Signs and Symptoms Abdominal Distention: Chapter 12 Constipation: Chapter 18 Diarrhea: Chapter 23 Gastrointestinal Bleeding: Chapter 33 Jaundice: Conjugated Hyperbilirubinemia: Chapter 44 Jaundice: Unconjugated Hyperbilirubinemia: Chapter 45 Lymphadenopathy: Chapter 47 Pain: Abdomen: Chapter 53 Vomiting: Chapter 81 Medical, Surgical, and Trauma Emergencies Infectious Disease Emergencies: Chapter 94 Metabolic Emergencies: Chapter 95 Oncologic Emergencies: Chapter 98 Renal and Electrolyte Emergencies: Chapter 100 Toxicologic Emergencies: Chapter 102 Abdominal Trauma: Chapter 103 Abdominal Emergencies: Chapter 116 Thoracic Emergencies: Chapter 124 Transplantation Emergencies: Chapter 125 KEY POINTS Abdominal pain may be a presenting sign of systemic disease Brisk bleeding is uncommon but can rapidly become life threatening GI bleeding may be a sign of bowel ischemia Previous hepatic or biliary surgery places a patient at high risk for cholecystitis and ascending cholangitis Hepatic encephalopathy is not often seen in patients with acute liver failure (ALF), but when identified, may be a life-threatening finding of ALF GASTROINTESTINAL BLEEDING Goals of Treatment GI bleeding is a common and occasionally life-threatening condition in infants and children An orderly approach to this problem is essential (see Chapter 33 Gastrointestinal Bleeding ) Significant GI bleeding places a patient at risk of circulatory collapse The goal for the ED provider is to address lifethreatening GI bleeding by stopping the ongoing losses and replacing intravascular volume Addressing ongoing bleeding will require a team of professionals that may include the emergency physician, hospitalist, surgeon, gastroenterologist, hematologist, and interventional radiologist Addressing potential circulatory compromise achieves two principal objectives: Oxygencarrying capacity is improved through administration of blood products and the perfusion pressure to vital organs is preserved via blood product and intravenous (IV) fluid administration The vast majority of patients with either upper or lower GI bleeding will not have experienced significant blood loss These patients can be managed successfully with judicious laboratory investigation, supportive care, and follow-up with a primary care provider or an appropriate subspecialist UPPER GASTROINTESTINAL BLEEDING Esophageal Varices Goals of Treatment The initial goals of therapy of suspected variceal hemorrhage are identical to those of massive upper GI bleeding from any source Volume resuscitation to maintain adequate perfusion and oxygen-carrying capacity is necessary, but overexpansion of the intravascular volume should be avoided because it may contribute to rebleeding Patients with actively bleeding esophageal varices (EV) may also have liver dysfunction and, as a result, early therapy should also correct existing coagulopathies CLINICAL PEARLS AND PITFALLS Patients with varices are likely to have portal hypertension, and therefore are at risk for ascites, spontaneous bacterial peritonitis, bleeding, and splenomegaly with associated thrombocytopenia and leukopenia Overexpansion of intravascular volume may contribute to rebleeding Patients with portal hypertension are also at risk for bleeding from congestive gastritis Coagulation abnormalities in the setting of active bleeding should be managed aggressively with IV vitamin K, fresh frozen plasma (FFP), and platelets Coagulation abnormalities without active bleeding not require FFP or platelets Prophylactic antibiotics are part of initial pharmacologic management Bleeding varices may be the initial sign of sepsis in patients with liver disease Octreotide is part of initial pharmacologic management with severe active bleeding due to portal hypertension Current Evidence Upper GI bleeding from EV is a major cause of morbidity and mortality in patients with underlying liver disease and portal hypertension Causes of EV can be seen in Table 91.1 Varices that develop as a result of portal hypertension are a type of portal-systemic collateral, which develop secondary to the abnormally elevated pressure within the portal system and can form in any area where veins draining the portal venous system are in close approximation to veins draining into the caval system (i.e., submucosa of the esophagus, submucosa of the rectum, and anterior abdominal wall) Patients with EV often have underlying portal hypertension, and their varices may develop over a few months or after many years Patients with portal hypertension are also at risk of GI bleeding from congestive or hemorrhagic gastritis EV are very common in patients with certain types of high-risk underlying liver disease, particularly biliary atresia (BA) and portal vein thrombosis where EV have been reported to be present in as many as 70% of patients Patients are at increased risk for EV if they have splenomegaly, thrombocytopenia, or hypoalbuminemia In addition to primary liver disease, patients with congestive heart failure are known to be at high risk for EV These factors should be taken into account when evaluating a patient with a history of an upper GI bleed or when counseling families for their risk of upper GI bleed Clinical Considerations Clinical Recognition Patients with EV may have occult bleeding, but more commonly, the bleeding is brisk Patients will have hematemesis, hematochezia, and/or melena The possibility of bleeding EV should be considered in any patient with a history of jaundice (beyond the newborn period), hepatitis, ascites, chronic right-sided heart failure, portal vein thrombosis, pulmonary hypertension, omphalitis, umbilical vein catheterization, or one of the hepatic parenchymal diseases noted in Table 91.1 Triage Considerations While it is common that bleeding will have stopped prior to arrival in the ED, patients with EV have the potential for significant blood loss Close attention should be given to tachycardia as an early indicator of hemodynamic compromise and patients should be triaged accordingly Patients with significant upper GI bleeding may also be at risk for airway compromise Clinical Assessment One should have a high suspicion of EV in any patient presenting with an upper GI bleed and any of the risk factors listed above One can also evaluate for the stigmata of portal hypertension, such as jaundice, ascites, rectal hemorrhoids, and hepatosplenomegaly ( Table 91.2 ) Other signs or symptoms of right-sided heart failure would also place a patient at higher risk Given the risk for sudden and life-threatening bleeding, assessing this risk is essential In patients with severe upper GI bleeding from EV, two large-bore IVs should be started immediately ( Fig 91.1 ) A nasogastric (NG) tube should be placed to evaluate for ongoing bleeding and to remove blood from the stomach, which may act as an irritant and potentially worsen hepatic encephalopathy Variceal bleeding is not a contraindication for passing an NG tube Immediate laboratory studies should include type and crossmatch, ... intravascular volume Addressing ongoing bleeding will require a team of professionals that may include the emergency physician, hospitalist, surgeon, gastroenterologist, hematologist, and interventional