GI notes

Pancreatitis
    Usually presentation to ED within 12h, maximal cytokines at 24h, end organ damage flares at 60h
    CT scan if severe clinical pancreatitis, high fever with leukocytosis, RANSON > 3, APAPCHE > 8, lack of improvement after 72h, acute deterioration after improvement
    Resp fails 35%, CV 20%, Renal and hepatic 15%
    Measure IAP in all severe acute pancreatitis with monitoring if initial one is > 18mmHg
    Pancreatitis + jaundice needs ERCP within 24h, else not necessary per 7RCTs
    Isenmann and Dellinger trials compared cipro/flagyl and meropenem; no difference
    Pederzoli 1993 gave imipenem for all severe acute panreatitis and saw benefit but methodology critized
    Probiotics with suggestion toward hard (Lancet 2008 meta)
    Suggestion that early total enteral nutrition has lower mortality
    FNA prior to intervention. If infection proven then pecutaneous drainage. Surgery increases mortality.
    HyperTG pancreatitis should be treated with prophy heparin and insulin gtt; plasmapheresis if failing therapies

GIB - Prevention of stress related mucosal injury
    Cook 1994 and Cook 2001 showed that OR for bleeding increased in MV 15.6, coagulopathy 4.3, hypotension 3.7 (NS), and sepsis 2.0 (NS).
    Old study suggested continuous infusion of H2 blocker was best to get gastric pH > 4
    1997 compared PPI vs H2 vs sucralfate; no difference
    PPI vs H2 blockers: PPI higher pH but no difference in GIB; Conrad 2005 CCM showed less positive NG aspirate in PPI but no difference in overt bleeding. CCM 2010 meta showed PPI has no important advantage in bleeding and H2 blockers are cheaper so H2 blockers became standard of care
    Marik CCM 2010 showed no benefit to H2 blockers over enteral nutrition; but if H2 blockers and enteral nutrition are used then higher risk of PNA

Cirrhotic bleeds
    70% of cirrhosis will have varices; 6% incidence of varices per year in cirrhotics; 30% will bleed; 10% will re-bleed
    Endoscopy lowers bleeding risk and re-bleeding risk but no survival benefit
    PPI has no data but since 25% of cirrhotic bleeds are nonvariceal, it is used
    TXA in Cochrane 2012 shows no significant difference

    Prehepatic - portal vein thrombosis; Intra-hepatic - scarring in liver; post-hepatic - heart failure or hepatic thrombosis
    Portal vein wedge pressure > 12mmHg leads to problems; < 5mmHg is normal

    NGT probably safe as swallowing produces esophageal pressures of 60-70mmHg
    NGT does not help in predicting high risk bleeds (17% neg lavages had high risk lesion and 67% of positive lavages did not have high risk lesion) RUGBE investigators in Gastro Endos 2004 pg174

    20% are infected at admission; 70% will develop an infection in house
    prophy abx are greatest benefit in Child's C

    Bleeding control was better with octreotide versus vasopressin with fewer side effects
    Octreotide 5d plus endoscopy had better secondary endpoints but no survival improvement

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