17.1 Gastrointestinal & Hepatic Emergencies: GI Bleeding, Cirrhosis Complications, Pancreatitis & Vomiting

17.1 Gastrointestinal & Hepatic Emergencies: GI Bleeding, Cirrhosis Complications, Pancreatitis & Vomiting

Acute Upper GI Bleeding

Risk Stratification and General Care

The Glasgow-Blatchford score uses BUN, hemoglobin, systolic blood pressure, heart rate, melena, syncope, liver disease and heart failure. ACG (2021) suggests that patients with a score of 0 or 1 can be managed as outpatients.

• Transfusion: restrictive, with a hemoglobin threshold of 7 g/dL (about 8 g/dL with cardiovascular disease).
• Anticoagulants and antiplatelets: hold and reverse according to bleeding severity (Section 10.1). Aspirin for secondary prevention is usually resumed soon after hemostasis.
• Tranexamic acid: not recommended. In HALT-IT (2020, about 12,000 patients), TXA did not reduce death from bleeding and increased venous thromboembolism (0.8% vs. 0.4%) and seizures.

Nonvariceal Bleeding (Peptic Ulcer)

Variceal Bleeding in Cirrhosis

Suspect varices in any patient with cirrhosis and GI bleeding. Treatment starts before endoscopy:

1. Vasoactive therapy: octreotide 50 mcg IV bolus, then 50 mcg/h, continued for 2 to 5 days after endoscopic therapy. Terlipressin is used outside the United States for this indication.
2. Antibiotic prophylaxis: ceftriaxone 1 g IV daily for up to 7 days. Infection is common after variceal bleeding, and prophylaxis reduces infection, rebleeding and death.
3. Restrictive transfusion: a hemoglobin target of about 7 g/dL. Over-transfusion raises portal pressure and increases rebleeding.
4. Endoscopic band ligation within 12 hours, followed by nonselective beta-blockers once the patient is stable.

INR is a poor guide to bleeding risk in cirrhosis because both procoagulant and anticoagulant factors fall. Do not give fresh frozen plasma just to correct the INR.

Complications of Cirrhosis

Hepatic Encephalopathy

• Look for and treat precipitants: GI bleeding, infection, constipation, dehydration, electrolyte disturbance, and sedatives or opioids.
• Lactulose 25 mL every 1 to 2 hours until at least two soft bowel movements, then titrate to 2 to 3 soft bowel movements a day. Give it by nasogastric tube or as an enema if the patient cannot swallow safely.
• Polyethylene glycol 4 L over 4 hours resolved encephalopathy faster than lactulose in the HELP trial (2014).
• Rifaximin 550 mg twice daily is added to lactulose to prevent recurrence.
• Avoid benzodiazepines, which worsen encephalopathy, except for alcohol withdrawal.

Spontaneous Bacterial Peritonitis (SBP)

The diagnosis is an ascitic fluid neutrophil count of 250 cells/mm3 or more.

• Antibiotics: a third-generation cephalosporin such as cefotaxime 2 g IV every 8 hours or ceftriaxone. Use broader therapy for hospital-acquired infection or recent antibiotic exposure.
• Albumin: 1.5 g/kg within 6 hours of diagnosis and 1 g/kg on day 3, given when creatinine is above 1 mg/dL, BUN is above 30 mg/dL or bilirubin is above 4 mg/dL. Albumin reduces kidney failure and death.
• Worked example: an 80-kg patient with a creatinine of 1.6 mg/dL needs 120 g of albumin on day 1 and 80 g on day 3.
• After large-volume paracentesis (more than 5 L), give 6 to 8 g of albumin per liter removed.

Hepatorenal Syndrome (HRS-AKI)

After stopping diuretics and nephrotoxins and giving albumin (1 g/kg/day for 2 days, maximum 100 g/day), HRS-AKI is treated with a vasoconstrictor plus albumin.

Terlipressin (approved in the US in 2022):

• 0.85 mg IV every 6 hours on days 1 to 3.
• On day 4, increase to 1.7 mg every 6 hours if creatinine has fallen less than 30%, and stop if creatinine is at or above baseline.
• Continue until 24 hours after two creatinine values of 1.5 mg/dL or less, taken at least 2 hours apart, or for a maximum of 14 days.

Norepinephrine plus albumin is an ICU alternative. Midodrine with octreotide is weaker and is used only when the other options cannot be.

Alcohol-Associated Hepatitis

For severe disease (Maddrey discriminant function 32 or higher, or MELD above 20) without active infection or GI bleeding, prednisolone 40 mg daily for 28 days is an option. A Lille score of 0.45 or higher on day 7 indicates nonresponse, and steroids are stopped. Prednisolone is used rather than prednisone because it does not need hepatic activation. Screen for infection first.

Acute Liver Failure Not Caused by Acetaminophen

IV N-acetylcysteine improved transplant-free survival in patients with early-grade (I to II) encephalopathy from non-acetaminophen acute liver failure (Lee, 2009). Contact a transplant center early.

Drug Dosing in Cirrhosis

• Acetaminophen is the preferred analgesic, usually limited to 2 g/day.
• Avoid NSAIDs, which cause kidney injury, GI bleeding and diuretic resistance.
• Use opioids cautiously at reduced doses and longer intervals. Hydromorphone or fentanyl are often preferred over morphine; avoid meperidine and codeine.
• Creatinine-based equations overestimate kidney function in patients with low muscle mass.

Acute Pancreatitis

• Fluids: in WATERFALL (2022), aggressive resuscitation (20 mL/kg bolus, then 3 mL/kg/h) caused more fluid overload (20.5% vs. 6.3%) than moderate resuscitation without reducing severe disease. The trial was stopped early. The moderate approach is 10 mL/kg only if the patient is hypovolemic, then 1.5 mL/kg/h, adjusted to clinical response. Lactated Ringer's is commonly preferred.
• Antibiotics: not given as prophylaxis. Use them only for documented infection or suspected infected necrosis.
• Analgesia: opioids are acceptable and do not worsen outcomes. Multimodal regimens reduce opioid needs.
• Feeding: start oral feeding early, within 24 to 48 hours, as tolerated.
• Hypertriglyceridemia above about 1,000 mg/dL: insulin infusion with dextrose, or plasmapheresis in selected cases.

Nausea, Vomiting and Cannabinoid Hyperemesis

Cannabinoid hyperemesis syndrome (cyclic vomiting with heavy cannabis use, often relieved by hot showers) responds poorly to ondansetron. In the HaVOC trial (2021), haloperidol 0.05 to 0.1 mg/kg IV relieved symptoms better than ondansetron 8 mg. Topical capsaicin 0.1% to the abdomen and droperidol are alternatives. Stopping cannabis is the only lasting cure.

Esophageal food impaction: glucagon 1 mg IV rarely works and must not delay endoscopy. A patient who cannot swallow saliva needs urgent endoscopy.