Discuss the options for the definitive management of acute severe lower gastrointestinal bleeding, including the potential advantages and disadvantages of each option.
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 |
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 | |
|
|
| Endoscopy | |
|
|
| Surgery | |
|
|
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.
Triantafyllou, Konstantinos, et al. "Diagnosis and management of acute lower gastrointestinal bleeding: European Society of Gastrointestinal Endoscopy (ESGE) Guideline." Endoscopy 53.08 (2021): 850-868.
Sengupta, Neil, et al. "Management of patients with acute lower gastrointestinal bleeding: an updated ACG guideline." The American Journal of Gastroenterology 118.2 (2023): 208-231.
Oakland, Kathryn, et al. "Diagnosis and management of acute lower gastrointestinal bleeding: guidelines from the British Society of Gastroenterology." Gut (2019): gutjnl-2018.