Gastroenterology and Hepatology
This block concentrates on gastrointestinal bleeding, decompensated cirrhosis, and acute pancreatitis - situations where a few hours change the outcome.
Upper gastrointestinal bleeding
Resuscitate before endoscopy, with restrictive transfusion (threshold Hb <7 g/dL, or <8 g/dL with cardiovascular disease). The pre-endoscopy Glasgow-Blatchford score triages need for admission. Variceal bleeding: vasoactive drug (octreotide or terlipressin) plus prophylactic ceftriaxone plus band ligation within 12 h; rescue with balloon tamponade or TIPS. Non-variceal bleeding: PPI infusion, endoscopic haemostasis, and eradication of Helicobacter pylori.
Cirrhosis complications
Perform diagnostic paracentesis on every admission; SAAG ≥1.1 g/dL indicates portal hypertension. Spontaneous bacterial peritonitis is defined by ascitic polymorphs ≥250/mm3 - treat with an intravenous third-generation cephalosporin plus albumin 1.5 g/kg on day 1 and 1 g/kg on day 3, then start secondary prophylaxis. For encephalopathy, exclude bleeding, infection, constipation, and electrolyte disturbance; titrate lactulose to 2-3 soft stools daily and add rifaximin for recurrence.
Acute pancreatitis
Diagnosis requires 2 of 3: typical epigastric pain, lipase >3× upper limit of normal, characteristic imaging. Give early isotonic crystalloid (lactated Ringer's), analgesia, and enteral feeding once tolerated. Prophylactic antibiotics are not indicated. ERCP within 24-48 h only for cholangitis or persistent biliary obstruction.
Worked example
A 45-year-old with alcoholic cirrhosis presents with melena, Hb 8.1 g/dL, pulse 112, BP 96/60. Secure two large-bore lines, cross-match, start octreotide and ceftriaxone, and scope within 12 h. Do not give a beta-blocker now - it blunts the compensatory tachycardia.
Traps that cost marks
- Excluding SBP because the ascites is not cloudy.
- Over-transfusing a variceal bleeder and raising portal pressure.
- Ordering early CT instead of scoring severity at 48-72 h.