GI Bleeding, Peptic Ulcer and Inflammatory Bowel Disease for NEET PG Medicine: ICMR Bleed Protocol, H. pylori, Crohn vs UC

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🎯 Exam priority: High. Expect: high-risk features and transfusion threshold in GI bleed, PPI and terlipressin doses, endoscopy timing, band ligation vs glue, causes of upper and lower GI bleed, duodenal ulcer pain pattern, H. pylori tests and therapy, perforation, Crohn vs UC differences, extraintestinal features and toxic colitis.

CBME mapping: GM 15.1–15.18. Ulcer and IBD pathology are in Pathology; portal hypertension in article 12; GI surgery in Surgery.

Crohn vs UC, ICMR GI bleed management, peptic ulcer and IBD extraintestinal features. Drawn by TrackNation.

Acute GI Bleeding

• Haematemesis or melaena points upper; fresh blood or maroon stools lower. Alcohol, jaundice, ascites or splenomegaly → think varices; epigastric pain, NSAIDs or antiplatelets → ulcer. Up to 15% of upper GI bleeds have no blood in the NG aspirate.

• Upper GI causes: duodenal ulcer, gastric ulcer, varices, Mallory–Weiss tear, erosions. In older adults, peptic ulcer, diverticular disease and angiodysplasia cause most major bleeds; haemorrhoids and colorectal cancer most minor ones. In the elderly, always rule out malignancy.

• Terlipressin is avoided with heart disease or peripheral vascular disease. Refractory variceal bleeding: covered oesophageal stent or TIPS. Resume low-dose aspirin on day 1 after control.

Peptic Ulcer and H. pylori

• Causes: H. pylori and NSAIDs; gastrinoma (Zollinger–Ellison) is rare.

• Duodenal ulcer: pain absent on waking, appears mid-morning, relieved by food, recurs 2–3 h after meals; night pain is highly suggestive. Posterior ulcers penetrate the pancreas (back pain).

• Biopsy gastric ulcers to exclude cancer. Perforation: free air on X-ray or CT — absence does not exclude it.

• H. pylori: causes gastritis, ulcer, gastric adenocarcinoma and MALT lymphoma. Tests: urea breath test, stool antigen, biopsy. Bismuth quadruple therapy (PPI + bismuth + 2 antibiotics) for 14 days where clarithromycin resistance exceeds 15%.

• Autoimmune atrophic gastritis: antibodies against parietal cells → low acid and intrinsic factor → B12 deficiency; treat with parenteral B12.

Crohn Disease and Ulcerative Colitis

• Crohn: transmural, anywhere in the gut (usually distal ileum and colon), skip areas, cobblestoning, non-caseating granulomas, fistulas, abscesses, strictures; perianal disease in 20%; Crohn colitis usually spares the rectum. Smoking worsens it and increases recurrence.

• UC: mucosal disease that begins in the rectum and extends proximally; bloody diarrhoea; loss of haustra. Toxic colitis with transverse colon > 6 cm is an emergency — avoid barium enema. Colon cancer risk rises with duration and extent. Smoking and appendectomy lower the risk of UC.

• Extraintestinal features that follow activity: peripheral arthritis, episcleritis, aphthous ulcers, erythema nodosum. Independent of activity: ankylosing spondylitis (HLA-B27), sacroiliitis, uveitis, pyoderma gangrenosum, primary sclerosing cholangitis (raised ALP and GGT).

• Treatment: mild UC — oral and/or rectal 5-ASA; moderate–severe — steroids, biologics or small molecules; severe UC not improving in 24–48 h → surgery. pANCA and ASCA do not reliably separate UC from Crohn disease.

Traps the Examiner Sets

• Transfuse at Hb < 7 (not 10); < 9 if heart disease.

• Endoscopy within 24 h of stabilisation — not before resuscitation.

• Oesophageal varices → band ligation; fundal varices → cyanoacrylate glue.

• Duodenal ulcer: food relieves; gastric ulcers need biopsy.

• Smoking: bad for Crohn, protective for UC.

Memory Hooks & Shortcuts

Shortcuts to lock in this article's numbers and lists. Each one only re-packages facts proven above.

• 🧠 GI bleed '100-90-60': pulse > 100, SBP < 90, age > 60 = high risk — high risk

• 🧠 Transfuse at 7, heart at 9 — transfusion

• 🧠 Varices: Band the Oesophagus, Glue the Fundus — endotherapy

• 🧠 Duodenal ulcer: Dinner Delivers relief; Gastric ulcer: Get a biopsy — ulcer pain

• 🧠 Crohn = Cobblestones, Clefts (fistulas), Chunks skipped, Cigarettes worsen — Crohn

• 🧠 UC = Up from the rectum, Continuous — UC

Rapid-Revision Cards

• GI bleed high risk

  Pulse > 100, SBP < 90, syncope, SpO2 < 90, confusion, age > 60.

• Transfusion threshold

  Hb < 7 (< 9 heart disease).

