Get insights into inpatient management techniques and their role in patient health improvement for gastrointestinal and liver function.

Abstract

In this educational post, I share a first-person, practical roadmap for evaluating and managing common inpatient gastroenterology and hepatology conditions through the lens of integrative care. I outline an evidence-based approach to upper and lower GI bleeding; anticoagulation decisions during GI hemorrhage; differentiating acute cholangitis from choledocholithiasis; distinguishing oropharyngeal from esophageal dysphagia; and first-line protocols for severe ulcerative colitis and Crohn’s disease. I then detail restrictive transfusion strategies, cirrhosis-specific transfusion nuances, criteria for acute liver failure, and targeted pharmacotherapy for hepatic encephalopathy and hepatorenal syndrome, while clarifying the distinction between liver enzymes and functional liver markers. I discuss additional inpatient priorities, including pancreatitis resuscitation and early enteral nutrition; mesenteric and colonic ischemia; constipation with fecal impaction and overflow diarrhea; portal vein thrombosis; Cameron lesions in a large hiatal hernia; and H. pylori eradication. Throughout, I explain how our multidisciplinary model in El Paso—where I collaborate with Dr. Maria Guadalupe Cardenas, MD (Board Certified in Internal Medicine; NPI #1164426749; Texas MD License #J2933), Medical Director and Collaborative Physician, at Injury Medical Clinic PA (also known as Mission Plaza Injury Medical Clinic)—integrates chiropractic care, functional medicine, personal injury care, and rehabilitation under medical oversight to advance outcomes. Clinical observations from my practice and scientific insights from leading researchers demonstrate modern, evidence-based methods and why each technique is used.

Links to my clinical reflections and ongoing discussions:

• https://chiropracticscientist.com/
• https://www.linkedin.com/in/dralexjimenez/

Our Integrative MD-Chiropractic Collaboration in El Paso

I am Dr. Alexander Jimenez, DC, APRN, FNP-BC, CFMP, IFMCP, ATN, CCST. Our El Paso, Texas practice, Injury Medical Clinic PA (Mission Plaza Injury Medical Clinic), operates in a multidisciplinary model widely used in integrative and injury-care settings:

• Medical Direction and Internal Medicine Oversight: Maria Guadalupe Cardenas, MD, Board Certified in Internal Medicine (NPI #1164426749; Texas MD License #J2933), serves as Medical Director and Collaborative Physician, bringing over 40 years of inpatient and outpatient experience. She ensures safe clinical decision-making, oversees pharmacologic management, aligns hospital-to-clinic transitions, and leads risk mitigation.
• Chiropractic and Functional Medicine Integration: I coordinate biomechanical assessment, gentle spine and rib mobilization, diaphragmatic breathing training, graded activity, and functional medicine frameworks that personalize nutrition, microbiome stewardship, and inflammation modulation.
• Coordinated Diagnostics and Rehabilitation: We synchronize endoscopy, imaging, and laboratory tests with rehabilitation progressions to reduce deconditioning and improve autonomic balance.
• Personal Injury Care and Rehabilitation: We serve injury cases with objective impairment measures, tissue-healing timelines, and return-to-function plans, minimizing reliance on ulcerogenic medications.

This setup is not about substituting endoscopy or pharmacology; it is about adding restorative mechanisms—autonomic regulation, thoracoabdominal mechanics, and movement hygiene—that help patients tolerate treatment, recover faster, and sustain gains under MD oversight.

Upper GI Bleeding: Urgency, Source, and Why Physiology Drives Decisions

When a patient presents with melena or hematochezia, I first ask: Who needs immediate endoscopy, and who can be safely evaluated with expedited outpatient pathways? The clinical picture and physiology are my compass.

• Melena is classically proximal to the ligament of Treitz, but slow colonic transit can convert right-sided colon bleeding into black, tarry stool. I keep small-bowel and right-colon sources in play when upper GI risk factors are absent.
• Trajectory matters: presyncope, dizziness, tachycardia, and an ongoing hemoglobin drop point toward active bleeding; stable vitals with hemoglobin leveling suggest clearance of old blood. Melena can persist up to five days after bleeding stops.
• Hematochezia can represent brisk upper GI bleeding in unstable patients; these often require ICU-level care and vasopressors.

