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  #1  
Old 10-25-2011
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GIT HIV with GI bleeding

A 34-year-old intravenous drug abuser who is HIV positive is admitted to the hospital because of gastrointestinal bleeding. He was admitted to the hospital 2 months ago for HIV treatment. At the time of discharge, he was in good health, able to tolerate regular diet, and take minimal medications. He went back to work and was feeling well. Two days before presenting to the hospital, he developed nonspecific abdominal discomfort, which he attributed to food poisoning and treated himself with lots of hydration. The abdominal discomfort persisted and he noticed bleeding per rectum, the night before coming to the hospital. The next morning, he noticed more blood per rectum, and alarmed by that, decided to come to the hospital. His temperature is 37 C (99.1 F), blood pressure is 110/70 mm Hg, and pulse is 96/min. His hematocrit is 28% compared with 34% on discharge a couple of months earlier. There are no signs of hemodynamic instability. Blood is sent for cross match and stool is sent for ova and parasites. A nasogastric tube is inserted and returns clear fluid. The next step in the investigation of this patient's gastrointestinal bleeding is a(n)

A. barium enema
B. colonoscopy
C. CT scan of the abdomen and pelvis
D. small bowel series
E. upper gastrointestinal endoscopy


I really need an opinion on this....I've seen a very similar situation in another Kaplan Step 3 Qbank and the answer given is different from what I've learn. Please, if anybody has a good explanation on this, I would highly appreciate it!
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  #2  
Old 10-30-2011
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B :

my though it he might have ulcers as in CMV ulcers and in tht situation since we already ruled out any bleed in the upper GI ( the ng tube coming up with clear fluid indicates tht upper GI is clear) I would go for colonoscopy IF that is also egative then i would go for a small bowel capsule endoscopy
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  #3  
Old 10-30-2011
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Quote:
Originally Posted by docnas View Post
B :

my though it he might have ulcers as in CMV ulcers and in tht situation since we already ruled out any bleed in the upper GI ( the ng tube coming up with clear fluid indicates tht upper GI is clear) I would go for colonoscopy IF that is also egative then i would go for a small bowel capsule endoscopy

For an identical scenario, 2 qbanks are giving different answers and this is the reason why I post this topic...one of the qbank is kaplan and the answer given is is attached to this answer(I don't agree with the management but I might be wrong....for me it does not make sence but you might shine some light); the second qbank is called Step 3 MCQ's and the explanation is next(I do agree with it and it makes more sence to me)....to be onest with you, there are a lot of similar questions between these 2 qbanks and some of the questions are identical; in my opinion, one is a little bit older and with some errors and the other one is newer and updated/free of errors....unfortunatelly I don't have the year of release for neither one of them.....

so, the explanation given to which I agree and makes sence is this:


The correct answer is B. A colonoscopy is the initial investigation of choice in gastrointestinal (GI) bleeding in HIV-positive patients. Gastrointestinal bleeding is an unusual occurrence in HIV infected individuals, but when it does occur, it is usually related to a complication of an HIV infection. Lower GI bleeding is twice as common as upper GI bleeding. Upper GI bleeding, when it occurs, is related to Kaposi's sarcoma or lymphoma 50% of the time. CMV ulcers do occur in the upper GI tract, but more frequently in lower GI tract. Lower GI tract bleeding is usually caused by localized colitis of infectious origin from Cytomegalovirus, herpes simplex, or bacteria. In a stable patient, colonoscopy is the procedure of choice for localizing the bleeding and obtaining biopsies to look for specific infections and antibiotic sensitivities.

A barium enema (choice A) is not as useful as the first investigation, unless a colonic carcinoma is suspected.

A CT scan of the abdomen and pelvis (choice C) may show thickening of the colon with the infiltration of fat in the surrounding mesentery, but may not be diagnostic.

A small bowel series (choice D) is rarely indicated as the initial investigation of choice in investigating gastrointestinal bleeding. If upper gastrointestinal endoscopy and colonoscopy do not reveal any lesions and the patient continues to bleed, then one should look for small bowel sources by means of small bowel series or enteroscopy.

Since upper gastrointestinal tract bleeding is less common than lower gastrointestinal tract bleeding, a upper gastrointestinal endoscopy (choice E) is not indicated in this patient. Also, a nasogastric tube return does not show blood in this patient. Although it is difficult to rule out upper gastrointestinal bleeding, there is no bile in the nasogastric tube, so a colonoscopy should still be the first investigation of choice.


on the other hand, the correct answer is another one in the other qbank and is attached to this message. The scenario is the same for both questions but the explanations and the right answer are different.

Thanks for the reply!
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  #4  
Old 10-30-2011
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Well im going to agree with you in this the first answer makes sense to me which is my reasoning for choosing colonoscopy.

That being said the second answer is also a possiblty because yes the NG isnt 100% diagnostic specially since we cant rule out a early Small bowel bleed since the tube didnt show any bile. I had thought about this when answering but i still felt that before we focus on the upper why dont we rule out the lower GI completely.

Kaplan does make mistakes so dont take everything it says on blind faith. In my opinion il stick with my answer of colonoscopy unless they give me some other info that more specifically localizes it to upper GI only then will i do a upper endoscopy before a colonoscopy in the presence of a negative ng tube test.
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anatomie (10-30-2011)



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