Bleeding from GIT & Diseases of Esophagus- 1 - Free MCQ Practice Test

The image shows a positive test for stool for occult blood also known as Guaiac test. The stool sample to be tested is applied on the strip followed by application of hydrogen peroxide. When the hydrogen peroxide is dripped on to the guaiac paper, it oxidizes the α-guaiaconic acid to a blue coloured quinone.

Type 1 Gastric ulcer is Located near the incisura on the lesser curvature and comprises 60% of all benign gastric ulcers. They are associated with normal to low acid production.
H. pylori have been found to be associated with these ulcers though it occurs even in those who have history of infection.
Modified Johnson classification for gastric ulcers
Type 1 Gastric ulcer is the most common type of gastric ulcer
Table: Gastric ulcer types

• The image shows peripheral placed bowel dilatations with loss of haustrations. It indicates large bowel dilatation.
• When transverse colon/ascending colon diameter is > 6 cm it indicates development of toxic megacolon.
• It occurs in patients of UC and can be triggered by electrolyte abnormalities and narcotics.

Main causes of toxic megacoion:

1. Ulcerative colitis
2. Crohns' disease
3. Pseudomembranous colitis
4. Amoebic colitis
5. Chagas disease

Pneumato sis intestinalis is characterised by presence of intra-mural bowel gas and is seen in necrotising enterocolitis.

• Persistent calibre artery is called Dieulafoy's lesion. It is a large calibre arteriole that runs beneath the gut mucosa and bleeds via pinpoint mucosal erosion.
• For management of bleeding in Dieulafoy's lesion, endoscopic therapy like thermal coagulation or band ligation is effective.
• In case of failure to control bleeding with above methods, angiographic embolization is used.
• Deep enteroscopy is used in patients with diffuse small bowel bleeding like vascular ectasia.

Less frequent causes of UGIB include

1. Erosive duodenitis
2. Neoplasms
3. Aortoenteric fistulas
4. Vascular lesions [including hereditary hemorrhagic telangiectasias (Osler-Weber-Rendu)]
5. Gastric antral vascular ectasia (“watermelon stomach’’)
6. Dieulafoy's lesion (in which an aberrant vessel in the mucosa bleeds from a pinpoint mucosal defect)
7. Prolapse gastropathy (prolapse of proximal stomach into esophagus with retching, especially in alcoholics)
8. Hemobilia
9. Hemosuccus pancreaticus (bleeding from the bile duct or pancreatic duct)

Most patients of hematemesis have a rebleed with in the next 3 days of an episode. UGIE is diagnostic as well as prognostic as a clean based ulcer has a least chance of re-bleed while visible bleeding vessel has the highest chances.

Dieulafoy's Lesions are characterized by a single large tortuous arteriole in the submucosa which does not undergo normal branching or a branch with caliber of 1-5 mm (more than 10 times the normal diameter of mucosal capillaries). The lesion bleeds into the gastrointestinal tract through a minute defect in the mucosa which is not a primary ulcer of the mucosa but an erosion likely caused in the submucosal surface by protrusion of the pulsatile arteriole.

• Approximately 75% of Dieulafoy’s lesions occur in the upper part of the stomach within 6 cm of the gastroesophageal junction, most commonly in the lesser curvature.
•  Extragastric lesions are seen in duodenum (the most common location 14%) followed by the colon (5%), surgical anastamoses (5%), the jejunum (1%) and the esophagus (1%),

Lower Gl bleeding in children

• Neonate = anal fissure
• 1 month - 1year = anal fissure
  • 1 year - 2 years = polyp
  • 2 years = polyp

• Rockall risk scoring system attempts to identify patients at risk of adverse outcome following acute upper gastrointestinal bleeding.
• The scoring system uses clinical criteria (increasing age, comorbidity, shock) as well as endoscopic finding (diagnosis, stigmata of acute bleeding).
• A convenient mnemonic is ABCDE i.e. Age, Blood pressure fall (shock), Co-morbidity, Diagnosis and Evidence of bleeding.

