RUSH-GI Bleeding

1. RUSH-GI Bleeding Arie E Pelta, MD FACS FASCRS Kaplan Medical Center Department of General Surgery Colon & Rectal Surgery

3. Risk Factors for Morbidity and Mortality in Acute Gastrointestinal Hemorrhage • Age >60 yr • Comorbid disease • Renal failure • Liver disease • Respiratory insufficiency • Cardiac disease • Magnitude of the hemorrhage • Systolic blood pressure <100 mm Hg on presentation • Transfusion requirement • Persistent or recurrent hemorrhage • Onset of hemorrhage during hospitalization • Need for surgery

5. Common Causes of Upper Gastrointestinal Hemorrhage

7. Hemoclip that has been applied to a bleeding duodenal ulcer

10. Indications for Surgery in Gastrointestinal Hemorrhage

11. Bleeding Dieulafoy's lesion of the stomach.

12. A, Gastric antral vascular ectasia (GAVE) can be seen in the gastric antrum, giving the stomach a watermelon appearance. B, APC therapy of a GAVE. C, Post-therapy appearance of the GAVE.

13. Nonbleeding esophageal varices secondary to cirrhosis

14. A, Actively bleeding varices. B, Effective control after variceal banding.

15. LGIB

17. LLQGI bleed Tc99m RBC scan

18. Bleeding hemorrhoid

19. Anal fissure

21. 1) A 50 yo pt is brought to ED with retching followed by hematemesis A. Treatment is by balloon tamponade B. Bleeding often stops spontaneously C. It is caused by vomiting D. There is air in the mediastinum E. Diagnosis is made by physical examination

22. 1) A 50 yo pt is brought to ED with retching followed by hematemesis(B.) A. Treatment is by balloon tamponadearterial bleed worse with ballon cause perfororation B. Bleeding often stops spontaneously – 1929 Mallory and Weiss. Tx: gastrotomy and oversew; endoscopic inject epi/cautery C. It is caused by forcefulvomiting against closed cardia D. There is air in the mediastinum E. Diagnosis is made by endoscopicexamination

23. 2) With regard to hemorrhage complicating duodenal ulcer, which is true ? A. It is a more common common complication of DU than is perforation B. Endoscopic treatment before operation decreases mortality C. Endoscopic treatment decreases the need for operation D. Operative management is indicated only if endoscopic treatment fails E. Operative management should not include an acid-reducing procedure

24. 2) With regard to hemorrhage complicating duodenal ulcer, which is true ? (A.) A. It is a more common common complication of DU than is perforation – melena/hematemesis; eroded GDU B. Endoscopic treatment before operation decreases mortality C. Endoscopic treatment decreases the need for operation D. Operative management is indicated only if endoscopic treatment fails – active arterial spurting/visible vessel predict recurrent bleed E. Operative management should not include an acid-reducing procedure – suture ligate GDA vessels. Truncalvagotomy + pyloroplasty; parietal cell vagotomy + antrectomy

25. 3) Concerning “stress” bleeding from acute erosive gastritis, which of the following statements is true ? A. Prophylactic treatments with H2 blockers and anatacids are equally effective B.The incidence of such bleeding has been decreasing C. The site of hemorrhage is most often in the antrum D. There is minimal recurrent bleeding after treatment by oversewing of bleeding sites, vagotomy, and pyloroplasty E. Effective surgical treatment necessitates total gastrectomy

26. 3) Concerning “stress” bleeding from acute erosive gastritis, which of the following statements is true ? (B.) A. Prophylactic treatments with H2 blockers and anatacids are equally effective antacids best titrated to gastric pH; sucralfate works in acid environment B.The incidence of such bleeding has been decreasing C. The site of hemorrhage is most often in the antrum. - proximal fundus D. There is minimal recurrent bleeding after treatment by oversewing of bleeding sites, vagotomy, and pyloroplasty – superficial bleeding E. Effective surgical treatment necessitates total gastrectomy – only IF not controlled by vagotomy and pyloroplasty

27. 4) Concerning Mallory-Weiss syndrome, which of the following statements is true ? A. It is a complication of GE reflux B. It involves esophageal rupture near the GE junction C. Profuse hemorrhage is the most common manifestation D. Bleeding can generally be managed medically E. Vagotomy is indicated for patients requiring surgical treatment

28. 4) Concerning Mallory-Weiss syndrome, which of the following statements is true ? (D.) A. It is a complication of GE refluxretching B. It involves tear mucosa submucosa GE jctesophageal rupture near the GE junction. Tear gastric side lesser curve C. Profuse hemorrhage is 10% the most common manifestation D. Bleeding can generally be managed medically E. Vagotomy is indicated for patients requiring surgical treatment – oversew site of tear no acid reducing operation

29. 5) With regard to Meckel’sdiverticula, which of the following statements are true ? A. They are found in various anatomic forms and clinical presentations in 50% of the population B. They are true diverticula C. All can be visualized on technetium 99m pertechnetate (99mTc) scans D. Most complications occur in the elderly E. Diverticulitis is the most common complication

