Abdominal, GI Bleeding, GU and Dialysis Emergencies

In depth

The one-page summary above is what the PDF prints. These sections go further.

GI bleeding: volume, varices and TXA

• Melena needs about 100 to 200 mL of blood in the upper tract and can last days after bleeding stops. Iron and bismuth blacken stool without coffee-ground vomit (Merck).
• Signs of significant loss: syncope, hypotension, pallor, diaphoresis, tachycardia and low urine output. Orthostatic checks are unreliable and can make a bleeding patient faint, so a supine, near-normal BP does not rule out a large bleed (Merck). Older adults tolerate massive bleeding poorly.
• Merck: short large-bore (14 to 16 gauge) antecubital lines; saline in 500 to 1,000 mL aliquots until hypovolemia resolves, up to about 2 L, then red cells. NASEMSO: rapid 500 mL boluses toward a MAP of 65, stopping for pulmonary edema, and blood where the service carries it.
• Varices: sudden, painless, often massive upper GI bleeding in cirrhosis (Merck). Coagulopathy and encephalopathy travel with it, so airway protection comes first and fluid follows the measured-bolus approach above. The old warning against overfilling is classic teaching; no source opened here states it.
• Encephalopathy precipitants (Merck): infection, low potassium, dehydration and diuretics, GI bleeding or a protein load, alcohol, sedatives and analgesics. Asterixis is seen in liver failure, uremia and severe heart failure, so the history decides.
• Beta blockers (nadolol or propranolol for varices) blunt the heart-rate rise (shock-types); judge loss by BP against the usual reading, skin and mental status.

HALT-IT randomized 12,009 adults with significant upper or lower GI bleeding (about 45% suspected variceal) to TXA 1 g over 10 min then 3 g over 24 h, or placebo. Death from bleeding within 5 days was 3.7% vs 3.8% (RR 0.99); deep vein thrombosis or pulmonary embolism rose from 0.4% to 0.8% (RR 1.85) and seizures from 0.4% to 0.6%. The authors concluded TXA should not be used for GI bleeding outside a trial. NASEMSO lists TXA for hemorrhagic shock within 3 h of injury and for postpartum hemorrhage only.

Pancreas, biliary tree and the surgical abdomen

• Pancreatitis (Merck): gallstones cause 40 to 70% and alcohol 25 to 35%. Pain is steady, boring, epigastric or left upper quadrant, often to the back, and eased by sitting forward. Grey Turner (flank) and Cullen (navel) bruising appear in under 3% and mean hemorrhagic exudate and a poor prognosis.
• Pancreatitis fluid: Merck gives lactated Ringer's at 1.5 mL/kg/h with a 10 mL/kg bolus if hypovolemic (800 mL for 80 kg), reassessed often. In WATERFALL (2022) 20 mL/kg then 3 mL/kg/h caused fluid overload in 20.5% vs 6.3% with no better outcome, and the trial stopped early.
• Cholecystitis (Merck): right upper quadrant pain over 6 h, referred to the right scapula, inspiration stopped by subcostal pressure (Murphy sign), often low-grade fever. Older adults may have vague symptoms and no fever.
• Cholangitis (Merck): Charcot triad of pain, jaundice and fever; add confusion and hypotension for the Reynolds pentad. It is an emergency needing urgent drainage, usually ERCP; antibiotics alone do not drain pus behind a stone, so destination matters more than a few minutes.
• Obstruction (Merck): adhesions and hernias lead; strangulation in nearly 25% of small-bowel obstructions, with infarction in as little as 6 h; steady severe pain suggests it.
• Mesenteric ischemia (Merck): embolus over 40% (often from atrial fibrillation), arterial thrombosis 30%, venous 15%, nonocclusive 15%. The abdomen stays soft early; necrosis can begin by 6 h.
• Diverticulitis (Merck): left lower quadrant pain and tenderness with fever and nausea; perforation, abscess, fistula and obstruction are the complications; peritoneal signs or sepsis mean surgery.
• Boerhaave (Merck): spontaneous rupture after vomiting or a large food bolus; chest and abdominal pain, fever, shock and sometimes subcutaneous emphysema; mortality 19 to 28% even with treatment.

Spleen, pregnancy and the post-surgical patient

• Mononucleosis (Merck): splenic rupture risk peaks 10 to 21 days after presentation, trauma is present only about half the time, and rupture is usually painful but can be painless hypotension. Left shoulder pain is a clue to a ruptured spleen (Merck). A young adult compensates: weigh HR, skin and postural symptoms over the systolic.
• Appendicitis in pregnancy: the leading nonobstetric surgical disease of pregnancy; the gravid uterus can displace the appendix (StatPearls abstract), and pain and tenderness are less marked (Merck). Keep preeclampsia and HELLP in mind with upper abdominal pain (ob-emergencies).
• Stoma necrosis (MISSTO-WSES): 1.6 to 20%, usually in the first postoperative days, more after emergency surgery, with colostomies and with obesity. Superficial necrosis is watched; deep necrosis below the fascia needs immediate resection. Depth is checked in hospital with a clear tube and light or a small endoscope.
• Gastrostomy: the tract forms over about 2 to 4 weeks; a tube out from an unhealed tract risks peritonitis, so no blind reinsertion (StatPearls abstract). ASPEN 2026 says a displaced tube needs timely replacement to prevent stomal stenosis; no source opened here gives hours. A tube under about 4 weeks old needs surgical input.