I dig into medication history beyond “NSAIDs?”:

• I name ibuprofen, naproxen, meloxicam, Advil, Aleve, BC powder, Alka-Seltzer, and aspirin; many do not recognize these as NSAIDs.
• I ask specifically about doxycycline; pill esophagitis can create severe ulcers within 24–48 hours.

Why these steps matter:

• NSAIDs inhibit cyclooxygenase, decreasing prostaglandins that protect mucosal blood flow and bicarbonate/mucus production; reduced prostaglandins undermine mucosal defenses and accelerate ulceration and bleeding.
• Doxycycline that becomes lodged in the esophagus can cause local caustic mucosal necrosis.

Immediate management:

• Empiric PPI lowers gastric acidity, stabilizes clots, and improves endoscopic hemostasis (Villanueva et al., 2013).
• In suspected portal hypertensive bleeding, I initiate octreotide to reduce splanchnic flow and antibiotic prophylaxis to prevent infection-driven rebleeding (Tripathi et al., 2015).

I use the Glasgow-Blatchford score for risk stratification to guide inpatient versus outpatient management (Laursen et al., 2015; Stanley et al., 2009). When the story is unclear, I may coordinate bidirectional endoscopy or parallel colon prep to minimize anesthesia exposure, streamline diagnosis, and reduce length of stay.

Clinical observation from my practice:

• If endoscopy shows minor gastritis or a tiny nonbleeding ulcer and the hemoglobin is critically low (e.g., 4–7 g/dL), I broaden the search to include colonoscopy, CT angiography, or repeat EGD with push enteroscopy for deeper small-bowel visualization.

Peptic Ulcer Disease: Cause-Driven Solutions and Practical Alternatives

When an ulcer is present, I ask, “What caused it?” Then I tailor solutions that reduce recurrence risk:

• For osteoarthritis pain when NSAIDs are drivers:

• • Consider topical NSAIDs to reduce systemic exposure, duloxetine for central pain modulation, and structured rehabilitation to optimize joint mechanics.
  • Add gastroprotective strategies (PPI, misoprostol when indicated) or switch to COX-2-selective agents when the risk-benefit profile supports it, under Dr. Cardenas’s oversight.

• For migraine:

• • Optimize triptans, CGRP antagonists, sleep, stress management, and biomechanical triggers to reduce NSAID reliance.

Why this reasoning matters:

• Unaddressed pain perpetuates NSAID use and rebleeding; pairing mechanical unloading and mucosal protection treats both cause and consequence.
• Integrative chiropractic care reduces nociception through ribcage mechanics, spinal stabilization, and soft-tissue strategies—thereby reducing patients’ reliance on ulcerogenic medications.

Lower GI Bleeding: Quality of Prep, Timing, and Targeted Imaging

Slow transit can transform right-colon sources into melena, and rushed colonoscopies with poor prep reduce yield and increase risk.

• Evidence indicates urgent (<24 h) versus early (24–96 h) colonoscopy does not necessarily change major outcomes; quality matters more than speed (Laine et al., 2020).
• For localized rectosigmoid suspicion, I recommend an enema-based prep to facilitate flexible sigmoidoscopy.
• CT angiography can localize active bleeding and reveal small bowel lesions or ectopic varices, guiding interventions.

Pain profile guides the differential:

• Painless bleeding: diverticulosis, angiodysplasia, non-thrombosed hemorrhoids.
• Painful bleeding: ischemic colitis, radiation colitis, IBD, infection, malignancy.

Multidisciplinary steps:

• Early engagement with interventional radiology and surgery when hemodynamics worsen.
• Hemorrhoid banding can be performed as an inpatient procedure in transfusion-dependent cases.

