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Approach to Stroke, MI, and Heart Failure: Detailed Management

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PART 1: ACUTE ISCHEMIC STROKE (AIS)

Overview

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Step 1: Initial Assessment (ABCs + Neuro)

• Protect the airway; supplemental O2 if SpO2 <94%
• Maintain head of bed >30 degrees to reduce aspiration risk
• Cardiac monitoring for at least 48 hours (ECG + troponin on arrival - concomitant cerebral and myocardial ischemia occurs in ~3-20%)
• Continuous BP monitoring for 48-72 hours

• Calculate NIHSS score (>15 = large infarction indicator)
• Forced eye deviation, hemiplegia, altered consciousness suggest large territory stroke

• Blood glucose <50 mg/dL is an absolute tPA exclusion; avoid aggressive insulin therapy (SHINE trial showed no benefit of intensive glucose control, with increased hypoglycemia risk)
• Target: avoid hypoglycemia; hyperglycemia worsens outcomes

• Optimal post-stroke SBP range: 160-200 mmHg; DBP 70-110 mmHg in untreated patients
• For tPA eligibility: must bring BP below 185/110 mmHg before and during infusion
• Do NOT aggressively lower BP unless >220/120 mmHg in patients not receiving thrombolytics

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Step 2: Emergency Imaging

• Non-contrast CT brain - first line; excludes hemorrhage
• CTA/CT perfusion - for patients potentially eligible for thrombectomy or extended thrombolysis window
• MRI-DWI is more sensitive but less available in acute setting
• Look for: large MCA territory (>1/3 territory) early ischemic changes as relative contraindication to thrombolysis

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Step 3: Reperfusion Therapy

A. IV Thrombolysis (tPA)

• Age ≥18
• Acute ischemic stroke with measurable neurological deficit
• Symptom onset <3 hours (or 3-4.5 hours for extended window)

• Intracranial hemorrhage or history of ICH
• Subarachnoid hemorrhage signs
• BP >185/110 mmHg (despite treatment)
• Major surgery/trauma within 14 days (head trauma within 3 months)
• GI bleeding within 21 days; active bleeding
• Platelet count <100,000/mm3
• INR >1.7; aPTT >40s
• Active DOAC use with elevated sensitive assays
• Blood glucose <50 mg/dL
• Large established infarct (>1/3 MCA territory)

B. Endovascular Thrombectomy (EVT/MT)

• Preferred for large vessel occlusion (LVO) - M1/M2 MCA, ICA, basilar artery
• Time window: 0-24 hours from last known well (extended with perfusion imaging selection)
• Eligibility broadened in 2026 guidelines (large ischemic core patients now included with imaging selection)
• Can be combined with IV thrombolysis (bridging therapy) or given alone
• Superior outcomes vs. medical therapy for basilar occlusion (per 2022 Jovin trial)

• Transradial or transfemoral approach
• Concurrent IV thrombolysis before EVT is standard unless contraindicated
• Chinese stroke association 2024 data: direct EVT alone may be non-inferior to bridging approach [PMID: 39832918]

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Step 4: General In-Hospital Management

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Step 5: Secondary Prevention

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PART 2: ACUTE MYOCARDIAL INFARCTION (MI)

Classification

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Step 1: Immediate Assessment

• 12-lead ECG within 10 minutes of arrival
• Serial troponins (hs-TnI or hs-TnT) - baseline + 1h/3h
• IV access, O2 (only if SpO2 <90%), continuous monitoring
• Aspirin 325 mg chewed immediately

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Step 2: Reperfusion Strategy for STEMI

• Superior TIMI 3 flow restoration
• Lower reinfarction rate
• Lower intracranial hemorrhage risk
• Improved survival regardless of age or lesion location
• Best for: cardiogenic shock (Killip III/IV), TIMI risk ≥5, prior PCI/CABG

• Door-to-balloon: ≤90 minutes (presentation to PCI-capable center)
• First medical contact-to-balloon: ≤120 minutes (transfer situations)
• Symptom onset: PCI beneficial up to 12h; consider 12-24h with ongoing symptoms

• In stable STEMI: complete revascularization of non-culprit vessels is recommended (reduces CV death + MI)
• In cardiogenic shock (CULPRIT-SHOCK trial): culprit-only PCI reduces all-cause mortality and renal replacement therapy need - do NOT multivessel PCI in shock
• Transradial access preferred (reduces bleeding, possible mortality benefit)

• Drug-eluting stents (DES) preferred over bare metal stents
• Reduces target vessel revascularization rates