Swallowed objects

• Food, usually poorly chewed meat, is the commonest esophageal foreign body. Hypersalivation and inability to swallow secretions mean complete obstruction, which needs emergent endoscopy; an impacted object left about 24 h can cause pressure necrosis and perforation (Merck).
• Glucagon does not seem particularly effective; effervescent agents and meat tenderizer are not recommended (Merck). Dyspnea, stridor or wheeze point to the airway instead.
• One swallowed magnet rarely causes harm; several can attract across bowel loops and cause necrosis, fistula, obstruction or perforation, and any magnet within endoscopic reach is removed (Merck). Ask how many are missing and bring the toy.

Children: green vomit, hernias and HUS

• Malrotation (Merck): about 40% present in the first month and over 80% by age 5. Bilious emesis in an infant is an emergency; untreated volvulus risks infarction, short bowel or death.
• Hernia (Merck): an incarcerated hernia cannot be reduced and can obstruct the bowel; strangulation adds steady worsening pain, tenderness and red skin. Any incarcerated or strangulated hernia needs urgent repair. NASEMSO flags children under 2 with abdominal pain as high risk.
• HUS: Shiga toxin E. coli causes the prodrome; anemia, low platelets and kidney injury follow about a week later and over half need dialysis (Merck). Perth Children's Hospital: present 5 to 10 days after bloody diarrhea; give saline only for true hypovolemia; with oliguria or overload, limit fluid to insensible losses plus urine; avoid NSAIDs, loperamide and antibiotics. CDC also advises no antimotility drugs.

Genitourinary and gynecologic detail

• Renal colic (MSD): excruciating, intermittent pain, 20 to 60 min waves, often with nausea and an ashen, restless patient; hematuria is common but not universal. Fentanyl for fast onset, ketorolac rapidly effective and nonsedating, ondansetron for vomiting. Consider aortic aneurysm or dissection, especially in older patients (aortic-htn).
• Infection with obstruction needs the kidney decompressed as soon as possible by stent or nephrostomy, plus antibiotics; the stone waits (MSD).
• Testicular torsion (Merck): peaks at 12 to 18 years with a second peak in infancy; sudden pain, nausea, an elevated horizontal testis, usually no cremasteric reflex. Salvage about 80 to 100% at 6 to 8 h, near zero by 12 h.
• Adnexal torsion (Merck): sudden severe pelvic pain with nausea and vomiting, often an ovary over 4 cm; peritoneal signs come late; exploratory surgery is immediate to save the ovary.
• Urinary retention (Selius 2008): BPH is the commonest cause in men. Anticholinergics and antihistamines weaken the detrusor; decongestants such as pseudoephedrine tighten the bladder neck; opioids also contribute. The bladder is palpable above about 200 mL. The hospital drains it fully by catheter and starts an alpha blocker.
• Fibroids (Merck): very common and can cause bleeding heavy enough for anemia. NASEMSO vaginal bleeding care: count pads, ask about syncope; for shock, supine (left side in the third trimester), warm, large-bore IV, crystalloid 1 to 2 L, save tissue, no hand in the vagina, notify early.

Dialysis: access, hypotension, disequilibrium and uremia

• Access (Merck, NIDDK): a fistula is the preferred access, a graft is used when veins are poor, and a catheter is temporary with high infection and clot risk. A working access has a vibration (thrill) you can feel (NIDDK); an absent bruit or pulse and thrombosis are listed as access problems (Merck).
• Bleeding access (emDocs 2016): direct pressure first, 5 to 10 min, then observe for rebleeding (1 to 2 h); heavy pressure can clot the access; a tourniquet or occlusive pressure only to prevent death; vascular surgery if it will not stop. Look for thin skin over an aneurysm as a rupture warning.
• Hypotension is the commonest hemodialysis complication, 4 to 17% of treatments (Merck): too-rapid fluid removal, osmotic shifts and warm dialysate, but also sepsis, ischemia, arrhythmia and cardiomyopathy. EBPG steps (Kanbay 2020): Trendelenburg, stop ultrafiltration, then isotonic saline.
• Disequilibrium (Mistry 2019): rapid urea removal moves water into the brain, mostly at the first sessions with a high urea. Mild: headache, nausea, vomiting, cramps, restlessness. Severe: confusion, asterixis, seizures, coma. A diagnosis of exclusion (subdural, glucose, sodium, stroke); stop dialysis.
• Missed dialysis: uremia (lassitude, anorexia, falling mental acuity first, Merck), overload and hyperkalemia. Uremic encephalopathy reverses with dialysis and is an indication to start it (StatPearls abstract). Hyperkalemia treatment: electrolytes and acls-algorithms; NASEMSO gives calcium chloride 1 g IV/IO over 5 minutes when findings of hyperkalemia are present (hyperglycemia guideline).
• Peritoneal dialysis (NIDDK): cloudy used fluid, abdominal pain, fever, nausea or a red, painful exit site mean infection; antibiotics go into the dialysis solution. Bringing the bag for testing is classic teaching; NIDDK does not say it.

Classic teaching points

• Nothing by mouth for acute abdominal pain, since surgery or endoscopy may follow.
• A 12-lead for upper abdominal pain in an adult: an inferior MI can present as epigastric pain.
• Keep the patient with a food bolus upright with suction; abdominal thrusts are for an airway, not the esophagus.
• Do not open, drain or remove a peritoneal dialysis catheter in the field.
• Keep BP cuffs, IVs and tourniquets off a fistula or graft arm unless life depends on it.