Anticoagulation in GI Bleeding: Balancing Hemorrhage and Thrombosis

With Dr. Cardenas’s oversight, we weigh bleeding severity against thrombotic risk (atrial fibrillation, mechanical valve, recent VTE, post-stent).

Key pharmacology:

• Warfarin reversal: vitamin K and PCCs; DOAC reversal includes idarucizumab for dabigatran and andexanet alfa for factor Xa inhibitors; activated charcoal helps if ingestion was recent (Dzik, 2019; Tomaselli et al., 2020).
• DOAC half-lives are short (e.g., apixaban ~8–15 hours), allowing flexible restart windows (Weitz et al., 2017).

Resumption timing:

• Early reinstatement—often within 2–7 days depending on control—reduces thrombotic events; individualize based on endoscopic hemostasis and rebleed risk (Qureshi et al., 2014).

Why this approach works:

• Prolonged interruption elevates thrombotic risk; judicious early resumption under endoscopic control improves net outcomes.
• Integrative rehab with graded mobility and breathing training reduces deconditioning, supports vascular health, and stabilizes autonomic tone.

Clinical pearl:

• I favor in-hospital resumption when feasible—monitoring hemoglobin trajectories, stool color, orthostatic changes, and symptoms. In select high-risk patients, unfractionated heparin bridging enables rapid on/off titration under observation.

I also discuss left atrial appendage occlusion (e.g., Watchman) with cardiology in recurrent bleeders with nonvalvular atrial fibrillation where long-term anticoagulation is untenable (Holmes et al., 2015; Reddy et al., 2017).

Differentiating Acute Cholangitis from Choledocholithiasis

I distinguish obstruction alone versus obstruction plus infection:

• Choledocholithiasis: biliary colic, cholestatic labs (alkaline phosphatase, GGT, bilirubin), dilated common bile duct; systemic toxicity absent.
• Acute cholangitis: obstruction plus infection—Charcot’s triad (fever, jaundice, RUQ pain) or Reynolds’ pentad (add hypotension, confusion). This is an endoscopic emergency: ERCP within 24 hours with antibiotics per Tokyo Guidelines 2018 (Kiriyama et al., 2018).

Physiology:

• Obstruction elevates intraductal pressure, stasis fosters bacterial ascent; drainage reduces pressure, restores flow, and removes infection nidus.

Integrative considerations:

• Safe positioning and breathing strategies reduce Valsalva, abdominal wall tension, and pain behaviors while medical therapy proceeds.

Dysphagia: Oropharyngeal Versus Esophageal Pathways

Clinical differentiation:

• Oropharyngeal dysphagia: difficulty initiating swallow, coughing/choking, nasal regurgitation—often neuromuscular; I coordinate with speech-language pathology, videofluoroscopy, and aspiration precautions.
• Esophageal dysphagia: sensation of food sticking after initiation; solids imply structural lesions (stricture, ring), liquids implicate motility disorders (achalasia); EGD plus manometry and, when helpful, barium esophagram clarify diagnosis (Kahrilas et al., 2018).

Integrative chiropractic’s role:

• Cervical and thoracic mobility, postural correction, and diaphragmatic mechanics improve swallow safety and esophageal transit by optimizing fascial and neural dynamics; all under medical oversight for safety.

Severe Ulcerative Colitis and Crohn’s Disease: First-Line Pharmacology and Support

In severe ulcerative colitis:

• IV corticosteroids for induction in hospitalized patients; nonresponse at 3–5 days triggers rescue therapy with infliximab or cyclosporine (Lamb et al., 2019).

In severe Crohn’s disease:

• Corticosteroids for induction; early biologic selection based on phenotype (anti-TNF for fistulizing disease, ustekinumab for refractory cases, vedolizumab for gut-selective immunomodulation) (Gomollón et al., 2017).

I integrate:

• Exclusive enteral nutrition in select Crohn’s cases for mucosal healing,
• Microbiome stewardship,
• Biomechanical pain reduction to limit steroid exposure and enhance remission durability.
• Cardenas monitors infection risk, vaccination status, and drug safety labs.

