DISTURBANCES OF GI MOTILITY, DIARRHEA, AND CONSTIPATION

Lecturer: RICARDO SANTI, MD, FPSG

1. When pain of any nature is perceives in the abdomen, usually any one, or a combination of, or all of the following is taking place: a. Stretching or tension is applied to a hollow viscus d. A and B b. Distension of the capsule of a solid organ e. B and C c. Crushing of the parietal peritoneum The correct answer is D. A and B Rationale: The abdominal viscera is SENSITIVE only to STRETCHING or TENSION. It is INSENSITIVE to cutting, tearing, or crushing. Free nerve endings are located in the: Capsule (solid organs e.g., Glissons capsule of the liver. Kaya kapag inflamed ang liver, masstretch ang Glissons capsule maiirritate nerve endings sa capsule abdominal pain) Wall (hollow viscus e.g., kapag may obstruction e.g, tumor, hindi makakalabas ang feces, madidistend ang intestine maiirritate nerve endings sa intestinal wall abdominal pain) 2. Intra-abdominal malignancies cause pain by: a. Directly infiltrating sensory nerve fibers b. Outgrowing its blood supply and thereby resulting in ischemia and necrosis c. Causing distention of hollow viscus d. All of the above e. None of the above The correct answer is D. All of the above Rationale: Factors causing pain: a. Tissue hormones (e.g. bradykinin, serotonin, prostaglandin in inflammation) b. Ischemia and necrosis ( concentration of metabolites irritates free nerve endings pain) c. Malignancy (malignant cells can infiltrate sensory nerve endings pain) 3. Least likely location of parietal pain from an acute appendicitis: a. Right lumbar area b. Right lower quadrant c. Periumbilical region

d. e.

Hypogastric area Right upper quadrant

The correct answer is C. Periumbilical region Rationale: The periumbilical abdominal pain in acute appendicitis is of the visceral type, resulting from distention of the appendiceal lumen. Types of Abdominal Pain VISCERAL PARIETAL REFERRED Dull and poorly localized More intense Felt in remote areas Midline location Localized Associated with visceral pain and skin Patient moves and looks for relieving (+) lateralization hyperalgesia position Aggravated by movement Sharp and well-localized Usually lateral than midline ______ 4. ______ 5. ______ 6. ______ 7. ______ 8. Felt in remote areas from its source Dull and poorly localized More intensity due to more nerve endings Usually felt over the midline areas Made worst by jarring or movement A. B. C. D. Psychosomatic pain Parietal/Somatic pain Referred Pain Visceral Pain The correct answers are: CDBDB 9. The visceral pain in early stages of acute appendicitis is usually felt by the patient over the a. Epigastric c. Hypogastric b. Umbilical d. Right lower quadrant

The correct answer is B. Umbilical Rationale: Remember our GIT integration activity case with Dr. Cruz. Initially, pain is felt over the periumbilical area then localized to the RLQ. 10. The epigastric pain in acute pancreatitis typically radiates to the a. RUQ b. LUQ c. Lumbosacral area Rationale: ORGAN AFFECTED ESOPHAGUS STOMACH AND DUODENUM PANCREAS HEPATOBILIARY TRACT JEJENUM up to MIDTRANSVERSE COLON MIDTRANSVERSE COLON up to ANAL CANAL PROJECTION Proximal: Base of neck or suprasternal notch Middle: Sub/midsternal Distal: Xiphoid or base of neck Midepigastric (with possible radiation to the BACK) Epigastric (with possible radiation to the BACK) Epigastric Periumbilical Hypogastric

d. e.

