Gastroenterology and Hepatology
This domain covers gastrointestinal bleeding, ascites and spontaneous bacterial peritonitis, pancreatitis, inflammatory bowel disease and viral hepatitis serology. Prioritise resuscitation and severity scoring over endoscopic detail.
Upper GI bleeding
Risk stratify with the Glasgow-Blatchford score; a score of 0–1 may permit outpatient management. Endoscopy within 24 hours, and within 12 hours for variceal bleeding. High-risk stigmata (active bleeding, visible vessel, adherent clot) require endoscopic therapy plus proton pump infusion. Variceal bleeding needs a vasoactive agent, prophylactic antibiotics and band ligation. Transfuse to a haemoglobin of 7–8 g/dL, higher only with significant cardiovascular disease.
Ascites and SBP
Perform diagnostic paracentesis on every admission with ascites. A serum-ascites albumin gradient of 1.1 g/dL or more indicates portal hypertension. A polymorphonuclear count of 250 cells/mm3 or more defines spontaneous bacterial peritonitis; treat with a third-generation cephalosporin for five days plus albumin 1.5 g/kg on day 1 and 1 g/kg on day 3.
Pancreatitis
The Atlanta classification separates interstitial oedematous from necrotising disease; organ failure lasting over 48 hours defines severe disease. Give early goal-directed fluids and enteral feeding within 72 hours. Prophylactic antibiotics are not indicated.
Worked example
Ascitic fluid with 480 PMNs/mm3 in a cirrhotic patient with fever is SBP. Start cefotaxime and albumin immediately, then arrange secondary prophylaxis with norfloxacin after recovery.
Traps that cost marks
- Withholding albumin in SBP.
- Transfusing liberally in variceal bleeding, which raises rebleeding risk.
- Using prophylactic antibiotics in sterile necrotising pancreatitis.