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Step 3: Fibrinolysis (when PCI not available in time)

• DAPT + anticoagulation (≥48h) for all patients
• Transfer ALL patients to PCI-capable facility; angiography within 3-24h
• Evidence of reperfusion: chest pain relief, >50% ST resolution at 90 min, reperfusion arrhythmia (AIVR)
• Failed reperfusion: rescue PCI immediately

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Step 4: Peri-Infarct Management

• CCU monitoring ≥24h: continuous telemetry, daily ECG, physical exam for murmurs/HF
• Baseline echocardiogram: EF, wall motion, valvular lesions, LV thrombus
• RV Infarction (inferior STEMI + proximal RCA occlusion):
  • Clinical triad: hypotension + elevated JVP + clear lungs
  • ST elevation in V1 or right-sided leads (V4R most sensitive)
  • Treatment: IV fluids (preload-dependent); if persists - dobutamine + IABP; avoid nitrates/diuretics
• Cardiac pacing: Anterior MI + AV block = unstable, needs pacemaker; Inferior MI + AV block = usually transient

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Step 5: Post-MI Medical Therapy

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PART 3: HEART FAILURE (HF)

Classification

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Step 1: Diagnosis

• History: dyspnea (exertional, orthopnea, PND), ankle swelling, fatigue
• Exam: elevated JVP, S3 gallop, displaced apex, pulmonary crackles, peripheral edema
• BNP/NT-proBNP: BNP >35 pg/mL or NT-proBNP >125 pg/mL (for ambulatory diagnosis)
• Echo: EF assessment, valvular disease, wall motion, diastolic function
• ECG, chest X-ray, basic metabolic panel, CBC, TFTs

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Step 2: HFrEF - The "Fantastic Four" (GDMT)

1. ARNI (First choice) or ACE inhibitor/ARB

• Starting dose: 49/51 mg twice daily; target 97/103 mg twice daily
• Reduces: HF hospitalization, CV mortality, all-cause mortality vs. enalapril (PARADIGM-HF)
• Key: 36-hour washout required when switching FROM ACE inhibitor (angioedema risk)
• Contraindicated with ACE inhibitors; history of angioedema
• Switch to ARNI if symptomatic on ACE/ARB
• Initiate even in decompensated HF during hospitalization (PIONEER-HF trial)

• Acceptable creatinine rise: up to 50% above baseline or 266 µmol/L (3 mg/dL)
• Stop if K+ >5.5 mmol/L or creatinine rise >100% or >310 µmol/L

2. Beta-Blocker

• Carvedilol substantially more effective than short-acting metoprolol
• Start only when patient is euvolemic (not in acute decompensation with fluid overload)
• Reduces sympathetic activation, heart rate, mortality, hospitalizations
• Doubles uptitration every 2 weeks as tolerated
• Do NOT abruptly discontinue

3. Mineralocorticoid Receptor Antagonist (MRA)

• Indicated: NYHA II-IV + EF ≤40%
• Monitor K+ and creatinine: 1, 4, 8, 12 weeks; then every 3-6 months
• Stop if K+ >6.0 mmol/L or creatinine >310 µmol/L (3.5 mg/dL)
• Contraindications: K+ >5.0 mmol/L, creatinine >2.5 mg/dL

4. SGLT2 Inhibitor (New cornerstone since 2021)

• Reduces: HF hospitalizations and CV death in both HFrEF AND HFpEF
• Works independent of diabetes status (benefit proven in non-diabetics)
• Mechanism: osmotic diuresis, sympatholytic effects, metabolic benefits, anti-fibrotic
• Check renal function at 4-8 weeks
• Key side effects: genital mycotic infections (5-10%), rare euglycemic DKA (especially with insulin)
• Stop 3 days preoperatively; hold during severe illness

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Step 3: Additional HFrEF Therapies

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Step 4: Device Therapy

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Step 5: Acute Decompensated Heart Failure (ADHF)

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Step 6: HFpEF Management

• No proven mortality-reducing therapy until SGLT2 inhibitors
• Empagliflozin/Dapagliflozin: reduce HF hospitalizations in HFpEF (EMPEROR-Preserved, DELIVER trials) - now recommended
• Diuretics for congestion; BP control; treat AF
• HFpEF update (2026): ACC/AHA HFpEF guideline update expected Q3 2026 per ACC pipeline; current evidence supports SGLT2i for all HFpEF (LVEF ≥40%) per [2026 systematic review PMID: 41953528]

