Certified Gastroenterology RN GI Bleeding Management 2 — Questions and Answers
Question 1: A Dieulafoy lesion is best characterized as:
- A linear mucosal tear at the gastroesophageal junction
- An ectatic submucosal artery that erodes through the overlying mucosa without an ulcer (Correct answer)
- Multiple small angiodysplasias scattered throughout the colon
- A perforated gastric ulcer with active arterial hemorrhage
Correct answer: An ectatic submucosal artery that erodes through the overlying mucosa without an ulcer
A Dieulafoy lesion is an abnormally large caliber submucosal artery that erodes through the mucosa, causing massive bleeding from a small, subtle defect.
Question 2: For endoscopic hemostasis of an actively bleeding peptic ulcer, which approach is considered most effective by current guidelines?
- Epinephrine injection therapy alone
- Thermal therapy alone with a heater probe
- Combination of injection therapy plus a second modality such as thermal or mechanical clips (Correct answer)
- Argon plasma coagulation as the sole treatment
Correct answer: Combination of injection therapy plus a second modality such as thermal or mechanical clips
Combining epinephrine injection with a second hemostatic modality (thermal or mechanical) achieves superior hemostasis and lower rebleeding rates than either method alone.
Question 3: A patient with known diverticulosis presents with sudden, painless, large-volume bright red rectal bleeding. This presentation is most consistent with:
- Colorectal adenocarcinoma
- Diverticular bleeding (Correct answer)
- Ischemic colitis
- Infectious colitis from Clostridioides difficile
Correct answer: Diverticular bleeding
Diverticular bleeding classically presents as sudden, painless, high-volume hematochezia and is the most common cause of significant lower GI bleeding in adults.
Question 4: Which patient position is recommended for a patient actively vomiting blood to minimize the risk of aspiration?
- Supine with legs elevated 30 degrees
- Left lateral decubitus (left-side down) (Correct answer)
- Prone position
- High Fowler's at 90 degrees
Correct answer: Left lateral decubitus (left-side down)
The left lateral decubitus position reduces aspiration risk by pooling blood in the dependent stomach and keeping it away from the airway.
Question 5: A restrictive transfusion threshold (hemoglobin <7 g/dL) is appropriate for most GI bleeding patients, but a HIGHER threshold is recommended for patients with:
- Peptic ulcer disease without cardiac history
- Variceal bleeding from compensated cirrhosis
- Acute coronary syndrome or significant cardiac disease (Correct answer)
- Diverticular bleeding with stable vital signs
Correct answer: Acute coronary syndrome or significant cardiac disease
Patients with acute coronary syndrome or significant cardiac disease require a higher transfusion threshold (Hgb <8 g/dL) to maintain adequate myocardial oxygen delivery.
Question 6: Following successful endoscopic hemostasis of a bleeding peptic ulcer, the recommended proton pump inhibitor regimen is:
- Oral PPI once daily for 2 weeks
- High-dose IV PPI bolus (80 mg) followed by continuous infusion (8 mg/hr) for 72 hours (Correct answer)
- Oral PPI twice daily for 7 days only
- IV PPI once every 24 hours for 48 hours
Correct answer: High-dose IV PPI bolus (80 mg) followed by continuous infusion (8 mg/hr) for 72 hours
High-dose IV PPI bolus plus 72-hour infusion maintains gastric pH >6, which stabilizes clot formation and significantly reduces rebleeding risk.
Question 7: Which endoscopic finding on a peptic ulcer (Forrest classification) carries the highest risk of rebleeding and mandates immediate hemostasis?
- Clean-based ulcer with no stigmata
- Flat pigmented spot within the ulcer base
- Actively spurting arterial hemorrhage (Correct answer)
- Adherent clot overlying the ulcer without a visible vessel
Correct answer: Actively spurting arterial hemorrhage
Actively spurting arterial hemorrhage (Forrest class Ia) carries the highest rebleeding risk (>80% without treatment) and requires immediate endoscopic intervention.
Certified Gastroenterology RN GI Bleeding Management 2
A Dieulafoy lesion is best characterized as: