Cholecystitis

• Common illness with over 15 million Americans affected.
• Present frequently for pain control.
• Typically in adult females. Tends to be associated with fatty meal. Incidence rises with age. While uncommon in children, presence may suggest underlying disorder (sickle cell, hemolytic anemia).

• May present with abdominal pain in right upper quadrant or epigastrium which tends to be constant and severe.
• Pain can radiate to shoulder or back.
• Nausea and vomiting common.
• Murphy’s sign: inspiratory arrest during palpation of RUQ.
• If fever or refractory pain is present or consider cholecystitis.
• Gallstones are either cholesterol (most common), pigment (associated with hemolytic anemia).
• Elevated liver function studies suggest common duct obstruction, cholangitis, cholecystitis or hepatic involvement.
• Ultrasound should be initial imaging study since it is over 90% sensitive and allows visualization of common bile duct:
• Duct size over 10 mm suggests obstruction
• Gallbladder wall thickening over 5 mm or pericolic fluid suggestive of cholecystitis.
• HIDA scanning may detect obstruction or cholecystitis if stone is at neck of gallbladder and nonvisualized on ultrasound.
• Routine abdominal films are of no utility.

• The first priority is analgesia. NSAIDs have been used with great success. Narcotic analgesics with antiemetic are also part of the initial therapy. Unsuccessful pain control or cholecystitis needs hospital admission.
• Surgical consultation is required in patients requiring admission or those diagnosed with cholangitis, common bile duct dilatation and/or cholecystitis.
• Antibiotics are indicated for acute cholecystitis, cholangitis, or common bile duct dilatation. First line antibiotics include amp/sulbactam, flouroquinolone and flagyl or pipercillin/tz.

Massive GI Hemorrhage Treatment

Massive upper GI bleeding is a far more common emergency than lower GI bleeding. It may present as hematemesis, melena or simply shock with a positive stool test for blood or NG aspirate. Sources include peptic ulcer and gastroesophageal varices. Massive lower GI bleeding is caused by angiodysplasia and diverticular disease.

Primary Survey Will Require Vigorous Suctioning of the Airway

• Wide open normal saline with multiple large bore IV’s (16 gauge or greater) are indicated to treat shock. Type O blood should follow the first 2 L via rapid transfuser, until type-specific and then cross-matched blood is available.
• Fresh frozen plasma is indicated for suspected coagulopathy (e.g., with stigmata of chronic liver disease). NG tube for lavage and gastric emptying is indicated and may be used as one gauge of active bleeding. Emergency endoscopy for hemostasis can be performed by qualified personnel.
• In addition to emergent consultation for endoscopy, emergent surgical consultation should be sought.
• Octreotide (50-100 mcg IV bolus followed by an infusion of 50 mcg/h) is indicated as an adjunct to other therapies or when other therapies are unavailable for massive upper GI bleeding.
• Balloon tamponade via Sengstaken/Blakemore or similar tube should be attempted in the event of severe uncontrolled upper GI hemorrhage.
• Apparent massive lower GI hemorrhage may be from an upper GI source (which may be revealed by NG tube or upper GI endoscopy).
• If these are negative, either interventional radiological methods or laparotomy will be required to stop bleeding.
• Although not entirely reliable in acute hemorrhage, acute pancreatitis, serial bedside hemoglobin determinations are helpful in guiding resuscitations.
• Hypothermia should be avoided by covering the patient with warm blankets and using warmed IV fluids and blood products.
• Stigmata of chronic liver disease as well as purpura and petechiae should be sought on initial survey. This may assist in predicting the site of bleeding (e.g., the possibility of esophageal and gastric varices) and need for factor replacement during the resuscitation.
• A history of aortic repair surgery may indicate a aortoenteric fistula, which is managed operatively.