Paul Miskovitz

Upper gastrointestinal hemorrhage in the inpatient hospital setting: a different beast?

A premise exists in current gastroenterologic wisdom that the time of onset of hemorrhage from the upper gastrointestinal tract (out of hospital vs. in hospital) has a profound influence on course and outcome. Nosocomial hemorrhage from the upper gastrointestinal tract is an important modern-day complication of hospitalization that is associated with a high rate of mortality. Although our ability to prevent this complication, known to be related to length of hospital stay and severity of underlying illness, suffers deficiencies, our facility to diagnose it accurately and in many instances to treat it with the use of endoscopy is well established (1-3).

A step-up approach to managing acute pancreatitis-associated fluid collections.

www.ccmjournal.org January 2015 • Volume 43 • Number 1 Acute pancreatitis (AP) is a multietiology inflammatory condition of the pancreas that varies in severity from a self-limiting inflammation of the gland to a rapidly deteriorating, often life-threatening condition involving multiple body organs. Well-recognized local complications of AP include peripancreatic fluid collection, pancreatic pseudocyst formation, acute necrotic collections and walled-off necrosis (both infected and sterile), peripancreatic vascular complications such as splanchnic venous thrombosis and pseudoaneurysm formation, and rarely the development of abdominal compartment syndrome. Optimal treatment of AP usually requires a multidisciplinary approach for the best patient care outcome. In this issue of Critical Care Medicine, Liu et al (1) report in a retrospective clinical cohort study that abdominal paracentesis drainage (APD) ahead of percutaneous catheter drainage (PCD) benefits patients with AP and fluid collections. One hundred two consecutive patients with AP from 2009 to 2011 seen at a large military hospital in China were subjected to a stepup treatment approach. All patients received medical management, PCD with or without previous APD, and necrosectomy, if necessary, according to indication. The patients were stratified into two groups of comparable demographic data and severity scores: 53 patients underwent APD followed by PCD (APD + PCD group) and 49 patients were managed only with PCD (PCD-alone group). Observed variables included mortality, infection, organ failure, inflammatory factor levels, indices of further intervention, and drainage-related complications. In this study, compared with the PCD-alone group, the mortality rate was lower in the APD + PCD group (3.8% vs 8.2%), the deranged laboratory variables of the APD + PCD group decreased more rapidly, the mean number of failed organs was lower, and the interval from the onset of AP to further interventions was much longer. However, there was no significant difference in the prevalence and duration of infections between the two groups. It was also noted that more patients in the PCDalone group had recurrent acute or chronic pancreatitis than in the APD + PCD group as determined by 2-year follow-up. Based on this retrospective report, the authors express the view that performing APD prior to PCD to treat patients with AP with fluid collections results in a better curative effect for several postulated reasons: 1) easing the inflammatory response by eliminating inflammatory factors; 2) preventing new-onset or secondary infection by removing the nutritive medium for bacteria; 3) hampering the development of organ failure by lowering abdominal pressure; and 4) deferring further intervention by serving as a transitional method. For reference, the 2012 revision of the Atlanta classification of AP, in an attempt to classify AP in a way that will allow a consistent, worldwide classification, has updated the terminology used to describe inflammatory pancreatic fluid collections in order to better reflect the underlying pathophysiology (2). The role of PCD in the management of pancreatic fluid collections (3, 4) and infected pancreatic necrosis (5) historically remains both exciting and controversial, the technique dating back more than 2 decades (6–8). Recently, PCD has become increasingly popular as a minimally invasive technique in the treatment armamentarium for treating patients with necrotizing pancreatitis requiring intervention (9), often competing with endoscopic (10) and surgical approaches (11). When successful, it may obviate the need for surgery and its attendant morbidity in a considerable number of patients in this setting. In this interesting preliminary retrospective study, Liu et al (1) have shown that a step-up approach incorporating APD ahead of PCD significantly enhances the outcome in a number but not all variables in these patients. Clearly, further study of this form of step-up therapy is warranted. The take-home message from this report is certainly consistent with Dr. Kenneth Wayne Warren’s admonition to the medical community from 5 decades ago.

Intestinal glucose transport in the critically ill--eavesdropping on a dialogue.

Glucose, the body’s fuel, has often been likened to gasoline. In this issue of Critical Care Medicine, Deane et al (1) explore the effects of critical illness on intestinal glucose sensing, transporters, and absorption. To understand the importance of their study, one must have a basic grasp of the physiology of intestinal glucose absorption (2–6). The gastrointestinal epithelium is in close contact with chyme the composition of which includes nutrients, bacteria, minerals, water, toxins, and waste matter. The epithelial barrier must decide which components are to be absorbed and which are to be excluded. In the small intestine, glucose is mainly absorbed by the sodium-linked glucose Intestinal Glucose Transport in the Critically Ill— Eavesdropping on a Dialogue*

Energy expenditure and the liver: acute fulminant hepatitis.

Prometheus, in Greek mythology, one of the Titans and the god who angered Zeus by giving fire to mankind, as punishment, was chained to a rock to have an eagle eat his immortal liver by day, only to have it replenish itself overnight. Thus, in ancient times, was established the pivotal role of the liver as a strategic organ in energy supply, biosynthesis and catabolism, and excretory function as well as recognition of its capacity for regeneration.