GI Bleed [Speed Live]

Concise Outline of GI Bleed

1. Overview of GI Bleeding (GIB)
   • Definition, Classification, Causes
   • Epidemiology and Trends
2. General Management
   • Resuscitation, Monitoring, Transfusion
3. Scores for GI Bleed
   • Glasgow-Blatchford, Rockall, AIMS 65
4. Localization of Bleeding
   • Diagnostic Techniques (NGT Lavage, CTA, Endoscopy)
5. Obscure GI Bleed
   • Diagnostic and Management Approaches
6. Video Capsule Endoscopy (VCE)
   • Indications, Diagnostic Yield
7. Enteroscopy Techniques
   • Push Enteroscopy, Double Balloon, Intraoperative
8. Specific Causes of GI Bleeding & Management
   • Peptic Ulcer Disease (PUD), Mallory-Weiss Tear, Dieulafoy Lesion, GAVE
9. Lower GI Bleed
   • Diverticulosis, Angiodysplasia, Neoplasms, Colitis, Ischemia, Infections
10. Surgical Management of LGIB
    • Indications, Preoperative Considerations, Surgical Options

---

Overview of Gastrointestinal Bleeding (GIB)

• Definition:
  • Gastrointestinal bleeding (GIB) refers to the loss of blood from anywhere along the alimentary canal.
  • GIB is classified based on its anatomic location relative to the ligament of Treitz:
    • Upper GIB (UGIB): Bleeding that occurs proximal to the ligament of Treitz.
    • Lower GIB (LGIB): Bleeding that occurs distal to the ligament of Treitz.
• Common Causes:
  • Upper GIB:
    • Most commonly caused by peptic ulcer disease (PUD) or esophageal varices.
    • Can also originate from pancreatic, liver, or other biliary sources.
  • Lower GIB:
    • Accounts for 30% to 40% of all GIB cases.
    • Most often originates from the colon due to diverticular disease or angiodysplasias.
    • Most Common Cause of LGIB: Neoplasia (as per SKF).
    • Most Common Cause of LGIB Requiring Hospitalization: Diverticular disease (as per SKF).
• Types of GIB:
  • Massive GIB:
    • Refers to intestinal blood loss that leads to hemodynamic instability or requires transfusion.
  • Occult GIB:
    • Refers to anemia that persists or recurs after a negative endoscopic evaluation and imaging workup.
• Epidemiology:
  • GIB is the most common cause of hospitalization from gastrointestinal disease in the United States.
  • The median length of hospital stay for GI hemorrhage is 3 to 6 days.
• Trends and Advancements:
  • The peak incidence of GIB has decreased by 1% annually since the mid-1990s.
  • This decline is attributed to the advent of proton pump inhibitors (PPIs), increased treatment of Helicobacter pylori, and avoidance of nonsteroidal anti-inflammatory drugs (NSAIDs).
  • Mortality rates for UGIB have significantly decreased from historical rates of 6% to 12% to less than 2% in recent years.
  • While hospital admissions for UGIB have decreased, admissions related to LGIB have increased.

General Management

1. Airway, Breathing, Circulation - Ensure stability.
2. Wide Bore 14/16 Gauge Cannula - For rapid fluid resuscitation.
3. Serum Lactate - Use as the end point of resuscitation.
4. Serum Hematocrit - Unreliable marker for assessing blood loss.
5. Hypotension - Indicates 30-40% blood loss.
6. Preferred IV Fluid: Crystalloids > Colloids
7. Blood Replacement - Use PRBC & FFP in a 2:1:1 ratio. [or 1:1:1]
8. Monitoring Coagulation - Through TEG (Thromboelastography).
9. Correction of Hypothermia - Ensure normothermia during resuscitation.

NG Aspiration and Lavage in UGI Bleed

1. NG Aspiration
   • Aspiration of bile and non-bloody effluent effectively rules out an active UGIB.
2. NG Lavage
   • NOT included as a standard treatment algorithm for UGI bleed.

Transfusion Policy

1. Restrictive Transfusion Policy
   • Target Hemoglobin (Hb): 7-9 g/dL.
2. Exception
   • Not applicable to massively hemorrhaging patients.

Scores for GI Bleed

1. Glasgow-Blatchford Score (GBS)
   • Factors: Pulse, BP, Hb, BUN, melena, syncope, hepatic/cardiac disease
   • Score Range: 0-23
2. Modified Glasgow-Blatchford Score (Modified GBS)
   • Factors: Pulse, BP, Hb, BUN
   • Purpose: Requirement for endoscopy
3. Rockall Score
   • Includes endoscopy
   • Factors: Age, shock, comorbidities, diagnosis, recent hemorrhage
4. AIMS 65 Score
   • Factors: Serum albumin, INR, altered mental status
   • easy to calculate
   • New and Important MCQ

Risk Scores for Upper GI Bleeding

Score Type	Components	Cut-off Values	Risk Stratification	Management
Blatchford Score	BUN, Hb, SBP, Melena, Syncope, Hepatic/Renal	0-23	0: Very low risk	Very low risk: May not require urgent intervention
			1-6: Intermediate risk	Intermediate risk: Observation and possible intervention
			≥7: High risk	High risk: Urgent endoscopy and intervention
Modified Blatchford Score	Pulse, SBP, Hb, BUN	0-16	0: Low risk	Low risk: May not require urgent intervention
			1-3: Intermediate risk	Intermediate risk: Observation and possible intervention
			≥4: High risk	High risk: Urgent endoscopy and intervention
Rockall Score	Age, Shock (SBP & pulse), Comorbidities, Diagnosis, Stigmata of recent hemorrhage	0-11	0-2: Low risk	Low risk: Observation and medical therapy
			3-4: Moderate risk	Moderate risk: Hospital observation
			≥5: High risk	High risk: Early endoscopy (within 12-24 hours) and possible intervention
AIMS65 Score	Albumin, INR, Mental status, SBP, Age	0-5	0-1: Low risk	Low risk: Observation and possible outpatient management
			2-3: Moderate risk	Moderate risk: Hospital observation and possible intervention
			≥4: High risk	High risk: Urgent endoscopy and intervention
BLEED Score	BUN >18 mg/dL, Liver disease, Endoscopic stigmata of recent hemorrhage, Elderly (>65 years), Drop in BP (SBP <100 mmHg or pulse >100 bpm)	0-6	0-2: Low risk	Low risk: Observation and possible outpatient management
			3-4: Moderate risk	Moderate risk: Hospital observation
			≥5: High risk	High risk: Urgent endoscopy and intervention

Key Management Strategies Based on Risk Stratification

1. Low-Risk Patients (Blatchford 0, Modified Blatchford 0, Rockall 0-2, AIMS65 0-1, BLEED 0-2):
   • Observation and medical therapy.
   • Consider outpatient management.
   • No immediate endoscopy required.
2. Intermediate-Risk Patients (Blatchford 1-6, Modified Blatchford 1-3, Rockall 3-4, AIMS65 2-3, BLEED 3-4):
   • Hospital observation.
   • Endoscopy within 24 hours if necessary.
3. High-Risk Patients (Blatchford ≥7, Modified Blatchford ≥4, Rockall ≥5, AIMS65 ≥4, BLEED ≥5):
   • Urgent endoscopy within 12-24 hrs

Localization of Gastrointestinal Bleeding (GIB)

• Initial Assessment:
  • History and physical exam guide the assessment and help determine whether the source is upper or lower GI.
  • Hematemesis (vomiting blood or coffee-ground material) suggests a UGIB, though it could be from a non-GI source like nasal or oropharyngeal bleeding.
  • Melena (malodorous, black, tar-like stool) typically indicates a proximal source of bleeding. Over 90% of melena cases arise from UGIB.
  • Hematochezia (bright red blood from the anus) is usually from lower GI bleeding (LGIB), but can also result from a brisk UGIB with rapid transit through the intestines.
• Diagnostic Approach:
  • Nasogastric tube (NGT) lavage: Used to detect the presence of blood above the ligament of Treitz and to prepare the stomach for endoscopy.
    • Bilious and nonbloody aspiration can rule out an active UGIB.
    • Negative lavage does not definitively exclude a nonactive UGI source if hemostasis occurred earlier.

Imaging in GI Bleed = Advanced Localization techniques

1. CTA (Computed Tomography Angiography)
   • Detection Sensitivity: 0.3 mL/min
   • Phases: Three phases
   • Note: No enteral contrast is required. [ instead give water which acts as a negative contrast and vessels appear white]
2. RBC Scan (Radionuclide Bleeding Scan)
   • Detection Sensitivity: 0.04 mL/min
   • Localization: Identifies the quadrant of the abdomen where bleeding is occurring.
   • Used in Chronic / Obscure Bleeds
   • Not used in Acute GI bleeds because it takes a lot of time.
3. Upper endoscopy:
   • Should be performed within 24 hours in patients with bleeding localized to the UGI tract.
4. Colonoscopy:
   • Performed if bleeding cannot be localized with imaging or angiography and the patient is stable.
   • Requires a mechanical bowel prep to ensure a high-quality exam.
   • If bleeding is localized to the lower GI, colonoscopy is essential for diagnosis and potential therapy.
   • The colonoscopy should include intubation of the terminal ileum to rule out proximal sources of bleeding.

Obscure GI Bleed

1. Definition
   • Small bowel bleed or middle GI bleed.
   • Occurs when UGI and LGI scopy are normal with no source identification.
2. Diagnostic Approach
   • First Test of Choice: CTA (Computed Tomography Angiography).
   • Stable Patient: VCE (Video Capsule Endoscopy) is the diagnostic modality of choice.
   • Unstable Patient
     • If the patient is not stable and requires massive transfusions:
       • The patient is taken to the OR.
       • Plan for intraoperative enteroscopy.
3. Further Evaluation
   • Repeat UGI and LGI scopy may be necessary.
   • Can identify lesions in up to 35% of patients after initial evaluation.
4. Post-Evaluation Management
   • If everything is negative after evaluation:
     • Loop ileostomy is performed for later evaluation.

