Rapid review I: the gut that bleeds, perforates, and obstructs

Seven presentations, each ending in the finding that forces escalation.

Upper GI bleed

Bleeding proximal to the ligament of Treitz. Hematemesis or coffee-ground emesis, then melena hours later. Blood in the small bowel is digested as protein, so the blood urea nitrogen climbs while creatinine stays flat. Hook: melena means the bleed is old enough to have traveled.

Lower GI bleed

Hematochezia from diverticula, angiodysplasia, tumor, or hemorrhoids. Hook: a brisk upper bleed also arrives as bright red blood, so volume and hemodynamics beat color as a cue.

Peptic ulcer

Duodenal pain eases with food and wakes the patient at two in the morning. Gastric pain worsens with eating and brings weight loss. Helicobacter pylori and nonsteroidal anti-inflammatory drugs drive both. Hook: the ulcer that feels better after a meal is duodenal.

Perforation

Sudden severe pain, a rigid board-like abdomen, rebound tenderness, absent bowel sounds, free air under the diaphragm on an upright film. Nothing by mouth, nasogastric decompression, fluids, antibiotics, operating room. Hook: a rigid abdomen is a surgical page, not a repositioning.

Appendicitis into peritonitis

Periumbilical pain migrating to McBurney's point, anorexia, low-grade fever, rebound. No heat, no enema, no laxative, no repeated deep palpation. Hook: sudden relief of the pain is not improvement, it is rupture.

Small versus large bowel obstruction

Small bowel gives colicky pain, early bilious vomiting, high-pitched sounds that later go silent, and adhesions as the usual cause. Large bowel gives gradual onset, marked distension, obstipation, and late feculent vomiting. Hook: pain that turns constant, with fever and a rising lactate, means strangulation.

Acute pancreatitis

Epigastric pain boring through to the back and eased by leaning forward. Lipase is the more specific enzyme. Third-space losses drop the pressure. Fat saponification consumes calcium, producing Chvostek and Trousseau signs. Cullen sign at the umbilicus and Grey Turner sign at the flanks mark hemorrhagic disease. Hook: carpal spasm in a pancreatitis patient is an electrolyte emergency.

☐ ☐ ☐ ☐ ☐ ☐ ☐

Margin notepain that suddenly stops is not good news.

Takeawaybleeding, perforating, obstructing, and inflaming each have one cue that outranks the rest, and hypotension is late in all four.

Shock classification → BOOK 09 · P4. Blood urea nitrogen, lipase, lactate, and calcium values → BOOK 07 · P5. Fluid replacement math → BOOK 06 · P4.