Its role is controversial, but it may help determine whether arteriography is needed.

Front 17

437. Arteriography for GI bleeds?

Back 17

a. Definitively locates the point of bleeding
b. Mostly used in pts w/lower GI bleeding
c. Should be performed during active bleeding
d. Potentially therapeutic (embolization or intra-arterial vasopressin infusion.

Front 18

438. Treatment of GI bleed?

Back 18

a. If pt is hemodynamically unstable, resuscitation is always top priority.
b. Remember ABCs. Once the pt is stabilized, obtain a diagnosis.
i. Supplemental oxygen.
1. Place 2 large-bore IV lines. Give IV fluids or blood if pt is volume depleted.
2. Draw blood for H&H, PT, PTT, and platelet count. Monitor Hemoglobin every 4-8 hours until the pt is hemoglobin stable for at least 24 hours.
3. Type and crossmatch adequate blood (PRBCs).
a. Transfuse as the clinical condition demands (e.g., shock, pts w/cardiopulmonary disease.

Front 19

439. Additional Treatment of GI blood loss depends on the cause/Source of the bleed: Tx for Upper GI bleeding?

Back 19

a. EGD w/coagulation of the bleeding vessel.
b. If bleeding continues, repeat endoscopic therapy or proceed w/surgical intervention (ligation of bleeding vessel).

Front 20

440. Additional Treatment of GI blood loss depends on the cause/Source of the bleed: Tx for Lower GI bleeding?

Back 20

a. Colonoscopy- polyp excision, injection, laser, cautery.
b. Arteriographic vasoconstrictor infusion.
c. Surgical resection of involved area- last resort.

Front 21

441. 5 Indications for surgery from GI bleed?

Back 21

1. Hemodynamically unstable pts who have not responded to IV fluid, transfusion, endoscopic intervention, or correction of coagulopathies.
2. Severe initial bleed or recurrence of bleed after endoscopic treatment.
3. Continued bleeding for more than 24 hours.
4. Visible vessel at base of ulcer (30-50% chance of rebleed).
5. Ongoing transfusion requirement (5 units w/I first 4-6 hours).

Front 22

442. What may an elevated PT be indicative of?

Back 22

1. Liver dysfunction
2. Vitamin K deficiency
3. Consumptive coagulopathy
4. Warfarin therapy

Front 23

443. Initial steps in any pt w/GI bleeding?

Back 23

a. Vital signs: ↓’d BP, tachycardia, or postural changes in BP or HR are signs of significant haemorrhage.
b. However, vital signs may also be normal when significant haemorrhage is present.
c. Resuscitation is the first step (e.g., IV fluids, transfusion)
d. Perform rectal examination (Hemoccult test).

Front 24

444. Survival rate at 1 year for squamous cell carcinoma of esophagus?

Back 24

a. 20%
b. 5-10% survival at 5 yrs.

Front 25

445. Barrett’s oesophagus?

Back 25

a. Complication of longstanding GERD in which there is columnar metaplasia of squamous epithelium.
b. Pts w/Barrett’s oesophagus are at increased risk of developing adenocarcinoma of the oesophagus.

Front 26

446. 2 pathologic types of Oesophageal cancer?

Back 26

a. Adenocarcinoma and squamous cell

Front 27

447. For which pathologic type of oesophageal cancer are Alcohol and tobacco risk factors for?!?!?!?!?

Back 27

a. Squamous cell.

Front 28

448. What are the main risk factors for Adenocarcinoma?

Back 28

a. GERD and Barrett’s oesophagus.

Front 29

449. What population has a higher incidence of SCC of oesophagus?

Back 29

a. Blacks.

Front 30

450. Most common location of SCC of oesophagus?

Back 30

a. Upper-thoracic and mid-thoracic oesophagus. About 1/3 may be in distal 10cm of oesophagus.