Gastrointestinal Bleeding and Emergency Gastroenterology
Emergency items reward systematic resuscitation and risk scoring. You should know when to scope, when to transfuse, and which drug combinations change mortality.
Risk stratification and resuscitation
- Glasgow-Blatchford score 1 or less identifies very-low-risk upper GI bleeding suitable for outpatient management. Rockall score predicts rebleeding and mortality after endoscopy.
- Resuscitate first: two large-bore cannulas, crystalloid, cross-match. Restrictive transfusion targeting hemoglobin 7-8 g/dL, with a higher threshold in massive bleeding or ischemic heart disease.
- Endoscopy within 24 hours after resuscitation; sooner in hemodynamic instability.
Upper GI bleeding
- Nonvariceal: Forrest classification guides therapy; combination endoscopic therapy plus high-dose PPI. Consider repeat endoscopy or interventional radiology for rebleeding.
- Variceal: vasoactive agent (terlipressin, octreotide or somatostatin), prophylactic antibiotics, and band ligation within 12 hours. Consider preemptive TIPS in high-risk patients (Child C or B with active bleeding).
- Mallory-Weiss tear usually stops spontaneously; Boerhaave perforation requires surgery and is suggested by subcutaneous emphysema and pleural effusion.
Lower GI bleeding and other emergencies
- Most lower GI bleeding stops spontaneously. Colonoscopy after bowel preparation within 24 hours is preferred; CT angiography for brisk bleeding; consider embolization.
- Acute mesenteric ischemia: pain out of proportion to examination, raised lactate; CT angiography is the test of choice; treat with heparin, revascularization and resection of dead bowel.
- Perforation: free air on erect chest radiograph or CT; resuscitate, give antibiotics, and proceed to surgery.
- Toxic megacolon: colonic diameter above 6 cm with systemic toxicity; stop antimotility agents and opioids, give IV steroids and antibiotics, and involve surgery early.
- Foreign body and food impaction: endoscopy within 24 hours, and urgently if airway compromise or disc battery in the esophagus.
Worked example
A 60-year-old with cirrhosis presents with hematemesis and blood pressure 88/50 mmHg. Give blood products with restrictive targets, start terlipressin and ceftriaxone, then band ligate within 12 hours. Assess for preemptive TIPS if bleeding is uncontrolled in a high-risk Child B or C patient.
Traps
- Scoping an unstable patient before resuscitation.
- Omitting antibiotics in variceal bleeding, which reduces mortality.
- Using a liberal transfusion threshold that raises rebleeding risk.
- Missing mesenteric ischemia because the abdomen is soft.