Video Capsule Endoscopy (VCE)

1. Purpose
   • Imaging of the small bowel.
   • Most common indication: Bleeding.
2. Modality of Choice
   • For obscure, overt GI bleeding in a stable patient.
3. Diagnostic Rates
   • Highest in cases of acute GI bleeding compared to obscure blood loss.
4. Factors Associated with Positive Study
   • Male sex
   • Age > 60 years
   • Hospitalization
5. Capsule Retention
   • Occurs in 1.5% of patients.
   • Dummy Capsule = dissolves within 40 hrs of ingestion.
   • Associated conditions:
     • Crohn's disease
     • Tumors
     • NSAID use
     • Prior Small bowel radiation or surgery
6. Alternative Imaging for Small Bowel Tumors
   • CTA (Computed Tomography Angiography) is the investigation of choice.

Enteroscopy Techniques

1. Push Enteroscopy
   • Reaches 50-70 cm past the ligament of Treitz.
2. Double Balloon Endoscopy
   • Capable of visualizing the entire small bowel.
   • we can also do therapeutic procedures
3. Intraoperative Enteroscopy
   • Performed after the failure of other modalities.

Peptic Ulcer Disease (PUD)

• Most common cause of UGIB.
• 10-15% of patients with PUD will develop bleeding.
• Most common causes: H. pylori and NSAIDs.
• UGIB is the diagnostic modality of choice (within 12-24 hours).
• Grading: According to FORREST classification.

• CT and embolization: Consider if endotherapy fails.

Hemorrhage in PUD

• Posterior Ulcer Bleed
  • Often associated with significant hemorrhage.
• Management
  • Wide bore cannula: For rapid resuscitation.
  • PPI use: Continuous or intermittent high dose [Bolus of 80mg with Infusion of 8mg/kg/ hr] (MCQ)
  • Consider Tranexamic acid.
  • NG aspirate: Bilious output rules out an upper GI source (not gastric content).
  • Early UGI endoscopy: within 12- 24 hrs ; Essential for diagnosis and treatment.
• Recurrent Bleeding
  • Second episode after initial endotherapy: Can be treated with repeat endoscopy.
• Most Common Artery Involved
  • Gastro-Duodenal Artery (GDA): Frequently implicated in posterior ulcer bleeds.

Hemorrhage (Forrest Classification)

• Risk of Rebleeding
  • Based on stigmata of recent hemorrhage.
• Endotherapy Indications
  • Active bleeding, adherent clot, visible vessel.
  • Relevant Forrest classifications: Ia, Ib, IIa, IIb.
• Dual Therapy
  • Combination of Clip / Thermal agent / Adrenaline.
• H. Pylori Testing
  • Check for H. pylori, though not sensitive in acute bleeding or with PPI use.

Algorithm on Nonvariceal Upper GI Bleeding Management

1. EGD Shows PUD Bleeding
   1. If No:
      1. Assess for H. pylori.
      2. Initiate PPI.
      3. Repeat EGD later if a gastric ulcer is present.
   2. If Yes:
      1. Check for high-risk features (Forrest classification Ia, Ib, IIa, IIb).
2. High-Risk Features Present
   • Proceed with endoscopic therapy.
3. Hemostasis Achieved?
   1. If Yes:
      1. Monitor, clear fluids, and continue PPI.
      2. If rebleeding occurs:
         • Repeat endoscopy.
         • If No:
           • Continue monitoring.
   2. If No:
      1. Consider angiography or surgery.
4. Repeat Endoscopy for Rebleeding
   1. If Hemostasis Achieved:
      1. Continue monitoring and PPI.
   2. If No:
      1. Consider angiography or surgery.

Surgery for Duodenal Ulcer

• Laparotomy
  • Initial surgical approach.
• Kocherization
  • Mobilization of the duodenum to facilitate surgical access.
• Longitudinal Duodenotomy
  • Incision made along the length of the duodenum.
• U-Stitch for GDA
  • U-stitch technique used to control bleeding from the Gastro-Duodenal Artery (GDA).
  • to ligate all the feeding branches of collaterals of GDA : SPDA-IPDA and ?
• Transverse Closure
  • The duodenotomy is closed transversely after hemostasis.
• Acid Reduction (Recommended if Stable)
  • Truncal Vagotomy or Antrectomy to reduce acid production and prevent recurrence.

Duodenal Ulcer Management

• Control of Bleeding + Acid Reduction
  • Consider based on hemodynamic status and presence of a refractory ulcer.
• Pyloromyotomy + Ligation of Bleeder
  • Recommended in an unstable patient to control active bleeding.
• Acid Reducing Surgery
  • Truncal Vagotomy + Pyloroplasty:
    • Most common surgical procedure for duodenal ulcer.
• Refractory Duodenal Ulcer/NSAID Intake
  • Antrectomy + Vagotomy:
    • Preferred for refractory ulcers or in patients with NSAID use.

Gastric Ulcer Management

• Concern of Malignancy
  • Always consider the risk of malignancy in gastric ulcers.
• Surgical Approach
  • Resection [Gastrectomy = Total Vs Distal] is preferred over ligation of bleeder or excision alone.
• Excision or Ligation
  • Acid reduction should be performed for Type II and III gastric ulcers following excision or ligation.

Additional Management Considerations for Gastric Ulcer

• H. Pylori Eradication
  • Decreases rebleed rate if present.
  • No need for long-term acid suppression after successful eradication.
• NSAID Use
  • Recommend COX-2 inhibitors + PPI for patients requiring NSAIDs.
  • H. pylori eradication improves the risk profile for NSAID use.
• Endotherapy
  • Options include Thermal coagulation or Clips, with or without epinephrine.
• Epinephrine Monotherapy
  • Associated with a higher risk of rebleeding compared to combination therapy.

Indications for Surgery in Gastrointestinal Hemorrhage

• Hemodynamic Instability
  • Despite vigorous resuscitation (requiring >6-unit transfusion).
• Failure of Endoscopic Techniques
  • Inability to arrest hemorrhage using endoscopic methods.
• Recurrent Hemorrhage
  • After initial stabilization, even with up to two attempts at obtaining endoscopic hemostasis.
• Shock
  • Associated with recurrent hemorrhage.
• Continued Slow Bleeding
  • When the transfusion requirement exceeds 3 units per day.

Source: Sabiston 1155 pg no

Mallory-Weiss Tear

• Nature of Tear
  • Partial thickness tear involving the mucosa and submucosa. = arterial bleed
• Most Common Site
  • GE junction near the cardia at the lesser curvature of the stomach.
• Diagnosis
  • Endoscopy (retroflexion) is the diagnostic modality of choice.
• Treatment
  • Acid suppression is successful in 90% of bleeding episodes.
  • Endoscopic therapy with injection or electrocoagulation.
• Further Intervention
  • Angiography if endoscopic therapy fails.
  • Surgery: High gastrostomy with suture of the mucosal tear.
• Recurrence
  • Uncommon after successful treatment.

Dieulafoy Lesion

• Nature of Lesion
  • Vascular malformation. = arterial
• Most Common Site
  • Lesser curvature within 6 cm of the GE junction.
• Bleeding Source
  • Originates from the gastric submucosa.
• Diagnostic Challenge
  • Mucosal defect is small, making it difficult to diagnose.
• Treatment
  • Endoscopic therapy is the first-line treatment.
  • If endoscopic therapy fails, proceed with angiographic embolization.

• Surgical Intervention = Last Option
  • Oversewing the ulcer is the surgical approach if needed.

GAVE (Gastric Antral Vascular Ectasia)

• Nature of Condition
  • Collection of dilated venules in the stomach lining.
  • Common Name
    • Also known as Watermelon stomach due to its appearance.
  • Clinical Presentation
    • Often presents with iron deficiency anemia.
  • Treatment Options
    • Argon Plasma Coagulation (APC) is a common treatment.
    • Antrectomy may be considered in severe or refractory cases.

Menetrier Disease = No Bleeding here

• Nature of Disease
  • Hypoproteinemic hypertrophic gastropathy characterized by enlarged gastric folds.
  • TGF alpha
• Gastric Involvement
  • Gastric folds are prominent in the fundus and body of the stomach.
  • The antrum is spared.
• Histopathology
  • Foveolar hyperplasia with absent parietal cells.
  • Associated with hypochlorohydria (reduced stomach acid production).
• Associated Infections
  • CMV infection in children.
  • H. pylori infection in adults.
• Treatment
  • Total gastrectomy may be required in severe cases.
• Risk Consideration
  • There is an associated risk of malignancy.

---

Lower GI Bleed

• Most Common Cause of LGIB: Neoplasia (as per SKF).
• Most Common Cause of LGIB Requiring Hospitalization: Diverticular disease (as per SKF).

Key Features of Lower Gastrointestinal Bleeding (LGIB)

• Bleeding Location
  • Distal to the ligament of Treitz.
• Presentation
  • Hematochezia or blood clots.
  • Involves both small bowel and colonic bleeding.
• Predictors of Severe Bleed
  • Heart Rate (HR) > 100 bpm.
  • Systolic Blood Pressure (SBP) < 115 mmHg.
  • Syncope.
  • Non-tender abdomen.
  • Use of aspirin.
  • Presence of more than 2 comorbidities.
  • Rectal bleeding occurring within the first 4 hours of evaluation.

