Git j club LGIB guides16.

1. Dr. Mohamed Alshekhani
Professor in Medicine
MBChB-CABM-FRCP-EBGH
2015
1

2. CME:1
• 1. Acute lower GI Bleeding constitutes what % of all acute GIB:
• A. 10%.
• B. 20%.
• C. 30%.
• D. 40%.
• E. 50%.

3. CME:2
• 2. What % of presumed acute lower GI Bleeding are found to have
upper GI source:
• A. 10%.
• B. 15%.
• C. 20%.
• D. 30%.
• E. 50%.

4. CME:3
• 3. What % of acute GI bleeding is due to small intestinal source:
• A. 1%.
• B. 5%.
• C. 10%.
• D. 15%.
• E. 20%.

5. CME:4
• 4. Bleeding from which colonic areas can present with melena
rather than hematochesia:
• A. Cecum.
• B. Transverse colon.
• C. Descending colon.
• D. Rectum.
• E. Splenic flexture.

6. CME:5
• 5. What % of melena could be from the colon:
• A. 10%.
• B. 20%.
• C. 30%.
• D. 40%.
• E. 50%.

7. CME:6
• 6. In acute lower GIB & hemodynamic instability, an upper GIT
source is best explored by:
• A. upper GI endoscopy.
• B. NT tube.
• C. Capsule endoscopy.
• D. RBC scan.
• E. CT Angio.

8. CME:7
• 7. The following should be the goal in patients with acute lower GIB
before enedoscopic evaluation except:
• A. Normal BP.
• B. Normal heart rate.
• C. Hb > 7 gms in low risk patients.
• D. Hb > 9 gram in high risk patients.
• E. Hb > 9 grams in all patients.

9. CME:8
• 8. In acute LGIB endoscopic hemostasis can be done safely without
the use of reversal agents , with INR up to:
• A. 3.
• B. 4.
• C. 2.5.
• D. 5.
• E. 6.

10. CME:9
• 9. In patients with acute LGIB, endoscopic intervention can be
carried out safely with platelet counts:
• A. 50000.
• B. 10000.
• C. 20000.
• D. 30000.
• E. 5000.

11. CME:10
• 10. Colonic preparation in acute LGI bleeding should be
adminstered over:
• A. One hour.
• B. Two hours.
• C. Three hours.
• D. Five hours.
• E. Six hours.

12. CME:11
• 11. In patients with ongoing acute LGI bleeding, colonoscopy should
be performed after stabilization & adequate preparation within:
• 6 hours.
• B. 12 hours.
• C. 24 hours.
• D. 36 hours.
• E. 48 hours.

13. CME:12
• 12. In patients with acute LGI bleeding but not ongoing,
colonoscopy should performed after stabilization & adequate
preparation within:
• 6 hours.
• B. 12 hours.
• C. When next available.
• D. 36 hours.
• E. 48 hours.

14. CME:13
• 13. Endoscopic interventions indications for acute LGI bleeding compared to
acute UGI bleeding is:
• A. The same.
• B. Different.
• C. Only done for spurting vessels.
• D. Done done for adherent clot.
• E. Contact thermal modalities are preferred.

15. CME:14
• 14. The preferred endoscopic intervention indicated for acute LGI
bleeding due to diverticulosis is:
• A. Clips.
• B. Bands.
• C. Thermal.
• D. APC.
• E. Saline injection only.

16. CME:15
• 15. The preferred endoscopic intervention indicated for acute LGI
bleeding due to angiodysplasia is:
• A. Clips.
• B. Bands.
• C. Thermal.
• D. APC.
• E. Saline injection only.

17. CME:16
• 16. The preferred endoscopic intervention indicated for acute LGI
bleeding post-polypectomy is:
• A. Clips.
• B. Bands.
• C. Thermal.
• D. APC.
• E. Saline injection only.

18. CME:17
• 17. The preferred endoscopic intervention indicated for acute LGI
bleeding from post-polypectomy if through the scope clips are not
available is:
• A. Over the scope clips.
• B. Bands.
• C. Thermal contact therapy.
• D. APC.
• E. Saline injection only.