30. 5) With regard to Meckel’sdiverticula, which of the following statements are true ? (B.) A. They are found in various anatomic forms and clinical presentations in 50% 2% of the population B. They are true diverticula – antimesenteric border 50cm from IC valve, band to umbilicus C. Some All can be visualized on technetium 99m pertechnetate (99mTc) scans – ectopic gastric mucosa peptic ulcer and bleed D. Most complications occur in the elderly pediatrics E. Diverticulitisbleeding, intussusception, obstruction are is the most common complication – diverticulitis is the least complication. Tx: diverticulectomy for diverticulitis; SBR for bleeding. NO prophylactic diverticulectomy for incidental finding unless gastric mucosa or narrow neck

31. 6) Which is true regarding capsule endoscopy of the SB ? A. It is a simple, complication free, outpatient procedure that allows examination of the entire length of small intestine B. Capsule endoscopy is not well tolerated by pts since the capsule is attached to a thin wire externalized through the nose to power the device and transmit images C. Capsule endoscopy of the SB may be completed in 1 day D. The capsule endoscope is reusable E. Endoscopic images are viewed using existing endoscopic imaging systems

32. 6) Which is true regarding capsule endoscopy of the SB ? A. It is a simple, complication free, outpatient procedure that allows examination of the entire length of small intestine – 1.cm in diameter can cause SBO B. Capsule endoscopy is not well tolerated by pts since the capsule is attached to a thin wire externalized through the nose to power the device and transmit images C. Capsule endoscopy of the SB may be completed in 1 day - reach colon in 7hrs D. The capsule endoscope is not reusable E. Endoscopic images are viewed using existing endoscopic imaging systems

33. 7) Which of the following is true regarding SB enteroscopy ? A. Capsule endoscopy has replaced push enteroscopy in the evaluation of the SB B. Capsule endoscopy is available only in specialized centers participating in clinical trials C. Intraoperativeenteroscopy is a simple, safe technique that eliminates the need for the less sensitive technique of capsule endoscopy D. Push enteroscopy is more sensitive and specific than capsule endoscopy in the area that can be examined by push enteroscopy

34. 7) Which of the following is true regarding SB enteroscopy ? (D.) A. Capsule endoscopy has replaced push enteroscopy in the evaluation of the SB – enteroscopyonly examine 50cm from prox or distal direction miss central SB B. Capsule endoscopy is available only in specialized centers participating in clinical trials C. Intraoperativeenteroscopy is a simple, safe technique that eliminates the need for the less sensitive technique of capsule endoscopy - laparotomy D. Push enteroscopy is more sensitive and specific than capsule endoscopy in the area that can be examined by push enteroscopy

35. 8) Which 2 of the following are the most common causes of massive colonic bleeding ? A. Cancer B. UC C. Diverticulosis D. Diverticulitis E. Angiodysplasia

36. 8) Which 2 of the following are the most common causes of massive colonic bleeding ? A. Cancer – occult bleed B. UC – mild bleeding C. **Diverticulosis ** – ruptured vasa recta D. Diverticulitis – mild bleeding E. Angiodysplasia – equal frequency with diverticulosis. Aging, intramural muscular hypertrophy obstructs the submucosal veins cause dilatation and bleed

37. 9) A 69 yo M admitted having 3 maroon colored stools. On arrival he passes more bloody stool and clots. He is pale, orthostatic, and tachycardic. NGT aspirate are bilious. After resuscitation, which is the most appropriate initial test ? A. Angiography B. Nuclear medicine RBC scan C. Rigid proctoscopy D. Colonoscopy E. BE

38. 9) A 69 yo M admitted having 3 maroon colored stools. On arrival he passes more bloody stool and clots. He is pale, orthostatic, and tachycardic. NGT aspirate are bilious. After resuscitation, which is the most appropriate initial test ? (C.) A. Angiography – 1 ml/min. #1SMA most bleeds R colon, #2 IMA , #3 celiac. Embolize, 25% rebleed, 5% ischemia/infarction. Vasopressin intra-arterial, cause arrythmia; when stop 30% rebleed. B. Nuclear medicine RBC scan – sulfur colloid cleared rapid. Technetium detect 0.1 ml/min can repeat scan C. Rigid proctoscopy – anorectal source, UC mucosa D. Colonoscopy – not use when bleed briskly. No bowel prep E. BE – barium will obscure angio; not show bleeding

39. With regard to LGIB. Match L column with R. A. 50% cases bleed Right colon B. Bleeding is arterial and severe C. After 1st episode, rate of recurrent bleed is 25% D. Extravasation of dye during angio can be seen in MOST cases E. Total colectomy is the procedure of choice a. Diverticulosis b. Angiodysplasia c. Both d. Neither

40. With regard to LGIB. Match L column with R. A. 50% cases bleed Right colon – (c) 80% of tics in sigmoid but R side bleeds more B. Bleeding is arterial and severe – (a). Angiodyslasia is Venous. C. After 1st episode, rate of recurrent bleed is 25% - (c) rebleed after 2nd episode is 50%. Angiodysplasia 85% rebleed D. Extravasation of dye during angio can be seen in MOST cases – (a) angiodysplasiaextravasate only 10%. Dense slowly emptying vein, vascular tuft, early filling vein E. Total colectomy is the procedure of choice – (d) prefer limited resection a. Diverticulosis b. Angiodysplasia c. Both d. Neither