Etiology of Lower Gastrointestinal Bleeding (LGIB)

• Most Common Etiology
  • Carcinoma.
• Most Common Etiology of Acute Symptomatic LGI Bleed
  • Diverticulosis.
• Diverticulosis
  • More common in older patients.
  • Self-limiting with fresh, painless bleeding.
  • 70-80% of cases have spontaneous resolution.
  • Colonoscopic evaluation (IOC) is important for diagnosis.

Vascular Ectasia (Angiodysplasia)

• Terminology
  • Includes angiodysplasia, AVM (arteriovenous malformation), angioectasia.
• Most Common Location
  • Right colon.
• Pathophysiology
  • Age-related degeneration of blood vessels.
• Diagnosis
  • Diagnosed through endoscopy.
  • Appears as flat red lesions with ectatic vessels radiating from a central point.
• Clinical Course
  • 90% of cases have spontaneous resolution.
• Treatment
  • Argon Plasma Coagulation (APC) combined with sclerotherapy. [ APC or slerotherapy is always used mostly for venous bleeds]

Diagnostic Algorithm for Lower Gastrointestinal Bleeding

1. Occult Bleed
   • Initial Step: Colonoscopy.
   • If Colonoscopy is negative with UGI symptoms, proceed with EGD.
2. Melena
   • Initial Step: EGD.
   • If EGD is negative, proceed with Colonoscopy.
3. Scant Intermittent Hematochezia
   • Age < 40 and no symptoms concerning for malignancy:
     • Flexible sigmoidoscopy.
   • If Flexible sigmoidoscopy is negative, further evaluation may be needed.
4. Severe Hematochezia
   • Age > 50 or symptoms concerning for malignancy:
     • Colonoscopy is recommended as the initial diagnostic step.

Treatment Algorithm for Severe Hematochezia

CTA comes earlier in the evaluation compared to Colonoscopy (MCQ) (MCQ) (MCQ) Colonoscopy is done in Stable or not actively bleeding patients only.

1. Initial Resuscitation and Evaluation
   • Large bore IV access
   • Physical exam
   • CBC/coags/type and crossmatch
2. NGT Lavage
   • If positive: Perform EGD and manage as UGIB.
   • If negative: Assess for evidence of active bleeding.
3. Evidence of Active Bleeding?
   • If Yes:
     • Assess hemodynamic stability.
       • If stable: Proceed with CT angiography.
       • If unstable: Continue resuscitation.
         • If fluid responsive: Proceed with CT angiography.
         • If not fluid responsive: Consider IR for angiography.
   • If No: Prepare for bowel preparation and colonoscopy.
4. CT Angiography
   • Localise the Bleed
5. Directed Colonoscopy with Endoscopic Therapy (if bleeding is localized)
   • Epinephrine injection
   • Bipolar or argon beam coagulation
   • Hemoclips
6. For persistent bleeding:
   • Consider IR for angiography.
     • If successful: Embolization.
     • If refractory: Consider surgery.

Prerequisites for Colonoscopy (MCQ)

• Hemodynamically Stable
  • The patient must be hemodynamically stable before proceeding with colonoscopy.
• Bowel Preparation
  • Adequate bowel preparation is essential for proper visualization during the procedure.
• Management for Unstable Patients
  • If the patient is unstable, proceed directly to mesenteric angiography [DSA].
• CTA for Active Bleeding
  • In cases of active bleeding where the patient is stable after resuscitation, CTA is recommended and then proceed to DSA if required.

DSAngiography in LGI Bleeding

• Success Rate
  • Varies between 40-78%.
• Therapeutic Options
  • IV vasopressin or embolization can be used during the procedure.
• Potential Complications
  • Renal toxicity
  • Arterial injury
  • Bowel ischemia
• Stable Patients
  • Endoscopy should be performed before angiography in stable patients.

Surgery in LGI Bleeding

• Preoperative Consideration
  • Ideally, the bleeding site should be localized before proceeding to surgery.
• Intraoperative Strategy
  • If the bleeding site is not localized preoperatively, intraoperative enteroscopy should be performed.
• Surgical Options
  • Segmental Colectomy: Preferred when the bleeding site is localized.
  • Subtotal Colectomy: Considered if the bleeding site cannot be localized.

---

MCQ’s

Question Title: Characteristics of Melena

Question:

Which of the following statements about melena is NOT true?

Options:

• A) Always suggests an upper GI bleed.
• B) Byproduct of hemoglobin degradation.
• C) Can persist until days after cessation of bleeding.
• D) Hematin causes brownish blue coloration.

Answer:

A) Always suggests an upper GI bleed.

Explanation:

Melena is the passage of black, tar-like stool, often malodorous, and is typically associated with a proximal source of bleeding in the GI tract. While over 90% of melena cases arise from an upper GI bleed (UGIB), it can also be seen in lower GI bleeding (LGIB) if the intestinal transit is slow. The dark coloration of melena is due to the byproduct of hemoglobin degradation by digestive enzymes and intestinal bacterial flora, resulting in the formation of hematin, which imparts a brownish-blue coloration. Although melena often indicates a UGIB, it is not exclusively suggestive of it, and therefore, option A is incorrect. Melena can persist for days even after the cessation of bleeding due to the slow transit and processing of blood through the intestines.

Question Title: Localization of Bleeding in Hemodynamically Stable Patients

Question:

Which of the following statements regarding the localization of GI bleeding in hemodynamically stable patients is NOT true?

Options:

• A) CTA can detect bleeding rates as low as 0.3 mL/min.
• B) CTA should be done in three phases with enteral contrast.
• C) RBC scintigraphy is poor in localization of bleed.
• D) RBC scintigraphy can detect bleeding up to 0.04 mL/min.

Answer:

B) CTA should be done in three phases with enteral contrast.

Explanation:

For the localization of GI bleeding, CTA (Computed Tomography Angiography) is highly effective and can detect bleeding rates as low as 0.3 mL/min. It should be performed in three phases (non-contrast, arterial, and venous) but does not require enteral contrast (positive contrast is not used). RBC scintigraphy is less effective for precise localization, with a lower accuracy compared to CTA, but it is sensitive enough to detect bleeding rates as low as 0.04 mL/min. However, due to its poor spatial resolution, it often fails to accurately localize the source of bleeding, making option C true and option B incorrect

Question Title: Definition of Middle Gastrointestinal Bleeding (GIB)

Question:

Middle gastrointestinal bleeding (Middle GIB) refers to:

Options:

• A) Bleeding proximal to the DJ flexure.
• B) Bleeding distal to the IC junction.
• C) Bleeding between the DJ flexure and IC junction.
• D) None of the above.

Answer:

C) Bleeding between the DJ flexure and IC junction.

Explanation:

Middle GIB is defined as bleeding that occurs in the portion of the gastrointestinal tract between the DJ (duodenojejunal) flexure and the IC (ileocecal) junction. This region includes the majority of the small intestine, specifically the jejunum and ileum. Option C correctly identifies the location of middle GI bleeding, distinguishing it from bleeding that occurs proximal (upper GI) or distal (lower GI) to this region.

Question Title: Next Investigation for Unexplained Rectal Bleeding

Question:

A 55-year-old male presents with bleeding per rectum. Both UGI and lower GI scopy are normal. He is otherwise hemodynamically stable. What should be the next investigation?

Options:

• A) CT Angio
• B) Capsule Endoscopy
• C) DSA (Digital Subtraction Angiography)
• D) RBC Scan

Answer:

A) CT Angio

Explanation:

In a hemodynamically stable patient with unexplained rectal bleeding after normal upper and lower GI scopy, the next best step is CT Angiography (CTA). CTA is highly sensitive for detecting active bleeding and can help localize the source of bleeding. If CTA is inconclusive or further localization is needed, Capsule Endoscopy can be considered as the subsequent investigation, especially for evaluating the small bowel. While DSA and RBC scans are useful in certain contexts, they are generally considered after CTA, especially in stable patients.

Question Title: Next Step After Normal CT Angio in Rectal Bleeding

Question:

A 55-year-old male presents with bleeding per rectum. Both UGI and lower GI scopy are normal, and CT angiography is also normal. What should be the next investigation?

Options:

• A) DSA (Digital Subtraction Angiography)
• B) Capsule Endoscopy
• C) RBC Scan
• D) Repeat UGI and LGI Endoscopy

Answer:

B) Capsule Endoscopy

Explanation:

After a normal CT Angiography (CTA) in a patient with ongoing rectal bleeding, the next best investigation is Capsule Endoscopy. Capsule endoscopy is particularly useful for evaluating the small bowel, which may be the source of bleeding when both upper and lower endoscopies and CTA are negative. It allows visualization of areas that are otherwise difficult to assess with standard endoscopic procedures. While DSA and RBC scans have their roles, capsule endoscopy is the most appropriate next step in this scenario.

Question Title: Factors Affecting Diagnostic Yield of Video Capsule Endoscopy (VCE)

Question:

The diagnostic yield of Video Capsule Endoscopy (VCE) is increased in all of the following conditions except:

Options:

• A) Obscure occult bleed
• B) Obscure overt bleed
• C) Male sex
• D) Age > 60

Answer:

A) Obscure occult bleed

Explanation:

The diagnostic yield of Video Capsule Endoscopy (VCE) is generally higher in cases of obscure overt bleeding (visible bleeding of unknown origin), male sex, and age > 60 years. However, the yield is lower in cases of obscure occult bleeding (hidden blood loss without visible bleeding), where the source of bleeding is often more challenging to detect. Therefore, option A is the correct answer, as VCE has a lower diagnostic yield in obscure occult bleeding compared to the other conditions listed.

