Gastrointestinal Bleeding Answers 315a normal fluid-filled appendix, effectively ruling out appendicitis. A prompt
surgical consult should be obtained in the presence of intestinal obstruction,
free perforation, abscess, or fistula formation. (d)The presence of diverticulitis
is demonstrated on abdominal CT, which is more sensitive than a barium enema.
Furthermore, both barium injected under high pressure and colonoscopy in the
presence of acute diverticulitis carry the risk of perforation and are relatively
contraindicated.(e)An exacerbation of CD, which may also present with RLQ
pain and heme-positive stool, may be treated with sulfasalazine and steroid
therapy, but neither is appropriate in the treatment of acute diverticulitis.
289.The answer is b.(Tintinalli, pp 539-545.)Pain and bleeding are
common complaints associated with anorectal disorders. A good history
and a thorough physical examination, including a digital rectal examination
and anoscopy should be performed whenever feasible. Anal fissures (ie,
fissures in ano)result from linear tears of the anal canal at or just inferior
to the dentate line and extend along the anal canal to the anal verge. This
area has a rich supply of somatic sensory never fibers. Consequently, anal
fissures are exquisitely painful and represent the most common cause of
painful rectal bleedingin the first year of life and in adults.They are usually
produced by the passage of a large, hard stool but may also occur with severe
diarrhea.
(a)External hemorrhoids also arise from below the dentate line and are
covered with well-innervated squamous epithelium making them painful.
They often cause bleeding, but not as common as anal fissures. (c)Early
anorectal malignancies usually present with nonspecific symptoms, such as
pruritus, pain, and bleeding mixed with stool, and represent less than 5% of
all large bowel malignancies. (d)Internal hemorrhoids are detected by
direct visualization using anoscopy. Uncomplicated internal hemorrhoids
are painless because of lack of sensory innervation. Consequently, they
present with painless, bright red bleeding with defecation. (e)Most venereal
diseases involving the anorectal region present with pruritus, discharge, and
mild to moderate pain or irritation, and may intermittently bleed.
290.The answer is a.(Rosen, pp 1241-1243.)The most serious complications
of PUD include hemorrhage, perforation, penetration, and gastric outlet
obstruction.Hemorrhage,which occurs in 15% of patients, is the most
common complication.
(b)GI perforation occurs when an ulcer erodes through the stomach or
bowel wall and leaks air and digestive contents into the peritoneal cavity.