BACKGROUND/AIMS: Patients with liver cirrhosis (LC) are at risk for critical events leading to Intensive Care Unit (ICU) admission. Coagulopathy in cirrhotic patients is complex and can lead to bleeding as well as thrombosis. The aim of this study was to investigate bleeding complications in critically ill patients with LC admitted to a medical ICU (MICU). METHODS: All adult patients admitted to our MICU with a diagnosis of LC from January 2006 to December 2012 were retrospectively assessed. Patients with major bleeding at the time of MICU admission were excluded from the analysis. RESULTS: A total of 205 patients were included in the analysis. The median patient age was 62 years, and 69.3% of the patients were male. The most common reason for MICU admission was acute respiratory failure (45.4%), followed by sepsis (27.3%). Major bleeding occurred in 25 patients (12.2%). The gastrointestinal tract was the most common site of bleeding (64%), followed by the respiratory tract (20%). In a multivariate analysis, a low platelet count at MICU admission (odds ratio [OR], 0.98; 95% confidence interval [CI], 0.97 to 0.99) and sepsis (OR, 8.35; 95% CI, 1.04 to 67.05) were independent risk factors for major bleeding. The ICU fatality rate was significantly greater among patients with major bleeding (84.0% vs. 58.9%, respectively; p = 0.015). CONCLUSIONS: Major bleeding occurred in 12.2% of critically ill cirrhotic patients admitted to the MICU. A low platelet count at MICU admission and sepsis were associated with an increased risk of major bleeding during the MICU stay. Further study is needed to better understand hemostasis in critically ill patients with LC.
Aged ; Blood Platelets ; Critical Illness ; Female ; Gastrointestinal Hemorrhage/blood/diagnosis/*etiology/mortality ; Hospital Mortality ; Humans ; Intensive Care Units ; Liver Cirrhosis/blood/*complications/diagnosis/mortality ; Male ; Middle Aged ; Multivariate Analysis ; Odds Ratio ; Platelet Count ; Prognosis ; Republic of Korea ; Respiratory Tract Diseases/blood/diagnosis/*etiology/mortality ; Retrospective Studies ; Risk Factors ; Sepsis/blood/complications ; Time Factors

INTRODUCTIONPatients with functional gastrointestinal disorders (FGIDs) have a decreased quality of life (QoL). Psychological illnesses are strongly associated with FGIDs. This study examined the effect of a comprehensive psychological intervention programme designed for refractory FGID patients.

METHODSRefractory FGID patients at a tertiary gastroenterology unit were encouraged to participate in a psychological intervention programme, which included screening for anxiety and depression in patients, educating patients and physicians on FGIDs, and providing early access to psychiatric consultation for patients with significant psychological illnesses. The duration of follow-up was six months. Outcomes were measured using the Irritable Bowel Syndrome-QoL (IBS-QoL) instrument and the EuroQol five dimensions (EQ-5D) questionnaire.

RESULTSA total of 1,189 patients (68% female, 80% Chinese, mean age 48.6 years) participated in the programme. Among these participants, 51% had a significant psychological disorder (Hospital Anxiety and Depression Scale [HADS] anxiety or depression score > 7). These participants had a significantly poorer QoL (IBS-QoL and EQ-5D, both p < 0.0001), and were more likely to be single or English-speaking, as compared to the participants without psychological disorders. Participants who completed ≥ 3 months of follow-up (n = 906) showed significant and durable improvement. High baseline HADS anxiety score predicted improvement (p < 0.001), with participant IBS-QoL and EQ-5D scores decreasing over time.

CONCLUSIONThe intervention programme was associated with a clinically meaningful improvement in the QoL of patients with refractory FGIDs. High baseline anxiety was predictive of improvement.

Adult ; Anxiety ; complications ; diagnosis ; therapy ; Depression ; complications ; diagnosis ; therapy ; Female ; Follow-Up Studies ; Gastrointestinal Diseases ; complications ; psychology ; therapy ; Humans ; Male ; Mental Disorders ; complications ; therapy ; Middle Aged ; Quality of Life ; Severity of Illness Index ; Singapore ; Surveys and Questionnaires ; Treatment Outcome

