Gastrointestinal Bleeding — MCQs

10 questions

A previously healthy infant presents with a recurrent episode of abdominal pain. The mother says that the child has been passing an altered stool after episodes of pain, but gives no history of vomiting or bleeding per rectum. Which of the following is the most likely diagnosis –

Which of the following is the most likely cause of bright red blood per rectum (hematochezia) in a 70-year-old patient?

What is the most common cause of lower gastrointestinal bleeding?

True statement regarding upper GI bleeds:

A 9 month old child presents with excessive cry, right iliac fossa sausage lump and blood in stools. What is the best treatment?

On the 4th postoperative day of laparotomy a patient presents with bleeding & oozing from the wound. Management is :

What is the most common differential diagnosis for appendicitis in children?

Which of the following is the most common adverse effect of omeprazole?

The most common cause of per rectal bleeding in infants is:

Q10

A 6-year-old child with abdominal pain and a rash is shown. Comment on the diagnosis?

Gastrointestinal Bleeding Indian Medical PG Practice Questions and MCQs

Question 1: A previously healthy infant presents with a recurrent episode of abdominal pain. The mother says that the child has been passing an altered stool after episodes of pain, but gives no history of vomiting or bleeding per rectum. Which of the following is the most likely diagnosis –

A. Intussusception (Correct Answer)
B. Meckel's Diverticulum
C. Rectal Polyps
D. Necrotizing Enterocolitis

Explanation: ***Intussusception*** - Recurrent episodes of **colicky abdominal pain** in an infant, followed by passage of **altered stool**, are classic signs of intussusception. - The "altered stool" likely represents **early mucosal changes** before the development of the characteristic "currant jelly" stool (blood mixed with mucus), which typically appears later in the disease course. - The absence of obvious bleeding per rectum (as reported by the mother) is consistent with **early intussusception**, where the classic triad (pain, vomiting, currant jelly stool) may not all be present initially. - Intussusception is the **most common cause of intestinal obstruction** in infants aged 6-36 months. *Meckel's Diverticulum* - Meckel's diverticulum typically presents with **painless rectal bleeding** due to ectopic gastric mucosa causing ulceration of adjacent ileal mucosa. - When symptomatic, it causes bright red or maroon rectal bleeding rather than the pattern described here. - Recurrent colicky pain with altered stool is not characteristic. *Rectal Polyps* - Juvenile rectal polyps present with **painless, bright red rectal bleeding** on the stool surface. - They do not typically cause recurrent episodes of severe colicky abdominal pain. - The bleeding is intermittent and not associated with the pain pattern described. *Necrotizing Enterocolitis* - NEC primarily affects **premature infants** and critically ill newborns in the neonatal period. - It presents acutely with abdominal distension, feeding intolerance, bloody stools, and systemic signs of sepsis. - It is not characterized by recurrent episodes in a **previously healthy infant** and would not present with this chronic pattern.

Question 2: Which of the following is the most likely cause of bright red blood per rectum (hematochezia) in a 70-year-old patient?

A. Esophageal varices
B. Diverticulosis (Correct Answer)
C. Gastric cancer
D. Peptic ulcer disease

Explanation: ***Diverticulosis*** - **Diverticular bleeding** is a common cause of **painless bright red blood per rectum (hematochezia)**, particularly in older adults, due to rupture of blood vessels within diverticula [1]. - The diverticula are often found in the **colon**, making the bleeding lower gastrointestinal and thus resulting in bright red blood rather than melena. *Esophageal varices* - Typically present with **hematemesis** (vomiting blood) or **melena** (black, tarry stools) due to upper GI bleeding, not bright red blood per rectum. - They are associated with **portal hypertension**, primarily seen in patients with chronic liver disease. *Gastric cancer* - More commonly causes chronic, **occult GI bleeding** leading to iron deficiency anemia [2], or if severe, **melena** or **hematemesis**. - **Bright red blood per rectum** is generally not a typical presentation unless there is massive bleeding with rapid transit through the GI tract, which is less common. *Peptic ulcer disease* - A common cause of **upper GI bleeding**, usually presenting as **melena** or **hematemesis** [2]. - **Hematochezia** from a peptic ulcer would imply a very rapid bleed with extremely fast bowel transit time, which is atypical and associated with massive blood loss.

