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PubMed1979

Monitoring the critically ill surgical patient.

Critically ill surgical patients account for approximately half the patients in an active multidisciplinary critical care unit. Hypovolemia and sepsis are common in such patients and affect a number of organ systems. Monitoring these systems provides therapeutically relevant information that may decrease morbidity and improve patient survival. Circulatory hemodynamics may be assessed by direct measurement of the arterial blood pressure, central venous and pulmonary artery pressure monitoring and cardiac output determination; the data thus obtained are valuable in guiding fluid replacement in the hypovolemic individual. The respiratory status may be assessed by bedside spirometry and measurement of arterial blood gas tensions to gauge pulmonary function and the need for assisted ventilation. Renal dysfunction is common in such patients; careful analysis of both urine and blood may identify prerenal as opposed to renal and postrenal factors. Monitoring of the gastrointestinal tract, especially for hemorrhage, is important. Finally, careful attention to nutritional status and provision of adequate protein and energy intake by mouth or by vein is a vital component of the optimal care of these patients.

Blood Volume↗

PubMed2001

Circulating secretory phospholipase A2 in critical illness--the importance of the intestine.

OBJECTIVE: To review the role of secretory phospholipase A2 in the pathogenesis of multiple organ failure in the critically ill patient. DATA SOURCES: Relevant articles and published reviews on secretory phospholipase A2 in critical illness. SUMMARY OF REVIEW: Secretory phospholipase A2 (sPLA2) has an important role in inflammation and in antimicrobial defence. However, excessive activity of sPLA2 has been shown to result in tissue damage and has been implicated as a mediator of organ failure associated with critical illness. Gastrointestinal release of secretory phospholipase A2 from Paneth cells increases during intestinal ischaemia and may be an important factor in the pathogenesis of the multiple organ dysfunction syndrome. In experimental models, specific PLA2 inhibitors reduce organ failure associated with sPLA infusion and may play an important role in reducing organ failure in the management of the critically ill patient. CONCLUSIONS: Intestinal ischaemia may play an important role in the pathogenesis of the multiple organ dysfunction syndrome in the critically ill patient. In patients with sepsis, specific PLA2 inhibitors have the potential to reduce organ failure and improve morbidity and mortality.

Journal Article↗

PubMed1982

[Phase II study on cis-diamminedichloroplatinum (II) by a collaborative study].

Phase II study of cis-diaminedichloroplatinum(II) (CIS-DDP) administered intravenously was performed in 77 patients with urologic malignancies for the evaluation of clinical responses and adverse effects. The eligibility of the patients and evaluation of response were carried out according to the general criteria proposed by Drs. Koyama and Saito. Out of 85 patients, entered in this phase II study, 77 patients were considered evaluable. Complete responses were seen in 4 patients, 3 testicular tumor and 1 bladder cancer. Partial response were obtained in 24 patients; 10 bladder cancer, 8 testicular tumor, 5 prostatic cancer, and 1 renal cell carcinoma. Overall response rates were 73.3% in testicular tumor, 50.0% in bladder tumor, 20.8% in prostatic cancer, and 7.7% in renal cell carcinoma. Incidences of toxicities were noted in the gastrointestinal tract. Nausea, vomiting, anorexia, abdominal pain, and diarrhea were observed in 78.5% of the patients treated with CIS-DDP. Myelosuppression, lassitude, renal and hearing dysfunction were other prominent adverse effects.

Cisplatin↗

PubMed2006

Approach to a case of autonomic peripheral neuropathy.

Autonomic neuropathy is the term used to describe autonomic disturbances resulting from diseases of the peripheral autonomic nervous system. This is a group of disorders in which the small, lightly myelinated and unmyelinated autonomic nerve fibers are selectively targeted. Most often, autonomic neuropathies occur in conjunction with a somatic neuropathy (i.e. with motor weakness and/or sensory loss), but they can occur in isolation. Causes of autonomic neuropathies are immune-mediated, paraneoplastic, infectious, toxic and drug-induced, hereditary, nutritional and idiopathic. Amongst all, diabetes mellitus is the most common cause. Autonomic features, which involve the cardiovascular, gastrointestinal, urogenital, sudomotor, and pupillomotor systems, occur in varying combination in these disorders. Orthostatic hypotension is often the first recognized and most disabling symptom. Noninvasive, well-validated clinical tests of autonomic functions along with a host of laboratory tests are of immense value to diagnose the presence and to demonstrate the distribution of autonomic failure. Treatment aims to treat specific cause of the autonomic neuropathy (if possible) and to control symptoms of autonomic dysfunction. Present review attempts to outline clinical approach to a case of autonomic peripheral neuropathy.

Arrhythmias, Cardiac↗

PubMed1990

Functional disorders of the stomach.

Gastroenterologists frequently encounter patients who report vague epigastric discomforts or sensations of fullness, bloating, and distention in the upper abdomen. The discomfort is neither burning in character nor severe in intensity; there is no nocturnal pain. The epigastric location of discomfort and lack of radiation may help to exclude biliary tract and pancreatic diseases. Nausea may be present, but there is little or no vomiting. After these patients ingest liquids or solid foods, the symptoms of easy filling or early satiety and increasing discomfort and nausea are almost always present. The patient may only report "indigestion," but a specific chief complaint, such as pain, discomfort, nausea, or bloating may be elicited with further inquiries. Solid foods usually provoke more symptoms than do liquids. Symptoms of early satiety, nausea, bloating, and abdominal discomfort may culminate in the vomiting of undigested food. These vague upper gastrointestinal (GI) symptoms have been termed "dyspepsia." When peptic diseases of the stomach are excluded, the symptom complex has been called "nonulcer" dyspepsia, a vague syndrome with symptoms attributed to stomach dysfunction. Nonulcer dyspepsia has been reviewed recently. Such symptoms, commonly attributed to a "functional" disorder, are very common in clinical practice, with an incidence of 30% of patients. In this review, we will discuss an approach to the evaluation and treatment of patients with symptoms of nausea, early satiety, bloating, and vague epigastric discomfort--dyspeptic symptoms associated with functional stomach disorders. We will review the anatomy and motility of the stomach and suggest potential neuromuscular malfunctions of the stomach that may result in epigastric symptoms. The potential role of stress and other brain-gut interactions, which may underlie these symptoms, will also be reviewed.

Dyspepsia↗

PubMedDate not supplied

[Gastrointestinal motility in the elderly].

The existence of specific, age-related changes in gastrointestinal motility with clinical significance is controversial. Beside the more infrequent primary motility disorders, secondary motility disturbances associated with collagen vascular diseases, endocrinopathies, and neuromuscular diseases are prominent in the older and often multimorbid patients. Especially in geriatric patients, motility associated symptoms are undesired side-effects of drug therapy. The pathophysiology, clinical syndromes, and therapeutic principles of motility disorders in the elderly are discussed. The major symptoms of esophageal dysfunction are dysphagia, chest pain, heartburn, and regurgitation. Oropharyngeal dysphagia, mostly caused by cerebrovascular accidents and other neurologic disorders, leads to disturbances in food intake, and is often complicated by broncho-pulmonary infections arising from recurrent aspiration of food or saliva. Gastrointestinal reflux disease and spastic motility disorders of the esophagus are regarded as possible causes of angina-like chest pain after exclusion of cardiac diseases. Motility disturbances of the stomach and small bowel are often related to systemic disease (i.e., diabetes mellitus, chronic intestinal pseudo-obstruction) of drug side-effects. Mental and physical decline, reduced fluid intake, and constipating drugs are the most relevant factors for idiopathic constipation in the elderly. Fecal incontinence means a great psychological strain for older patients and leads to social isolation.

Age Factors↗

PubMed1992

Necrotizing enterocolitis in infancy.

