Gastrointestinal Bleeding Answers 311flow and portal blood pressures and is effective in the initial control of
bleeding related to portal hypertension. It should be administered promptly
to all patients with active upper GI bleeding and evidence of liver disease or
portal hypertension until the source of bleeding can be clarified by endoscopy.
(e)A GI consult should be obtained in all cases of high-risk upper GI bleeds.
Most patients with upper GI bleeding should undergo upper endoscopy after
the patient is hemodynamically stable. High-risk patients or those with con-
tinued active bleeding require more urgent endoscopic evaluation to identify
the source of bleeding, determine the risk of rebleeding,and provide hemosta-
sis via sclerotherapy or rubber band ligation.
282.The answer is e.(Rosen, pp 179, 1330-1331, 1345.)The combination
of lower GI bleed with weight loss and decreased appetite points toward
carcinoma, most likely adenocarcinoma of the colon.The lack of esophageal,
abdominal, or rectal pain makes the other choices unlikely, as does thelack of
associated symptoms (nausea, vomiting, or fever). Anemia or rectal bleeding in
an elderly person should be assumed to be malignancy until proven otherwise.
(a)Bleeding with defecation is the most common complaint with
hemorrhoids and unless the hemorrhoids are thrombosed the bleeding is
usually painless. Patients usually report bright red blood on the toilet paper
or in the toilet bowl. Weight loss would not be expected, and only in rare
circumstances is the blood loss substantial. (b)Diverticulitis occurs with
inflammation of a diverticulum, and is the most common complication of
diverticulosis. Patients typically present with persistent abdominal pain.
Initially, the pain may be vague and generalized, but it often becomes localized
to the LLQ. Most patients can be managed medically with bowel rest, hydration,
analgesics, and antibiotics. (c)A Mallory-Weiss tear is a partial tear of the
esophagus that usually results from significant vomiting or retching. (d)Diver-
ticulosis is the presence of diverticula with massive painless lower GI bleeding.
It is one of the most common causes of massive GI bleeding in this population.
In most instances, the bleeding stops spontaneously.
283.The answer is d.(Rosen, pp 210, 1391-1392, 1420, 1447, 1498.)
Patients with coronary artery disease, valvular heart disease, and arrhythmias,
particularlyatrial fibrillation,are at high risk for mesenteric ischemia.In
addition, age greater than 50 years, congestive heart failure, recent myocardial
infarction, critically ill patients with sepsis or hypotension, use of diuretics
or vasoconstrictive medications, and hypercoagulable states place patients at
higher risk. The most common cause of acute mesenteric ischemia is arterial