Gastroenterology and Hepatology
Questions here combine the bleeding patient, the jaundiced patient, the patient with ascites, and the patient with acute pancreatitis. Egypt adds high background prevalence of hepatitis C and schistosomal periportal fibrosis, so always reason about chronic liver disease when ascites or varices appear.
Gastrointestinal bleeding
- Resuscitate first, then risk stratify with the Glasgow-Blatchford score; a score of 0-1 may allow outpatient care.
- Suspected variceal bleeding: restrictive transfusion to a haemoglobin around 7-8 g/dL, vasoactive drug (terlipressin or octreotide), prophylactic antibiotics such as ceftriaxone, and endoscopic band ligation within 12 hours.
- Peptic ulcer bleeding: high-dose proton pump inhibitor infusion after endoscopic haemostasis; repeat endoscopy if rebleeding.
Ascites and liver disease
- Diagnostic paracentesis on admission: a serum-ascites albumin gradient of 1.1 g/dL or more indicates portal hypertension.
- Spontaneous bacterial peritonitis is a polymorphonuclear count of 250 cells/mm3 or more; treat with a third-generation cephalosporin plus albumin and start secondary prophylaxis.
- Management: sodium restriction, spironolactone with furosemide, therapeutic paracentesis with albumin for large-volume taps.
- Hepatic encephalopathy: lactulose titrated to two or three soft stools, rifaximin for recurrence, and always search for the precipitant (infection, bleeding, constipation, hypokalaemia, drugs).
Pancreatitis and jaundice
- Acute pancreatitis needs two of three: typical pain, lipase above three times the upper limit, or characteristic imaging. Give moderate crystalloid, analgesia, early oral feeding; ERCP within 24 hours only with cholangitis or persistent obstruction.
- Cholestatic jaundice with a dilated duct suggests obstruction; ultrasound first, then MRCP or ERCP.
Worked example
A 52-year-old with known cirrhosis presents with fever, abdominal distension and drowsiness. Paracentesis shows 600 neutrophils/mm3. This is spontaneous bacterial peritonitis precipitating encephalopathy: give intravenous cefotaxime plus albumin 1.5 g/kg on day one and 1 g/kg on day three, start lactulose, stop unnecessary sedatives, and begin secondary prophylaxis with norfloxacin after treatment.
Traps
Giving a purely lactulose-based explanation for encephalopathy without hunting the trigger; transfusing bleeding cirrhotic patients to a normal haemoglobin; missing that a high SAAG can still coexist with infection; and calling a lipase of twice normal diagnostic without clinical or imaging support.