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Summary: The GDMT "Fantastic Four" for HFrEF

HFrEF (EF <40%) + NYHA II-IV
         |
    +---------+---------+---------+
    |         |         |         |
  ARNI    Beta-blocker  MRA    SGLT2i
(sacubitril/ (carvedilol/ (spiro/ (dapagliflozin/
valsartan)  bisoprolol/  eplerenone) empagliflozin)
            metoprolol XL)
         |
    Add diuretics PRN for congestion
    Consider ICD/CRT if EF ≤35% after 3 months GDMT

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Key Guideline Updates (2025-2026)

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Part 1: Heart Failure - Detailed Management

(This builds on the previous response with emphasis on acute decompensated HF and the complete management framework)

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Classification

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A. Chronic HFrEF: The "Fantastic Four" (GDMT)

1. ARNI - Sacubitril/Valsartan (FIRST LINE over ACE-I)

• Starting dose: 49/51 mg BD → Target: 97/103 mg BD
• Mechanism: Inhibits neprilysin (enhances natriuretic peptides) + blocks AT1 receptor
• 36-hour washout mandatory if switching FROM ACE inhibitor (angioedema risk)
• Contraindications: History of angioedema, concurrent ACE-I, SBP <95 mmHg
• If ARNI not tolerated → ACE-I (enalapril 10-20 mg BD, lisinopril 20-35 mg OD, ramipril 10 mg OD) or ARB (candesartan 32 mg OD, valsartan 160 mg BD)

2. Beta-Blocker (start only when euvolemic)

• Double dose every 2 weeks as tolerated
• Do NOT start in acutely decompensated fluid-overloaded patient; do NOT stop in compensated patient

3. Mineralocorticoid Receptor Antagonist (MRA)

• Check K+ and creatinine at 1, 4, 8, 12 weeks; then every 3-6 months
• Stop if K+ >6.0 mmol/L or creatinine >310 µmol/L (3.5 mg/dL)
• Contraindications: K+ >5.0, Cr >2.5 mg/dL

4. SGLT2 Inhibitor (works regardless of diabetes status)

• Benefits: Reduces HF hospitalization + CV death in both HFrEF AND HFpEF
• Side effects: Genital mycotic infections (5-10%), rare euglycemic DKA
• Stop 3 days before surgery; hold during severe illness

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B. Additional Therapies

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C. Devices

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D. Acute Decompensated Heart Failure (ADHF)

• L - Lasix (IV furosemide): 1-2.5x home oral dose IV; target urine output 0.5-1 mL/kg/h
• M - Morphine (low doses - caution, may worsen outcomes; use only for severe distress)
• N - Nitrates (IV nitroglycerin): reduces preload; use only if SBP >90 mmHg
• O - Oxygen + positioning (sit up, CPAP/BiPAP for pulmonary edema with respiratory distress)
• P - Positive pressure ventilation / inotropes if needed

• Continue/initiate GDMT during admission (PIONEER-HF trial: sacubitril/valsartan safe in hospital)
• Reassess daily: weight, urine output, BMP, fluid balance

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E. HFpEF Management

• SGLT2 inhibitors (dapagliflozin/empagliflozin): reduce HF hospitalization - now recommended for all HFpEF (EMPEROR-Preserved, DELIVER trials)
• Control BP, HR (rate control in AF), and volume
• Diuretics for congestion symptom relief
• Treat underlying causes (hypertension, obesity, diabetes, AF, coronary disease)
• No confirmed mortality benefit from ARNI, beta-blockers, or MRA in HFpEF (still under study)

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Part 2: Snakebite - Approach and Management

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A. Snake Identification

Venomous vs. Non-Venomous (North America)

• Red + yellow bands adjacent = coral snake (venomous, elapid)
• Red + black bands adjacent = king snake (non-venomous)

Two Main Categories

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B. Pathophysiology of Venom

• Most venoms contain BOTH neurotoxic and hematotoxic components; one predominates
• Crotalid venom: Phospholipase A2, hyaluronidase, serine proteases - cause tissue necrosis, coagulopathy (DIC), rhabdomyolysis
• Elapid venom: Pre-synaptic phospholipase A2 + post-synaptic alpha-neurotoxin - blocks neuromuscular junction → respiratory paralysis
• Systemic absorption via lymphatics, hence compression bandage used for elapids

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C. Clinical Features and Grading

Crotalid (Pit Viper) Grading

Elapid Features (delayed presentation)

