Gastroenterology and Hepatology
Core concepts
Master upper and lower GI bleeding, peptic ulcer disease, pancreatitis, cirrhosis and its complications, inflammatory bowel disease, and viral hepatitis. Upper bleeding is stabilized first, then endoscopy; variceal bleeding adds octreotide and prophylactic ceftriaxone. Pancreatitis requires two of three criteria: characteristic pain, lipase above three times the upper limit, and imaging. Cirrhosis management includes ascites sodium restriction plus spironolactone and furosemide, spontaneous bacterial peritonitis (ascitic PMN at least 250), variceal prophylaxis with beta-blockers or banding, and lactulose for hepatic encephalopathy. Distinguish hepatocellular from cholestatic enzyme patterns.
Traps
- Diagnosing SBP only by culture; the cell count triggers treatment.
- Giving NSAIDs or aminoglycosides in cirrhosis.
- Withholding antibiotics in variceal bleeding because the patient is afebrile.
- Using prophylactic antibiotics in sterile necrotizing pancreatitis.
- Missing that lipase can be elevated in renal failure, so clinical context matters.
- Confusing cholangitis with cholecystitis; Charcot triad (fever, RUQ pain, jaundice) suggests ascending cholangitis requiring biliary drainage.
Worked example
A 52-year-old with heavy alcohol use has epigastric pain radiating to the back, lipase 4 times the upper limit, and hypocalcemia. No antibiotics are indicated; care is aggressive fluid resuscitation, analgesia, antiemetics, and early enteral nutrition. Rule of thumb: in pancreatitis, the first 24 hours are about fluids and finding gallstones; CT is for complications, not initial diagnosis.