Med-Surg · Gastrointestinal / Hepatic
GI Bleed, Pancreatitis & Liver Failure
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Prepared for Pass the Shift (owner: Kristina, RN). Always follow your facility’s protocols, provider orders, and current drug references.
1. Overview and Pathophysiology
GI bleeding can be upper (proximal to ligament of Treitz: PUD, varices, Mallory–Weiss, gastritis) or lower (diverticula, angiodysplasia, colitis, cancer). Blood loss threatens perfusion; variceal bleeds can be torrential.
Acute pancreatitis is autodigestion of the pancreas by activated enzymes—gallstones and alcohol are leading causes. Fluid shifts and SIRS can cause hypovolemic/distributive shock and ARDS.
Cirrhosis is irreversible fibrosis with portal hypertension. Key decompensations: ascites, varices, , hepatorenal syndrome, coagulopathy, SBP.
2. Causes and Risk Factors
- Bleed: H. pylori, NSAIDs/steroids, alcohol, portal HTN, anticoagulants, prior ulcers
- Pancreatitis: gallstones, alcohol, high triglycerides, ERCP, drugs, trauma
- Cirrhosis: chronic viral hepatitis, alcohol, MASLD/NASH, autoimmune, biliary disease
3. Signs and Symptoms
- Bleed: hematemesis, coffee-ground emesis, melena, hematochezia, tachycardia, hypotension, syncope, oliguria, cool skin
- Pancreatitis: severe epigastric pain radiating to back, N/V, fever, Cullen/Grey Turner (late, severe), guarding
- Liver: jaundice, ascites, spider angiomas, palmar erythema, gynecomastia, asterixis, confusion, bruising, pruritus
- Perforation/peritonitis: board-like abdomen, rebound tenderness—surgical emergency
4. Diagnostics and Labs
Lab reference ranges vary by laboratory. Always use your facility’s ranges.
| Test | Typical / note | Nursing relevance |
|---|---|---|
| Hgb / Hct | M ~14–18 / F ~12–16 g/dL | May lag acute bleed; trend serials |
| BUN | Often rises in upper GI bleed | Digested blood + hypovolemia |
| PT/INR, platelets | Coagulopathy in liver disease | Bleeding risk |
| ALT/AST, bilirubin, albumin | Liver injury / synthetic function | Albumin falls in chronic disease |
| Ammonia | Lab-dependent | Encephalopathy trends (treat the patient, not only the number) |
| Lipase (preferred) / amylase | Markedly elevated in pancreatitis | Lipase more specific |
| Triglycerides, calcium | Pancreatitis workup | Hypocalcemia in severe disease |
| Ultrasound / CT / endoscopy | — | Cause finding / intervention |
5. Priority Nursing Assessments
- ABCs, VS trends (restlessness may be early shock), orthostatics when safe
- Abdominal exam order: inspect → auscultate → percuss → palpate
- Stool/emesis character; occult blood testing when ordered
- Mental status / asterixis in liver disease
- Fluid balance, abdominal girth, daily weight (ascites)
- Pain, glucose (pancreatitis), alcohol withdrawal risk
6. Priority Nursing Interventions
GI bleed: large-bore IVs (≥ 2), fluid/blood products as ordered, NPO, oxygen if needed, type & crossmatch, prepare for endoscopy, reverse anticoagulation per order, balloon tamponade rarely for refractory varices (airway expertise required).
Pancreatitis: NPO initially, aggressive IV fluids, opioid analgesia as ordered, antiemetics, monitor glucose/Ca²⁺/SpO₂, advance diet per tolerance; ERCP if gallstone obstruction.
Cirrhosis: sodium restriction as ordered, diuretics, lactulose/rifaximin for encephalopathy, bleeding precautions, paracentesis care (empty bladder first, monitor VS for hypotension), avoid nephrotoxins/alcohol, vaccine/teach infection risk (SBP).
