Gastrointestinal Emergencies
What to know
Gastrointestinal emergencies include hemorrhage, inflammation, obstruction, and perforation. Upper GI bleeding presents with hematemesis or melena; an elevated BUN-to-creatinine ratio suggests an upper source. Cirrhotic patients with suspected variceal bleeding need two large-bore IVs, restrictive transfusion targeting a hemoglobin near 7 g/dL, octreotide, prophylactic antibiotics such as ceftriaxone, and urgent endoscopy. Acute pancreatitis presents with epigastric pain radiating to the back, nausea, and elevated lipase; treatment is aggressive isotonic fluids (often lactated Ringer), analgesia, and early nutrition - antibiotics are not routine. Bowel obstruction causes vomiting, distension, and absent stools, while mesenteric ischemia causes pain out of proportion to examination findings. Perforation produces a rigid abdomen and free air.
Traps
Enzyme levels do not grade pancreatitis severity. A normal lipase does not exclude early disease. Be cautious with nasogastric tubes in known varices. Older adults may present atypically with confusion or dyspnea rather than abdominal pain. Avoid NSAIDs for pain in suspected ulcer bleeding.
Worked example
A 55-year-old with cirrhosis arrives with hematemesis and a blood pressure of 92/60. Place two large-bore IVs, start octreotide and ceftriaxone, transfuse conservatively, and arrange urgent endoscopy. Rule of thumb: variceal bleeding is a two-drug, two-line, one-scope emergency.