Gastrointestinal haemorrhage

1.A 52-year-old man presented to the emergency department reporting black, tarry stools. He had a history of gastric bypass surgery seven years ago for obesity but no other comorbidities. He had been using ibuprofen for back pain. Pulse was 110 beats per minute and blood pressure 100/58 mmHg.

Investigations:

Haemoglobin	95 g/L
Mean corpuscular volume (MCV)	78 fL
Platelet count	395 × 10⁹/L
Serum urea	14 mmol/L
Serum creatinine	80 µmol/L
Prothrombin time	13 seconds

Which of these contributes to the Glasgow-Blatchford score (GBS)?

A. Platelet count

B. Presentation with melaena

C. Previous gastric bypass surgery

D. Prothrombin time

E. Use of non-steroidal anti-inflammatory drugs (NSAIDs)

2.A 23-year-old woman presented after her housemate noticed blood-stained vomit in the bathroom. She had been drinking heavily the night before but was no longer intoxicated. She reported a few episodes of loose, brown stools and nausea, but was able to tolerate oral fluids. Physical examination was unremarkable. She was afebrile with blood pressure of 122/74 mmHg and pulse 86 beats per minute.

Investigations:

Haemoglobin	133 g/L
Platelet count	289 × 10⁹/L
Serum sodium	143 mmol/L
Serum potassium	3.6 mmol/L
Serum urea	5.4 mmol/L
Serum creatinine	115 µmol/L

What is the most appropriate management?

A. Admit for overnight observation

B. Discharge with outpatient gastroscopy

C. Intravenous fluids and anti-emetic

D. Intravenous proton pump inhibitor (PPI) infusion

E. Urgent inpatient gastroscopy

3.A 42-year-old man presented to the emergency department with haematemesis and melaena. He had a past medical history of gout and had recently increased his dose of ibuprofen.

Investigations:

Gastroscopy See Fig. 1.1

Fig. 1.1 Endoscopic image of the second part of the duodenum. See also Plate 1

Which Forrest classification best describes this lesion?

4.A 45-year-old man presented with melaena. He smoked 20 cigarettes per day. He was otherwise fit and well, and not taking any regular medication.

Investigations:

Gastroscopy Duodenal ulcer with a clean base (Forrest III)

With regard to duodenal ulcers, which of the following statements is true?

A. Duodenal ulcers are an infrequent cause of gastrointestinal bleeding

B. Gastric ulcers have a higher risk of perforation

C. PPI infusion given before endoscopy reduces risk of re-bleeding

D. Routine follow-up gastroscopy is required because of high risk of malignancy

E. Most duodenal ulcers are associated with Helicobacter pylori

5.A 63-year-old woman underwent urgent gastroscopy for weight loss, dyspepsia, and melaena. She had a history of type 2 diabetes but with good performance status.

Investigations:

Haemoglobin	54 g/L
Gastroscopy	Partially obstructing pyloric tumour with active diffuse bleeding
Staging computed tomography (CT)	Not yet performed

How should the bleeding be controlled?

A. Adrenaline injection alone

B. Adrenaline injection with placement of multiple clips

C. Bipolar coagulation

D. Haemostatic powder

E. Pyloric stent placement

6.A 73-year-old man with a history of cirrhosis presented with large-volume haematemesis. Emergency endoscopy revealed three columns of Grade 3 oesophageal varices with active bleeding. Despite band ligation, the patient continued to bleed and was not stable for transfer to his local hepatology unit for consideration of porto-systemic shunting.

Which one of the following statements about management of refractory variceal bleeding is true?

A. Balloon tamponade can be safely used for three days

B. Patients must be kept nil by mouth once a self-expanding metal stent (SEMS) has been inserted and the bleeding controlled

C. SEMS is as effective and safer than balloon tamponade

D. SEMS can be useful for managing refractory gastric variceal bleeding

E. SEMS can only be inserted under direct endoscopic guidance

7.A 54-year-old man with Hepatitis C virus-related cirrhosis presented with haematemesis and syncope. Following resuscitation, he underwent urgent gastroscopy.

Investigations:

Gastroscopy

Two columns of Grade 2 oesophageal varices, not bleeding, no red spots. Large varix extending from oesophagus into fundus and towards the greater curvature with active bleeding

What is the most appropriate next management step?

A. Adrenaline injection + clip placement

B. Cyanoacrylate injection

C. Insertion of a Sengstaken-Blakemore tube

D. Transjugular intrahepatic porto-systemic shunt (TIPSS)

E. Variceal band ligation

8.A 69-year-old man presented with breathlessness and a one-week history of melaena. He had a background of a metallic mitral valve replacement and was on warfarin. Blood pressure was 110/65 mmHg with pulse 88 bpm. He had a similar presentation two months previously with a normal gastroscopy. Outpatient colonoscopy to the caecum showed minor sigmoid diverticulosis but no cause of bleeding was found. Bowel preparation was excellent.

Investigations:

Haemoglobin	75 g/L
MCV	69 fL
Serum urea	7.6 mmol/L
Serum creatinine	70 µmol/L
INR	3.2
Repeat gastroscopy	Normal

What is the next most appropriate investigation?

A. CT angiogram

B. CT colonoscopy

C. Magnetic resonance enterography

D. Red cell scintigraphy

E. Video capsule endoscopy (VCE)

9.An 83-year-old woman presented with symptomatic anaemia. Eight units of red blood cells had been transfused in the past two months. Gastroscopy was normal but colonoscopy revealed bleeding angiodysplasia in her ascending colon, which was treated with argon plasma coagulation.

Which of the following investigations would be most important to arrange?