7. Medications
| Class / examples | Role | Nursing considerations |
|---|---|---|
| PPIs (-prazole) | Acid suppression; ulcer bleed | IV drip protocols post-endoscopy sometimes used |
| Octreotide | Variceal bleed / pancreatitis adjunct | Glucose monitoring |
| Vasopressin / terlipressin (where available) | Portal pressure | Ischemia risk—cardiac monitoring |
| Lactulose | Trap/eliminate ammonia | Goal often 2–3 soft stools/day + clearer mentation |
| Rifaximin | HE adjunct | GI tolerability |
| Pancreatic enzymes | Chronic pancreatitis / insufficiency | With meals and snacks |
| Spironolactone ± furosemide | Ascites | K⁺ balance |
| Antibiotics | SBP, variceal bleed prophylaxis protocols | Timely dosing |
| Vitamin K / blood products | Coagulopathy | Doesn’t fully fix portal hypertensive bleed mechanics |
8. Patient Education
- NSAID caution; H. pylori treatment adherence; alcohol cessation resources
- Black stools / vomiting blood = emergency care
- Pancreatitis: alcohol abstinence, low-fat diet as advised, triglyceride control
- Lactulose purpose (not “just a laxative”); don’t skip when confused risk is high
- Ascites: sodium limit, weigh daily, report fever/abdominal pain (SBP)
- No OTCs without pharmacist check (acetaminophen limits in liver disease)
9. Complications
- Hypovolemic shock, aspiration
- Rebleeding; esophageal perforation (procedural)
- Pancreatic necrosis, pseudocyst, ARDS, hypocalcemia, diabetes
- Variceal hemorrhage, HE, SBP, hepatorenal syndrome, HCC
10. Memory Aids
- “Two big IVs for big bleeds”
- “Lipase loves the pancreas”
- “Empty bladder before paracentesis”
- “Lactulose works when stool + sense improve”
- “Board-like belly = don’t wait”
11. NCLEX-Style Practice Questions
1. Rigid, board-like abdomen after peptic ulcer disease—priority?
A. Give an antacid and reassess tomorrow
B. Keep NPO and notify the provider immediately—possible perforation
C. Encourage a fatty meal
D. Apply heat to the abdomen
Answer: B. Peritonitis/perforation is a surgical emergency.
2. Best indicator lactulose is effective in hepatic encephalopathy?
A. Decreased jaundice alone
B. Improved mentation with a few soft stools daily
C. Increased ascites
D. Darker urine only
Answer: B. Clinical goal is ammonia removal reflected in stooling and clearer cognition.
3. Client with acute pancreatitis—appropriate intervention?
A. Immediate high-fat diet
B. NPO, IV fluids, and pain control as ordered
C. Place in Trendelenburg routinely
D. Give metformin to rest the pancreas
Answer: B. Rest the GI tract, replace fluids, treat pain.
4. Preparation for abdominal paracentesis includes:
A. Having the client void first
B. Keeping the bladder as full as possible
C. Holding all antibiotics forever
D. Flat bed rest without VS checks afterward
Answer: A. An empty bladder reduces puncture risk; monitor VS after fluid shifts.
5. Early sign of significant GI bleeding?
A. SpO₂ 100% and HR 60 always
B. Restlessness and tachycardia
C. Only after Hgb drops 5 g overnight without VS change
D. Increased appetite
Answer: B. Sympathetic response often precedes lab changes.
References
MedlinePlus. (n.d.). Gastrointestinal bleeding. National Library of Medicine. Retrieved October 15, 2026, from https://medlineplus.gov/gastrointestinalbleeding.html
MedlinePlus. (n.d.). Cirrhosis. National Library of Medicine. Retrieved October 15, 2026, from https://medlineplus.gov/cirrhosis.html
National Council of State Boards of Nursing. (2026). 2026 NCLEX-RN test plan. https://www.nclex.com/test-plans.page
Gapp, J., Tariq, A., & Chandra, S. (2023). Acute pancreatitis. In StatPearls. StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK482468/
Sharma, A., & Nagalli, S. (2023). Chronic liver disease. In StatPearls. StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK554648/