American Board of Internal Medicine (ABIM) Certification Practice Exam

In the case of failed endoscopic hemostasis or recurrent lower GI bleeding, what is the next therapeutic step?

1. Consultation with general surgery

2. Consultation with interventional radiology

3. Increased dose of proton pump inhibitors

4. Emergency laparotomy

The correct answer is: Consultation with interventional radiology

In cases of failed endoscopic hemostasis or recurrent lower gastrointestinal (GI) bleeding, consulting with interventional radiology is often the most appropriate next step. Interventional radiology plays a critical role in managing GI bleeding through minimally invasive techniques such as transarterial embolization (TAE), which can effectively target and control the source of hemorrhage, particularly when endoscopic approaches have not succeeded. This approach allows for the identification of vascular abnormalities or bleeds that may not be easily accessible via endoscopy. Interventional radiology can provide options for managing vascular lesions, such as diverticular bleeding, by occluding blood vessels that supply the affected area, thereby minimizing the need for more invasive surgical procedures. Consultation with general surgery may be necessary later if interventional radiology is not successful or if there are other indications for surgical intervention based on the clinical scenario. While an increased dose of proton pump inhibitors may be beneficial for acid-related disorders, it would not address the immediate concern of lower GI bleeding, and emergency laparotomy is typically a last resort due to its invasive nature and potential complications. Therefore, interventional radiology is the recommended next therapeutic step when faced with persistent or recurrent lower GI bleeding following failed endoscopic hemostasis.