Lower gastrointestinal complications often develop in end stage renal disease patients, and among the more problematic is recurrent colon ulcer. The exact pathogenesis of this condition is not known and there were no specific therapeutic modalities concerning this type of disease entity. We report, with a literature review, a case of recurrent colon ulcer with intermittent hematochezia in an end stage renal disease patient on long term hemodialysis that improved after conversion to peritoneal dialysis.
Aspirin/therapeutic use ; Colon/pathology ; Colonic Diseases/complications/*diagnosis/drug therapy ; Colonoscopy ; Drug Therapy, Combination ; Gastrointestinal Hemorrhage ; Humans ; Kidney Failure, Chronic/*complications ; Male ; Middle Aged ; Peritoneal Dialysis ; Recurrence ; Ticlopidine/therapeutic use ; Ulcer/complications/*diagnosis/drug therapy

Variceal bleeding is common in chronic liver disease and is a frequent cause of acute upper gastrointestinal bleeding. The most common site of varices is the lower oesophagus but they may occur at any location where there are portosystemic anastomoses and collateral vascular formation. Location of ectopic varices at the site of enterocutaneous stomas is rare. We report on three cases of recurrent and severe bleeding from parastomal varices, requiring hospital admission. The patients had chronic liver disease but of different aetiological factors. Variceal formation results from portal hypertension due to chronic liver disease. There are various treatment options for parastomal variceal bleeding, including local, medical, and surgical interventions. Management of parastomal variceal bleeding presents a recurring and difficult problem. Bleeding may be considerable and sometimes life threatening. This diagnosis must be considered in patients with chronic liver disease presenting with stomal bleeding, even where the variceal formation may not be readily visible.
Aged, 80 and over ; Chronic Disease ; Female ; *Gastrointestinal Hemorrhage ; Humans ; Liver Diseases/complications/*pathology ; Male ; Middle Aged ; Recurrence ; Severity of Illness Index ; Tomography, X-Ray Computed ; Varicose Veins/complications/*diagnosis

PURPOSE: The study was done to develop an evidence-based enteral nutrition (EN) protocol for effective nutritional support for dysphagia in patients with acute stroke, and to evaluate effects of this protocol on clinical outcomes. METHODS: A methodological study was used to develop the EN protocol and a quasi-experimental study to verify the effectiveness of the protocol. The preliminary EN protocol was drawn by selecting recommendations from previous well-designed EN guidelines, and then developing additional recommendations based on high-quality evidence. Content validation was assessed by an expert group, and clinical applicability by care providers and patients. The scale-level content validity index of the final EN protocol was 0.99. Assessment was done of differences in percentage of caloric goals achieved and presence of undernutrition, aspiration pneumonia, and gastrointestinal (GI) complications after application of the EN protocol. RESULTS: In the EN protocol group, the percentage of caloric goals achieved (R2=.24, p=.001) and the reduction of GI complications (p=.045) were significantly improved, but the presence of undernutrition (p=.296) and aspiration pneumonia (p=.601) did not differ from the usual care group. CONCLUSION: Results indicate that the new EN protocol for dysphagia in patients with acute stroke significantly increased their nutritional intake and reduced GI complications.
Aged ; Aged, 80 and over ; Body Weight ; Deglutition Disorders/complications/*diagnosis ; Energy Intake ; Enteral Nutrition/*methods ; Evidence-Based Nursing ; Female ; Gastrointestinal Diseases/complications ; Humans ; Intensive Care Units ; Male ; Middle Aged ; Pneumonia/diagnosis ; *Program Development ; *Program Evaluation ; Questionnaires ; Stroke/complications/*diagnosis

Spontaneous bacterial peritonitis (SBP) is the most common infection in liver cirrhosis patients, and is not a result of surgery or intra abdominal infection. Argon plasma coagulation (APC) is an endoscopic procedure used with a high-frequency electrical current for control of bleeding from gastrointestinal vascular ectasias including angiodysplasia and gastric antral vascular ectasia. This procedure is known to be safe because it uses a noncontact method. Therefore, tissue injury is minimal and up to two to three millimeters. However, we experienced a case of SBP occurring immediately after performance of APC for control of severe bleeding from angiodysplasia in the colon in a patient with liver cirrhosis and hepatocellular carcinoma.
Aged ; Angiodysplasia/complications/*diagnosis ; Anti-Bacterial Agents/therapeutic use ; *Argon Plasma Coagulation ; Bacterial Infections/*diagnosis/drug therapy/microbiology ; Carcinoma, Hepatocellular/complications/diagnosis ; Colonic Diseases/complications/*diagnosis ; Colonoscopy ; Female ; Gastrointestinal Hemorrhage/therapy ; Gram-Negative Bacteria/isolation & purification ; Humans ; Liver Cirrhosis/complications/diagnosis ; Liver Neoplasms/complications/diagnosis ; Peritonitis/*diagnosis/drug therapy/microbiology