Back Periumbilical area The correct answer is D. Back

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11. The visceral pain in early stages of acute cholecystitis is usually felt by the patient over the a. Epigastric c. Hypogastric b. Umbilical d. Right lower quadrant 12. In classic cases of acute diverticulitis involving the sigmoid colon, the early visceral pain is usually felt by the patient over the: a. Epigastric c. Hypogastric b. Umbilical d. Right Lower Quadrant 13. In a patient presenting with severe abdominal pain, for the history taking and physical examination to be most revealing of the pain etiology, the interviewer/examiner must see the patient: a. When the patients relative who knew the patient very well has arrived b. When the pain medications given by the nurse has taken effect c. When the patient has recovered from his/her sleep d. All of the above e. None of the above The correct answer is E. None of the above Rationale: The best time to interview and examine is at the HEIGHT OF THE PAIN, or at least while the PAIN IS PRESENT. Retrospective evaluation is usually not much clinically rewarding. 14. When the colicky pain in a young patient is disproportionate to the findings on palpation when the abdomen is examined, foremost to be considered among the following differential diagnoses is: a. Acute gastroenteritis d. Diverticular disease b. Biliary ascariasis e. Ectopic pregnancy c. Choledocholithiasis The correct answer is B. Biliary ascariasis Rationale: The keyword here is disproportionate. Some of the pertinent questions to be asked in the history: EVOLVING PATTERN Is the pain visceral to parietal? May help investigate for acute appendicitis and acute cholecystitis. DISPROPORTIONATE PAIN Does the patient manifest ischemia or BILIARY ASCARIASIS? POST-PRANDIAL ONSET Does the patient manifest PUD, pancreatitis, biliary obstruction, or irritable bowel? RELIEF BY BENDING FORWARD Indicates if the pain is of retroperitoneal source 15. Pain from assuming the semi-reclined position or bending forward is suggestive that the origin of the pain is from: a. Pelvic area c. Colonic origin b. Gastro-duodenal source d. Esophageal origin The correct answer is B. Gastro-duodenal source Rationale: Refer to the table in number 14. However, duodenum, colon (ascending and descending), as well as esophagus are all retroperitoneal organs. SADPUCKER, remember?! Di ko alam kung bakit B ang tamang sagot!!! 16. Which of the following is a special maneuver for acute abdomen? a. Cullen sign b. Carvallo sign

c. d.

Psoas sign Kernings sign

The correct answer is C. Psoas sign Rationale: Cullen sign is a bruise/bluish discoloration of the umbilicus; suggestive of acute hemorrhagic pancreatitis or ruptured ectopic pregnancy. Carvallo sign a clinical sign found in patients with tricuspid regurgitation CARDIO not GASTRO Kernigs sign symptom of meningitis NEURO not GASTRO

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17. A digital rectal examination in the setting of acute abdomen, include/s: a. Full finger insertion b. Circumferential sweep c. Tactation for the cul-de-sac (Pouch of Douglas)

d. e.

All of the above None of the above

The correct answer is D. All of the above Rationale: RECTAL DIGITAL EXAMINATION Purpose: To determine presence of para-rectal tenderness or masses in the rectal lumen or cul-de-sac Landmarks: Intersphincteric groove Sacrospinous ligament Anorectal ring Prostate Lower valve of Houston Cervix Ischial spines 18. When the vomiting is of central nervous system in origin, it is expected to be: a. A passive act d. b. Associated with significant nausea e. c. With prominent retching

Projectile Bloody

The correct answer is D. Projectile Rationale: VOMITING is an active act of forceful expulsion of gastric contents while REGURGITATION is a passive act of expulsion of small amounts of esophageal contents, and not associated with nausea. PROJECTILE VOMITING is caused by increased intracranial pressure. It has no nausea nor retching. Delayed (one hour after eating) Soon after eating Relief of pain by vomiting PROJECTILE Gastric outlet obstruction Diabetic neuropathy Postvagotomy states Pyschoneurotic vs pyloro-antral irritability (ulcer) (+) in acid peptic diseases (-) in pancreatic/biliary INCREASED INTRACRANIAL PRESSURE NO NAUSEA NOR RETCHING CNS ORIGIN (TUMOR) Fecaloid odor Intestinal obstruction (ileus) Gastric outlet obstruction (with bacterial overgrowth) GASTRIC OUTLET OBSTRUCTION Gastric outlet obstruction Vomiting first medical abdomen e.g. acute gastroenteritis Pain then vomiting surgical e.g. acute appendicitis

SUCCUSSION SPLASH (CLAPPOTAGE) Voluntarily-induced Vomiting and pain sequence

NO ANTECEDENT NAUSEA

19. When vomiting is associated with the PE finding of (+) succussion splash, it usually signifies: a. Colonic obstruction c. Gastric outlet obstruction b. Biliary obstruction d. Pancreatitis The correct answer is C. Gastric outlet obstruction Rationale: Refer to the table above. 20. Encopresis may be associated with: a. Large stool diarrhea b. Infectious etiologic agent c. Self-limiting course

d. e.

