Gastrointestinal, Genitourinary, and Renal Emergencies
Core concepts
Gastrointestinal bleeding: resuscitate first, then risk-stratify. Suspected variceal hemorrhage gets octreotide, ceftriaxone, and endoscopy within 12 hours; ulcer bleeding gets high-dose proton-pump inhibitor infusion. Mesenteric ischemia presents with pain out of proportion to examination in an older patient with atrial fibrillation; lactate may be normal early, and CT angiography is the test. Perforation may show free air on upright radiograph, but CT is more sensitive. Pancreatitis is diagnosed by two of three criteria (characteristic pain, lipase >3× upper limit, imaging); early fluids and early feeding matter, and gallstone pancreatitis with cholangitis needs urgent ERCP. Cholangitis (Charcot triad, Reynolds pentad) requires antibiotics and biliary drainage. Small bowel obstruction with fever, tachycardia, or peritoneal signs suggests strangulation and needs surgery. Renal colic: CT is definitive, NSAIDs are first-line analgesia, and stone size predicts passage. Testicular torsion is a clinical diagnosis - do not delay exploration for Doppler. Acute kidney injury is classified as prerenal, intrinsic, or postrenal; urinary indices are unreliable after diuretics. Dialysis indications: refractory acidosis, electrolytes, intoxication, overload, uremia.
Traps
Older patients with appendicitis or perforation often lack classic signs. Abdominal pain in a reproductive-age woman demands a pregnancy test. A normal lipase does not exclude late pancreatitis, and a normal lactate does not exclude ischemia. NSAIDs in renal insufficiency and forgetting a bladder scan for postrenal AKI are common errors.
Rule of thumb
Pain out of proportion to the abdominal examination in a patient over 60 means CT angiography for mesenteric ischemia - not analgesia and observation.