Question 3

College answer

Syllabus topic/section: 2.1.6 Gastrointestinal Intensive Care / Acute gastrointestinal bleeding: L1

Discussion: This is a common presentation of critical illness and core knowledge. Overall, most candidates did well in outlining assessment of potential causes, severity of pathology, basic investigations and expected examination findings. Most candidates assessed for liver disease or other haemostatic pathologies, including basic resuscitation and outlining transfusion targets. Candidates would demonstrate they had achieved the standard required of a transitional fellow if they wrote not just what they would do but why (rationale). For example, a simple list of investigations does not distinguish an acceptable standard final year fellowship candidate, but a prioritised plan of investigations with rationale will display a higher level of thought. Marks will be allocated accordingly. Candidates are reminded to pay attention to the glossary of terms. “Outline” requires more detail than “List “. Answers outlining management of the patient including specific therapies of potential causes of upper GI bleeding and management of complications of high-volume resuscitation. The superior answer prioritised endoscopy as the first line intervention for upper GI bleeding, detailing its use for therapeutic as well as diagnostic means. Higher marks were also awarded to answers that prioritised plans and provided a rationale for the prioritisation.

Discussion

Assessment:

• History
  • Liver disease, alcoholism, IVDU, Hep C, NSAID use, anticoagulation, weight loss, liver and cardiac failure
  • High risk: syncope, frequency of haematemesis, hypotension and tachycardia, more than 4 units of PRBCs transfused over 12 hrs, age > 60
• Examination
  • Clinical features of shock: vital signs, urine output, mental state
  • Airway grade and access difficulty
  • Stigmata of chronic liver disease or IV drug use
  • Weight and abdominal masses, organomegaly, ascites, lymphadenopathy
• Investigations
  • ABG for lactate, Hb and ionised calcium; 
  • EUC for urea to observe the digestion of blood
  • LFTs for albumin and other biomarkers suggestive of liver disease
  • FBC, coags and TEG to see whether factors and platelets are required
  • Group and hold, crossmatch (to prepare for transfusions)
  • CXR, for gas under the diaphragm (perforated DU)
  • CT mesenteric angiogram to look for embolisable lesions
• Scoring systems
  • Glasgow-Blatchford Bleeding Score (Laursen et al, 2012)
  • AIMS65 score (Hyett et al, 2013) 

Management:

• Conservative management
  • ​​​​Peptic ulcers: PPI infusion, H2 antagonists, octreotide
  • For varices:  balloon tamponade, terlipressin, octreotide, non-selective beta blockade
• Definitive management
  • Endoscopy is first line; options are:
    • P​​​​eptic ulcers: Adrenaline injection, heat coagulation, clipping
    • Varices: sclerotherapy, banding
    • Masses: diagnostic biopsy
  • IR angioembolisation of arterial bleeders is second line
    • for venous bleeding, TIPS may be offered where varices are refractory
  • Surgery is the last resort