All of the above None of the above

The correct answer is E. None of the above Rationale: ENCOPRESIS paradoxical diarrhea in constipation Overflow diarrhea in constipation Caused by tumor in the recto-sigmoid or anorectal area obstruction fecal retention colon irritation goblet cells will secrete mucus to lubricate the colon more frequent defecation (mostly of mucus with some amount of blood) It is actually constipation, not diarrhea, caused by a lesion or tumor, not infectious agent. As long as the tumor is there, it will not resolve, hence not self-limiting. 21. Paradoxical diarrhea is usually associated with: a. Pelvic abscess b. Amoebiasis

Anorectal new growth Pancreatitis The correct answer is C. Anorectal new growth Rationale: Anorectal new growth is a neoplasm, a tumor in the anorectal area. Refer to discussion of encopresis in number 20. AMOEBIASIS is the prototype of dysentery. DYSENTERY is a type of SMALL STOOL diarrhea characterized by prominent TENESMUS, usually BLOODY and MUCOID, and of LARGE INTESTINAL origin.

c. d.

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22. Constipation maybe attributable to the intake of: a. Calcium containing antacids b. Anticholinergic agents c. Iron containing vitamins Rationale:

d. e.

All of the above None of the above The correct answer is D. All of the above

23. Constipation may mean: a. Small stools b. Dyschezia c. Rectal fullness

d. e.

All of the above None of the above

The correct answer is D. All of the above Rationale: Dyschezia is another term for constipation. One has a feeling of rectal fullness due to the inability to pass out stool. Small stools are a result of excessive mucosal absorption by the colon, which one of the mechanism of constipation. 24. Clinical features of dysentery: a. Belongs to large stool diarrhea classification b. Usually of small intestinal origin c. Very watery stools thereby prone to severe dehydration

d. e.

Usually with mucus and hematochezia Tenesmus is uncommon

The correct answer is D. Usually with mucus and hematochezia Rationale: Refer to discussion in number 21 regarding dysentery. Hematochezia is the presence of fresh blood in the stool. SMALL STOOL LARGE STOOL Large intestinal origin Small intestinal origin More frequent BMs Less frequent BMs Prominent tenestmus Absent tenesmus Bloody/mucoid stools Watery, greasy, foul smelling stools Hypogastric pain Periumbilical pain 25. Bloody, mucoid diarrhea with tenesmus are the hallmark symptoms of: a. Giardiasis b. Amoebiasis c. Cholera Rationale: Again, the prototype of dysentery is amoebiasis. 26. The most cost-effective diagnostic workup for a young adult presenting with asymptomatic anemia with no definite risk factors for serious colonic condition is: a. Colonoscopy d. Colonic transit studies b. Barium enema e. Fecal occult blood test c. Capsule endoscopy The correct answer is E. Fecal occult blood test Rationale: Among the choices, pinakamura ang FOBT kasi tae lang kailangan, non-invasive. 27. A patient is complaining of passage of fresh blood admixed with stools. The diagnostic/laboratory procedure least indicated in this situation is: a. Proctosigmoidoscopy d. CBC, blood typing, bleeding time b. Barium enema (double contrast) e. Fecal occult blood test c. Colonoscopy The correct answer is E. Fecal occult blood test Rationale: FOBT checks for occult or hidden blood in the stool. The patient is the case is already complaining of passage of fresh blood admixed with stools.

d. e.