Question Title: Most Common Cause of Obscure Overt Bleeding

Question:

What is the most common cause of obscure overt bleeding?

Options:

• A) Small bowel tumor
• B) Angiodysplasia
• C) Ulcers
• D) None of the above

Answer:

B) Angiodysplasia

Explanation:

The most common cause of obscure overt bleeding, which refers to visible bleeding of unknown origin that persists after upper and lower endoscopic evaluations, is angiodysplasia. Angiodysplasia is a vascular malformation in the gastrointestinal tract, particularly in the small bowel, and is a frequent source of bleeding in these cases. Small bowel tumors and ulcers can also cause obscure bleeding, but angiodysplasia is the most common cause.

Question Title: Next Management Steps in NSAID-Related Hematemesis

Question:

A 25-year-old male presents with hematemesis and a history of NSAID use. His pulse is 120 bpm, and BP is 90/60 mmHg. After initial resuscitation, the next management steps include all of the following except:

Options:

• A) Antibiotics
• B) UGI within 12-24 hours
• C) PPI infusion
• D) Metoclopramide

Answer:

A) Antibiotics

Explanation:

In the management of hematemesis, particularly in a patient with a history of NSAID use and signs of hemodynamic instability, the next steps after initial resuscitation typically include PPI infusion to reduce gastric acid and promote healing, and UGI endoscopy within 12-24 hours to identify and treat the source of bleeding. Metoclopramide may be used to enhance gastric emptying. However, antibiotics are generally indicated only in cases of variceal bleeding to prevent infection and are not routinely used in non-variceal upper GI bleeds, making option A the correct answer.

Question Title: Management of Visible Vessel with Adherent Clot in UGI Endoscopy

Question:

UGI endoscopy reveals a visible vessel with an adherent clot. What is the risk of rebleed, and what should be the further management?

Options:

• A) High - Removal of adherent clot and epinephrine
• B) Low - Conservative management
• C) Intermediate - Removal of adherent clot and assessment
• D) None of the above

Answer:

C) Intermediate - Removal of adherent clot and assessment

Explanation:

When UGI endoscopy shows a visible vessel with an adherent clot, the risk of rebleeding is considered intermediate. The recommended management involves the removal of the adherent clot followed by an assessment of the underlying vessel or ulcer base. Depending on the findings after clot removal, further therapeutic measures such as the application of epinephrine injection or thermal coagulation may be necessary to reduce the risk of rebleeding. Conservative management alone is not sufficient in this scenario, making option C the correct answer.

Question Title: Diagnosis of Massive Upper GI Bleed in Alcoholic

Question:

A 50-year-old known alcoholic presents with a massive upper GI bleed after a binge of alcohol drinking. UGI endoscopy shows bleeding from the area of the lesser curvature near the GE junction, but no ulcer is visible. What is the most likely diagnosis?

Options:

• A) Mallory-Weiss tear
• B) Dieulafoy lesion
• C) Watermelon stomach
• D) None of the above

Answer:

B) Dieulafoy lesion

Explanation:

The most likely diagnosis in this scenario is a Dieulafoy lesion. This condition involves a large, tortuous arteriole in the stomach wall (most commonly located near the lesser curvature) that can cause significant bleeding. Unlike ulcers, Dieulafoy lesions may not present with an obvious mucosal defect, which aligns with the findings of no visible ulcer on endoscopy. Mallory-Weiss tear typically presents as a longitudinal tear at the gastroesophageal junction, and Watermelon stomach (Gastric Antral Vascular Ectasia) usually shows characteristic streaked, vascular appearances, primarily in the antrum, not the lesser curvature. Thus, option B is the correct answer.

Question Title: Therapy for GAVE in a Patient with Melena and Iron Deficiency Anemia

Question:

A 50-year-old patient presents with melena and iron deficiency anemia. Endoscopy shows the following picture (assumed to display features consistent with GAVE - Gastric Antral Vascular Ectasia). What is the most appropriate therapy?

Options:

• A) APC (Argon Plasma Coagulation)
• B) PPI infusion
• C) H. pylori eradication
• D) Metronidazole

Answer:

A) APC (Argon Plasma Coagulation)

Explanation:

The endoscopic findings described are consistent with Gastric Antral Vascular Ectasia (GAVE), also known as "Watermelon Stomach." GAVE is characterized by the presence of dilated blood vessels in the antral region of the stomach, which can lead to chronic blood loss, resulting in melena and iron deficiency anemia. The most appropriate therapy for GAVE is Argon Plasma Coagulation (APC), which helps to coagulate and reduce the bleeding from these vascular lesions. PPI infusion, H. pylori eradication, and Metronidazole are not specifically effective for treating GAVE, making option A the correct answer.

Question Title: Initial Diagnostic Step for Hematemesis in a Patient with Alcohol and NSAID Use

Question:

A 55-year-old male presents to the emergency department with hematemesis. He reports a history of chronic alcohol use and occasional NSAID use. His blood pressure is 90/60 mmHg, and his heart rate is 110 beats per minute. Laboratory tests reveal a hemoglobin level of 7.5 g/dL. What is the most appropriate initial diagnostic step?

Options:

• A) Abdominal ultrasound
• B) Esophagogastroduodenoscopy (EGD)
• C) CT scan of the abdomen
• D) Angiography

Answer:

B) Esophagogastroduodenoscopy (EGD)

Explanation:

In a patient presenting with hematemesis, especially with a history of chronic alcohol use and NSAID use, the most appropriate initial diagnostic step is Esophagogastroduodenoscopy (EGD). EGD allows for direct visualization of the upper GI tract to identify and potentially treat the source of bleeding, which could be related to peptic ulcers, varices, or other lesions. Given the patient's hemodynamic instability and low hemoglobin, urgent EGD is crucial for diagnosis and management. Abdominal ultrasound and CT scan are not first-line diagnostic tools for upper GI bleeding. Angiography is generally reserved for cases where the source of bleeding cannot be identified or controlled endoscopically. Therefore, option B is the correct answer.

Question Title: Management of Actively Bleeding Duodenal Ulcer in Hemodynamically Stable Patient

Question:

A 60-year-old woman with a history of peptic ulcer disease presents with melena and is hemodynamically stable. An EGD shows an actively bleeding duodenal ulcer. Which of the following is the most appropriate next step in management?

Options:

• A) Start intravenous proton pump inhibitors (PPIs) and monitor
• B) Endoscopic injection therapy
• C) Surgical intervention
• D) Transfusion of packed red blood cells (PRBCs)

Answer:

A) Start intravenous proton pump inhibitors (PPIs) and monitor

Explanation:

In a hemodynamically stable patient with an actively bleeding duodenal ulcer, the most appropriate next step after confirming the diagnosis with EGD is to start intravenous proton pump inhibitors (PPIs). PPIs help to reduce gastric acid secretion, promote clot stability, and enhance ulcer healing. While endoscopic therapy (such as injection therapy or thermal coagulation) may also be necessary depending on the severity of the bleeding and the patient's response to PPIs, the initial step in a stable patient would be medical management with PPIs. Surgical intervention and transfusion of PRBCs are generally reserved for cases where there is ongoing or severe bleeding, or if the patient becomes hemodynamically unstable. Therefore, option A is the correct answer.

Question Title: Risk Assessment in Cirrhotic Patient with Hematemesis

Question:

A 70-year-old male with a known history of cirrhosis presents with hematemesis. He is hemodynamically stable. His laboratory results include a hemoglobin of 10 g/dL, platelets of 70,000/uL, and an INR of 1.7. What is the most appropriate method for assessing his risk of rebleeding and mortality?

Options:

• A) Rockall score
• B) Glasgow-Blatchford score
• C) AIMS65 score
• D) Child-Pugh score

Answer:

C) AIMS65 score

Explanation:

The AIMS65 score is specifically designed to assess the risk of mortality in patients presenting with upper gastrointestinal bleeding. It includes parameters such as albumin levels, INR, altered mental status, systolic blood pressure, and age. This score is particularly useful in patients with liver disease, like cirrhosis, where the risk of rebleeding and mortality is higher. While the Rockall score and Glasgow-Blatchford score are also used to evaluate the risk of rebleeding in GI bleed patients, the AIMS65 score is more tailored for predicting outcomes in this patient population. The Child-Pugh score is primarily used to assess the severity of cirrhosis rather than the risk of rebleeding or mortality specifically related to an acute GI bleed. Therefore, option C is the correct answer.

Question Title: Management of Refractory Bleeding in Gastric Ulcer

Question:

A 65-year-old male presents with recurrent hematemesis after endoscopic therapy for a bleeding gastric ulcer. Despite high-dose intravenous PPI therapy, the patient continues to bleed. His hemoglobin level continues to drop, and he requires repeated blood transfusions and multiple endoscopic therapies. What is the next best step in management?

Options:

• A) Repeat endoscopic therapy
• B) Angiographic embolization
• C) Surgical intervention
• D) Increase the dose of PPI therapy

Answer:

C) Surgical intervention

Explanation:

In a patient with a bleeding gastric ulcer that is refractory to multiple endoscopic therapies and high-dose PPI therapy, and who continues to experience significant bleeding with a drop in hemoglobin requiring repeated transfusions, the next best step in management is surgical intervention. Surgery is indicated when endoscopic and medical therapies fail to control the bleeding. Repeat endoscopic therapy is unlikely to be successful after multiple failed attempts, and increasing the dose of PPI therapy would not address the ongoing hemorrhage. Angiographic embolization is an option but is generally considered after or in conjunction with surgical intervention if the patient is not a surgical candidate. Therefore, option C is the correct answer.

