Myriad gastrointestinal (GI) maladies may affect patients in the intensive care unit (ICU), from GI bleeding to complications from liver cirrhosis. In this chapter, we review several of the most common GI-related clinical scenarios encountered in the ICU.
Upper Gastrointestinal Bleeding
Upper GI bleeding (UGIB) is a common indication for ICU admission. With advances in critical care and endoscopy, the in-hospital mortality of patients admitted for UGIB has modestly decreased over the past several decades, but remains around 2.1%.1 Etiologies of UGIB can be divided into variceal and nonvariceal hemorrhage; in this section, we will primarily discuss nonvariceal hemorrhage.
Peptic ulcer disease (PUD) is the most common etiology of nonvariceal UGIB, accounting for up to 40% of cases, followed by gastritis or esophagitis, Mallory-Weiss tears, cancer, angiodysplasias, and Dieulafoy lesions.2 The most common risk factors for PUD are infection with Helicobacter pylori and use of nonsteroidal anti-inflammatory drugs (NSAIDs).3 Ulcer disease may present with epigastric pain but is frequently asymptomatic until a patient presents with signs and symptoms of GI bleeding. If a patient does have pain related to a duodenal ulcer, it typically improves with food and recurs 1 to 3 hours after a meal. In contrast, gastric ulcers are often made worse with eating. Patients with UGIB related to PUD or any etiology typically present either with melena or with hematemesis. If UGI bleeding is very brisk, patients may present with hematochezia. Labs suggestive of an acute UGIB include a decrease of hemoglobin/hematocrit from baseline values, a mildly elevated white blood cell (WBC) count, and an elevated blood urea nitrogen (BUN) out of proportion to creatinine.
The risk of mortality can be estimated using the pre-endoscopic Rockall score (Table 24-1), and the Glasgow-Blatchford score can be utilized to estimate the need for inpatient endoscopic intervention.4,5 Patients with a Blatchford score of 0 (BUN < 18.2 mg/dL, hemoglobin [Hgb] ≥ 13 g/dL, systolic blood pressure [SBP] ≥ 100 mmHg, heart rate [HR] < 100 beats/min, no melena, no syncope, no heart disease, no liver failure) have a low likelihood of requiring endoscopic intervention and may be discharged from the emergency department (ED).6
TABLE 24-1Pre-endoscopic Rockall Score |Favorite Table|Download (.pdf) TABLE 24-1Pre-endoscopic Rockall Score
| ||Score |
|Variable ||0 ||1 ||2 ||3 |
|Age ||< 60 y ||60–79 y ||≥ 80 y || |
|Shock ||None ||HR > 100 beats/min, SBP > 100 mmHg ||Hypotension (SBP < 100 mmHg) || |
|Comorbidity ||None || ||Cardiac failure, ischemic heart disease, other major comorbidities ||Renal failure, liver failure, disseminated malignancy |
Initial therapy for UGIB, as for hemorrhage of any etiology, is timely resuscitation. Patients should have adequate intravenous (IV) access placed with 2 large-bore IVs, infusion of IV fluids to correct volume deficits, and transfusion of packed red blood cells to a goal hemoglobin of 7 g/dL. This transfusion goal has been validated in a large clinical trial comparing a hemoglobin ...