Gastrointestinal, Hepatic, and Nutrition Support
Bleeding, liver, and feeding
Three topic clusters dominate: upper GI bleeding, cirrhosis complications, and nutrition timing.
- Nonvariceal GI bleed: resuscitate, IV proton pump inhibitor (80 mg bolus then 8 mg/h for 72 hours), transfuse to a restrictive hemoglobin threshold (about 7 g/dL), endoscopy after stabilization. Hold clopidogrel only as directed - do not routinely stop aspirin for secondary prevention.
- Variceal bleed: octreotide plus prophylactic ceftriaxone plus endoscopic band ligation.
- Hepatic encephalopathy: lactulose titrated to 2–3 soft stools daily, rifaximin for secondary prophylaxis, treat precipitants (infection, bleeding, constipation, electrolytes). Ammonia levels do not track severity.
- Spontaneous bacterial peritonitis: ceftriaxone; add albumin 1.5 g/kg day 1 and 1 g/kg day 3 in high-risk patients (renal impairment or high bilirubin).
- Nutrition: start enteral feeding within 24–48 hours in the critically ill when the gut works; trophic feeding is acceptable in shock with high pressor requirements; protein 1.2–2 g/kg/day; do not use albumin as a nutrition source.
Traps
Starting high-calorie feeds in a malnourished patient without thiamine (give thiamine before or with glucose); using lactulose to a goal of continuous diarrhea; repeating albumin for every cirrhosis patient; forgetting that stress ulcer prophylaxis is indicated mainly for mechanical ventilation and coagulopathy, not for every ICU admission.
Worked example
Refeeding risk (low BMI, little intake for days, low magnesium or phosphate): start feeds at 10–20 kcal/kg/day, give thiamine 100 mg before glucose-containing fluids, and recheck phosphate, potassium, and magnesium every 12–24 hours.
Rule of thumb
Feed the gut early, start low if the patient is malnourished, and check phosphate before increasing calories.