• Minimal local tissue injury (unlike pit vipers)
• Neurotoxicity: confusion, blurred vision, dysarthria, muscle fasciculations, dysphagia
• Respiratory paralysis (diaphragm) → death if untreated
• Coral snakes: 2-5 hour delay; mambas: 15-30 minutes

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D. Initial Management

Prehospital/First Aid

• DO: Immobilize the bitten extremity below heart level, remove constrictive items (rings, watches), keep patient calm, transport immediately
• DON'T: Tourniquets, incision/suction, ice, electrotherapy (all harmful or delay treatment)
• Elapid/neurotoxic bites (Australia, cobra/mamba): Compression bandage is used to slow lymphatic absorption - NOT recommended for North American crotalid bites

Emergency Department

1. ABCs - airway, breathing, circulation (prepare for intubation in elapid bites)
2. IV access in unaffected extremity; IV normal saline
3. Labs: CBC, fibrinogen, PT/PTT, D-dimer, BMP, CK, urinalysis, type & screen
4. Mark leading edge of swelling; measure extremity circumference at bite site and 5 inches proximal
5. Tetanus prophylaxis
6. IV opioids for analgesia
7. Serial labs every 4-6 hours

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E. Antivenom Therapy

Crotalid Antivenom (North America)

• Dose: Children require same amount as adults (venom, not body weight, determines dose)
• Titrate by clinical response: control of swelling progression, improvement in coagulation, resolution of systemic symptoms
• Repeat 2-vial doses if initial control not achieved
• Pre-medicate: Diphenhydramine before infusion; epinephrine ready at bedside for allergic reactions

Elapid/Exotic Antivenom

• No commercially available antivenom for North American coral snakes currently
• Exotic Elapid antivenom: Contact local zoo, Association of Zoos & Aquariums (AZA), or American Association of Poison Control Centers (1-800-222-1222)
• Neostigmine included in elapid envenomation treatment (reverses post-synaptic blockade)
• Treatment primarily supportive: mechanical ventilation for respiratory failure

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F. Wound Care and Complications

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G. Disposition

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Part 3: Common Respiratory Emergencies

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A. Acute Severe Asthma / Status Asthmaticus

Severity Assessment (GINA criteria)

Management (stepwise)

• High-flow O2 (target SpO2 93-95%)
• Salbutamol/Albuterol SABA 2.5-5 mg nebulized every 20 min x3, then every 1-4h (or MDI 4-8 puffs with spacer)
• Ipratropium bromide 0.5 mg nebulized every 20 min x3 (adds bronchodilation)
• IV/oral corticosteroids: Prednisolone 40-50 mg OD or methylprednisolone 60-125 mg IV; continue 5-7 days

• Continue back-to-back nebulizers
• Magnesium sulfate 2g IV over 20 min (relaxes smooth muscle; reduces hospitalization)
• Heliox (70% helium/30% O2): reduces work of breathing, improves drug delivery
• NIV (BiPAP): cautious use in severe asthma; may avoid intubation

• Intubation (RSI): Use ketamine (bronchodilator properties) as induction agent; succinylcholine or rocuronium
• Post-intubation: permissive hypercapnia, low tidal volumes (6-8 mL/kg), prolonged expiratory time (I:E ratio 1:3 to 1:5), low RR, allow intrinsic PEEP to dissipate
• IV bronchodilators: IV salbutamol infusion, IV aminophylline (loading 5 mg/kg over 20 min - avoid if already on theophylline)
• Avoid: high PEEP, overly aggressive ventilation (risk of barotrauma, auto-PEEP, pneumothorax)

• Identify and treat trigger
• Discharge criteria: PEFR >60-75% predicted, SpO2 >94% on room air
• Discharge medications: SABA + inhaled corticosteroid + written asthma action plan

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B. Acute Exacerbation of COPD (AECOPD)

Definition

Precipitants (85% infectious)

Severity (GOLD criteria)

• Mild: Treated with SABA alone
• Moderate: Requires antibiotics and/or corticosteroids
• Severe: Requires hospitalization; NIV/mechanical ventilation

Management

• SABA (salbutamol 2.5 mg nebulized) + SAMA (ipratropium 500 mcg) - combine in nebulizer
• Titrate frequency based on response; switch to MDI with spacer as soon as possible

• Prednisolone 30-40 mg PO for 5 days (REDUCE trial: 5 days non-inferior to 14 days)
• IV methylprednisolone if cannot take orally

