Module 22 · GI, liver & haematology

GI bleeding and abdominal emergencies

NewPhase 2

GI emergencies in the ICU: variceal and non-variceal upper GI bleeding with Glasgow-Blatchford, severe acute pancreatitis, intra-abdominal hypertension and compartment syndrome, acute mesenteric ischaemia, and ileus/colonic pseudo-obstruction.

6 topics

Drugs in this module

Doses written for this module's context. The same drug may read differently in another module.

Terlipressin

Vasopressin analogue (splanchnic vasoconstrictor)

Indications
Acute variceal bleeding
Adult dose
2 mg IV every 4 h until bleeding controlled (first 48 h), then 1 mg every 4 h; continue 2-5 days.
Preparation (India)
1 mg vials; give as IV bolus.
Cautions
Ischaemia (cardiac, mesenteric, digital), hyponatraemia, bradycardia; avoid in significant IHD/PVD.

Octreotide

Somatostatin analogue

Indications
Variceal bleeding (alternative to terlipressin)
Adult dose
50 mcg IV bolus, then 50 mcg/h infusion for 2-5 days.
Preparation (India)
100 mcg/mL ampoules; 500 mcg in 50 mL NS = 10 mcg/mL (5 mL/h = 50 mcg/h).
Cautions
Hyper/hypoglycaemia, bradycardia.

Ceftriaxone

Third-generation cephalosporin

Indications
Antibiotic prophylaxis in cirrhosis with GI bleeding
Adult dose
1 g IV once daily for up to 7 days.
Preparation (India)
1 g vials.
Cautions
Choose per local resistance (e.g. if high ESBL rates).

Erythromycin

Macrolide (motilin agonist)

Indications
Pre-endoscopy gastric emptying in UGIB
Adult dose
250 mg IV over 30 min, 30-120 min before endoscopy.
Preparation (India)
IV erythromycin lactobionate has limited availability in India.
Cautions
QT prolongation; drug interactions.

Pantoprazole (or esomeprazole)

Proton pump inhibitor

Indications
Non-variceal (peptic ulcer) bleeding
Adult dose
Pre-endoscopy: 80 mg IV bolus. After endoscopic therapy of high-risk ulcer: 80 mg bolus then 8 mg/h for 72 h, or 40 mg IV twice daily (intermittent high dose, non-inferior); then oral twice daily to complete 2 weeks.
Preparation (India)
40 mg vials; infusion 80 mg in 100 mL NS (0.8 mg/mL) at 10 mL/h = 8 mg/h.

Ringer lactate

Balanced crystalloid

Indications
Acute pancreatitis fluid resuscitation
Adult dose
Hypovolaemic: 10 mL/kg bolus, then 1.5 mL/kg/h; reassess at 3, 12, 24, 48 and 72 h (WATERFALL moderate strategy). Not hypovolaemic: 1.5 mL/kg/h without bolus.
Preparation (India)
500 mL / 1 L bags.
Cautions
Aggressive fluids (20 mL/kg bolus + 3 mL/kg/h) increased fluid overload without benefit.

Unfractionated heparin

Anticoagulant

Indications
Acute mesenteric ischaemia (arterial and venous)
Adult dose
80 units/kg IV bolus, then 18 units/kg/h titrated to aPTT 1.5-2.5x control.
Preparation (India)
25,000 units in 50 mL = 500 units/mL.

Neostigmine

Acetylcholinesterase inhibitor

Indications
Acute colonic pseudo-obstruction (Ogilvie) not responding to conservative care
Adult dose
2 mg IV over 3-5 min with cardiac monitoring; may repeat once. Atropine 0.6-1 mg at bedside for bradycardia.
Preparation (India)
0.5 mg/mL ampoules.
Cautions
Contraindicated in mechanical obstruction, perforation, recent bowel anastomosis, bradycardia, active bronchospasm.

Module references (16)

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  2. 2

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    Gralnek IM, Stanley AJ, Morris AJ, et al. Endoscopic diagnosis and management of nonvariceal upper gastrointestinal hemorrhage (NVUGIH): ESGE Guideline - Update 2021. Endoscopy 2021;53:300-32.

  4. 4

    Laine L, Barkun AN, Saltzman JR, Martel M, Leontiadis GI. ACG Clinical Guideline: Upper Gastrointestinal and Ulcer Bleeding. Am J Gastroenterol 2021;116:899-917.

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    Blatchford O, Murray WR, Blatchford M. A risk score to predict need for treatment for upper-gastrointestinal haemorrhage. Lancet 2000;356:1318-21.

  6. 6

    Villanueva C, Colomo A, Bosch A, et al. Transfusion strategies for acute upper gastrointestinal bleeding. N Engl J Med 2013;368:11-21.

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  8. 8

    Lau JYW, Yu Y, Tang RSY, et al. Timing of endoscopy for acute upper gastrointestinal bleeding. N Engl J Med 2020;382:1299-308.

  9. 9

    Banks PA, Bollen TL, Dervenis C, et al. Classification of acute pancreatitis - 2012: revision of the Atlanta classification and definitions by international consensus. Gut 2013;62:102-11.

  10. 10

    de-Madaria E, Buxbaum JL, Maisonneuve P, et al. Aggressive or moderate fluid resuscitation in acute pancreatitis (WATERFALL). N Engl J Med 2022;387:989-1000.

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    Tenner S, Vege SS, Sheth SG, et al. American College of Gastroenterology Guidelines: Management of Acute Pancreatitis. Am J Gastroenterol 2024;119:419-37.

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    van Santvoort HC, Besselink MG, Bakker OJ, et al. A step-up approach or open necrosectomy for necrotizing pancreatitis (PANTER). N Engl J Med 2010;362:1491-502.

  13. 13

    Wu BU, Johannes RS, Sun X, et al. The early prediction of mortality in acute pancreatitis: a large population-based study. Gut 2008;57:1698-703.

  14. 14

    Kirkpatrick AW, Roberts DJ, De Waele J, et al. Intra-abdominal hypertension and the abdominal compartment syndrome: updated consensus definitions and clinical practice guidelines from the World Society of the Abdominal Compartment Syndrome. Intensive Care Med 2013;39:1190-206.

  15. 15

    Bala M, Catena F, Kashuk J, et al. Acute mesenteric ischemia: updated guidelines of the World Society of Emergency Surgery. World J Emerg Surg 2022;17:54.

  16. 16

    Ponec RJ, Saunders MD, Kimmey MB. Neostigmine for the treatment of acute colonic pseudo-obstruction. N Engl J Med 1999;341:137-41.