Shigellosis Viral enteritis The correct answer is B. Amoebiasis

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28. A middle-aged patient with a strong family history for colon malignancy comes over with altered bowel pattern and weight loss should undergo: a. Total colonoscopy d. Colonic transit studies b. FOBT e. Double contrast X-ray c. CT Scan/MRI of the whole abdomen The correct answer is A. Total Colonoscopy Rationale: COLONOSCOPY OR COLOSCOPY is the endoscopic examination of the large bowel and the distal part of the small bowel with a CCD camera or a fiber optic camera on a flexible tube passed through the anus. It can provide a visual diagnosis (e.g. ulceration, polyps) and grants the opportunity for biopsy or removal of suspected colorectal cancer lesions. 29. The following are indicated in the empirical management of diarrhea EXCEPT: a. Ciprofloxacin b. Oral rehydrating solutions c. Opiates d. Kaolin-pectin The correct answer is C. Opiates Rationale: PRINCIPLES OF MANAGEMENT for DIARRHEA Fluid and electrolyte replacement (ORS + pectin, Gatorade or IV fluids) Antidiarrheal Bismuth subsalicylate Kaolin-pectin Antibiotics Specific antimicrobials based on culture and sensitivity test Ciprofloxacin or cotrimoxazole while awaiting results OPIATES AND ANTICHOLINERGIC drugs are usually CONTRAINDICATED 30. Secretory diarrhea may be associated with intake of, EXCEPT: a. Metformin b. Bisacodyl

c. d.

Senna Antacids

The correct answer is: D. Antacids Rationale: TYPES OF DIARRHEA BASED ON MECHANISM OSMOTIC SECRETORY EXUDATIVE Non-absorbable solute Active secretion into the lumen by: Mucosal sloughing Laxatives (castor oil, bisacodyl, senna) Amoebiasis Causes: Other drugs (metformin, prostaglandins) Shigellosis Laxatives (lactulose, Mg(OH)2) Toxins (seafood/shellfish, bacterial) Enteroinvasive E. coli Acarbose (-glucosidase inhibitor) Magnesium-containing antacids can cause osmotic diarrhea. Aluminum-containing antacids can cause constipation.

TO GOD BE THE GREATEST GLORY!

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JAUNDICE AND ABNORMAL LIVER SPAN

Lecturer: DEAN DINA C. GONZALES, MD, MPHED, FPCP, FPSG, FPSDE
Introduction: 2 main pathophysiologic mechanisms of jaundice: a. Hepatocellular disease b. Cholestasis Differential Diagnosis of Yellowish Skin a. Carotenoderma b. Quinacrine treatment (antimalarial) c. Excessive exposure to phenols Bilirubin production: 250-300 mg/day 70-80% from breakdown of senescent RBC (main source) 20-30% from prematurely destroyed erythroid cells, turnover of hemoproteins 1. Bilirubin glucoronides are excreted across the canalicular membranes into the bile canaliculi by: a. Passive diffusion b. Renal glomerular filtration c. Carrier-mediated transport d. ATP-dependent transport process

Rationale: BILIRUBIN FORMATION and METABOLISM 1. Oxidative cleavage of alpha bridge of porphyrin group to open heme ring catalysed by HEME OXYGENASE 2. Reduction of central methylene bridge of bilirubin catalysed by BILIRUBIN REDUCTASE 3. Unconjugated bilirubin + Albumin (main carrier of bilirubin in the blood para matransport sa liver) 4. Transported to the liver 5. Hepatic uptake without albumin (Hihiwalay si bilirubin kay albumin, tagatransport lang si albumin) 6. Unconjugated bilirubin coupled predominantly to GLUTATHIONE S-TRANSFERASE 7. In the endoplasmic reticulum, Bilirubin + glucoronic acid Bilirubin mono/diglucoronide (catalysed by UGT/URIDINE DIPHOSPHATE GLUCORONOSYLTRANSFERASE) 8. Bilirubin glucoronides are excreted across the canalicular membrane into the bile canaliculi by ATP-dependent transport process mediated by canalicular membrane protein called MULTIDRUG RESISTANCE-ASSOCIATED PROTEIN-2 (MRP2) 2. Which of the following provides an estimate of unconjugated bilirubin a. Difference between total and direct bilirubin b. Direct reacting bilirubin c. Difference between indirect and direct bilirubin d. Sum total of direct and indirect bilirubin

Rationale: MEASUREMENT OF SERUM BILIRUBIN NORMAL SERUM BILIRUBIN (VAN DEN BERGH METHOD) DIRECT REACTING

TOTAL SERUM BILIRUBIN INDIRECT FRACTION

<1 mg/dl (17 mol/L 30% provides approximate determination of conjugated bilirubin in serum 0.3 mg/dL (5.1 mol/L) Conjugated bilirubin + unconjugated bilirubin The amount that reacts after the addition of alcohol. Difference between total and direct bilirubin Provides estimate of unconjugated bilirubin in serum

3.