Question Title: Next Diagnostic Step for Bright Red Blood Per Rectum in Stable Patient

Question:

A 65-year-old male presents to the emergency department with bright red blood per rectum. He is hemodynamically stable. A digital rectal examination reveals no hemorrhoids or masses. His hemoglobin is 11 g/dL, and he has a history of diverticulosis. What is the next best diagnostic step?

Options:

• A) Abdominal ultrasound
• B) Colonoscopy
• C) CT angiography (CTA)
• D) Esophagogastroduodenoscopy (EGD)

Answer:

B) Colonoscopy

Explanation:

In a hemodynamically stable patient presenting with bright red blood per rectum and a history of diverticulosis, the next best diagnostic step is colonoscopy. Colonoscopy allows for direct visualization of the colon and identification of the source of bleeding, which is particularly important given the patient's history of diverticulosis, a common cause of lower gastrointestinal bleeding. Abdominal ultrasound is not typically used for diagnosing sources of GI bleeding. CT angiography (CTA) is usually reserved for cases where colonoscopy cannot be performed or fails to identify the bleeding source. Esophagogastroduodenoscopy (EGD) is more appropriate for upper GI bleeding, not for evaluating bright red blood per rectum, which indicates a lower GI source. Therefore, option B is the correct answer.

Question Title: Management of Diverticular Bleeding After Spontaneous Resolution

Question:

A 70-year-old female presents with painless hematochezia and is diagnosed with diverticular bleeding via colonoscopy. The bleeding stops spontaneously. Which of the following is the most appropriate next step in management?

Options:

• A) Immediate surgical intervention
• B) Observation and supportive care
• C) Repeat colonoscopy for therapeutic intervention
• D) Initiation of anticoagulation therapy

Answer:

B) Observation and supportive care

Explanation:

Diverticular bleeding often stops spontaneously, as in this patient's case. The most appropriate next step in management after spontaneous resolution of bleeding is observation and supportive care. This approach includes monitoring the patient for any signs of rebleeding and providing supportive care such as ensuring adequate hydration and managing any underlying conditions. Immediate surgical intervention is not necessary unless there is recurrent or severe bleeding that cannot be controlled. Repeat colonoscopy is not indicated when the bleeding has already resolved. Initiation of anticoagulation therapy would be inappropriate in this context and could exacerbate bleeding. Therefore, option B is the correct answer.

Question Title: Predictors of Severe Lower GI Bleeding

Question:

Which of the following is NOT a predictor of severe lower GI bleeding?

Options:

• A) Tachycardia (heart rate > 100 beats/min)
• B) Hypotension (systolic blood pressure < 115 mm Hg)
• C) A history of aspirin use
• D) Presence of hemorrhoids

Answer:

D) Presence of hemorrhoids

Explanation:

Severe lower GI bleeding is often predicted by factors such as tachycardia (heart rate > 100 beats/min), hypotension (systolic blood pressure < 115 mm Hg), and a history of aspirin use, as these can indicate significant blood loss and increased risk of ongoing or recurrent bleeding. The presence of hemorrhoids, however, is typically associated with minor bleeding that is not life-threatening and does not predict severe lower GI bleeding. Therefore, option D is the correct answer.

Question Title: Management of Aspirin Use in CAD Patient with Melena

Question:

A 67-year-old male with a history of CAD and stent placement 10 years ago, on Aspirin 150 mg, presents with melena. UGI endoscopy shows diffuse gastritis. Which of the following is true about his management?

Options:

• A) Stop Aspirin and restart after 8 weeks of cessation of bleeding.
• B) Restart Aspirin within 1 week of bleeding cessation with PPI.
• C) Replace Aspirin with Clopidogrel.
• D) All of the above.

Answer:

B) Restart Aspirin within 1 week of bleeding cessation with PPI.

Explanation:

In patients with a history of CAD, particularly those with a stent, it is important to minimize the duration without antiplatelet therapy to reduce the risk of thrombotic events. Therefore, the recommendation is to restart Aspirin within 1 week of bleeding cessation, alongside PPI therapy to protect the gastric lining and reduce the risk of further bleeding. Stopping aspirin for an extended period, such as 8 weeks, or replacing it with clopidogrel without a compelling reason, would increase the risk of cardiovascular events. Hence, option B is the correct answer.

---

Question Title: Next Step After Failed Colonoscopy in Hemodynamically Unstable Patient with Rectal Bleeding

Question:

A 68-year-old male with ongoing, brisk rectal bleeding has undergone a colonoscopy that failed to identify the source of bleeding. The patient is hemodynamically unstable despite fluid resuscitation. What is the next best step in management?

Options:

• A) Repeat colonoscopy
• B) CT angiography (CTA)
• C) Mesenteric angiography with embolization
• D) Immediate surgical intervention

Answer:

C) Mesenteric angiography with embolization

Explanation:

In a hemodynamically unstable patient with brisk rectal bleeding where colonoscopy fails to identify the bleeding source, the next best step is mesenteric angiography with embolization. This procedure allows for both the localization of the bleeding source and potential therapeutic embolization to control the hemorrhage. Repeat colonoscopy is unlikely to be successful, and immediate surgical intervention is typically reserved for cases where less invasive measures have failed. Therefore, option C is the correct answer.

---

Question Title: Surgical Strategy After Failed Mesenteric Angiography

Question:

Mesenteric angiography failed to localize the bleeding source. The patient was taken up for surgery. Which of the following is the most appropriate strategy?

Options:

• A) Subtotal colectomy
• B) Intraoperative enteroscopy
• C) Loop ileostomy
• D) Right hemicolectomy

Answer:

A) Subtotal colectomy

Explanation:

When mesenteric angiography fails to localize the source of bleeding, and the patient is hemodynamically unstable, the most appropriate surgical strategy is a subtotal colectomy. This approach removes the majority of the colon, which is often necessary when the exact source of bleeding cannot be determined, but the bleeding is presumed to be colonic. Intraoperative enteroscopy and loop ileostomy are more appropriate in different clinical scenarios, and a right hemicolectomy would be indicated only if the source of bleeding was localized to the right colon, which it was not in this case. Therefore, option A is the correct answer.

Question Title: Initial Management of Hemodynamically Unstable Patient with Dark Red Blood in Stool

Question:

A 78-year-old female presents with dark red blood in her stool and reports a history of chronic kidney disease and hypertension. She is tachycardic and hypotensive on arrival. What is the most important initial step in her management?

Options:

• A) Immediate colonoscopy
• B) Blood transfusion and fluid resuscitation
• C) CT angiography (CTA)
• D) Administration of IV proton pump inhibitors (PPIs)

Answer:

B) Blood transfusion and fluid resuscitation

Explanation:

In a patient presenting with signs of significant blood loss, such as tachycardia and hypotension, the most critical initial step is blood transfusion and fluid resuscitation to stabilize the patient hemodynamically. Once the patient is stabilized, further diagnostic tests like colonoscopy or CTA can be performed. Immediate colonoscopy or CTA should not be done before the patient is stabilized, and PPIs are more appropriate for upper GI bleeding rather than lower GI bleeding unless the source is uncertain. Therefore, option B is the correct answer.

---

Question Title: Initial Diagnostic Test for Iron Deficiency Anemia with Occult GI Bleeding

Question:

A 62-year-old male presents with iron deficiency anemia but denies visible blood in his stool. He has a history of aspirin use. What is the most appropriate initial diagnostic test?

Options:

• A) Esophagogastroduodenoscopy (EGD)
• B) Colonoscopy
• C) Capsule endoscopy
• D) CT angiography (CTA)

Answer:

B) Colonoscopy

Explanation:

For a patient presenting with iron deficiency anemia without visible blood in the stool, particularly with a history of aspirin use, the initial diagnostic test should be colonoscopy. This is because the most common sources of occult GI bleeding are often found in the lower GI tract, such as polyps or colorectal cancer. If colonoscopy does not reveal the source, then an upper GI endoscopy (EGD) may be performed next. Capsule endoscopy and CTA are generally considered later in the diagnostic process if both colonoscopy and EGD are inconclusive. Therefore, option B is the correct answer.

---

Question Title: Next Diagnostic Step After Persistent Heavy Rectal Bleeding Post-Resuscitation

Question:

A 66-year-old male presents with active rectal bleeding. A nasogastric tube aspirate shows bile but no blood. After initial resuscitation, the patient continues to bleed heavily. What is the next diagnostic step?

Options:

• A) Repeat nasogastric tube placement
• B) Scintigraphy
• C) CT angiography (CTA)
• D) Emergency surgery

Answer:

C) CT angiography (CTA)

Explanation:

In a patient with ongoing heavy rectal bleeding after initial resuscitation, and with a nasogastric tube aspirate showing bile but no blood (suggesting the bleeding is not from the upper GI tract), the next appropriate diagnostic step is CT angiography (CTA). CTA is effective in localizing the source of active bleeding, particularly in the lower GI tract, and can guide subsequent therapeutic interventions. Scintigraphy is less specific, and emergency surgery is generally reserved for cases where less invasive methods have failed or are not feasible. Therefore, option C is the correct answer.

Question Title: Treatment of Vascular Ectasias in Chronic Kidney Disease Patient

Question:

A 72-year-old female with a history of chronic kidney disease presents with recurrent episodes of painless hematochezia. Colonoscopy reveals multiple vascular ectasias in the cecum and ascending colon. What is the most appropriate treatment?

