Gastroenterology & Hepatology

Acute Upper Gastrointestinal Bleed (UGIB) Protocol

flowchart TD
    Presentation["Acute Hematemesis / Melena / Hemodynamic Instability"] --> Resuscitation["2 Large-Bore IVs (16-18G) + Isotonic Crystalloids (LR or NS)"]
    Resuscitation --> Transfusion{"Active Hemorrhage / Hemoglobin Check"}

    Transfusion -- "Hb < 7 g/dL (or < 8 g/dL with CAD)" --> PRBC["Restrictive Transfusion Strategy (Target Hb 7-9 g/dL)"]
    Transfusion -- Coagulopathy --> CoagFix["Correct Coagulopathy (PCC for Warfarin; Platelets if < 50k)"]

    PRBC --> Meds["Immediate Medical Therapy:\n1. IV PPI (Pantoprazole 80 mg bolus + 8 mg/hr infusion)\n2. IV Octreotide (50 mcg bolus + 50 mcg/hr) for suspected varices\n3. IV Ceftriaxone (1 g/day) for cirrhotic patients (prevents SBP)"]
    CoagFix --> Meds

    Meds --> EGD["Upper Endoscopy (EGD) within 24 hours\n(within 12 hours if suspected variceal hemorrhage)"]
    EGD --> Refractory{"Hemostasis Achieved?"}
    Refractory -- No --> TIPS["Balloon Tamponade (Blakemore) -> Emergent TIPS"]
    Refractory -- Yes --> PostCare["Band Ligation -> Secondary Prophylaxis with Nonselective Beta-Blocker (Nadolol/Propranolol)"]

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Acute Pancreatitis Management

Diagnostic Criteria (Requires 2 of 3)

1. Severe epigastric pain radiating to the back.
2. Serum lipase or amylase ≥ 3 times the upper limit of normal.
3. Characteristic findings on abdominal imaging (CT with contrast, MRI, or ultrasound). Note: CT is NOT required if criteria 1 and 2 are met.

Evidence-Based Step 3 Management Algorithm

• Fluid Resuscitation: Goal-directed infusion with Lactated Ringer’s (preferred over normal saline to reduce hyperchloremic acidosis and SIRS).
• Pain Control: IV Hydromorphone or Fentanyl.
• Nutrition: Early oral or enteral feeding (within 24–48 hours) as soon as pain and ileus resolve. Prolonged NPO or TPN is harmful.
• Gallstone Pancreatitis:
  • If acute cholangitis present (fever, jaundice, RUQ pain) → Emergent ERCP within 24 hours.
  • Perform laparoscopic cholecystectomy during the same hospitalization once acute inflammation subsides to prevent recurrent fatal pancreatitis.
• Antibiotics: Prophylactic antibiotics are NOT recommended in sterile necrosis. If infected necrosis is suspected (>7–14 days with clinical deterioration), perform CT-guided FNA or empiric carbapenem (Meropenem).

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Cirrhosis: Decompensation & Complications

Complication	Diagnostic Hallmark	Step 3 Acute Management & Pearls
Spontaneous Bacterial Peritonitis (SBP)	Diagnostic paracentesis: Aspergillus / PMN count ≥ 250/mm³	1. IV Cefotaxime or Ceftriaxone 2g stat. 2. IV Albumin (1.5 g/kg within 6 hr, 1.0 g/kg on Day 3) to prevent Hepatorenal Syndrome. 3. Lifelong secondary prophylaxis: Oral Ciprofloxacin or TMP-SMX.
Hepatic Encephalopathy	Elevated ammonia (clinical diagnosis; asterixis, confusion)	1. Oral / Rectal Lactulose (titrated to 2–3 soft bowel movements/day). 2. Add Rifaximin 550 mg BID for recurrent episodes. 3. Search for triggering event: GI bleed, infection/SBP, hypokalemia, constipation.
Hepatorenal Syndrome (HRS)	AKI with Cr doubling, no response to 48 hr volume expansion, normal urine sediment (FeNa < 0.1%)	1. Discontinue diuretics immediately. 2. Albumin infusion + Vasoconstrictors: Terlipressin (first-line) or Midodrine + Octreotide. 3. Definitive cure: Liver Transplantation.

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Inflammatory Bowel Disease Comparison

Key Differential Contrast

Crohn Disease vs Ulcerative Colitis

Clinical Feature	Crohn Disease	Ulcerative Colitis (UC)	Discriminating Clue
Anatomic Distribution	Transmural inflammation; skip lesions ('cobblestoning'); can affect mouth to anus (terminal ileum most common)	Mucosal and submucosal inflammation; continuous lesions starting in rectum extending proximally	Rectal sparing favors Crohn; rectal involvement is universal in UC
Histopathology	Noncaseating granulomas, transmural lymphoid aggregates, creeping mesenteric fat	Crypt abscesses, mucosal ulceration without granulomas, pseudopolyps	Granulomas confirm Crohn Disease
Complications	Fistulas (enteroenteric, enterovesical), strictures/bowel obstruction, perianal abscesses, gallstones, oxalate kidney stones	Toxic megacolon (dilation > 6 cm with systemic toxicity), severe hemorrhage, Primary Sclerosing Cholangitis (PSC)	Fistulas and perianal disease are hallmarks of Crohn
Cancer Surveillance	Colonoscopy 8 years post-diagnosis if >1/3 of colon involved, then every 1-2 years	Annual surveillance colonoscopy beginning 8 years post-diagnosis due to high adenocarcinoma risk	Surveillance begins 8 years after disease onset