What are the common symptoms, signs, and treatment options for acute gastrointestinal conditions, including gastroenteritis, inflammatory bowel disease, gastrointestinal bleeding, and acute appendicitis?

Common Gastrointestinal Conditions in Emergency Medicine: Symptoms, Signs, and Treatment

The most common gastrointestinal conditions presenting to emergency departments include acute gastroenteritis, inflammatory bowel disease exacerbations, gastrointestinal bleeding, and acute appendicitis, each requiring prompt diagnosis and specific treatment protocols to reduce morbidity and mortality.

1. Acute Gastroenteritis

Clinical Presentation

• Symptoms: Diarrhea (watery, may contain blood/mucus), nausea, vomiting, abdominal cramping
• Signs: Fever, tachycardia, hypotension (in severe cases), signs of dehydration (dry mucous membranes, decreased skin turgor, sunken eyes)
• Assessment of Dehydration:
  • Mild: 3-5% fluid loss, slightly dry mucous membranes
  • Moderate: 6-9% fluid loss, decreased skin turgor, sunken eyes
  • Severe: ≥10% fluid loss, hypotension, tachycardia, altered mental status

Diagnostic Approach

• Stool studies: Culture for bacterial pathogens, C. difficile toxin assay, ova and parasites examination 1
• Blood tests: CBC, electrolytes, BUN/creatinine, inflammatory markers (CRP, ESR) 1

Treatment

1. Rehydration:

   • Mild-to-moderate dehydration: Oral rehydration solution (ORS) is first-line therapy 2, 3
   • ORS administration: 50-100 mL/kg over 3-4 hours 4
   • Severe dehydration: IV fluids (normal saline or lactated Ringer's) 20 mL/kg boluses until hemodynamically stable 3

2. Antiemetics (if vomiting prevents oral rehydration):

   • Ondansetron: 4-8 mg IV/PO for adults; 0.15 mg/kg for children
   • Improves tolerance of oral rehydration and reduces need for IV fluids 2

3. Antimicrobials: Only if bacterial etiology confirmed or strongly suspected

   • Avoid empiric antibiotics as they may worsen certain infections (e.g., STEC)

2. Inflammatory Bowel Disease (IBD) Exacerbations

Clinical Presentation

• Ulcerative Colitis (UC):

  • Bloody diarrhea, tenesmus, urgency, lower abdominal pain
  • Extraintestinal manifestations: arthritis, uveitis, erythema nodosum

• Crohn's Disease (CD):

  • Abdominal pain (often right lower quadrant), diarrhea (may be bloody), weight loss
  • Perianal disease: fistulas, abscesses
  • Extraintestinal manifestations similar to UC

Complications Requiring Emergency Care

1. Toxic Megacolon:

   • Signs: Severe abdominal pain, distention, fever, tachycardia, altered mental status
   • Radiographic finding: Colonic dilation >6 cm 5

2. Intestinal Obstruction:

   • Signs: Abdominal distention, vomiting, obstipation
   • More common in CD due to strictures 5

3. Gastrointestinal Bleeding:

   • More common in UC with pancolitis 5, 6

Treatment of Acute Severe UC

1. Medical Management:

   • IV corticosteroids: Hydrocortisone 400 mg/day or methylprednisolone 60 mg/day 5, 1
   • If no improvement after 3 days: Consider rescue therapy with infliximab 5 mg/kg 5, 1
   • Subcutaneous heparin for thromboembolism prophylaxis 5
   • Nutritional support if malnourished 5

2. Surgical Management (indications):

   • Perforation, massive hemorrhage, toxic megacolon not responding to medical therapy within 24-48 hours 5
   • Procedure: Subtotal colectomy with ileostomy 5

Treatment of Crohn's Disease Flare

1. Medical Management:

   • Corticosteroids: Prednisone 40 mg daily PO with gradual taper over 8 weeks 5, 7
   • For perianal disease: Antibiotics (ciprofloxacin) plus anti-TNF therapy 5

2. Management of Complications:

   • Abscesses: Drainage plus antibiotics 5
   • Strictures: Surgery if not amenable to endoscopic dilation 5

3. Gastrointestinal Bleeding

Clinical Presentation

• Upper GI Bleeding: Hematemesis, melena, coffee-ground emesis
• Lower GI Bleeding: Hematochezia, maroon stools
• Signs of Significant Blood Loss: Tachycardia, hypotension, orthostatic changes, pallor

Diagnostic Approach

1. Hemodynamically Unstable Patients:

   • Immediate resuscitation with large-bore IV access
   • Blood type and cross-match
   • Consider immediate endoscopy or surgery 5

2. Hemodynamically Stable Patients:

   • Upper and lower GI endoscopy to identify bleeding source 5
   • CT angiography if endoscopy inconclusive 5

Treatment

1. Resuscitation:

   • IV fluid resuscitation
   • Blood transfusion to maintain hemoglobin >7 g/dL (>9 g/dL in patients with cardiovascular disease) 5

2. Specific Management:

   • Variceal Bleeding: Octreotide 50 μg IV bolus followed by 50 μg/hr infusion, endoscopic band ligation
   • Peptic Ulcer Disease: IV PPI (80 mg bolus followed by 8 mg/hr infusion), endoscopic therapy
   • Diverticular Bleeding: Endoscopic hemostasis, angiographic embolization if needed
   • IBD-Related Bleeding: IV steroids, rescue therapy with infliximab if severe 5

3. Surgical Management (indications):

   • Persistent hemodynamic instability despite resuscitation
   • Failure of endoscopic or angiographic control
   • For IBD-related massive hemorrhage: Subtotal colectomy with ileostomy 5

4. Acute Appendicitis

Clinical Presentation

• Classic Symptoms: Periumbilical pain migrating to right lower quadrant, anorexia, nausea, vomiting
• Signs: Right lower quadrant tenderness, rebound tenderness, guarding
• Atypical Presentations: Elderly patients may have minimal pain; retrocecal appendix may cause flank or back pain

Diagnostic Approach

• Laboratory: Leukocytosis with left shift
• Imaging: Ultrasound (first-line in children and pregnant women), CT scan (highest sensitivity and specificity)

Treatment

1. Preoperative Management:

   • IV fluids
   • Antibiotics: Cefazolin 2g IV (or clindamycin 900 mg + gentamicin 5 mg/kg if penicillin-allergic)

2. Surgical Management:

   • Appendectomy (laparoscopic preferred if available)
   • If perforated with abscess: Consider initial antibiotics and drainage, with interval appendectomy

Common Pitfalls to Avoid

1. Delaying corticosteroid treatment in acute UC while waiting for stool microbiology results 1

   • Start steroids promptly while awaiting results

2. Failing to consider joint medical and surgical management for severe UC 1

   • Early surgical consultation is essential in severe cases

3. Overlooking thromboembolism risk in severe UC patients 1

   • Always provide thromboprophylaxis

4. Neglecting maintenance therapy in UC patients 5, 1

   • Lifelong maintenance therapy is generally recommended to prevent relapse and reduce colorectal cancer risk

5. Overreliance on IV fluids for mild-moderate dehydration in gastroenteritis 3

   • Oral rehydration is equally effective and has fewer complications

6. Missing appendicitis as a potential risk factor for later development of Crohn's disease 8

   • Consider follow-up for patients with complicated appendicitis

By following these evidence-based approaches to diagnosis and management, emergency physicians can effectively treat these common gastrointestinal conditions while minimizing morbidity and mortality.