19. CME:18
• 18. Before surgery is considered for acute LGI Bleeding , the most
important point is:
• A. Localize the bleeding site.
• B. Risk stratification.
• C. Anesthesia tolerance.
• D. Good history taking.
• E. Hb level.

20. CME:19
• 19. The diagnostic modality to localize the bleeding site in acute LGI
Bleeding before angiography is:
• A. CT Angio.
• B. RBC scan.
• C. MRI Angio.
• D. CT Colonography.
• E. Barium enema.

21. CME:20
• 20. Radiographic intervention is indicated for acute LGI bleeding
with all the following characteristics except:
• A. Ongoing bleeding.
• B. High risk patient.
• C. Preparation intolerants.
• D. Colonoscopy intolerants.
• E. All massive bleeders.

22. CME:21
• 21. In the majority of patients with acute LGI bleeding the initial
diagnostic modality is:
• A. Colonoscopy.
• B. CT Angio.
• C. Angiograpy.
• D. Barium enema.
• E. CT colonography.

23. Introduction:
• Acute overt LGIB accounts for ~20% of all cases of GIB.
• Usually leads to hospital admission with invasive diagnostic
evaluations& consumes significant medical resources.
• Most patients with ALGIB stop bleeding spontaneously with
favorable outcomes, morbidity / mortality are increased in older
patients & those with comorbid medical conditions.
• ALGIB classically presents with the sudden onset of hematochezia
(maroon or red blood passed per rectum).
• In rare cases, patients with bleeding from the cecum/right colon can
present with melena (black, tarry stools)
• Hematochezia can be seen in patients with brisk UGIB.
• 15% with ALGIB are ultimately found to have an UGI source.
• LGIB: from the colon or the rectum, SIB (middle GIB) is distinct from
colonic bleeding in terms of presentation, management &
outcomes.

39. Conclusion:
• Hemodynamic status should be initially assessed with intravascular
volume resuscitation started as needed.
• Risk stratification based on clinical parameters should be performed
to help distinguish patients at high&low-risk of adverse outcomes.
• Hematochezia associated with hemodynamic instability may be
indicative of UGI bleeding source &warrants an upper endoscopy.
• In the majority of patients,colonoscopy should be the initial
diagnostic procedure performed within 24 h of patient presentation
after adequate colon preparation.
• Endoscopic hemostasis therapy should be provided to patients with
high-risk endoscopic stigmata of bleeding including active bleeding,
non-bleeding visible vessel, or adherent clot.
• The endoscopic hemostasis modality used (mechanical, thermal,
injection, or combination) is most often guided by the etiology of
bleeding, access to the bleeding site&endoscopist experience.

40. Conclusion:
• Repeat colonoscopy, with endoscopic hemostasis performed if
indicated, should be considered for evidence of recurrent bleeding.
• Radiographic interventions (tagged RBC scintigraphy, CT
angio&angiography) should be considered in high-risk patients with
ongoing bleeding who do not respond adequately to resuscitation &
who are unlikely to tolerate bowel preparation&colonoscopy.
• Strategies to prevent recurrent bleeding should be considered:
NSAIDs use should be avoided in patients with a history of ALGIB,
particularly if secondary to diverticulosis or angioectasia.
• Patients with established CVD who require aspirin (2ndary
prophylaxis) should resume aspirin ASAP after bleeding ceases at
least within 7 days, exact timing depends on bleeding severity,
perceived adequacy of hemostasis& risk of a thromboembolism.
• Surgery for prevention of recurrent LGIB should be individualized&
source of bleeding should be carefully localized before resection.

41. CME:1
• 1. Acute lower GI Bleeding constitutes what % of all acute GIB:
• A. 10%.
• B. 20%.
• C. 30%.
• D. 40%.
• E. 50%.

42. CME:2
• 2. What % of presumed acute lower GI Bleeding are found to have
upper GI source:
• A. 10%.
• B. 15%.
• C. 20%.
• D. 30%.
• E. 50%.

43. CME:3
• 3. What % of acute GI bleeding is due to small intestinal source:
• A. 1%.
• B. 5%.
• C. 10%.
• D. 15%.
• E. 20%.

44. CME:4
• 4. Bleeding from which colonic areas can present with melena
rather than hematochesia:
• A. Cecum.
• B. Transverse colon.
• C. Descending colon.
• D. Rectum.
• E. Splenic flexture.