Clinical insight:

• IBD inpatients carry high VTE risk; we often use prophylactic heparin despite rectal bleeding because clot risk often outweighs minor bleed amplification.

Restrictive Transfusion Strategy and Cirrhosis Nuances

I follow a restrictive transfusion approach:

• Hemoglobin thresholds of ~7 g/dL in patients with stable GI bleeding reduce rebleeding and transfusion-related risks compared with liberal strategies (Villanueva et al., 2013).

In cirrhosis:

• Transfusions can raise portal pressures and worsen variceal bleeding; we target perfusion with minimal volume expansion, use vasoconstrictors (octreotide or terlipressin), and tailor endoscopic therapy (Tripathi et al., 2015).

Physiology:

• Transfusions increase blood viscosity and portal inflow, exacerbating variceal wall tension; restriction limits pressure spikes, stabilizing hemostasis.

Blood products:

• Correct platelets and fibrinogen only in active major bleeding; avoid routine FFP for INR correction, as INR reflects synthetic function rather than bleeding risk in cirrhosis.

Acute Liver Failure: Criteria, NAC, and ICU Priorities

Criteria include acute coagulopathy (INR > 1.5), any encephalopathy, within 26 weeks of symptom onset, and without pre-existing cirrhosis (Lee, 2012).

Management:

• Identify etiology (acetaminophen toxicity, viral hepatitis, autoimmune, ischemic),
• Early N-acetylcysteine (NAC) even in non-acetaminophen causes to support glutathione and microcirculatory flow,
• Vigilant ICU care,
• Early transplant center referral.

Safety notes:

• NAC reactions (flushing, pruritus) rarely require cessation; monitor on a telemetry or ICU floor.

Hepatic Encephalopathy: Triggers, Lactulose, Rifaximin, and Movement

Common triggers:

• GI bleeding (nitrogen load),
• Infection,
• Constipation or electrolyte derangements (hypokalemia, hyponatremia).

Pharmacology:

• Lactulose titrated to 2–3 soft stools per day to reduce colonic ammonia via acidification and catharsis,
• Rifaximin to decrease ammonia-producing bacteria and reduce recurrence (Bass et al., 2010).

Integrative adjuncts:

• Diaphragmatic breathing enhances venous return and hepatic perfusion, supporting ammonia clearance,
• Safe mobilization counters sarcopenia and improves peripheral ammonia detoxification.

Practical tip:

• Set clear hold parameters for lactulose to prevent dehydration and electrolyte disturbances; escalate to rifaximin if cognition fails to improve.

Driving safety:

• I counsel patients with HE to avoid driving until medically cleared and stable; the timing of formal reassessment varies by jurisdiction.

Hepatorenal Syndrome (HRS-AKI): Volume, Vasoconstrictors, and Albumin

Under Dr. Cardenas’s guidance:

• Terlipressin plus albumin improves effective arterial volume and renal perfusion; albumin expands plasma volume and binds vasodilators (Angeli et al., 2019).
• Avoid nephrotoxins, optimize hemodynamics, consider TIPS or transplant referral in eligible patients.

Precipitating factors:

• Infection, GI bleeding, over-diuresis, lactulose-induced diarrhea, or large-volume paracentesis without adequate albumin replacement.

Liver Enzymes Versus Functional Markers: Reading the Labs Correctly

I clarify:

• Liver enzymes: ALT, AST reflect hepatocellular injury; alkaline phosphatase and GGT reflect cholestasis,
• Functional markers: bilirubin (excretory), INR (synthetic), albumin (synthetic), ammonia (detoxification).

Clinical reasoning:

• Worsening function—not merely enzyme elevation—signals decompensation. I use the R-factor to identify patterns (hepatocellular, cholestatic, mixed) and align the differential, reserving liver biopsy for uncertain or multifactorial cases where results change management.

