Question 16

Discuss the options for the definitive management of acute severe lower gastrointestinal bleeding, including the potential advantages and disadvantages of each option.

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College Answer

Syllabus topic/section:
2.1.6 Gastrointestinal Intensive Care – L1.
Aim:
To allow the candidate to demonstrate knowledge of management of a common life-threatening condition to the standard of a transitional fellow.
Discussion:
Generally, candidates performed well in this question. Candidates who performed less well did so because they did not do what the question specified and therefore did not gain the marks available.
For example, many candidates wrote detailed notes about aetiology and general supportive care when the question specifically asked for "options for definitive management" only. Several candidates might have gained a few extra marks with the additional time this could have created had they focused on the question.
It is frustrating for candidates (and SOTs) to reflect on why candidates did less well than they imagined as they “wrote a lot”. If, however, the information they have provided is not what was requested, it will therefore attract no marks. The way to improve is to practice answering SAQs and show them to as many colleagues as possible so that this skill is reproducible under examination conditions.
Candidates are encouraged to reflect on ALL the key parts of the knowledge that might be required to answer a question. One minute spent entitling a section and adding a few simple points is much better than spending all 10-minutes demonstrating only some of the required knowledge areas.
On the next page is the marking rubric. Please note the rubric is in tabulated form, however this was not required in the candidate answer, simple headings and bullet point structure was sufficient. Consider how the marking grid prioritises higher level facts, understanding of the subject and short- and long-range insight in the ramifications of the therapeutic options available. Ability to demonstrate this will achieve the written standard required of a transition level fellow that is ready for independent practice.

Marking rubric

Angio

Minimal detail, mostly missing/blank or only simple points, e.g. mentions radiation exposure only.

0-1.5 marks

Some detail,

e.g. recognizes the safety aspect of transport to/from angio as a disadvantage.

1.5-2 marks

Good amount of information and insight, e.g. recognizes the short timeframe between CTA and DSA, need to quickly organise an IR suite or hybrid theatre, anaesthetist, IR radiologist,

2-3 marks

Shows a thorough understanding of the advantages and disadvantages including staffing, Safety profile and limitations of intervention.

Knows rate of blood loss (<0.5ml/min) as a detailed and important limitation of the procedure

3-4 marks

Scope

Minimal detail, i.e. only mentions the obvious (direct visualization of bleeding structures, as an advantage, etc.)

<1.5 marks

Some details, essential points, e.g. recognizes the loss of value from unprepped colon as a major disadvantage. notes the anatomical extent limitations of endoscopy, mentions the risk of perforation.

1.5 marks-2 marks

All the important disadvantages; brings up good advantages, e.g. ability to get biopsy samples or multiple options for hemostasis.

2-2.5 marks

Complete or near complete list of advantages and disadvantages, including higher level thinking facts such as no outcome difference with early (<24) endoscopy, or that UGI bleeding can be identified as the cause of apparent PR frank blood loss.

2.5-3 marks

Surgery

Minimal detail: need to mention that Sx is the last option to score any marks.

<1.5 marks

Recognise significant morbidity and mortality, understand that the site of bleeding should be known for surgery to be effective/safe.

1.5 –2 marks

All the important disadvantages; also recognise the value of getting larger anatomical samples (e.g. for staging of malignancy).

2.0-2.5 marks

All the important points, plus longer-range insight, e.g. longer-term risks from surgery.

2.5-3.0 marks

Discussion

The temptation to tabulate this response is significant, as anything that asks for "advantages and disadvantages" naturally falls into columns. Thus:

Advantages Disadvantages
Interventional radiology: angioembolisation
  • Good chance of definitive control of bleeding
  • Minimally invasive
  • Safety profile comparable with colonoscopy
  • Should be performed as soon as possible after a positive CT angiogram, ideally within 60min
  • Unable to localise the site of bleeding in patients with slow blood loss (<0.5 ml/min)
  • Radiation and contrast exposure
  • Requires the availability of an interventional radiology team, which may not be immediately available. Considerations of safety of patient transfer if the intervention cannot be performed on site.
Endoscopy
  • Biopsy samples can be collected for planning future management options, eg. where malignancy is the source of bleeding
  • Endoscopic haemostasis options are available which may be safer and more directed than angioemobolisation (eg. snare ligation, clipping, injection, thermal coagulation)
  • Rapid bowel prep (4–6 L of PEG solution within 3–4 hours, usually via NG tube) is an option
  • Upper GI endoscopy may reveal the upper GIT to be the source of bleeding where the CTA is negative
  • Diagnostic colonoscopy is an alternative to CTA/angiography
  • Early colonoscopy (within 24 hrs) may not influence outcomes
  • Bowel prep greatly increases the yield of this investigation; unprepped acute colonoscopy/sigmoidoscopy is not recommended
  • Risk of perforation
  • CTA has a higher yield for localising the source of bleeding, particularly in patients with severe haemorrhage, and acute bleeding where the patient is not prepped
  • Unable to address bleeding after the illeocaecal valve or past the D3/early jejunum
  • Rapid bowel prep is not a great option, and will still usually require six hours.
Surgery
  • Definitive control of major bleeding can be achieved by bowel resection
  • Good samples can be collected intraoperatively to aid diagnosis (eg. of malignancy)
  • Source of bleeding may not be easily localised
  • Significant morbidity and mortality, long recovery, risk of perforation, post-operative wound infection
  • High morbidity: emergency laparotomy should be reserved only for those patients in whom medical and radiological intervention options have been exhausted

One might be tempted to put all kinds of octreotide and terlipressin and Factor VIIa in there, but the reader is reminded that the college asked for definitive management, and those haemostatic strategies are all conservative, in the sense that they do nothing about the source of the bleeding.