Unconjugated bilirubin is characterized as being: a. Filtered in the renal glomeruli b. Reabsorbed in the proximal renal tubules c. Bound to albumin in serum d. All of the above

Rationale: MEASUREMENT OF URINE BILIRUBIN UNCONJUGATED BILIRUBIN Always bound to albumin in serum Not filtered in kidney Not found in urine

CONJUGATED BILIRUBIN Filtered at glomerulus Majority reabsorbed by proximal tubules Small fraction excreted in urine

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4.

A jaundiced patient who appears to be recovering clinically showed slow decline in the serum bilirubin elevation. This can be attributed to: a. Conjugated bilirubin in the albumin-linked form b. Prolonged half-life of bilirubin c. Hypoalbuminemia in liver diseases d. Renal glomerular filtration of albumin

Rationale: UNEXPLAINED ENIGMAS IN JAUNDICED PATIENTS WITH LIVER DISEASE Can be explained by prolonged half-life of ALBUMIN (not of bilirubin) 1. Some patients with conjugated hyperbilirubinemia do not exhibit bilirubinuria during the recovery phase of their disease because a certain fraction of conjugated bilirubin is still bound to albumin and therefore not filtered by renal glomeruli. 2. Elevated serum bilirubin levels decline more slowly than expected in some patients who otherwise appear to be recovering satisfactorily. o Late in recovery phase of hepatobiliary disorders all conjugated bilirubin may be in albumin linked form o Its value in serum falls slowly because of long half-life of albumin 5. Which of the following is associated with high serum levels of gamma glutamyl transferase activity? a. Progressive familial Intrahepatic Cholestasis (FIC) b. Benign Recurrent Intrahepatic Cholestasis (BRIC) c. Dubin Johnson Syndrome d. Rotors Syndrome

Rationale: UGT/URIDINE DIPHOSPHATE GLUCORONOSYLTRANSFERASE o If completely absent CRIGLER-NAJJAR TYPE I o If mutated CRIGLER-NAJJAR TYPE I o If reduced activity GILBERTS SYNDROME HEREDITARY DEFECTS IN BILIRUBIN CONJUGATION UNCONJUGATED HYPERBILIRUBINEMIA CRIGLER-NAJJAR TYPE I CRIGLER-NAJJAR TYPE II GILBERTS SYNDROME Exceptionally rare condition in neonates More common than type I Marked by impaired conjugation of Complete absence of bilirubin UDP Mutation in bilirubin UDP glucuronosyl bilirubin due to reduced bilirubin UDP glucuronosyl transferase activity transferase gene causes reduced but not glucuronosyl transferase activity Unable to conjugate and excrete bilirubin completely absent enzyme activity Mild unconjugated hyperbilirubinemia < 6 Characterized by severe jaundice (bilirubin Patients live to adulthood mg/dL > 20 mg/dL) + neurologic impairment 2 Serum bilirubin: 6-25 mg/dL Serum bilirubin levels may fluctuate and kernicterus jaundice often identified only during Treatment: Phenobarbital Induces Frequently leads to death in infancy or periods of fasting UDP glucuronosyl transferase activity childhood Very common (+) marked jaundice but survives into Only effective treatment: Orthotopic liver 3-7% adulthood with intercurrent illness transplantation Male predominance (2-7:1) (surgery) Kernicterus FAMILIAL DEFECTS IN HEPATIC EXCRETORY FUNCTION CONJUGATED HYPERBILIRUBINEMIA BENIGN RECURRENT DUBIN-JOHNSON ROTORS PROGRESSIVE FAMILIAL INTRAHEPATIC INTRAHEPATIC SYNDROME SYNDROME CHOLESTASIS (FIC) CHOLESTASIS (BRIC) Defect is a point (+) problem with Rare disorder Phenotypically related syndromes mutation in the gene for hepatic storage of characterized by Byler disease/Progressive FIC Type 1 canalicular multi-specific bilirubin recurrent attacks of Presents in early infancy as cholestasis, initially organic anion pruritus and jaundice episodic; mutation in FIC1 gene transporter Familial recessive Type 2 (+) altered excretion of pattern of inheritance mutation in protein sister of p-glycoprotein, major bilirubin into bile ducts Jaundice and pruritus bile canalicular exporter of bile acids (BSEP bile salt may be debilitating and excretory protein) Both present with asymptomatic jaundice prolonged Type 3 Bilirubin measurement is abnormal, but all other associated with mutation of MDR3- protein essential workups are normal for normal hepatocellular excretion of phospholipids Typically in 2nd generation of life and across the bile canaliculus differentiation possible but clinically unnecessary Associated with high serum levels of gamma glutamyl due to their benign nature transferase activity ______ 6. ______ 7. ______ 8. ______ 9. ______ 10. Neurologic impairment/kernicterus Recurrent pruritus and jaundice Initially episodic cholestasis Jaundice during periods of fasting with fluctuating serum bilirubin Asymptomatic jaundice, typically in 2nd generation of life A.Point mutation in the gene for canalicular multispecific organic anion transporter B. Reduced bilirubin UDP glucoronosyl transferanse activity C. Mutation in protein sister p glycoprotein D. Mutation in bile salt excretory protein (BSEP) E. Absent bilirubin UDP glucoronosyl transferase The correct answers are: EDCBA