Question 3: What is the most common cause of lower gastrointestinal bleeding?

A. Anal fissure
B. Angiodysplasia (Correct Answer)
C. Diverticulitis
D. Colorectal carcinoma

Explanation: ***Angiodysplasia*** - Angiodysplasia is the **most frequent cause** of lower gastrointestinal bleeding, particularly in **elderly patients**, and often presents as painless, recurrent bleeding [1]. - These are **small vascular malformations** that can be found throughout the GI tract, most commonly in the right colon [1]. *Diverticulitis* - While **diverticular disease** (diverticulosis) is a common cause of lower GI bleeding, **diverticulitis** itself (inflammation of diverticula) typically presents with abdominal pain and fever, and bleeding is less common. - Bleeding from diverticulosis is usually **painless** and can be substantial, but **diverticulitis** is not the most common cause of bleeding overall. *Anal fissure* - An anal fissure is a small tear in the lining of the anus, causing **bright red bleeding** on toilet paper or stool, but the volume of blood is usually **minimal** and not considered a major cause of significant lower GI bleeding. - It is typically associated with **severe pain during defecation**, which is not implied in a general question about the most common cause of lower GI bleeding. *Colorectal carcinoma* - Colorectal carcinoma can cause chronic, **occult bleeding** or intermittent, small amounts of **frank blood** in the stool [1]. - While it's a serious cause of GI bleeding, it is **not the most common** cause in the general population compared to angiodysplasia or diverticulosis (when considered broadly) [1].

Question 4: True statement regarding upper GI bleeds:

A. Upper GI bleeding is defined as bleeding originating proximal to the ampulla of Vater, not the ligament of Treitz
B. Endoscopic banding is the first-line treatment for all types of upper GI bleeding
C. The most common cause of upper GI bleeds is peptic ulcer disease, not variceal bleeding. (Correct Answer)
D. Rockall score is primarily used for immediate treatment decisions rather than risk stratification

Explanation: ***The most common cause of upper GI bleeds is peptic ulcer disease, not variceal bleeding.*** [1] * **Peptic ulcer disease (PUD)**, particularly **duodenal and gastric ulcers**, accounts for the majority of upper GI bleeding cases. * While **variceal bleeding** is severe and life-threatening, it is a less frequent cause overall compared to PUD. *Endoscopic banding is the first-line treatment for all types of upper GI bleeding* * **Endoscopic banding** is primarily indicated and highly effective for **esophageal variceal bleeding**, not for all types of upper GI bleeds. * For non-variceal bleeding, such as **peptic ulcers**, treatments like **epinephrine injection**, **heater probe**, or **clips** are more commonly utilized [1]. *Upper GI bleeding is defined as bleeding originating proximal to the ampulla of Vater, not the ligament of Treitz* * **Upper GI bleeding** is classically defined as bleeding occurring **proximal to the ligament of Treitz**, which marks the anatomical division between the duodenum and the jejunum. * The **ampulla of Vater** is located in the second part of the duodenum, and bleeding upstream of this point is still considered upper GI bleed. *Rockall score is primarily used for immediate treatment decisions rather than risk stratification* * The **Rockall score** is a validated tool specifically designed for **risk stratification** in upper GI bleeding, predicting rebleeding and mortality [1]. * While it informs overall management, immediate treatment decisions are often guided by the patient's **hemodynamic stability** and endoscopic findings, rather than solely by the score.

Question 5: A 9 month old child presents with excessive cry, right iliac fossa sausage lump and blood in stools. What is the best treatment?