The most common gastrointestinal emergency in the newborn is necrotizing enterocolitis. Premature babies are the most likely victims, but it also occurs in full-term infants. Although great strides have been made in elucidating some of the factors responsible for necrotizing enterocolitis, such as intestinal ischemia, bacterial overgrowth, and feeding dysfunction, the exact etiology is as yet unclear. The timing and indications for surgery differ from institution to institution, but the long-term outcome is similar in most large series. The overall mortality rate remains about 20% to 40%, and of the survivors, about one half seem to have no sequelae, the remaining infants having neurologic and gastrointestinal deficits of various degrees of significance.

Enterocolitis, Pseudomembranous↗

PubMed1998

Motility disorders in childhood.

Motility disorders are very common in childhood, causing a number of gastrointestinal symptoms: recurrent vomiting, abdominal pain and distension, constipation and obstipation, and loose stools. The disorders result from disturbances of gut motor control mechanisms caused by either intrinsic disease of nerve and muscle, central nervous system dysfunction or perturbation of the humoral environment in which they operate. Intrinsic gut motor disease and central nervous system disorder are most usually congenital in origin, and alterations of the humoral environment acquired. Irritable bowel syndrome occurs in children as well as adults and is multifactorial in origin, with an interplay of psychogenic and organic disorders.

Adult↗

PubMed1986

Gastrointestinal complications in critically ill patients: the intensivists' overview.

The critical care environment may be characterized by invasive monitoring, vasoactive drugs, and major interventions which may have adverse effects on gastrointestinal function. Furthermore, conditions such as heart failure or sepsis may compromise oxygen delivery to gastrointestinal organs. Life threatening illness from a variety of causes may produce endoscopically evident gastritis or ulceration in up to 100% of patients, and clinically evident bleeding in 20%. Clinical studies suggest that antacids or H2 receptor blockers may reduce the frequency of this complication. Other conditions are associated with a spectrum of hepatic dysfunction ranging from the cholestatic jaundice of reactive hepatopathy during sepsis to centrilobular necrosis and hepatitis of shock liver. Additionally, many drugs used in the critical care setting may adversely affect mesenteric oxygen delivery and result in ischemia or infarction of the bowel. An increased awareness and understanding of these and other gastrointestinal complications in critically ill patients will, it is hoped, lead to earlier detection and better therapy than is now available.

Animals↗

PubMed1999

Current management of endoscopic feeding tube dysfunction.

Surgically placed gastrostomy and jejunostomy feeding tubes allow administration of enteral nutrition for patients who are unable to swallow safely. Several endoscopic techniques have been used for tube placement. Endoscopically placed feeding tubes provide access to the gastrointestinal tract, but only when patent. Use of the approaches presented permits optimal feeding tube care and prolongs tube patency. Table 1 summarizes the recommendations for preventing and restoring patency to feeding tubes.

Adult↗

PubMed1997

Autonomic neuropathy: clinical and instrumental findings.

The development of sensitive techniques evaluating functions under autonomic control has allowed the early detection of widespread abnormalities in diabetes mellitus. However, despite a high frequency of functional abnormalities, an overt clinical syndrome develops slowly and is quite rare. Characteristic clinical features, more recent methods for evaluating autonomic function, diagnostic procedures, and main instrumental findings in a diabetic population are reported. Emphasis is given to more promising techniques evaluating autonomic control of the cardiovascular system, such as myocardial scintigraphy and assessment of 24-h blood pressure and heart rate variability. The clinical meaning of the number of functional abnormalities observed in diabetic patients is considered. While the role of autonomic neuropathy in the pathogenesis of gastrointestinal motor disorders, hypoglycaemia unawareness or diabetic impotence needs to be revised, the importance of autonomic-related sweating and blood flow abnormalities in the pathogenesis of diabetic foot lesions is now better documented. Moreover, growing evidence of the importance of autonomic control of cardiovascular system, together with cardiovascular dysfunction linked to diabetic autonomic neuropathy, supports the hypothesis of a possible role of autonomic neuropathy in the increased cardiovascular morbidity and mortality observed in diabetic patients.