• PPI in bleed

  80 mg IV, then 40 mg 12-hourly.

• Terlipressin

  2 mg then 1 mg 6-hourly × 3–5 d; avoid in IHD/PVD.

• Octreotide

  50 µg bolus + 50 µg/h × 3–5 d.

• Variceal antibiotic

  Ceftriaxone 1 g 12-hourly.

• Endoscopy timing

  Within 24 h of stabilisation.

• Oesophageal varices

  Band ligation.

• Fundal varices

  Cyanoacrylate glue.

• Ulcer haemostasis

  Adrenaline 1:10000 + clip/thermal; PPI 72 h.

• Post-variceal

  Propranolol to HR 60; EVL q2–3 wk.

• Aspirin after bleed

  Resume day 1.

• Major bleed (elderly)

  Ulcer, diverticula, angiodysplasia.

• Duodenal ulcer

  Relieved by food; night pain.

• Gastric ulcer

  Biopsy to exclude cancer.

• Perforation

  Free air; absence doesn't exclude.

• H. pylori tests

  Urea breath, stool antigen, biopsy.

• H. pylori Rx

  Bismuth quadruple × 14 d.

• Autoimmune gastritis

  Parietal cell → B12 deficiency.

• Crohn

  Transmural, skip, cobblestone, granulomas, fistulas.

• UC

  Rectum upward, mucosal, bloody diarrhoea.

• Toxic colitis

  Transverse colon > 6 cm; no barium.

• Smoking and IBD

  Worse Crohn; less UC.

• IBD independent of activity

  AS, uveitis, pyoderma, PSC.

Sources

Facts in this article were checked against these documents.

• Standard Treatment Workflow: Acute Gastrointestinal Bleed in Adults, Parts A and B — Indian Council of Medical Research, DHR, 2020 (link)

• MSD Manual Professional: Overview of GI Bleeding; Varices; Peptic Ulcer Disease; H. pylori Infection; Autoimmune Metaplastic Atrophic Gastritis; Overview of IBD; Crohn Disease; Ulcerative Colitis — Merck & Co. (MSD Manuals), reviewed 2025–26 (link)

• Competency Based Undergraduate Curriculum, General Medicine (GM 15) — National Medical Commission, 2024

Test Yourself: Practice Questions

Thirty questions in NEET PG style, most of them clinical vignettes.

Practice Questions (NEET PG pattern)

Original questions written in the style of the exam: +4 for a correct answer, −1 for a wrong one. Every answer was checked against the sources listed above. NEET PG papers are not published by NBEMS, so these are not past-paper questions.

Q1. A man with haematemesis has pulse 118/min and BP 84/50 mm Hg. Under the ICMR workflow he is

• (a) low risk — discharge with PPI

• (b) high risk only if Hb < 5

• (c) high risk — resuscitate and refer after stabilisation

• (d) not a GI bleed

Q2. In acute GI bleeding without heart disease, packed red cells are given when haemoglobin falls below

• (a) 7 g/dL

• (b) 10 g/dL

• (c) 5 g/dL

• (d) 12 g/dL

Q3. A patient with known heart disease has an active GI bleed. The transfusion threshold per ICMR is haemoglobin below

• (a) 12 g/dL

• (b) 6 g/dL

• (c) 9 g/dL

• (d) 7 g/dL

Q4. Every patient with acute upper GI bleeding should initially receive

• (a) IV tranexamic acid only

• (b) nothing until endoscopy

• (c) IV pantoprazole or esomeprazole 80 mg, then 40 mg 12-hourly

• (d) oral antacids only

Q5. A man with alcohol use, ascites and splenomegaly vomits blood. Before endoscopy, the vasoactive drug regimen per ICMR is

• (a) adrenaline infusion

• (b) vasopressin orally

• (c) terlipressin 2 mg IV then 1 mg 6-hourly for 3–5 days

• (d) propranolol IV

Q6. Terlipressin should be avoided in a patient with suspected variceal bleeding who also has

• (a) ischaemic heart disease or peripheral vascular disease

• (b) hepatitis B

• (c) asthma

• (d) diabetes

Q7. In suspected variceal bleeding, along with vasoactive drugs, the patient should receive

• (a) no antibiotics

• (b) vancomycin

• (c) oral metronidazole only

• (d) IV ceftriaxone 1 g 12-hourly for 3–5 days

Q8. Per the ICMR workflow, endoscopy in acute GI bleeding should be done

• (a) within 24 hours of initial stabilisation

• (b) only if bleeding recurs

• (c) before any resuscitation

• (d) after 1 week

Q9. Endoscopy shows bleeding oesophageal varices. The preferred endoscopic therapy is

