Gastrointestinal bleeding: Pathology review

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Gastrointestinal bleeding: Pathology review


Peritoneum and peritoneal cavity disorders




Gastrointestinal bleeding: Pathology review

USMLE® Step 1 questions

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USMLE® Step 1 style questions USMLE

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A 28-year-old man is brought to the emergency department for evaluation of upper gastrointestinal bleeding. The patient had spent the evening at a bar with friends and consumed 7-10 shots of liquor. Shortly after leaving the bar, he felt nauseated and vomited multiple times. The last episode of vomiting produced bright red emesis. The patient denies dyspnea or recent trauma. Past medical history is notable for asthma, for which he takes albuterol as needed. His vitals are within normal limits. Physical examination reveals a thin male in mild distress. Cardiac, pulmonary, and abdominal exams are noncontributory. The patient has no additional episodes of hematemesis. Laboratory testing reveals the following findings:  
Laboratory value  Result
 Sodium  139 mg/dL 
 Potassium  3.8 mg/dL 
 Chloride  100 mg/dL 
 Bicarbonate  33 mg/dL 
Which of the following would be most useful in providing a definitive diagnosis of the patient’s condition?  


A 30-year-old male named Joseph came to the emergency department because of sharp chest pain radiating to his back. He recently graduated from medical school and has been celebrating for the past week at local bars. He says that he was drinking to the point of vomiting and blacking out. He thinks his pain began after a particularly intense night of vomiting and retching. His vital signs show no abnormalities. On the other hand, a 54-year-old lawyer called Lance has been noticing blood in his stool for the past 2 weeks. As he describes the problem, he mentions that there are “streaks of bright red blood” on top of the stool and didn’t notice any pain during bowel movements. Also, he reports a marble-sized, soft mass at the anus that can be pushed back into the anal canal. He denies abdominal pain, weight loss, or a history of colon cancer.

Now both people have gastrointestinal bleeding, but with different presentations. Gastrointestinal bleeding can be divided into upper and lower GI bleeding. Upper GI bleeding arises above the ligament of Treitz, also called the suspensory ligament of the duodenum, and it includes bleeding from the esophagus, stomach, or duodenum. Typical presentation includes hematemesis, or vomiting of blood; ‘coffee ground’ vomitus, which suggests that the blood has been oxidized by the acid in the stomach so that the iron in the blood has turned dark; and melena, which refers to black, tarry stools. On the other hand, lower GI bleeding arises below the ligament of Treitz and includes bleeding from the small intestine past the ligament of Treitz, large intestines, rectum, and anus. Typical presentation includes hematochezia, which is fresh blood passing through the anus which may or may not be mixed with stool.

Now, since these individuals are losing blood, they can develop anemia, or they can even become hemodynamically unstable. In mild hypovolemia, when they lose less than 15% of the blood volume, these individuals can experience resting tachycardia. In moderate hypovolemia, when they lose from 15% to 40% of the blood volume, they can experience orthostatic hypotension; and finally, in severe hypovolemia, when they lose over 40% of the blood volume, these individuals will develop hypotension.


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  2. "Harrison's Principles of Internal Medicine, Twentieth Edition (Vol.1 & Vol.2)" McGraw-Hill Education / Medical (2018)
  3. "Rosen's Emergency Medicine - Concepts and Clinical Practice E-Book" Elsevier Health Sciences (2013)
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  5. "The Overall Approach to the Management of Upper Gastrointestinal Bleeding" Gastrointestinal Endoscopy Clinics of North America (2011)
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  7. "Hemorrhoids" Clinics in Colon and Rectal Surgery (2011)
  8. "Management of Ischemic Colitis" Clinics in Colon and Rectal Surgery (2012)
  9. "Management of Colonic Volvulus" Clinics in Colon and Rectal Surgery (2012)
  10. "Intestinal Intussusception: Etiology, Diagnosis, and Treatment" Clinics in Colon and Rectal Surgery (2016)

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