No abstract available.
Adult ; Angiography ; Balloon Occlusion ; Capsule Endoscopy ; Gastrointestinal Hemorrhage/*complications/therapy ; Humans ; Jejunal Diseases/*diagnosis/etiology ; Jejunum/*blood supply ; Male ; Recurrence ; Tomography, X-Ray Computed ; Varicose Veins/*diagnosis/etiology

Cytomegalovirus (CMV) infections are usually diagnosed in immunocompromised patients. A 74-year-old male without any significant medical history visited our center because of abdominal pain and diarrhea which began about a month ago. Abdominal computed tomography revealed segmental enhanced bowel wall thickening on jejunum and single-balloon enteroscopy showed multiple geographic shaped ulcerations covered with exudates on proximal jejunum. Biopsy samples taken during endoscopic examination demonstrated necrotic fibrinopurulent tissue debris and benign ulcer. Nested-PCR analysis of CMV DNA from jejunal tissue was positive. The patient was finally diagnosed with CMV jejunitis and was treated by intravenous ganciclovir for 14 days after which, abdominal pain and diarrhea improved. Our case shows that CMV jejunitis can occur in an immunocompetent adult as multiple jejunal ulcers which can be diagnosed using a single-balloon enteroscope.
Aged ; Antiviral Agents/therapeutic use ; Cytomegalovirus/genetics/isolation & purification ; Cytomegalovirus Infections/complications/*diagnosis/drug therapy ; DNA, Viral/analysis ; Endoscopy, Gastrointestinal ; Enteritis/*diagnosis/etiology/virology ; Ganciclovir/therapeutic use ; Humans ; Injections, Intravenous ; Jejunal Diseases/*diagnosis/etiology/virology ; Male ; Polymerase Chain Reaction ; Tomography, X-Ray Computed

While esophagogastric varices are common manifestations of portal hypertension, variceal bleeding from the jejunum is a rare complication of liver cirrhosis. In addition, ectopic variceal bleeding occurs in the duodenum and at sites of previous bowel surgery in most cases, including of stomas. We report a case of obscure overt gastrointestinal bleeding from jejunal varices in a 55-year-old woman who had not previously undergone abdominal surgery, who had liver cirrhosis induced by the hepatitis C virus. Emergency endoscopy revealed the presence of esophageal varices without stigmata of recent bleeding, and no bleeding focus was found at colonoscopy. She continued to produce recurrent melena with hematochezia and received up to 21 units of packed red blood cells. CT angiography revealed the presence of jejunal varices, but no active bleeding was found. Capsule endoscopy revealed fresh blood in the jejunum. The patient submitted to embolization of the jejunal varices via the portal vein, after which she had a stable hemoglobin level and no recurrence of the melena. This is a case of variceal bleeding from the jejunum in a liver cirrhosis patient without a prior history of abdominal surgery.
Angiography ; Capsule Endoscopy ; Embolization, Therapeutic ; Esophageal and Gastric Varices/complications/diagnosis ; Female ; *Gastrointestinal Hemorrhage ; Humans ; Hypertension, Portal ; Jejunal Diseases/*diagnosis/therapy ; Liver Cirrhosis/*diagnosis ; Melena/complications ; Middle Aged ; Tomography, X-Ray Computed

The Dieulafoy lesion is a rare cause of severe gastrointestinal hemorrhage. Although it may occur anywhere in the gastrointestinal tract, the lesion is most commonly located in the stomach, and the small bowel is an extremely uncommon site. Since Dieulafoy lesion in the small bowel is difficult to access by endoscopy, it seems impossible to diagnose and treat by initial endoscopy unlike the lesions in stomach. We experienced a case of Dieulafoy lesion of jejunum with massive hemorrhage in 54-year-old male. Active jejunal bleeding was shown by computed tomography scan and mesenteric angiography. Partial resection of the jejunum was performed. Final pathologic finding revealed Dieulafoy lesion of the jejunum.
Angiography ; Gastrointestinal Hemorrhage/complications/*diagnosis ; Humans ; Jejunal Diseases/complications/*diagnosis/surgery ; Male ; Mesenteric Arteries/radiography ; Middle Aged ; Tomography, X-Ray Computed