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 HIV with GI bleeding  



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  #1

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 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!




  #2

answer should be E ?

the most common cause of GI bleed is upper GI so need EGD then rule out lower GI bleed with colonoscopy.. if it was active where colonscopy will be negative or friable where u can not do colonscopy then RBC tag ( L vs R ) vs arteriogram..

if still no then u can do pill endoscopy for Upper GI cuz remeber EGD does not go all the way down..

also remember upper GI bleed can be fresh or tarry ( oxidation ) but lower GI bleed is usually fresh..


On Oct 31, 2011 - 5:13 AM, anatomie responded:
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); 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; this specific question is one of them which has the same scenario but has different explanations/correct answers; 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 different 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!


  #3

alirizvi wrote:
answer should be E ?

the most common cause of GI bleed is upper GI so need EGD then rule out lower GI bleed with colonoscopy.. if it was active where colonscopy will be negative or friable where u can not do colonscopy then RBC tag ( L vs R ) vs arteriogram..

if still no then u can do pill endoscopy for Upper GI cuz remeber EGD does not go all the way down..

also remember upper GI bleed can be fresh or tarry ( oxidation ) but lower GI bleed is usually fresh..




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  #4

well after skimming what u posted.. i think what it was trying to say is that we do EGD to rule out upper GI bleed but if the patient is HIV positive then we do colonsocopy first..

UGIB mcc of BPR in healthy patient and LGIB mcc of BPR in HIV +

if i m wrong or misunderstood then sorry in advance


  #5

I read the question w/o reading the answer and came with COLONOSCOPY, which in my view is the correct answer, and it's very unlikely that I would have answered otherwise in a fast pace examination. The reason is that the nasogastric tube showed clear fluid and thus the pretest probability is very low for doing any upper GI thing.

When thinking about what in HIV infection could cause lower GI bleeding I thought of lymphoma, mucosal damage due to infection, and kaposi's sarcoma. All of these I can picture better in the lower GI than in the upper GI.

In fact the first test that I'd ask is a peripheral blood count.

Good question. thanks.

 





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