Options:

• A) Oral iron supplementation
• B) Endoscopic ablation with argon plasma coagulation
• C) Surgical resection of the affected bowel
• D) Observation and reassurance

Answer:

B) Endoscopic ablation with argon plasma coagulation

Explanation:

In patients with vascular ectasias, particularly in the context of chronic kidney disease, the most appropriate treatment is endoscopic ablation with argon plasma coagulation (APC). This technique effectively reduces bleeding by coagulating the abnormal blood vessels. Oral iron supplementation may help manage anemia but does not address the underlying cause. Surgical resection is generally reserved for cases where endoscopic management fails, and observation and reassurance alone would not be sufficient for recurrent bleeding. Therefore, option B is the correct answer.

---

Question Title: Timing of Upper Endoscopy in Stable Hematemesis and Melena

Question:

A 58-year-old male presents with hematemesis and melena. He is hemodynamically stable after initial resuscitation with IV fluids and blood transfusion. According to recent guidelines, when should an upper endoscopy (EGD) be performed?

Options:

• A) Within 2 hours of presentation
• B) Within 12 hours of presentation
• C) Within 24 hours of presentation
• D) After stabilization and resolution of bleeding

Answer:

B) Within 12 hours of presentation

Explanation:

Recent guidelines recommend that in a hemodynamically stable patient presenting with upper GI bleeding (e.g., hematemesis and melena), upper endoscopy (EGD) should be performed within 12 hours of presentation. This timing allows for appropriate diagnosis and therapeutic intervention while ensuring patient stability. Performing EGD within 2 hours is typically reserved for hemodynamically unstable patients. Waiting for 24 hours or until the complete resolution of bleeding is not recommended in stable patients with active bleeding. Therefore, option B is the correct answer.

---

Question Title: Management of Antiplatelet Therapy in Lower GI Bleed

Question:

A 72-year-old female on dual antiplatelet therapy (aspirin and clopidogrel) for coronary artery disease presents with a significant lower GI bleed. According to recent guidelines, how should her antiplatelet therapy be managed?

Options:

• A) Discontinue both antiplatelet agents permanently
• B) Discontinue clopidogrel and continue aspirin
• C) Hold both antiplatelet agents temporarily and resume aspirin within 7 days
• D) Continue both antiplatelet agents without interruption

Answer:

C) Hold both antiplatelet agents temporarily and resume aspirin within 7 days

Explanation:

In a patient on dual antiplatelet therapy presenting with a significant lower GI bleed, the current guidelines recommend temporarily holding both antiplatelet agents to manage the bleeding. However, aspirin should be resumed within 7 days to minimize the risk of thrombotic events, especially in patients with a history of coronary artery disease. Discontinuing both agents permanently or continuing both without interruption would either increase the risk of further bleeding or a thrombotic event, respectively. Discontinuing clopidogrel and continuing aspirin may be an option but resuming aspirin after a temporary hold is the recommended approach. Therefore, option C is the correct answer.

Question Title: Endoscopic Treatment for Bleeding Peptic Ulcer

Question:

A 70-year-old male presents with hematemesis and is found to have a bleeding peptic ulcer on endoscopy. According to recent guidelines, what is the recommended endoscopic treatment?

Options:

• A) Mechanical clipping alone
• B) Thermal coagulation alone
• C) Injection of epinephrine followed by thermal coagulation or mechanical therapy
• D) Injection of epinephrine alone

Answer:

C) Injection of epinephrine followed by thermal coagulation or mechanical therapy

Explanation:

The recommended endoscopic treatment for a bleeding peptic ulcer, according to recent guidelines, involves injection of epinephrine followed by thermal coagulation or mechanical therapy (such as clipping). Epinephrine injection helps to achieve initial hemostasis by vasoconstriction, while thermal or mechanical methods provide a more definitive treatment to prevent rebleeding. Using epinephrine alone is not sufficient, and mechanical or thermal therapy alone may not be as effective without the initial epinephrine injection. Therefore, option C is the correct answer.

---

Question Title: Timing of Colonoscopy in Hemodynamically Stable Patient with Bright Red Blood Per Rectum

Question:

A 68-year-old male presents with bright red blood per rectum and is hemodynamically stable after initial resuscitation. According to recent guidelines, when should colonoscopy be performed?

Options:

• A) Within 8 hours of presentation
• B) Within 12-24 hours of presentation
• C) Only after a positive CT angiography (CTA)
• D) After 48 hours to allow for bowel preparation

Answer:

B) Within 12-24 hours of presentation

Explanation:

For a hemodynamically stable patient presenting with bright red blood per rectum, recent guidelines recommend performing a colonoscopy within 12-24 hours of presentation. This timing allows for adequate bowel preparation while still providing timely diagnostic and therapeutic intervention. Performing a colonoscopy earlier than 12 hours is generally unnecessary, and delaying beyond 24 hours could lead to missed opportunities for intervention. A positive CTA is not required before colonoscopy in stable patients, and waiting 48 hours may be too long. Therefore, option B is the correct answer.

---

Question Title: Management of Severe Hematemesis in Cirrhotic Patient

Question:

A 58-year-old male presents to the emergency department with severe hematemesis. He has a history of cirrhosis due to chronic alcohol use. On examination, he is tachycardic with a blood pressure of 70/50 mm Hg, and his abdomen is distended with ascites. Laboratory tests show a hemoglobin level of 6 g/dL and an INR of 2.5. What is the most appropriate next step in managing this patient?

Options:

• A) Immediate endoscopic band ligation
• B) Intravenous proton pump inhibitor (PPI) therapy
• C) Transjugular intrahepatic portosystemic shunt (TIPS)
• D) Balloon tamponade with a Sengstaken-Blakemore tube

Answer:

D) Balloon tamponade with a Sengstaken-Blakemore tube

Explanation:

In a patient with severe hematemesis, cirrhosis, and signs of hemodynamic instability, such as tachycardia, hypotension, and a low hemoglobin level, balloon tamponade with a Sengstaken-Blakemore tube is the most appropriate next step to control the bleeding temporarily. This procedure is particularly useful in variceal bleeding, which is common in cirrhotic patients, especially when endoscopic therapy is not immediately available or feasible. Immediate endoscopic band ligation would be the treatment of choice if the patient were stable enough to undergo endoscopy. IV PPI therapy is not sufficient for variceal bleeding. TIPS may be considered later if other treatments fail, but it is not the immediate next step in this acute scenario. Therefore, option D is the correct answer.

Question Title: Management of Hemodynamically Unstable Patient with Bleeding Duodenal Ulcer

Question:

A 55-year-old male with CKD (Creatinine 3.5) and a history of peptic ulcer disease presents to the emergency department with severe hematemesis. Despite IV fluids and blood transfusion, he remains hemodynamically unstable. Upper endoscopy reveals a large, actively bleeding duodenal ulcer with a visible vessel, but attempts at endoscopic hemostasis with epinephrine injection and thermal coagulation have failed. What is the next best step in the management of this patient?

Options:

• A) Repeat endoscopy with additional attempts at hemostasis
• B) Immediate surgical intervention with duodenal ulcer excision and vessel ligation
• C) Angiographic embolization of the gastroduodenal artery
• D) Transfusion of additional blood products and observation in the intensive care unit

Answer:

B) Immediate surgical intervention with duodenal ulcer excision and vessel ligation

Explanation:

In a patient who remains hemodynamically unstable despite attempts at endoscopic hemostasis for a bleeding duodenal ulcer, the next best step is immediate surgical intervention. This involves duodenal ulcer excision and vessel ligation to control the bleeding. Repeat endoscopy is unlikely to be successful after failed initial attempts, and while angiographic embolization can be considered, surgery is more definitive in this unstable situation. Observation without addressing the source of bleeding is not appropriate given the patient's instability. Therefore, option B is the correct answer.

---

Question Title: Management of Massive Hematemesis in Patient with Aortic Aneurysm Repair

Question:

A 68-year-old female with a known history of aortic aneurysm repair 5 years ago presents with a sudden onset of massive hematemesis and collapse. On arrival, she is in shock with a blood pressure of 70/40 mm Hg and a heart rate of 130 bpm. Despite aggressive fluid resuscitation, she remains unstable. Upper endoscopy is performed and reveals fresh blood in the duodenum, but the source of bleeding is not identified. What is the most likely diagnosis, and what should be the next step in management?

Options:

• A) Mallory-Weiss tear; repeat endoscopy
• B) Duodenal ulcer; intravenous proton pump inhibitor (PPI) and observation
• C) Aortoenteric fistula; emergency surgical repair
• D) Gastric cancer with ulceration; biopsy and surgical consultation

Answer:

C) Aortoenteric fistula; emergency surgical repair

Explanation:

In a patient with a history of aortic aneurysm repair presenting with sudden massive hematemesis and collapse, the most likely diagnosis is an aortoenteric fistula. This is a life-threatening condition where a connection forms between the aorta and the gastrointestinal tract, often leading to massive bleeding. Given the patient’s instability and the potential for rapid deterioration, emergency surgical repair is the most appropriate next step. Repeat endoscopy or PPI therapy would not address the underlying vascular issue, and a biopsy for suspected gastric cancer is inappropriate in this acute scenario. Therefore, option C is the correct answer.