• Amoxicillin-clavulanate 875/125 mg BD x 5-7 days
• Doxycycline 100 mg BD or azithromycin 500 mg OD x 5 days
• Fluoroquinolone (levofloxacin) if Pseudomonas risk (frequent exacerbations, chronic steroids, bronchiectasis, prior FEV1 <35%)

• Indications: pH <7.35 with PaCO2 >45 mmHg (hypercapnic respiratory failure) despite medical therapy
• Settings: IPAP 12-20 cmH2O, EPAP 4-6 cmH2O; titrate to improve pH and PaCO2
• Reduces: Need for intubation, ICU stay, mortality (NNT ~8 to prevent 1 intubation)
• Contraindications: Respiratory arrest, uncooperative patient, facial trauma, vomiting, hemodynamic instability

• Consider if pH <7.25, severe hypoxemia, declining consciousness, hemodynamic instability

• DVT prophylaxis
• Nutritional support
• Identify and treat precipitating cause
• Theophylline: generally avoided acutely (narrow therapeutic index, arrhythmia risk)

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C. Pulmonary Embolism (PE)

Risk Stratification

Anticoagulation (3 Strategies per Harrison's 2025)

1. DOAC monotherapy (preferred): Rivaroxaban 15 mg BD x 3 weeks then 20 mg OD, OR Apixaban 10 mg BD x 7 days then 5 mg BD - no bridging needed
2. Parenteral bridge: UFH/LMWH/fondaparinux x5 days → switch to dabigatran or edoxaban
3. Traditional: UFH/LMWH bridge → warfarin (INR 2-3)

• Provoked (major transient risk): 3 months
• Unprovoked (no identifiable risk): 6-12 months; consider extended if low bleeding risk
• Cancer: indefinite until cancer-free
• Antiphospholipid syndrome: indefinite

Management of Massive PE

1. Fluids: 500 mL normal saline (do NOT over-fluid - worsens RV dilation and LV filling)
2. Vasopressors: Norepinephrine (maintains systemic BP)
3. Inotropes: Dobutamine (improves RV contractility, lowers filling pressures)
4. Systemic thrombolysis (tPA): Alteplase 100 mg IV over 2h (FDA approved); consider 50 mg if major bleeding risk. Contraindications: ICH, recent surgery/trauma, active bleeding. Major bleeding ~10%, ICH 2-3%
5. Catheter-directed therapy: Pharmacologic (low-dose tPA infusion) ± mechanical (suction thrombectomy, ultrasound-assisted); lower bleeding risk vs. systemic thrombolysis
6. Surgical pulmonary embolectomy: When thrombolysis fails or contraindicated; increasingly viable with ECMO support
7. IVC filter: Only when anticoagulation absolutely contraindicated OR recurrent VTE despite therapeutic anticoagulation

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D. Pneumothorax

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E. Acute Respiratory Failure

Type 1 (Hypoxemic): PaO2 <60 mmHg, PaCO2 normal or low

• Causes: ARDS, pneumonia, pulmonary edema, PE
• Management: High-flow O2, NIV (CPAP preferred), prone positioning (ARDS)

Type 2 (Hypercapnic): PaCO2 >45 mmHg + respiratory acidosis

• Causes: COPD exacerbation, asthma, neuromuscular disease
• Management: NIV (BiPAP), controlled O2, treat cause

ARDS (Berlin Definition)

• Acute onset (<1 week), bilateral infiltrates, PaO2/FiO2 <300 (mild), <200 (moderate), <100 (severe)
• Management: Low tidal volume ventilation (6 mL/kg IBW), PEEP titration, fluid restriction, prone positioning (≥16h/day for P/F <150), neuromuscular blockade if P/F <150, ECMO if refractory

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Part 4: Gastrointestinal Emergencies

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A. Upper GI Bleeding (UGIB)

Common Causes (in order of frequency)

1. Peptic ulcer disease (most common, ~50%)
2. Gastroesophageal varices (~10-20%; highest mortality)
3. Mallory-Weiss tear (retching-induced mucosal tear at GEJ)
4. Esophagitis / gastritis / duodenitis
5. Arteriovenous malformation (AVM)
6. Dieulafoy's lesion
7. Malignancy

Presentation

• Hematemesis (fresh blood or coffee grounds)
• Melena (black tarry stools - blood from above ligament of Treitz)
• Hematochezia (bright red rectal blood - usually lower GI, but massive UGIB can present this way)

