Acute Gastrointestinal and Genitourinary Disorders

1. Acute Gastrointestinal and Genitourinary Disorders Christiana E. Hall, MD MS Division of Neurocritical Care University of Texas Southwestern Medical Center Dallas, Texas

2. Upper & Lower GI bleeding UGIB CAUSES Peptic ulcer disease most common Variceal hemorrhage most feared Aortoenteric fistula deadly Other causes: esophagitis, mallory-weiss tear, Dieulafoy�s lesion, angiodysplasia, tumors

3. Upper & Lower GI bleeding LGIB CAUSES Diverticular Dz most common Angiodysplasia second most common Ischemic colitis most feared Postpolypectomy bleeds most annoying Other causes: (LGIB) Colitis, Dieulafoy�s lesion, tumors, anorectal fissures/varices/ hemorrhoids. **Meckel�s diverticulum � rare, small bowel, ALWAYS rule out in young people

4. Upper & Lower GI bleeding Initial approach & management UGIB more likely hemodynamically unstable than LGIB Adequate IV access ie 2 large bore IVs Stat type & cross, CBC, coags, chemistry, LFT Up to 2 liters crystalloid; consider O(-) Transfuse as appropriate correct coagulopathy and consider holding additional PRBC units NGT for room temp saline lavage unless clearly LGIB Consult GI endoscopist If massive, initiate massive bleeding transfusion protocol to include FFP & Plts etc; rapid infuser/warmer to BSD

5. Upper & Lower GI bleeding UGIB Non-variceal Begin resuscitation Hgb > 7 Arrange endoscopy for dx and tx (w/in 24 hrs) Consider pre-endoscopy PPI; definite PPI post treatment No promotility agents, no somatostatin, no H2 antagonists Surgery or intravascular tx when endoscopy fails F/U testing for H pylori Home on PPI antiplt or NSAID tx safer with PPI UGIB Variceal Prompt attn. Hgb ~ 8 Urgent endoscopy for dx & tx (w/in 12 hrs) Consider protective intubation Balloon Tamponade � temporize (Sengstaken-Blakemore Tube) somatostatin immediately?3-5 d *TIPS if endoscopy + pharmaco- therapy unsuccessful Cirrhotics: I week SBP prophylaxis w/ quinolone or Ceftriaxone *TIPS � transjugular intrahepatic portosystemic Shunt