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A quiz testing your knowledge of the causes and complications of GI bleeds! 

Reviewed by: Daniel Mercer and Jonathan Loomes-Vrdoljak

Approach to the patient with Gastrointestinal Bleeding

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Question 1

STEM 1, QUESTION 1 OF 5

An 18-year old male has been diagnosed with extensive ulcerative colitis after presenting to his GP with a 3-week history of bloody diarrhoea and tiredness.

Chronic blood loss can lead to anaemia. In anaemia caused by chronic blood loss, what would the red blood cells look like on a blood smear?
A
Microcytic and hypochromic
B
Macrocytic and hypochromic
C
Normocytic and normochromic
D
Microcytic and normochromic
E
Normocytic and hypochromic
Question 1 Explanation: 
Microcytic (meaning small cells) and hypochromic (meaning pale cells) red cells can be due to chronic blood loss. Blood loss leads to iron deficiency anaemia, which leads to low haemoglobin in red cells.
Question 2

STEM 1, QUESTION 2 OF 5

Extensive colitis is diagnosed when inflammation extends proximally beyond which anatomical structure?  
A
Gastro-oesophageal junction
B
Hepatic flexure
C
Major duodenal papilla
D
Sigmoid colon
E
Splenic flexure
Question 2 Explanation: 
In ulcerative colitis, mucosal inflammation extends upwards from the rectum and is continuous. The degree to which it extends past the rectum can vary. Extensive colitis goes proximally beyond the splenic flexure. https://cks.nice.org.uk/topics/ulcerative-colitis/background-information/definition/
Question 3

STEM 1, QUESTION 3 OF 5

Which of the following is NOT a typical endoscopic finding of ulcerative colitis?
A
Erythematous mucosa
B
Continuous lesions
C
Rectal sparing
D
Only the colon is affected
E
Mucosa which bleeds easily
Question 3 Explanation: 
Ulcerative colitis usually affects the rectum.
Question 4

STEM 1, QUESTION 4 OF 5

Which of the following is NOT a typical extra-intestinal manifestation of ulcerative colitis?
A
Erythema nodosum
B
Pyoderma gangrenosum
C
Uveitis
D
Conjunctivitis
E
Metabolic bone disease
Question 4 Explanation: 
Conjunctivitis is usually caused by a viral or bacterial infection, or allergy. Ulcerative colitis is, however, associated with other red-eye conditions, such as episcleritis and uveitis. https://cks.nice.org.uk/topics/ulcerative-colitis/background-information/extra-intestinal-manifestations/
Question 5

STEM 1, QUESTION 5 OF 5

The patient returns to his GP with a 1-month history of lower back pain and stiffness. The pain is reported to be worse in the morning, lasting for around 40 minutes after getting out of bed. The pain gets better with movement and responds to NSAIDs. Which blood test should the GP consider performing now?
A
Antinuclear antibody (ANA)
B
Anti-Ro and anti-La antibody
C
HLA-B27
D
HLA-DQ8
E
Rheumatoid factor
Question 5 Explanation: 
Axial arthritis, such as ankylosing spondylitis, is another potential extra-articular manifestation of inflammatory bowel disease (IBD). The HLA-B27 gene is linked to both ankylosing spondylitis and IBD and is therefore an important blood test to consider in this case.
Question 6

STEM 2, QUESTION 1 OF 5

A patient in hospital with liver cirrhosis has suffered a sudden episode of vomiting large quantities of bright red blood due to ruptured oesophageal varices. Following the episode, the patient is unable to obey commands for movement but quickly moves his hand towards pain. He opens his eyes when someone calls his name and can maintain a confused conversation.

What is the patient's GCS score?
A
15
B
14
C
12
D
9
E
5
Question 6 Explanation: 
The patient's score is 5 for motor response, 4 for verbal response, and 3 for eye opening response.
Question 7

STEM 2, QUESTION 2 OF 5

Which anatomical feature separates upper and lower GI bleeds?
A
The major duodenal papilla
B
The gastro-oesophageal junction
C
The suspensory ligament of the duodenum (ligament of Treitz)
D
The hepatic flexure
E
The caecum
Question 7 Explanation: 
The suspensory ligament of the duodenum is an anatomical landmark which can be used to separate upper and lower GI bleeding.
Question 8

STEM 2, QUESTION 3 OF 5

Which scoring system should be used as the first risk assessment for patients with acute upper GI bleeds?
A
HAS-BLED score
B
CHA2DS2-VASc score
C
Glasgow-Blatchford Bleeding score
D
The full Rockall score
E
CURB-65 score
Question 8 Explanation: 
The Glasgow-Blatchford bleeding score is used at first assessment. The full Rockall score is used after endoscopy. https://www.nice.org.uk/guidance/cg141/chapter/Key-priorities-for-implementation
Question 9

STEM 2, QUESTION 4 OF 5

Terlipressin is offered to the patient. Which one of the following statements is true about terlipressin?
A
Terlipressin is given orally
B
Terlipressin is a vasopressin analogue
C
Terlipressin is a vasopressin antagonist
D
Terlipressin is given intra-muscularly
E
Terlipressin is an aldosterone-receptor antagonist
Question 9 Explanation: 
Terlipressin binds to vasopressin (aka antidiuretic hormone) receptors, causing splanchnic vasoconstriction to reduce portal pressure and reduce bleeding.
Question 10

STEM 2, QUESTION 5 OF 5

Once stabilised, the patient discusses their chronic heavy alcohol use. Wernicke encephalopathy is a neurological condition which can be associated with alcohol misuse. Deficiency in which vitamin causes this condition?
A
B1
B
B2
C
B4
D
B6
E
B12
Question 10 Explanation: 
Wernicke's encephalopathy is caused by acute B1 (thiamine) deficiency. https://bestpractice.bmj.com/topics/en-gb/405
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