A. IV Fluids - antibiotics - barium enema
B. IV Fluids - antibiotics - NG tube
C. IV Fluids - antibiotics - warm saline enema
D. IV Fluids - antibiotics - air enema (Correct Answer)

Explanation: ***IV Fluids - antibiotics - air enema*** - The presentation of an excessive cry, a **right iliac fossa sausage-shaped lump**, and **blood in stools** (currant jelly stools) is classic for **intussusception** in an infant. - An **air enema** is the preferred initial treatment for uncomplicated intussusception as it is diagnostic and therapeutic, often reducing the intussusception while being safer than barium. Prompt IV fluids and antibiotics are crucial for stabilization and infection prophylaxis. *IV Fluids - antibiotics - barium enema* - While a **barium enema** can also be used for reduction, it carries a higher risk of **perforation** and is less frequently used than air enema due to its lower safety profile. - The diagnostic capabilities are similar, but the therapeutic benefits of air enema, particularly with lower complications, make it the preferred option. *IV Fluids - antibiotics - NG tube* - An **NG tube** is used for **gastric decompression** in cases of intestinal obstruction, which might be a part of the management if patients are vomiting or have significant abdominal distension. - However, an NG tube alone does not address the underlying **intussusception** and is not a definitive treatment for reducing the telescoped bowel itself. *IV Fluids - antibiotics - warm saline enema* - A **warm saline enema** is primarily used for evacuating contents from the bowel or for diagnostic purposes (e.g., imaging the colon). - It is **ineffective in reducing intussusception**, as it lacks the pressure capabilities required to successfully push back the invaginated bowel.

Question 6: On the 4th postoperative day of laparotomy a patient presents with bleeding & oozing from the wound. Management is :

A. Send for USG abdomen
B. Start treatments for peritonitis
C. IV fluids
D. Dressing of wound & observe for dehiscence (Correct Answer)

Explanation: ***Dressing of wound & observe for dehiscence*** - **Bleeding and oozing from the wound** on the 4th postoperative day could indicate early wound dehiscence or a seroma/hematoma. - **Dressing the wound** provides local control, while diligent observation is crucial to detect progressive dehiscence requiring surgical intervention. *Send for USG abdomen* - An **ultrasound (USG) abdomen** would be useful for assessing intra-abdominal collections such as abscesses or hematomas, or to detect an incisional hernia, but not the immediate bleeding and oozing from the wound site itself. - While it might provide additional information, it's not the **first-line management** for local wound issues like bleeding and oozing. *Start treatments for peritonitis* - **Peritonitis** presents with signs of severe abdominal infection, such as fever, generalized abdominal pain, rigidity, and rebound tenderness, which are not described in the patient's presentation of only local wound bleeding and oozing. - Initiating peritonitis treatment without signs of widespread infection would be **inappropriate** and delay appropriate wound care. *IV fluids* - **Intravenous (IV) fluids** are used to manage dehydration, electrolyte imbalances, or hypovolemia, but the patient's primary complaint is localized wound bleeding and oozing, not systemic signs of instability requiring fluid resuscitation at this stage. - While **fluid balance** is always important postoperatively, it is not the specific management for the described wound issue.

Question 7: What is the most common differential diagnosis for appendicitis in children?

A. Intussusception
B. Meckel's diverticulitis
C. Mesenteric lymphadenitis (Correct Answer)
D. Gastroenteritis

Explanation: ***Mesenteric lymphadenitis*** - **Mesenteric lymphadenitis** commonly mimics appendicitis in children due to similar symptoms like **abdominal pain**, **fever**, and **vomiting**. - It often follows a **viral infection** and causes enlarged lymph nodes in the mesentery, leading to pain in the **right lower quadrant**. *Gastroenteritis* - While gastroenteritis also causes **abdominal pain**, **vomiting**, and often **diarrhea**, the pain is usually more generalized or diffuse, unlike the localized **right lower quadrant pain** of appendicitis. - Furthermore, patients with gastroenteritis typically do not present with the progressive, worsening pain characteristic of appendicitis. *Intussusception* - Intussusception usually presents with sudden onset of **crampy, intermittent abdominal pain** and **currant jelly stools** in younger children (typically 3 months to 3 years), which is distinct from appendicitis pain. - A palpable **sausage-shaped mass** in the abdomen can also be a key diagnostic feature, rarely seen in appendicitis. *Meckel's diverticulitis* - **Meckel's diverticulitis** can mimic appendicitis very closely in its presentation of **right lower quadrant pain** and inflammation. - However, it is a less common condition than mesenteric lymphadenitis and appendicitis itself, making it a differential rather than the **most common differential diagnosis**.

Question 8: Which of the following is the most common adverse effect of omeprazole?

