Gastroenterology and Hepatology
Core concepts
Organize around the GI bleed, the jaundiced patient, and chronic liver disease. Upper GI bleeding: resuscitate first, risk-stratify with Glasgow-Blatchford, give a PPI infusion for high-risk ulcers, and endoscope within 24 hours (sooner if unstable). For variceal bleeding, add vasoactive therapy (octreotide/terlipressin) and prophylactic antibiotics. Know the Child-Pugh and MELD scores, the complications of cirrhosis (ascites, SBP, hepatic encephalopathy, varices, HCC surveillance), and the interpretation of liver enzymes - hepatocellular (AST/ALT) vs cholestatic (ALP/GGT) patterns.
Traps
Spontaneous bacterial peritonitis is diagnosed at a polymorphonuclear count ≥250/mm³ even with a negative culture; do not wait for culture. Ascites in cirrhosis is managed with sodium restriction, spironolactone plus furosemide, and large-volume paracentesis with albumin replacement. Watch for the "normal AST/ALT does not exclude serious disease" trap in alcoholic hepatitis (AST:ALT >2) and for paracetamol overdose where transaminases can be deceptively low early.
Worked rule of thumb
New ascites in a cirrhotic: always perform diagnostic paracentesis. If PMN ≥250/mm³, start a third-generation cephalosporin and give albumin (1.5 g/kg day 1, 1 g/kg day 3) to reduce renal failure.
Key points
- Resuscitate before endoscopy in GI bleeding.
- Variceal bleed = vasoactive drug + antibiotics + endoscopic banding.
- SBP diagnosis is by ascitic PMN count, not culture.
- Child-Pugh and MELD guide prognosis and transplant listing.
- Cholestatic vs hepatocellular enzyme patterns narrow the differential.