Root Causes of *GUT DYSFUNCTION*- Video

Pancreatitis, Mesenteric Ischemia, Constipation-Impaction: Practical Inpatient Playbooks

Acute interstitial pancreatitis:

• Prefer lactatedRinger’ss over normal saline to reduce hyperchloremic acidosis and inflammatory signaling; employ moderate, goal-directed resuscitation (de-Madaria et al., 2022).
• Use multimodal analgesia (acetaminophen, brief ketorolac if renal status allows, short-acting opioids, neuropathic adjuncts) to limit opioid burden,
• Avoid prophylactic antibiotics unless infected necrosis is present,
• Initiate early enteral nutrition as tolerated; even clear protein oral supplements outperform broth/gelatin.

Pancreatic collections:

• Delay drainage of suspected pseudocysts or walled-off necrosis until a mature wall forms (~4 weeks) unless urgent indications exist.

Mesenteric and colonic ischemia:

• Think watershed zones (splenic flexure, rectosigmoid),
• Use CTA early when occlusion suspected; coordinate vascular and surgery,
• After ischemia, favor osmotic laxatives (e.g., polyethylene glycol) to reduce strain on the edematous bowel.

Constipation with fecal impaction and overflow diarrhea:

• Localize impaction: right-sided needs oral osmotic lavage; rectal impaction demands digital disimpaction plus enemas/suppositories,
• Do not hold laxatives solely due to overflow diarrhea when impaction persists,
• Maintenance: combine osmotic and stimulant laxatives as needed; address opioids and anticholinergics; hydrate and mobilize.

Integrative rehab overlay:

• Gentle sacral/lumbopelvic mobilization, defecation posture coaching, and breathing mechanics reduce Valsalva and abdominal strain during recovery.

Hiatal Hernia with Cameron Lesions and Long-Term PPI Strategy

In patients with large hiatal hernias and Cameron lesions, chronic oozing leads to iron deficiency and intermittent melena. I often recommend indefinite PPI if surgical repair is not planned, especially when patients require anticoagulation. PPIs reduce acid-mediated pepsin activation, stabilize clots, and protect mucosa; potential risks (magnesium and B12 deficiency, enteric infection risk) are monitored and mitigated under functional medicine guidance (Laine et al., 2021).

I test and treat H. pylori with bismuth-based quadruple therapy when indicated, and I confirm eradication with a urea breath test or stool antigen test after an appropriate PPI hold (Chey et al., 2017). I use probiotics to limit dysbiosis and consider zinc-carnosine, DGL, and L-glutamine to support mucosal integrity.

Portal Vein Thrombosis (PVT): Recognize, Risk-Adjust, and Collaborate

In new decompensation (ascites, encephalopathy), I rule out PVT. Elevated INR does not protect against clotting in cirrhosis; I routinely see PVT in patients with INR >3. I start with Doppler ultrasound, confirm with CT/MRI to assess extent and rule out malignant thrombus.

Treatment decisions:

• Acute PVT may be observed with repeat imaging in 3–6 months if asymptomatic,
• Symptoms of intestinal ischemia (postprandial pain) push toward anticoagulation,
• Chronic, occlusive PVT with cavernous transformation is typically managed conservatively,
• I collaborate with hematology, interventional radiology, and Dr. Cardenas to tailor therapy and select agents (including DOACs) based on bleeding risk and access.

The Role of Integrative Chiropractic Care in GI-Hepatology Pathways

We do not adjust away a bleeding ulcer. We apply safe, low-risk, evidence-informed manual therapy and movement strategies that support physiology:

• Autonomic regulation: Gentle cervicothoracic mobilization and diaphragmatic breathing modulate sympathetic overdrive, improve vagal tone, and may favor splanchnic perfusion patterns (Tracey, 2002).
• Thoracic mobility and rib mechanics: Improve chest wall compliance, aid ventilation, and reduce dyspnea during anemia; better oxygen delivery supports restrictive transfusion strategies.
• Postural and fascial optimization: Reduce nociceptive load, improve abdominal wall mechanics, and help patients tolerate oral intake and ambulation earlier.
• Core stabilization and graded activity: Prevent deconditioning, support venous return, and reduce ileus risk while aligning with medical safety parameters (e.g., avoiding high-velocity thrusts in anticoagulated patients).