• The presence of multiple corrugated rings and linear furrows all through a narrowed oesophagus is called feline oesophagus. This is seen in eosinophilic esophagitis.
• Histological confirmation of eosinophilic esophagitis is made with demonstration of 15 eosinophils per HPF.

• Normally the aortic arch and left main bronchus cause smooth external indentation of oesophagus.
• However in case of dysphagia lusoria since the patient has aberrant right subclavian artery originating from the left sided aortic arch, the vessel will have to reach the right axilla by crossing the oesophagus at oblique angle.
• The diagnosis is best made in the arterial phase of CT chest where the vessel reading is observed.
• Dysphagia aortica is due to compression of distal esophagus by ectasia or aneurysm of the descending thoracic aorta.

• Manometry is used to diagnose motility disorders (achalasia, diffuse esophageal spasm) and to assess peristaltic integrity prior to the surgery for reflux disease.
• Esophageal manometry, or motility testing, entails positioning a pressure sensing catheter within the esophagus and then observing the contractility following test swallows.
• The upper and lower esophageal sphincters appear as zones of high pressure that relax on swallowing while the inter-sphincteric esophagus exhibits peristaltic contractions.

Diffuse esophageal Spasm is managed with following Interventions:

1. Nitrates and CCB
2. Hydralazine
3. Botulinum toxin
4. Anxiolytics
5. Long myotomy or esophagectomy for severe weight loss or unbearable pain

• Mechanisms of GERD:
  • Transient LES relaxations
  • LES hypotension
  • Anatomic distortion of the esophagogastric junction inclusive of hiatus hernia
• The acid can reflux can lead to chemical tracheitis leading to nocturnal cough and bronchospasm.
• GERD is often diagnosed in the absence of endoscopic esophagitis, which would otherwise define the disease. In setting of partially treated disease ambulatory 24 hours pH monitoring is done and the outcome is expressed as the percentage of the day that the pH was less than 4 (indicative of recent acid reflux), with values exceeding 5% indicative of GERD.

• Zenker's diverticulum, aka pharyngoesophageal diverticulum is a diverticulum of the mucosa of the pharynx, just above the cricopharyngeal muscle. It is a false diverticulum.
• Pharyngo-oesophageal wall herniates through the point of least resistance (known as Killians triangle).
• Zenker diverticulum often causes clinical manifestations such as dysphagia, and sense of a lump in the neck, regurgitation, cough, halitosis, infection, involuntary gurgling noises when swallowing.

The endoscopic view shows corrugation or rings appearance which is suggestive of diagnosis of eosinophilic esophagitis.
To confirm the diagnosis of eosinophilic esophagitis

1. Presence of 15 or more eosinophils per high power field (HPF) on esophageal biopsy
2. Exclusion of other disorders associated with similar clinical, histological, or endoscopic features, especially GERD

• In long-standing achalasia, the esophagus may assume a sigmoid configuration. The diagnostic criteria for achalasia with esophageal manometry are impaired LES relaxation and absent peristalsis.
• High-resolution manometry has somewhat advanced this diagnosis; three subtypes of achalasia are differentiated based on the pattern of pressurization in the nonperistaltic esophagus.
• Because manometry identifies early disease before esophageal dilatation and food retention, it is the most sensitive diagnostic test.

Cervical esophageal diverticulum (Zenker Diverticulum) is located in Killian-Laimer triangle which is located inferior to the cricopharyngeus in the posterior midline above the confluence of the longitudinal layer of esophageal muscle. Laimer’s triangle is covered only by the circular layer of esophageal muscle.

• Endoscopy technique is the procedure of choice for both diagnosis and therapy of these lesions. Endoscopic diagnosis of a Mallory-Weiss tear is readily made by identifying active bleeding, an adherent clot, or a fibrin crust over a mucosal split within or near the gastroesophageal junction.
• A contact thermal modality, such as multipolar electrocoagulation (MPEC) or heater probe, with or without epinephrine injection, is typically used to treat an actively bleeding Mallory-Weiss tear.
• Angiotherapy with either selective vasopressin infusion or embolization of the left gastric artery can be performed in patients whose lesions have failed to respond to endoscopic therapy or who are at high risk of endoscopic complications.