Initial Resuscitation

1. Airway: Consider elective intubation if hematemesis with altered mental status or respiratory compromise (caution - associated with worse outcomes if done unnecessarily)
2. IV access: Two large-bore (≥18G) peripheral IVs or large-bore central cordis
3. Fluids: Aggressive crystalloid resuscitation; start IV PPI immediately
4. Transfusion strategy:
   • Restrictive: Transfuse if Hgb <7 g/dL (lower all-cause mortality + rebleeding vs. liberal)
   • Active/brisk bleeding with hemodynamic instability: do NOT wait for lab results; transfuse immediately
   • Massive transfusion: 1:1:1 PRBCs:FFP:platelets
5. Reverse anticoagulation: Vitamin K + 4-factor PCC for warfarin; specific reversal agents for DOACs
6. ICU admission for hemodynamically unstable patients

Medical Management

Endoscopy

• Early endoscopy within 24 hours for most UGIB
• Within 12 hours for suspected variceal bleeding
• Forrest Classification (peptic ulcer bleeding risk):
  • Ia (spurting) + Ib (oozing): high risk → endoscopic therapy
  • IIa (visible vessel) + IIb (adherent clot): high risk → endoscopic therapy
  • IIc (flat spot) + III (clean base): low risk → PPI + discharge
• Endoscopic therapies: Injection (epinephrine), thermal coagulation, hemostatic clips, band ligation (varices)
• Variceal management: Endoscopic band ligation preferred over sclerotherapy

Surgical/Interventional Rescue Therapy

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B. Acute Pancreatitis

Severity (Revised Atlanta Classification)

Scoring Systems

• BISAP Score: BUN >25, impaired mental status, SIRS, age >60, pleural effusion (score ≥3 = high risk)
• Ranson criteria: On admission + 48h parameters; ≥3 = severe
• CTSI (CT Severity Index): Balthazar grade + % necrosis; score ≥6 = high risk

Management

1. Aggressive IV hydration: Lactated Ringer's preferred over normal saline (Ringer's reduces SIRS); 250-500 mL/h initially; reassess at 6-12h
2. Nil by mouth → early oral/enteral feeding: Early oral refeeding is safe and reduces complications in mild pancreatitis. For severe pancreatitis with ileus - nasojejunal enteral nutrition (NEN) is preferred over TPN
3. Analgesia: IV opioids (morphine or hydromorphone); NSAIDS as adjunct if no contraindications
4. ICU monitoring for severe pancreatitis

• NOT recommended prophylactically even in necrotizing pancreatitis
• Use ONLY for proven/suspected infected pancreatic necrosis (culture or clinical features)
• Agents: Imipenem-cilastatin, meropenem (good pancreatic penetration), or carbapenem + metronidazole

• ERCP + sphincterotomy indicated within 24-72h if concurrent acute cholangitis or persistent biliary obstruction
• Cholecystectomy recommended after resolution of inflammation (same admission for mild, 6-8 weeks for severe)

1. Documented infected pancreatic necrosis (FNA-proven or emphysematous pancreatitis)
2. Severe sterile necrosis failing conservative management
3. Symptomatic organized necrosis after 4 weeks
4. Diagnostic uncertainty / suspected intra-abdominal catastrophe (perforated viscus)

1. Percutaneous CT-guided drainage
2. If inadequate: endoscopic transgastric or VARD necrosectomy
3. If still inadequate: open surgical necrosectomy

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C. Lower GI Bleeding (LGIB)

1. Resuscitation (same as UGIB)
2. Exclude UGIB first (NG aspirate, upper endoscopy if hemodynamically unstable)
3. Colonoscopy after bowel prep (within 24h for urgent, within 72h for stable)
4. If colonoscopy non-diagnostic: CT angiography → mesenteric angiography with embolization
5. Surgery for persistent or recurrent massive bleeding not amenable to endoscopy/IR

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D. Intestinal Obstruction

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E. Acute Cholecystitis / Cholangitis

Acute Cholecystitis

• Features: RUQ pain, fever, Murphy's sign, US showing gallstones + wall thickening/pericholecystic fluid
• Management: IV fluids, NPO, IV antibiotics (cefazolin or piperacillin-tazobactam), analgesics; cholecystectomy (laparoscopic, within 72h is preferred - reduces conversion rates and complications)

Acute Cholangitis (Charcot's triad: RUQ pain + fever + jaundice; Reynolds' pentad adds shock + confusion)

• Management: Emergency ERCP + biliary decompression/stone extraction; IV antibiotics; cholecystectomy electively after resolution

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Quick Reference Summary Table