45. CME:5
• 5. What % of melena could be from the colon:
• A. 10%.
• B. 20%.
• C. 30%.
• D. 40%.
• E. 50%.

46. CME:6
• 6. In acute lower GIB & hemodynamic instability, an upper GIT
source is best explored by:
• A. upper GI endoscopy.
• B. NT tube.
• C. Capsule endoscopy.
• D. RBC scan.
• E. CT Angio.

47. CME:7
• 7. The following should be the goal in patients with acute lower GIB
before enedoscopic evaluation except:
• A. Normal BP.
• B. Normal heart rate.
• C. Hb > 7 gms in low risk patients.
• D. Hb > 9 gram in high risk patients.
• E. Hb > 9 grams in all patients.

48. CME:8
• 8. In acute LGIB endoscopic hemostasis can be done safely without
the use of reversal agents , with INR up to:
• A. 3.
• B. 4.
• C. 2.5.
• D. 5.
• E. 6.

49. CME:9
• 9. In patients with acute LGIB, endoscopic intervention can be
carried out safely with platelet counts:
• A. 50000.
• B. 10000.
• C. 20000.
• D. 30000.
• E. 5000.

50. CME:10
• 10. Colonic preparation in acute LGI bleeding should be
adminstered over:
• A. One hour.
• B. Two hours.
• C. Three hours.
• D. Five hours.
• E. Six hours.

51. CME:11
• 11. In patients with ongoing acute LGI bleeding, colonoscopy should
be performed after stabilization & adequate preparation within:
• 6 hours.
• B. 12 hours.
• C. 24 hours.
• D. 36 hours.
• E. 48 hours.

52. CME:12
• 12. In patients with acute LGI bleeding but not ongoing,
colonoscopy should performed after stabilization & adequate
preparation within:
• 6 hours.
• B. 12 hours.
• C. When next available.
• D. 36 hours.
• E. 48 hours.

53. CME:13
• 13. Endoscopic interventions indications for acute LGI bleeding compared to
acute UGI bleeding is:
• A. The same.
• B. Different.
• C. Only done for spurting vessels.
• D. Done done for adherent clot.
• E. Contact thermal modalities are preferred.

54. CME:14
• 14. The preferred endoscopic intervention indicated for acute LGI
bleeding due to diverticulosis is:
• A. Clips.
• B. Bands.
• C. Thermal.
• D. APC.
• E. Saline injection only.

55. CME:15
• 15. The preferred endoscopic intervention indicated for acute LGI
bleeding due to angiodysplasia is:
• A. Clips.
• B. Bands.
• C. Thermal.
• D. APC.
• E. Saline injection only.

56. CME:16
• 16. The preferred endoscopic intervention indicated for acute LGI
bleeding post-polypectomy is:
• A. Clips.
• B. Bands.
• C. Thermal.
• D. APC.
• E. Saline injection only.

57. CME:17
• 17. The preferred endoscopic intervention indicated for acute LGI
bleeding from post-polypectomy if through the scope clips are not
available is:
• A. Over the scope clips.
• B. Bands.
• C. Thermal contact therapy.
• D. APC.
• E. Saline injection only.

58. CME:18
• 18. Before surgery is considered for acute LGI Bleeding , the most
important point is:
• A. Localize the bleeding site.
• B. Risk stratification.
• C. Anesthesia tolerance.
• D. Good history taking.
• E. Hb level.

59. CME:19
• 19. The diagnostic modality to localize the bleeding site in acute LGI
Bleeding before angiography is:
• A. CT Angio.
• B. RBC scan.
• C. MRI Angio.
• D. CT Colonography.
• E. Barium enema.

60. CME:20
• 20. Radiographic intervention is indicated for acute LGI bleeding
with all the following characteristics except:
• A. Ongoing bleeding.
• B. High risk patient.
• C. Preparation intolerants.
• D. Colonoscopy intolerants.
• E. All massive bleeders.

61. CME:21
• 21. In the majority of patients with acute LGI bleeding the initial
diagnostic modality is:
• A. Colonoscopy.
• B. CT Angio.
• C. Angiograpy.
• D. Barium enema.
• E. CT colonography.