A. Headache (Correct Answer)
B. Constipation
C. Liver dysfunction
D. Upper gastrointestinal bleeding

Explanation: ***Headache*** - **Headache** is the most frequently reported adverse effect of omeprazole and other proton pump inhibitors (PPIs), occurring in approximately 2-7% of patients. - While generally mild and self-limiting, it is the most common reason for patients to report side effects during PPI therapy. - Other common adverse effects include diarrhea, nausea, and abdominal pain, but headache remains the most prevalent. *Constipation* - Constipation can occur with omeprazole use, but it is less common than headache or diarrhea. - Gastrointestinal side effects like constipation typically occur in a smaller proportion of patients compared to headache. *Liver dysfunction* - Mild **transient elevation of liver enzymes** can occur with omeprazole, but clinically significant liver dysfunction is rare. - Routine monitoring of liver function is generally not required unless there is pre-existing hepatic impairment. *Upper gastrointestinal bleeding* - Omeprazole is used to **treat and prevent** upper gastrointestinal bleeding by reducing gastric acid secretion in conditions like peptic ulcers and erosive esophagitis. - It is a therapeutic agent for this condition, not a causative factor.

Question 9: The most common cause of per rectal bleeding in infants is:

A. Anal fissure (Correct Answer)
B. Rectal polyp
C. Intussusception
D. Meckel's diverticulum

Explanation: ***Anal fissure*** - **Anal fissures** are tiny tears in the **anus** lining, causing bright red blood on the stool surface or diaper. - They are very common in infants due to **constipation** or passing **hard stools**, leading to trauma. *Rectal polyp* - Rectal polyps can cause **painless rectal bleeding**, but they are **less common** than anal fissures in infants. - Bleeding from polyps is usually **intermittent** and can be darker or mixed with stool. *Intussusception* - Intussusception presents with sudden onset of **crampy abdominal pain**, **vomiting**, and **currant jelly stools** (blood mixed with mucus). - This condition is an **emergency** and typically affects infants between 3 months and 3 years old. *Meckel's diverticulum* - **Meckel's diverticulum** can cause painless, recurrent **dark red or maroon bleeding**, often described as "brick-red" due to ectopic gastric mucosa. - While a significant cause of bleeding, it is **less common** than anal fissures as the primary etiology in infants.

Question 10: A 6-year-old child with abdominal pain and a rash is shown. Comment on the diagnosis?

A. Kawasaki
B. Varicella
C. Meningococcemia
D. Henoch-Schonlein purpura (Correct Answer)

Explanation: ***Henoch Schonlein purpura*** - This diagnosis is strongly suggested by the child's age (6 years old), presentation of abdominal pain, and the characteristic **palpable purpuric rash**, particularly on the lower extremities, as seen in the image. - **Henoch-Schönlein purpura (HSP)**, now known as IgA vasculitis, is a systemic small-vessel vasculitis predominantly affecting children, characterized by the classic triad of palpable purpura, arthritis/arthralgia, and abdominal pain. *Kawasaki* - **Kawasaki disease** primarily affects children under 5 years of age and presents with persistent fever, conjunctivitis, oral mucosal changes (strawberry tongue), cervical lymphadenopathy, and a polymorphous rash. Abdominal pain is less common as a primary feature. - The rash in Kawasaki disease is typically not purpuric but can be maculopapular or scarlatiniform, and does not show the characteristic distribution seen in the image. *Varicella* - **Varicella (chickenpox)** is characterized by a pruritic vesicular rash that progresses from macules to papules to vesicles and then crusts, usually starting on the trunk and spreading centrifugally. This is distinctly different from the purpuric rash shown. - While it can cause abdominal pain, the skin lesions are the key differentiator, and the image does not depict vesicular lesions. *Meningococcemia* - **Meningococcemia** is a severe bacterial infection often presenting with petechial or purpuric rash, fever, and signs of sepsis. However, the rash in meningococcemia rapidly progresses to large ecchymoses and is often associated with signs of critical illness (e.g., hypotension, altered mental status). - While purpura is present, the widespread, relatively uniform appearance of the rash, combined with abdominal pain in a 6-year-old, points away from the fulminant course typical of meningococcemia towards a vasculitis like HSP.

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