DUBIN-JOHNSON SYNDROME GILBERTS SYNDROME FIC BRIC CRIGLER-NAJJAR TYPE I

Point mutation in the gene for canalicular multispecific organic anion transporter Reduced bilirubin UDP glucoronosyl transferanse activity Mutation in protein sister p glycoprotein Mutation in bile salt excretory protein (BSEP) Absent bilirubin UDP glucoronosyl transferase

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A.) UNCONJUGATED HYPERBILIRUBINEMIA B.) CONJUGATED HYPERBILIRUBINEMIA 1. Impaired Hepatic Uptake 2. Impaired conjugation 3. Cholestasis 4. Increased bilirubin production 5. Backward leakage of bile pigments Answers: AABAB UNCONJUGATED HYPERBILIRUBINEMIA Overproduction of bilirubin Impaired hepatic uptake Impaired conjugation CONJUGATED HYPERBILIRUBINEMIA Cholestasis Due to decreased excretion into bile ductules or backward leakage of pigments

DISORDERS OF BILIRUBIN METABOLISM LEADING TO UNCONJUGATED HYPERBILIRUBINEMIA

From Past Semestrals (2013): For rationale, please refer to the discussion above. 1. Which of the following disorders will most likely present with bilirubinuria? a. Hemolysis b. Crigler-Najjar Type I

c. d.

Gilberts Syndrome Rotors Syndrome

Rationale: Keyword is bilirubinuria. Bilirubin is excreted in the urine, thus, conjugated. Among the choices, conjugated hyperbilirubinemia is found in Rotors Syndrome. 2. Increased serum conjugated bilirubin is observed in disorders due to: a. Backward leakage of bile pigments b. Impaired hepatic transport

c. d.

Overproduction of bilirubin Impaired hepatic uptake of bilirubin

3.

Unconjugated hyperbilirubinemia is due to reduced UDP glucoronosyl transferase gene activity? a. Dubin Johnson Syndrome c. BRIC b. Crigler-Najjar Type II d. Rotors Syndrome Falsely decreased liver span can be appreciated in: a. Consolidation pneumonia b. Pleural effusion FALSELY INCREASED LIVER SPAN 1. Consolidation (pneumonia) 2. Pleural effusion 3. Atelectasis/fibrosis

4.

c. d.

Emphysema Atelectasis

FALSELY DECREASED LIVER SPAN 1. Pneumothorax 2. Emphysema

5.

Palpable liver with true hepatomegaly can be appreciated in the presence of: a. Emphysema c. b. Subdiaphragmatic abscess d.

Riedels lobe Extramedullary hematopoiesis

CONDITIONS PRESENTING WITH PALPABLE LIVER WITHOUT HEPATOMEGALY 1. Right diaphragm displaced downwards (e.g. emphysema, asthma) 2. Subdiaphragmatic lesions (e.g. abscess) 3. Aberrant lobe of the liver (Riedels lobe) 4. Extremely thin or relaxed abdominal muscles 5. Occasionally present in normal persons Normal liver span is 8-12 cm.

