Gastrointestinal, Renal and Genitourinary Emergencies
What the board tests
Risk stratification of gastrointestinal bleeding, safe transfusion, emergency decompression of the obstructed infected kidney, hyperkalaemia management, and the surgical clock in testicular torsion.
GI bleeding and pancreatitis
- Resuscitate first, then risk-stratify: Glasgow-Blatchford score 0-1 can be discharged; a score of 7 or more predicts intervention.
- Restrictive transfusion to a haemoglobin threshold of 7 g/dL (8 g/dL with active ischaemic heart disease).
- Suspected variceal bleed: octreotide, prophylactic ceftriaxone, and endoscopic band ligation within 12 h; avoid over-transfusion which raises portal pressure.
- Acute pancreatitis: aggressive isotonic fluids, analgesia, no prophylactic antibiotics; urgent ERCP within 24 h when there is cholangitis or persistent obstruction.
Renal and genitourinary
- AKI: classify prerenal, intrinsic and postrenal; check urine sodium, microscopy and a bladder scan; relieve obstruction with a catheter or nephrostomy.
- Hyperkalaemia with ECG changes: IV calcium gluconate first, then insulin-dextrose, nebulised salbutamol, bicarbonate if acidotic, and dialysis for refractory cases.
- Renal colic: NSAID first-line; CT KUB for diagnosis; an obstructed infected kidney is an emergency needing decompression, not analgesia and discharge.
- Testicular torsion: detorsion within 6 h preserves the testis. Doppler ultrasound must never delay surgery; operating on clinical suspicion is correct.
- Urinary retention: catheterise and look for causes; dialysis patients with missed sessions may present with pulmonary oedema or hyperkalaemia.
Worked example
A 70-year-old with cirrhosis vomits fresh blood, BP 90/60, pulse 118, Hb 7.5 g/dL. Insert two large cannulae, give blood and octreotide, add ceftriaxone, and arrange endoscopy within 12 h. Do not transfuse to a normal haemoglobin; target 7 g/dL. If he is on a non-selective beta-blocker, that does not replace endoscopic therapy. Reasoning: variceal haemorrhage needs vasoactive therapy, antibiotics and early banding, with restrictive transfusion to avoid rebound portal hypertension.
Traps
Transfusing a variceal bleed to 10 g/dL; giving NSAIDs in renal impairment; waiting for Doppler before theatre in torsion; sending the obstructed infected kidney home on antibiotics; forgetting calcium in hyperkalaemia with ECG changes.