GI Emergencies in the ICU

Abstract

• The morbidity and mortality of GI bleeding developing in patients hospitalized for other reasons is higher than in those presenting primarily with GI bleeding.2 In the absence of known or overt liver disease, non-variceal UGI bleeding related to gastroduodenal erosions or ulcers is common. Stress prophylaxis with H2 blockers or proton pump inhibitors (PPI) is recommended after major abdominal, cardiac, orthopaedic, or neurosurgeries.3 Frank blood in NG lavage, a significant drop in hematocrit, or persistent hemodynamic compromise warrant urgent endoscopy. Otherwise, initiation of PPI therapy and close clinical monitoring might suffice. Lower GI bleeding in ICU patients should prompt evaluation for ischemic colitis by multidetector computed tomography (MDCT). Mankongpaisarnrung et al discuss a patient presenting with a GI bleed in this issue of the Southwest Respiratory and Critical Care Chronicles reiterating the role of risk stratification in the appropriate management to identify the low risk patients who can be triaged to optimal outpatient management while recognizing the high risk patients needing in-patient care. Manifestations include unexplained abdominal distension, absence of bowel sounds, diarrhea, and/or lower GI bleeding. A quick review of history must check for atrial fibrillation, presence of hypercoagulable states (prior DVT/PE), lowflow states (CHF), or conditions associated with advanced atherosclerosis (ESRD). MDCT excludes other etiologies while directing further management.4 Flexible sigmoidoscopy can be helpful when clinical suspicion for ischemic colitis is very high but imaging is negative (non-occlusive mesenteric ischemia, NOMI). Aswanetmanee et al discuss the role of MDCT in the timely diagnosis of acute mesenteric ischemia in this issue of the Chronicles in which an elderly woman in the ICU with septic shock developed unexplained abdominal distension and ileus. An urgent MDCT demonstrated jejunal pneumatosis intestinalis and occlusion of the superior mesenteric artery. Prompt recognition led to successful embolectomy and small bowel resection.