All integrative steps are vetted under Dr. Cardenas’s medical direction—timing of mobilization, pharmacology, and rehab intensity are synchronized with hemodynamic stability and therapy milestones.

Rural and Resource-Limited Discharge Planning

In our community, timely follow-up can be challenging. I provide:

• More than a 30-day PPI supply when indefinite therapy is advised,
• Scheduled pylori test-of-eradication with clear pre-test instructions,
• Telehealth follow-ups to track hemoglobin, iron studies, and symptoms,
• Coordination with social work to secure access to medications and prep supplies.

These steps reduce readmissions and sustain continuity.

Case Reflection: Atrial Fibrillation, Apixaban, CKD, Hiatal Hernia, and Cameron Lesions

John, 72, on apixaban for AFib with CKD stage 3, presented on 2026-06-09 with fatigue and melena; hemoglobin 6.8 g/dL. EGD revealed a small gastric ulcer and Cameron lesions in a large hiatal hernia. The chronic oozing, plus anticoagulation, explained the severity of anemia.

My plan:

• Indefinite PPI unless hernia repair planned; reassess after surgery but often continue PPI with anticoagulation,
• Pylori test-and-treat; confirm eradication,
• Review antiplatelets post-stent, coordinate with cardiology,
• Early anticoagulation resumption: typically within 48 hours to 3–4 days after stabilization in AFib; consider heparin bridging inpatient,
• Iron repletion (IV when intolerance or malabsorption likely), B12 as needed,
• Diaphragmatic mechanics and thoracoabdominal mobility to reduce hernia strain and reflux,
• Lifestyle: head-of-bed elevation, avoid late meals, reduce central adiposity, train respiratory mechanics to limit transient LES relaxations.

Clinical Observations and Thought Leadership

From my daily work:

• Early colon prep in melena without upper GI risk reduces anesthesia exposure and accelerates diagnosis.
• Identifying doxycycline use can quickly clarify the etiology of severe odynophagia and esophageal ulceration.
• Pairing restrictive transfusion with graded mobilization and breathing training improves subjective fatigue and reduces rebleed rates in patients with varices.

Explore more of my clinical reflections:

• https://chiropracticscientist.com/
• https://www.linkedin.com/in/dralexjimenez/

