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Here are seven more questions to test your understanding of the management, investigation and pathophysiology of GI bleeds.

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GI bleeds 2

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Question 1

STEM 1 - Question 1

A 27 year old male patient presents to ED with abdominal pain in the left lower quadrant and a three week history of bloody diarrhoea. They are apyrexic and have painful red sores on their knees.

What is the most likely diagnosis?
A
Diverticulitis
B
Gastroenteritis
C
Haemorrhoids
D
Irritable bowel syndrome
E
Ulcerative colitis
Question 1 Explanation: 
The clues in this question were the patient's age, diarrhoea, and the tender sores on the legs. These sores would have been erythema nodosum and of the five differentials to choose from, UC is the only one likely to cause them. Diarrhoea in IBS tends not to be bloody. Haemorrhoids are more commonly associated with constipation. The patient doesn't have a fever so gastroenteritis is less likely. And at 27 years old, they are unlikely to be suffering from diverticulitis, although in an older patient this may present in a similar way, without the rashes.
Question 2

Stem 1 - Question 2

Which HLA region is most commonly associated with ulcerative colitis?
A
HLA-B27
B
HLA-B29
C
HLA-DR2
D
HLA-DR3
E
HLA-DR4
Question 2 Explanation: 
HLA-B27 is most commonly associated with UC. It is also associated with ankylosing spondylitis and reactive arthritis. B29 is associated with Type I diabetes. DR2 is associated with SLE, DR3 with Sjogren’s and DR4 with type I diabetes and rheumatoid arthritis.
Question 3

Stem 1 - Question 3

True or False: IBD can increase your chances of osteoporosis?
A
True
B
False
Question 4

Stem 1 - Question 4

True or False: UC increases the risk of colorectal cancer?
A
True
B
False
Question 4 Explanation: 
According to meta-analysis published in 2005, UC increases the risk of colorectal cancer 2.4-fold, although it notes that some of the data was several decades old. It also increases the risk of small bowel cancers. See American Journal of Gastroenterology. 100(12), 2724-2729.
Question 5

Stem 1 - Question 5

Which scale can be used to assess the severity of UC in adults?
A
Blatchford Socre
B
Oakland Score
C
Rockall Score
D
PUCAI
E
Truelove and Witts Score
Question 5 Explanation: 
All of the options were different tools used to assess the severity of GI bleeds. PUCAI is the severity index used in children and young people. The Oakland Score is used to assess risk of rebleeding and death following a lower GI bleed. The Blatchford (aka Glasgow-Blatchford) and Rockall Scores are used to assess upper GI bleeds.
Question 6
A 57 year old male is admitted to ED after vomiting up approximately a cup-full of blood. He is tachycardic. Apart from epigastric pain associated with the recent vomiting, he denies any history of acid reflux or indigestion. He denies any significant past medical history and is on amlodipine to control his blood pressure. He doesn’t smoke but is a regular drinker of alcohol, drinking up to 30 units/week. On examination, his liver is palpable two finger breadths below the ribs, he has several red spots on his chest with lines radiating from them that disappear when pressed, and has pitting oedema on his ankles. Given his presentation, what treatment should be started?
A
Adrenaline
B
Lansoprazole
C
Prothrombin complex concentrate
D
Terlipressin
E
Vitamin K
Question 6 Explanation: 

The patient’s alcohol intake and findings on examination suggest the patient has liver damage (although the pitting oedema could also be caused by his calcium channel blocker). Therefore, it is likely he has portal hypertension and the haematemesis is caused by ruptured oesophageal varices. The immediate treatment is terlipressin. This should also be given with a prophylactic antibiotic. See https://www.nice.org.uk/guidance/cg141/chapter/1-Guidance.

Proton pump inhibitors should not be given to patients with an upper GI bleed until a non-variceal bleed is confirmed via endoscopy. Adrenaline can sometimes be given as part of the treatment to repair non-variceal bleeds during endoscopy.

As the patient is not on warfarin, he does not need prothrombin complex concentrate which would be used to reverse the effects of warfarin. Interestingly, the NICE guidelines do not indicate that patients on warfarin need vitamin K, although British Society of Gastroenterology guidelines for the management of lower GI bleeds recommend reversing warfarin with both prothrombin complex concentrate and vitamin K.

Question 7
A 76 year old male is admitted to hospital following acute bleeding from the rectum. He is haemodynamically unstable and DRE and anoscopy are inconclusive. What is the most appropriate imaging modality to investigate the bleeding further.
A
Abdominal x-ray
B
Colonoscopy
C
Colonoscopy plus upper GI endoscopy
D
CT angiography
E
Sigmoidoscopy
Question 7 Explanation: 
2019 British Society of Gastroenterology guidelines (https://gut.bmj.com/content/68/5/776) recommend that for patients who are haemodynamically unstable, or who have a shock index (HR/systolic BP) >1, CT angiography is recommended before planning any endoscopic or radiological therapy. It is the fastest and least invasive investigation at the time. Stable patients should receive a colonoscopy. If the CTA is inconclusive, an upper GI endoscopy is then indicated in unstable patients.
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