---

Acute Lower Gastrointestinal Hemorrhage (LGIB)

[Note from Sabiston]

• Definition
  • LGIB refers to bleeding originating distal to the ligament of Treitz, and in some cases, it specifically refers to bleeding distal to the ileocecal valve due to its distinct characteristics compared to small bowel bleeding.
• Common Presentation
  • Painless hematochezia: Bright red blood, clots, or burgundy stools.
  • A brisk UGIB can also present similarly, so initial evaluation should rule out UGIB.
  • Melena (commonly associated with UGIB) can occasionally indicate LGIB.
• Evaluation
  • Directed history and physical examination can suggest specific causes:
    • Abdominal pain with diarrhea: Suggests inflammatory, ischemic, or infectious colitis.
    • Altered bowel habits, iron-deficiency anemia, or unexplained weight loss: May suggest malignancy.
• Epidemiology
  • LGIB accounts for 30% to 40% of gastrointestinal bleeding (GIB) with an annual incidence of 35 per 100,000 persons in the U.S.
  • Mortality rate: Slightly below that of UGIB, at just below 2%, increasing to about 5% in those over 85 years old.
  • Incidence of hospitalization, morbidity, and mortality increases with age.
• Source of Bleeding
  • More than 95% of LGIB sources are in the colon.
• Causes by Age Group
  • Middle-aged and elderly adults: Vascular lesions and diverticular disease.
  • Pediatric population: Intussusception.
  • Young adults: Consider Meckel diverticulum.
• Clinical Presentation
  • Ranges from severe hemorrhage (diverticular disease or vascular lesions) to minor bleeding (anal fissure or hemorrhoids).

Diagnosis of Acute Lower Gastrointestinal Hemorrhage (LGIB)

• Severity and Intermittency
  • LGIB tends to be less severe and intermittent, often resolving spontaneously between localization attempts.
  • Multiple lesions: Over 40% of patients have more than one lesion as the potential bleeding source, making it crucial to confirm the responsible lesion before initiating aggressive therapy.
• Challenges in Diagnosis
  • No diagnostic modality is as sensitive or specific in LGIB as endoscopy is in UGIB.
  • Observation period: Patients may need longer observation and could suffer multiple episodes of bleeding before a definitive diagnosis.
  • In up to 25% of patients, the source of bleeding is never accurately identified.
• Initial Evaluation and Resuscitation
  • Begin with initial evaluation and resuscitation.
  • Anticoagulation should be reversed, and coagulation disorders treated aggressively (except in patients with high-risk cardiovascular disease where ASA may be continued).
• First Steps in Workup
  • Digital rectal examination, anoscopy, or sigmoidoscopy to rule out anorectal bleeding and provide appropriate treatment.
  • Rule out UGIB: Up to 15% of patients with hematochezia have a UGIB source. A nasogastric aspirate with bile and no blood can effectively rule out an active upper GI bleeding site.
• Classification of Hemorrhage
  • Minor LGIB: Hemodynamically stable patients, often evaluated as outpatients. Common causes include anorectal lesions (hemorrhoids, fissures), IBD, infectious colitis, arteriovenous malformations, polyps, and malignancy.
  • Major LGIB: Associated with hemodynamic instability, altered mental status, or the need for two or more units of blood.
  • Massive LGIB: Requires 10 or more units of blood products.
• Management of Unstable Patients
  • Unstable patients requiring aggressive resuscitation should be taken to the operating room for expeditious diagnosis and intervention.
  • Hybrid operating rooms: Angiography may be used to localize bleeding or attempt endovascular therapy in conjunction with immediate surgical intervention.
  • Intraoperative endoscopy: Useful adjunct for identifying the bleeding source.
• Evaluation of Hemodynamically Stable Patients
  • Colonoscopy is the mainstay for evaluation and therapeutic intervention. It should be performed after an adequate bowel prep, ideally within 24 hours.
  • Other modalities: CTA, mesenteric angiography, and tagged RBC scintigraphy are important components of the evaluation.
• Colonoscopy
  • Initial examination of choice for stable patients.
  • Success in treatment: Causes like diverticular disease, angioectasia, and postpolypectomy are most likely to respond to endoscopic treatment.
  • Findings predictive of high risk for rebleeding: Active bleeding, visible vessel, or adherent clot.
  • Endoscopic therapeutic interventions: Include polypectomy, epinephrine injection, thermal coagulation, argon plasma coagulation, metal clips, and band ligation.
• Angiography
  • Used when endoscopy is unable to localize the bleeding source.
  • CTA and tagged RBC scintigraphy improve angiography localization.
  • Superselective embolization: Isolates bleeding from a specific diverticulum with high success rates.
• Other Modalities
  • Tagged RBC scan: Positive in 39% to 45% of LGIB cases, with a significant false-positive rate of 10%.
  • Capsule endoscopy: Can reveal bleeding lesions in the prepped colon.

Surgical Management of Lower Gastrointestinal Bleeding (LGIB)

• Indications for Surgery:
  • Persistent hemodynamic instability despite resuscitation.
  • Administration of more than 4 units of blood in 24 hours.
  • More than 10 units of blood required during the hospital stay.
• Preoperative Considerations:
  • Identification of the culprit lesion is crucial before surgery.
  • Without localization, total abdominal colectomy and end ileostomy may be performed.
• Empiric Surgery for Unlocalized LGIB:
  • Blind subtotal colectomy is considered when the bleeding site is not localized.
  • This approach is supported by lower rebleeding rates (4% with total colectomy vs. 18% with segmental resection).
  • High mortality rate (20% to 30%) associated with emergent subtotal colectomy.
• Intestinal Anastomosis Considerations:
  • Avoid anastomosis in unstable patients with high transfusion requirements due to the high mortality risk from anastomotic leaks.
• Oncologic Resection:
  • Should be considered when suspicion of malignancy exists, provided the patient is hemodynamically stable.
• Alternative Strategy:
  • In critically ill patients, a damage control operation may be performed, with delayed definitive therapy to allow stabilization of the patient’s physiology.

Specific Causes of Lower Gastrointestinal Tract Bleeding:

1. Diverticula

• Prevalence:
  • Diverticula are the most common cause of significant lower gastrointestinal bleeding (LGIB) in the United States.
  • Among individuals with colonic diverticula, 3% to 15% will experience bleeding.
• Age-Related Incidence:
  • The incidence of diverticula increases with age:
    • 20% at age 40.
    • 60% and beyond at age 60.
  • Once considered rare in individuals under 40, diverticula are now increasingly diagnosed in this younger age group.
• Pathophysiology:
  • Diverticula form at points of weakness in the bowel wall where the vasa recta penetrate the circular muscle layer.
  • As the diverticulum expands, the penetrating vessel stretches and may rupture, leading to bleeding.
• Location and Bleeding:
  • In western countries, left-sided diverticular disease is more common, but right-sided disease is responsible for over 50% of significant diverticular bleeding.
  • More than 75% of diverticular bleeding stops spontaneously.
  • 10% of patients will rebleed within a year, and almost 50% will rebleed within 10 years.
• Diagnosis and Treatment:
  • Colonoscopy is the best modality for both diagnosis and therapy.
  • Endoscopic treatment options are similar to those for peptic ulcer disease (PUD):
    • Injection (e.g., epinephrine)
    • Thermal coagulation
    • Plasma argon coagulation
    • Mechanical clips
    • Fibrin glue
  • Clips can also mark the location of bleeding for repeat intervention if needed.
  • Monotherapy with epinephrine should be combined with another modality.
  • Tattooing the bleeding site is recommended if no clip is placed.
• Recurrent Bleeding:
  • If colonoscopy fails to isolate or visualize the bleeding site, or if there is recurrent bleeding:
    • Angiography with superselective cannulation and embolization can be considered.
    • Clips placed during colonoscopy can aid in localizing the bleeding site.
• Surgical Intervention:
  • Surgery should be a last resort when all other therapeutic options fail, and the patient remains hemodynamically unstable despite aggressive resuscitation.
  • Colonic resection should only be undertaken with some mode of localization to ensure the correct lesion is resected.
  • Blind total abdominal colectomy carries high morbidity and mortality and does not eliminate the risk of rebleeding (~4%).
  • Segmental resection may be performed if bleeding is localized to a specific portion of the colon but carries a higher rebleeding risk (~18%) compared to total colectomy.

2. Colitis and Lower Gastrointestinal Bleeding (LGIB)

• Causes of Colitis:
  • Inflammatory Bowel Disease (IBD): Includes Ulcerative Colitis (UC) and Crohn's Disease.
  • Infectious Colitis: Caused by bacterial, viral, or parasitic infections.
  • Radiation Proctitis: Occurs after treatment for pelvic malignancies.
  • Ischemic Colitis: Results from reduced blood flow to the colon.
• Ulcerative Colitis (UC):
  • Manifestation with GIB: UC is more likely than Crohn's disease to present with gastrointestinal bleeding (GIB).
  • Prevalence of Bleeding: Most UC patients and about one-third of Crohn's patients experience gross bleeding at some point.
  • Disease Characteristics:
    • UC is a mucosal disease beginning in the rectum and can progress proximally to involve the entire colon.
    • Patients often present with bloody diarrhea, crampy abdominal pain, and tenesmus.
  • Diagnosis: Made through careful history and colonoscopy with biopsy.
  • Treatment:
    • Supportive care with steroids, 5-aminosalicylic acid (5-ASA) compounds, immunomodulators, biologics, and antibiotics if indicated.
    • Major hemorrhage is rare and typically arises from diffuse colitis without discrete lesions for endoscopic treatment.
    • Surgical intervention may be required for ongoing bleeding or complications such as toxic megacolon or refractory symptoms.
• Crohn's Disease:
  • Manifestation with GIB: Typically associated with guaiac-positive diarrhea and mucous stools without gross blood.
  • Disease Characteristics:
    • Can affect any part of the GI tract, characterized by skip lesions, transmural thickening, and inflammation.
    • Granulomas may be present on biopsy.
  • Diagnosis: Made through endoscopy, biopsy, and contrast studies.
  • Treatment:
    • Similar to UC, using steroids, 5-ASA compounds, antibiotics, immunomodulators, and biologics.
    • Significant bleeding requiring intervention is rare but more likely to have discrete lesions for endoscopic or angiographic treatment.
    • Ulcers can occur anywhere in the GI tract, including the small bowel, and may erode into a vessel, requiring intervention.