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1. 2.

3.

CAUSES OF HEPATOMEGALY Vascular congestion C. Glycogen (diabetes, esp. after insulin excess) e.g. CHF, hepatic vein thrombosis D. Amyloid Bile duct obstruction E. Iron (hemochromatosis and hemosiderosis) e.g. lesion in common duct hepatomegaly 4. Inflammatory disorders biliary cirrhosis A. Hepatitis drugs, infectious Infiltrative disorders B. Cirrhosis except late stage small liver A. Bone Marrow and reticuloendothelial cells 5. Tumors a. Extramedullary hematopoeisis A. Primary b. Leukemia B. Metastatic c. Lymphoma 6. Cysts B. Fat A. Polycystic disease a. Fatty liver (alcohol, diabetes or toxins) B. Congenital hepatic fibrosis

GI BLEEDING: HEMATEMESIS, MELENA AND HEMATOCHEZIA

Lecturer: MA. TERESITA GAMUTAN, MD, FPCP, FPSG, FPSDE
COMMON PRESENTATIONS OF BLEEDING HEMATEMESIS Vomiting of red blood or coffee-ground materia MELENA Passage of black, tarry, foul-smelling stool HEMATOCHEZIA Passage of bright red or maroon blood from the rectum OCCULT GI BLEEDING Identified in the absence of overt bleeding by a fecal occult blood test or the presence of iron deficiency Detected by a chemical change: Prepare the patient Do not ingest red meat and NSAIDs False Positive Avoid Vit C False Negative At least 20 mL is needed to be positive BLOOD LOSS/ SYMPTOMS OF ANEMIA Pallor Dizziness Light-headedness Headache Dyspnea

Upper GI bleeding above the ligament of Treitz (esophagus, stomach, duodenum)

Can be both upper or lower GI bleeding (usually upper) 60 mL: minimum criteria Blood must be present in GIT for at least 14 hours Blood + HCl = hematin black

Lower GI bleeding; can also be a MASSIVE upper GI bleeding If massive GI bleeding, check VS for hypotension and tachycardia

The color depends on: a. concentration of HCl b. duration of HCl and blood contact

Most common source of acute upper GI bleeding: ULCERS (GASTRIC or DUODENAL) Other sources of Upper GI Bleeding: VARICES, MALLORY-WEISS TEARS, GASTRODUODENAL EROSIONS, EROSIVE ESOPHAGITIS, MALIGNANCY Most common source of lower GI bleeding: HEMORRHOIDS 1. The presence of a mass in a rectal examination will present with: a. Blackish stool b. Bloody stool A patient with ileo-cecal tuberculosis will most likely present with: a. Melena b. Hematochezia

c. d.

Hematemesis All of the above

2.

c. d.

Hematemesis All of the above

3.

The minimum amount of GI blood loss that will result to single blackish stool or melena is a. 20 mL c. 100 mL b. 60 mL d. 150 mL The color of vomitus in a 24 year old patient with hematemesis is dependent on the: a. Gastric pepsin present b. Duration of HCl contact with blood c. Size of gastric ulcer d. Distensibility of the gastric wall The usual source of gastrointestinal bleeding above the ligament of Treitz is a. Esophageal varices c. b. Gastric and duodenal ulcers d. The most common source of bleeding below the ligament of Treitz is: a. Small intestine b. Cecum

4.

5.

Small intestinal malignancy GERD

6.

c. d.

Anorectal area Sigmoid

Rationale: Hemorrhoids, the most common source of lower GI bleeding, are found in the anorectal area.

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7.