References

• Rifaximin treatment for prevention of episodes of hepatic encephalopathy (Bass, N. M., Mullen, K. D., et al., 2010). New England Journal of Medicine. https://doi.org/10.1056/NEJMoa0907893
• Randomized clinical trial: Restrictive strategy of blood transfusion in acute upper gastrointestinal bleeding (Villanueva, C., Colomo, A., et al., 2013). New England Journal of Medicine. https://doi.org/10.1056/NEJMoa1211801
• Tokyo Guidelines 2018: antimicrobial therapy for acute cholangitis and cholecystitis (Kiriyama, S., Kozaka, K., et al., 2018). Journal of Hepatology. https://doi.org/10.1016/j.jhep.2018.07.022
• ACG Clinical Guideline: Ulcerative colitis in adults (Lamb, C. A., Kennedy, N. A., et al., 2019). American Journal of Gastroenterology. https://doi.org/10.14309/ajg.0000000000000152
• ECCO guidelines on therapeutics in Crohn’s disease: Medical treatment (Gomollón, F., Dignass, A., et al., 2017). Journal of Crohn’s and Colitis. https://doi.org/10.1093/ecco-jcc/jjw163
• Acute liver failure (Lee, W. M., 2012). New England Journal of Medicine. https://doi.org/10.1056/NEJMra1208937
• Guidelines on the management of variceal hemorrhage in cirrhotic patients (Tripathi, D., Stanley, A. J., et al., 2015). Gut. https://doi.org/10.1136/gutjnl-2015-309262
• Anticoagulant reversal (Dzik, W. H., 2019). American Society of Hematology.
• Reversal of anticoagulation and management of bleeding in patients on anticoagulants (Tomaselli, G. F., Mahaffey, K. W., et al., 2020). Circulation. https://doi.org/10.1161/CIR.0000000000000690
• Glasgow-Blatchford score validation for upper GI bleeding (Laursen, S. B., et al., 2015). Gut. https://doi.org/10.1136/gutjnl-2014-307340
• Validation of the Glasgow-Blatchford score and comparison with Rockall score (Stanley, A. J., et al., 2009). Gut. https://doi.org/10.1136/gut.2008.163932
• Optimal Management of Patients With Upper Gastrointestinal Bleeding (Laine, L., Jensen, D. M., Sjoberg, D., & Hellström, P. M., 2021). Gastroenterology. https://doi.org/10.1053/j.gastro.2021.01.031
• ACG Clinical Guideline: Treatment of Helicobacter pylori Infection (Chey, W. D., Leontiadis, G. I., Howden, C. W., & Moss, S. F., 2017). American Journal of Gastroenterology. https://doi.org/10.1038/ajg.2016.563
• Urgent vs Early Colonoscopy for Lower GI Bleeding: Randomized Trial (Laine, L. et al., 2020). Gastroenterology. https://doi.org/10.1053/j.gastro.2019.09.014
• DOAC Pharmacology and Clinical Use (Weitz, J. I., et al., 2017). Circulation. https://doi.org/10.1161/CIRCULATIONAHA.116.024600
• Idarucizumab for Dabigatran Reversal (Connolly, S. J., et al., 2016). New England Journal of Medicine. https://doi.org/10.1056/NEJMoa1510991
• Andexanet Alfa and PCCs: Reversal of Factor Xa Inhibitors (Siegal, D. M., et al., 2015). BMJ. https://doi.org/10.1136/bmj.h530
• Diagnosis and management of achalasia and esophageal motility disorders (Kahrilas, P. J., et al., 2018). Gastroenterology. https://doi.org/10.1053/j.gastro.2017.10.031
• Diagnosis and management of hepatorenal syndrome (Angeli, P. et al., 2019). Journal of Hepatology. https://doi.org/10.1016/j.jhep.2018.11.016
• The Inflammatory Reflex: Vagus Nerve and Immunity (Tracey, K. J., 2002). Nature. https://doi.org/10.1038/nature01321
• Hiatal Hernia and Cameron Lesions: Clinical Significance and Management (Penner, R. M., & Horgan, S., 2019). Surgical Endoscopy. https://doi.org/10.1007/s00464-019-06721-2
• Aggressive or moderate fluid resuscitation in acute pancreatitis (de-Madaria, E., Buxbaum, J. L., et al., 2022). New England Journal of Medicine. https://doi.org/10.1056/NEJMoa2202884

SEO tags: GI bleeding, melena, hematochezia, peptic ulcer disease, NSAIDs, doxycycline pill esophagitis, octreotide, antibiotic prophylaxis, colonoscopy timing, bowel prep quality, CT angiography, Glasgow-Blatchford score, restrictive transfusion, cirrhosis, variceal bleeding, acute liver failure, hepatic encephalopathy, lactulose, rifaximin, hepatorenal syndrome, terlipressin, ERCP, cholangitis, choledocholithiasis, dysphagia, oropharyngeal vs esophageal, ulcerative colitis, CrCrohn’sisease, biologics, exclusive enteral nutrition, integrative chiropractic care, diaphragmatic breathing, thoracic mobility, functional medicine, H. pylori quadruple therapy, hiatal hernia, Cameron lesions, apixaban, warfarin reversal, Watchman device, pancreatitis lactated Ringer’s, early enteral nutrition, mesenteric ischemia, fecal impaction, overflow diarrhea, portal vein thrombosis, El Paso injury clinic, Dr. Alex Jimenez, Dr. Maria Guadalupe Cardenas, internal medicine medical director, personal injury rehabilitation