Key Points

• UC vs. Crohn's Disease:
  • UC is more likely to cause visible bleeding, while Crohn's often presents with occult bleeding.
  • Major bleeding in UC is rare and diffuse, making it less amenable to targeted endoscopic treatment.
  • Crohn's may have discrete ulcers that can be treated endoscopically or angiographically.
• Surgical Intervention:
  • Reserved for cases with ongoing bleeding unresponsive to medical therapy or when complications arise.
  • UC may require surgery for toxic megacolon or refractory symptoms, while Crohn's may need surgery for discrete, bleeding lesions.

3. Angiodysplasia/Arteriovenous Malformation (AVM)

• Terminology:
  • Angiodysplasias are also referred to as arteriovenous malformations (AVMs), angiectasias, and vascular ectasia.
  • These are acquired degenerative lesions, distinct from congenital AVMs, thought to result from progressive dilatation of normal submucosal blood vessels due to venous obstruction.
• Location and Prevalence:
  • Can be found anywhere in the GI tract but are most commonly located in the cecum.
  • Prevalence increases with age and is associated with conditions like aortic stenosis and renal failure.
  • There is no gender predilection.
• Clinical Presentation:
  • Similar to diverticular bleeding, angiodysplasia bleeding is typically painless, self-limiting, and intermittent.
  • Unlike diverticular bleeding, angiodysplasia tends to involve venous bleeding, which is less brisk and often presents as occult or chronic bleeding.
  • However, significant hemorrhage can occur in up to 15% of cases.
• Diagnosis:
  • Colonoscopy and angiography are the primary diagnostic tools.
  • CT scan is emerging as a reliable diagnostic modality.
  • On colonoscopy, lesions appear as flat, bright-red, stellate lesions with a surrounding rim of pale mucosa.
  • Angiography may show dilated, slowly emptying veins and sometimes early venous filling.
• Treatment:
  • Incidentally discovered lesions typically do not require treatment.
  • Endoscopic treatment: Noncontact thermal therapy with argon plasma coagulation (APC) is the preferred method.
  • Angiographic techniques can also be used for hemostasis.
  • If bleeding has been localized and endoscopic or angiographic treatments fail, or if bleeding recurs, segmental colon resection (most commonly right colectomy) can be effective.

4. Neoplasms and Lower Gastrointestinal Bleeding (LGIB)

• Colon Cancer:
  • Prevalence: Colon cancer is an uncommon cause of significant LGIB but must be ruled out in any patient with LGIB or iron-deficiency anemia.
  • Bleeding Characteristics: Typically painless, intermittent, and slow.
  • Diagnosis:
    • Colonoscopy is the gold standard for diagnosing colon cancer.
    • In cases of massive hemorrhage, CTA, angiography, or emergent surgery may be necessary.
• Gastrointestinal Stromal Tumor (GIST):
  • Prevalence: GISTs are the most common soft tissue sarcoma in the digestive tract.
  • Bleeding Incidence: Bleeding occurs in 20% to 30% of cases.
  • Common Locations: GISTs most frequently occur in the stomach and small intestine but can also affect the colon.
  • Mechanism of Bleeding: Hemorrhage occurs due to erosion into a blood vessel or alteration of mucosal blood supply by tumor growth.
  • Diagnosis and Treatment:
    • Endoscopy is the best diagnostic tool.
    • Oncologic resection is required based on the malignant risk of the tumor.
• Small Bowel Tumors:
  • Prevalence: Small bowel tumors are uncommon but can cause occult or frank gastrointestinal bleeding (GIB).
  • Diagnosis: Typically diagnosed by small bowel contrast series or spiral CT scan.
  • Treatment: Involves surgical resection of the tumor.
• Intestinal Polyps:
  • Prevalence: Rarely cause significant blood loss but are more commonly associated with iatrogenic bleeding after polypectomy.
  • Pediatric Considerations: In children, intestinal polyps represent the second most common cause of bleeding.
  • Treatment: If bleeding is due to a polyp, it is usually treated with endoscopic therapy.

5. Ischemia and Lower Gastrointestinal Bleeding (LGIB)

• Causes of Insufficient Blood Flow:
  • Cardiogenic shock or low flow states.
  • Mesenteric vascular disease.
  • Diversion of flow from the splanchnic circulation (e.g., embolism, vasopressors, vascular surgery).
• Risk Factors:
  • Cardiovascular disease, peripheral vascular disease, or vasculitis.
  • Recent abdominal vascular surgery.
  • Shock or hypercoagulable states.
  • Use of high-dose vasopressors.
• Mesenteric Ischemia:
  • Should be considered in any patient with bleeding who has a history of the above risk factors.
  • Acute colonic ischemia is the most common form of mesenteric ischemia.
  • Tends to occur in watershed areas such as the splenic flexure and rectosigmoid colon but can be right-sided in up to 40% of cases.
• Clinical Presentation:
  • Characteristic "pain out of proportion to exam".
  • Diarrhea that is often guaiac-positive or bloody due to mucosal degradation.
• Diagnosis:
  • CT Scan may show:
    • Thickened bowel wall.
    • Pneumatosis (air within the bowel wall).
    • Calcification of the mesenteric vasculature.
  • Flexible endoscopy generally confirms the diagnosis by revealing abnormal mucosa.
• Treatment:
  • Supportive care:
    • Bowel rest.
    • IV antibiotics.
    • Blood pressure support.
    • Correction of the low-flow state.
  • In 85% of cases, the ischemia is self-limited and resolves without incident, though some may develop a delayed colonic stricture.
  • Surgery is indicated in 15% of cases due to progressive ischemia and gangrene.
    • Indications for surgery include:
      • Marked leukocytosis.
      • Fever.
      • Ongoing resuscitation.
      • Lactic acidosis.
      • Severe pain.
    • Surgical intervention typically involves resection of the ischemic bowel and end ostomy creation.

6. Infectious Colitis and Lower Gastrointestinal Bleeding (LGIB)

• Overview:
  • Infectious colitis can present with bleeding, and diagnosis is informed by history, laboratory assessment, and culture data.
  • The two most notable organisms that can lead to LGIB are Clostridium difficile and cytomegalovirus (CMV).
• Clostridium difficile Colitis:
  • Etiology: C. difficile colitis represents the overgrowth of a pathogenic bacterium, often occurring after the disruption of normal gut microflora due to antibiotic use.
  • Clinical Presentation:
    • Explosive, voluminous, and sometimes bloody bowel movements can occur, especially in severe cases with associated mucosal sloughing.
    • Profound leukocytosis is often observed.
    • A characteristic foul smell may be present.
  • Treatment:
    • Stop antibiotics that may have caused the disruption in gut flora.
    • Provide supportive care.
    • Administer oral or IV metronidazole, oral vancomycin, or fidaxomicin.
• Cytomegalovirus (CMV) Colitis:
  • Risk Factors: CMV colitis should be suspected in immunocompromised patients who present with bloody diarrhea.
  • Diagnosis:
    • Confirmed by endoscopy with biopsy.
  • Treatment:
    • IV ganciclovir is the treatment of choice.

7. Diverticula and Lower Gastrointestinal Bleeding (LGIB)

• Meckel Diverticulum:
  • Origin: Meckel diverticula are congenital remnants of the vitelline duct and may contain ectopic gastric or pancreatic tissue.
  • Mechanism of Bleeding:
    • Bleeding occurs due to ulceration of neighboring ileal tissue caused by irritation from active gastric mucosa.
    • Bleeding is typically painless and presents as LGIB.
  • Diagnosis:
    • Can be diagnosed using capsule endoscopy, CT, or angiography during active bleeding.
    • Angiographic Findings:
      • May reveal the presence of the vitelline artery, a branch of the superior mesenteric artery, which is pathognomonic for Meckel diverticulum.
    • Meckel Diverticulum Scan:
      • Performed by administering 99mTc-pertechnetate to demonstrate ectopic gastric mucosa, which can be localized with scintigraphy.
  • Treatment:
    • Surgical resection of the affected segment, ensuring the inclusion of the ulcerated ileal tissue typically found on the intestinal wall opposite the diverticulum.
• Small Bowel Diverticula:
  • Prevalence: Small bowel diverticula are less common but can be a source of bleeding, often occult.
  • Diagnosis:
    • Suspected based on a history of known small bowel diverticula, capsule endoscopy, or angiography.
  • Treatment:
    • Surgical resection is the definitive management for bleeding caused by small bowel diverticula.

8. Radiation Therapy and Lower Gastrointestinal Bleeding (LGIB)

• Complications from Radiation Therapy:
  • Radiation therapy, particularly for pelvic cancers, can lead to bleeding-related complications such as enteritis and proctitis.
  • These complications affect 1% to 5% of treated patients.
• Mechanism of Bleeding:
  • Bleeding results from mucosal changes induced by radiation.
  • Endoscopic Findings:
    • Friability (easily damaged tissue)
    • Angioectasias (dilated blood vessels)
    • Ulcerations
• Guidelines and Treatment Recommendations:
  • The American Society of Colon and Rectal Surgeons has published guidelines for treating radiation-induced bleeding.
  • Strongly Recommended Treatments:
    • Formalin 4% to 10%: Applied topically to affected areas to control bleeding.
    • Sucralfate enemas: Used to coat and protect the mucosa.
    • Hyperbaric oxygen therapy: Promotes healing by increasing oxygen delivery to damaged tissues.
  • Endoscopic Therapy:
    • Argon plasma coagulation (APC) is recommended as an effective treatment for radiation-induced bleeding.
    • Risks of APC: Associated with complications such as fistula and stricture formation in 3% of patients.