Haemodynamically unstable gastrointestinal haemorrhage with a negative initial CT angiogram — MRCEM SBA MCQ

Instant feedback + full explanation. One question, done properly.

HardGastrointestinal and surgical emergenciesHaemodynamically unstable gastrointestinal haemorrhage with a negative initial CT angiogramMRCEM SBA

A 68-year-old woman presents after passing a large volume of dark red blood per rectum. She has previously been treated for a duodenal ulcer but reports no haematemesis or melaena. A major haemorrhage protocol has been activated, and resuscitation is continuing with anaesthetic support. After initial resuscitation, her pulse is 126/min and blood pressure is 90/54 mmHg. CT angiography with arterial and portal venous phases, completed 10 minutes ago, shows no active extravasation or bleeding source. She remains haemodynamically unstable. Gastroenterology, interventional radiology and surgery are available. Which procedure should be arranged next?

Educational content. Not a substitute for clinical judgement or local policy.

Reveal the answer and explanation

Correct answer: C — Arrange urgent upper gastrointestinal endoscopy.

Her shock index is 1.4, indicating persistent haemodynamic instability after initial resuscitation. Dark red rectal bleeding does not establish a lower gastrointestinal source: brisk upper gastrointestinal bleeding can present this way, and her ulcer history adds to that possibility. The British Society of Gastroenterology recommends immediate upper endoscopy when a patient with apparent lower gastrointestinal bleeding remains unstable and the initial CT angiogram identifies no source. Resuscitation and anaesthetic support must continue while it is arranged. ([gut.bmj.com](https://gut.bmj.com/content/68/5/776?ijkey=aad8f1d04bf5fefbfd3289a5ca1cf2ea937dce2b&keytype2=tf_ipsecsha&utm_source=openai)) A is attractive because catheter angiography can lead to embolisation, but the guideline prioritises it after a *positive* CT angiogram identifies a bleeding site. B may be appropriate for a stable patient admitted with major lower gastrointestinal bleeding; bowel preparation and colonoscopy should not delay assessment of a possible upper source in this unstable patient. D acknowledges that bleeding can be intermittent, but repeating a negative scan completed minutes ago is not the recommended next step. E may become necessary if haemorrhage cannot be controlled, but proceeding to exploration before further assessment of the source is premature here. ([gut.bmj.com](https://gut.bmj.com/content/68/5/776?ijkey=aad8f1d04bf5fefbfd3289a5ca1cf2ea937dce2b&keytype2=tf_ipsecsha&utm_source=openai))

Reference: Diagnosis and management of acute lower gastrointestinal bleeding: guidelines from the British Society of Gastroenterology (2019) — https://gut.bmj.com/content/68/5/776?ijkey=aad8f1d04bf5fefbfd3289a5ca1cf2ea937dce2b&keytype2=tf_ipsecsha Acute upper gastrointestinal bleeding in over 16s: management — recommendations (Published 13 June 2012; last updated 25 August 2016) — https://www.nice.org.uk/guidance/cg141/chapter/Recommendations