A 45-year old male presented with melena. EGD and colonoscopy revealed unremarkable findings. The most likely source of bleeding is: a. Large intestine b. Small intestine c. Stomach d. Esophagus

Rationale: The usual endoscope can only reach the duodenum, while the colonoscope can only reach the terminal ileum; since the small intestine is beyond the reach of the usual scope, the small intestine is the major source of obscure (uncertain) bleeding. 8. The best initial parameter to assess a 49 year old male with gastrointestinal bleeding is to check the a. CBC b. Sensorium c. Heart rate and blood pressure d. Presence of pallor

Rationale: VITAL SIGNS: Heart rate and blood pressure Postural changes in heart rate or blood pressure, tachycardia; recumbent hypotension Vasovagal reaction with bradycardia during bleeding episodes Hemoglobin in the CBC may be normal, or slightly decreased initially o In acute bleeding, there is proportionate loss in plasma and RBC initial hemoglobin may be normal o For compensation, the extravascular fluid goes intravascularly and the RBC becomes diluted (initially) o Hemoglobin then slightly decreases, and takes 72 hours to stabilize back to normal 9. What do you expect in the initial hemoglobin of a 23-year old female with acute bleeding of 2 hours duration? a. Normal b. Low c. High

10. The source of GI bleeding in a 19year old male with 4 days history of bloody mucoid diarrhea and fever is a. Colonic malignancy b. Diverticulosis c. Amoebic colitis d. Haemorrhoids e. Angiodysplasia Rationale: Refer to the table below:

11. In 69 year old cirrhotic male with hematemesis, the most likely source of bleeding would be: a. Ruptured esophageal varices b. Bleeding duodenal ulcer c. Mallory-Weiss tear d. Tumor in the jejunum 12. The important data to include in the history of a patient with Mallory-Weiss Tear is the presence of: a. Forceful coughing or vomiting b. Intake of NSAIDs c. Fresh blood in the stool d. Change in bowel habits Rationale: Refer to the table. Intake of NSAIDs is associated with gastritis and PUD. Bleeding in Mallory-Weiss tear presents as hematemesis not hematochezia. Change in bowel habits is associated with colonic malignancy. 13. A 39 year old male with gastric outlet obstruction will most likely present with: a. Hematemesis b. Melena c. Hematochezia d. All of the above Rationale: Since, there is obstruction in the gastric outlet, blood can pass to the small intestine. There is nowhere for blood to go but up, hence hematemesis. Memorize this table by heart!

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14. The most likely source of upper gastrointestinal bleeding in a 50-year old male patient with obliterated Traubes space and positive fluid wave is: a. Gastric ulcer b. Esophageal malignancy c. Gastric malignancy d. Esophageal varices Rationale: Obliterated Traubes space indicates splenomegaly. Positive fluid wave indicates ascites. Splenomegaly and ascites are signs of liver cirrhosis. One of the complications of liver cirrhosis is bleeding esophageal varices which may manifest as hematemesis. Refer to the table. 15. A 75-year old female consulted because of significant weight loss, alternating diarrhea and constipation, and hematochezia. The most likely source of LGIB is: a. Haemorrhoids b. Colonic diverticulosis c. Angiodysplasia d. Colonic malignancy e. Colitis Rationale: Again, refer to the table. 16. GI bleeding in a 50-year old alcoholic male with jaundice, splenomegaly, and ascites is most likely due to: a. PUD b. Esophageal varices c. GERD d. Gastric malignancy e. All of the above 17. Epigastric pain, weight loss, early satiety, and hematemesis in a 69-year old male is most likely due to: a. PUD b. Esophageal varices c. GERD d. Gastric malignancy e. None of the above 18. Endoscopically visualized gastric subepithelial haemorrhage and erosions secondary to ingestion of NSAIDs: a. PUD b. Esophagitis c. Hemorrhagic duodenitis d. Erosive gastropathy e. All of the above Rationale: HEMORRHAGIC & EROSIVE GASTROPATHY Endoscopically visualized subepithelial hemorrhages and erosions Lesions are limited only to the mucosal layer, thus they do not cause major GI bleeding Caused by history of ingestion of NSAIDs, alcohol, and stress Treatment: o H2-receptor antagonist o Sucralfate 19. Majority of obscured gastrointestinal (GI) bleeding are due to what sources a. Large intestine b. Small intestine c. Stomach 20. The most common cause of lower GI bleeding is/are: a. Colonic malignancy b. Anal fissure and haemorrhoid c. Colonic diverticular disease

d. e.

Esophagus All of the above

d. e.

Angiodysplasia All of the above

TO GOD BE THE GREATEST GLORY!

READ AT YOUR OWN RISK!

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