• (a) argon plasma coagulation

• (b) cyanoacrylate glue

• (c) variceal band ligation

• (d) adrenaline injection alone

Q10. Endoscopy shows bleeding gastric fundal varices. The ICMR workflow advises

• (a) cyanoacrylate glue injection

• (b) PPI only

• (c) biopsy

• (d) band ligation

Q11. A duodenal ulcer shows a visible vessel. Endoscopic haemostasis includes

• (a) no therapy

• (b) glue injection

• (c) adrenaline 1:10000 injected around the ulcer plus clips or thermal therapy

• (d) band ligation

Q12. After endoscopic control of a variceal bleed, discharge treatment includes

• (a) propranolol titrated to heart rate 60/min and repeat band ligation every 2–3 weeks

• (b) long-term terlipressin

• (c) NSAIDs

• (d) aspirin

Q13. A patient on aspirin for a coronary stent has an ulcer bleed controlled endoscopically. Low-dose aspirin should be

• (a) replaced with an NSAID

• (b) stopped for 6 months

• (c) never restarted

• (d) resumed on day 1 after control

Q14. In older adults, the commonest causes of major GI bleeding are

• (a) typhoid

• (b) Meckel diverticulum

• (c) peptic ulcer, diverticular disease and angiodysplasia

• (d) haemorrhoids and fissures

Q15. A patient with melaena has a clear nasogastric aspirate. This

• (a) proves a colonic source

• (b) rules out upper GI bleeding

• (c) means no bleeding

• (d) does not exclude upper GI bleeding (up to 15% have no blood in the aspirate)

Q16. A man has epigastric pain that is absent on waking, starts mid-morning, is relieved by food, returns 2–3 hours after meals and wakes him at night. The likely diagnosis is

• (a) duodenal ulcer

• (b) pancreatitis

• (c) gastric cancer

• (d) biliary colic

Q17. The two main causes of peptic ulcer disease are

• (a) smoking and coffee

• (b) gastrinoma and alcohol

• (c) Helicobacter pylori and NSAIDs

• (d) stress and spicy food

Q18. A gastric ulcer is found at endoscopy. It should be

• (a) biopsied to distinguish benign ulcer from ulcerating cancer

• (b) left alone

• (c) treated surgically at once

• (d) ignored if painless

Q19. A patient with a known ulcer develops sudden severe abdominal pain; an erect chest X-ray shows no free air. Perforation is

• (a) excluded

• (b) irrelevant

• (c) not excluded — get a CT

• (d) confirmed

Q20. A non-invasive test for active H. pylori infection is

• (a) CEA

• (b) barium meal

• (c) urea breath test

• (d) serum gastrin

Q21. Where clarithromycin resistance exceeds 15%, the best initial H. pylori regimen is

• (a) PPI alone

• (b) clarithromycin triple therapy for 7 days

• (c) amoxicillin alone

• (d) bismuth quadruple therapy for 14 days

Q22. H. pylori infection is associated with all EXCEPT

• (a) gastric adenocarcinoma

• (b) ulcerative colitis

• (c) peptic ulcer

• (d) MALT lymphoma

Q23. A patient has B12 deficiency due to antibodies against gastric parietal cells. The treatment is

• (a) folate alone

• (b) oral iron

• (c) H. pylori eradication

• (d) parenteral vitamin B12

Q24. A patient has chronic diarrhoea, abdominal pain and a perianal fistula; colonoscopy shows patchy ulcers with normal intervening mucosa and a cobblestone pattern. The diagnosis is

• (a) ischaemic colitis

• (b) Crohn disease

• (c) irritable bowel syndrome

• (d) ulcerative colitis

Q25. Biopsy of the bowel in Crohn disease may show

• (a) non-caseating granulomas

• (b) Reed–Sternberg cells

• (c) crypt abscesses only in the rectum

• (d) caseating granulomas

Q26. A patient has bloody diarrhoea with inflammation starting at the rectum and extending continuously upward. The diagnosis is

• (a) ulcerative colitis

• (b) coeliac disease

• (c) Crohn disease

• (d) amoebic liver abscess

Q27. A patient with severe ulcerative colitis has abdominal distension and suspected toxic colitis. The investigation to avoid is

• (a) careful sigmoidoscopy

• (b) blood counts and electrolytes

• (c) plain abdominal X-ray

• (d) barium enema

Q28. The risk of colon cancer in ulcerative colitis relates mainly to

• (a) age at first flare only

• (b) number of flares only

• (c) duration and extent of disease

• (d) smoking

Q29. Cigarette smoking

• (a) has no link with IBD

• (b) protects against Crohn disease

• (c) worsens Crohn disease but lowers the risk of ulcerative colitis

• (d) worsens UC only

Q30. An extraintestinal manifestation of IBD that runs independently of bowel disease activity is

• (a) erythema nodosum

• (b) peripheral arthritis

• (c) aphthous stomatitis

• (d) primary sclerosing cholangitis

Active Recall

From memory: list high-risk features and the ICMR steps in acute GI bleed (transfusion, PPI, vasoactive drugs, antibiotics, endoscopy and endotherapy), give causes of GI bleeding, describe duodenal ulcer pain, H. pylori tests and treatment, and contrast Crohn disease with ulcerative colitis including extraintestinal features.