Cardiovascular Diseases↗

PubMed2007

Emerging aspects of gut sulfur amino acid metabolism.

PURPOSE OF REVIEW: This review discusses the recent evidence indicating that sulfur amino acid metabolism in gastrointestinal tissues may be linked to human health and gut disease. RECENT FINDINGS: Studies indicate that the gastrointestinal tract metabolizes 20% of dietary methionine and that its main metabolic fate is transmethylation to homocysteine and transsulfuration to cysteine. The gastrointestinal tract accounts for approximately 25% of whole-body transmethylation and transsulfuration and is a site of net homocysteine release. The production of homocysteine within the intestinal mucosa may contribute to the inflammatory response and endothelial cell dysfunction in patients with inflammatory bowel disease. Studies also show that the availability of S-adenosylmethionine as a precursor for methylation reactions and polyamines plays a key role in epigenetic DNA methylation, gene expression and colon carcinogenesis. Cysteine derived from the diet and methionine transsulfuration is a functional constituent of antioxidant systems and impacts several elements of redox status that regulate epithelial intracellular signaling, proliferation and survival. SUMMARY: Further studies are warranted to establish how local production of homocysteine, S-adenosylmethionine and antioxidants contributes to the development of gastrointestinal diseases and whether dietary intervention with folate and cysteine is an efficacious approach to prevention and treatment.

Amino Acids, Sulfur↗

PubMed1991

[A comparative evaluation of the results of studies of multi-moment chromatic intubation and cholecystography].

These methods were employed in examinations of 55 patients with various gastrointestinal diseases. The findings of both methods coincided in assessment of gallbladder kinetic function in 36 (66%) patients. In 19 (34%) patients the results did not coincide, in 9 of them multi-moment chromatic duodenal intubation with xylite stimulation has yielded overstated results, and in the remaining 10 patients gallbladder hyperfunction was detected by x-ray examination after egg yolk stimulation. Individual reactions of the body may be responsible for this discrepancy; other explanations are unstable pathologic dysfunction of the gallbladder and the psychoemotional status of patients during the examination.

Adult↗

PubMed2005

Adrenomedullin treatment abolishes ileal mucosal hypoperfusion induced by Staphylococcus aureus alpha-toxin--an intravital microscopic study on an isolated rat ileum.

OBJECTIVE: Disturbances of intestinal microcirculation associated with sepsis and septic shock result in diminished mucosal oxygenation. Tissue hypoxia as well as mediator formation may lead to intestinal mucosa dysfunction. As a consequence, bacteria and their products as well as gut-derived inflammatory mediators may further perpetuate septic and inflammatory events. Adrenomedullin is produced in the mucosa of the gastrointestinal tract and has been shown to improve survival in experimental sepsis. Using pore-forming Staphylococcus aureus alpha-toxin as a potent initiator of inflammatory reactions, we tested the hypothesis that exogenously added adrenomedullin improves ileal mucosal perfusion. DESIGN: Prospective, experimental study. SETTING: University laboratory. SUBJECTS: Isolated perfused ileum from male Sprague-Dawley rats INTERVENTIONS: Adrenomedullin treatment of S. aureus alpha-toxin infused ileum. MEASUREMENT AND MAIN RESULTS: An infusion of alpha-toxin (0.05 microg/mL) induced a significant decrease of red blood cell velocity in villus terminal arterioles from 1.7 to 0.7 mm/sec assessed by intravital microscopy. This was accompanied by a significant reduction of mucosal hemoglobin oxygenation from 71.8% to 17.5% and impaired oxygen uptake. At constant bulk flow and oxygen delivery, these data indicate a redistribution of blood perfusion away from mucosa. Subsequent intervention with 0.1 microM adrenomedullin redistributed blood flow back toward the mucosa, causing an improvement of mucosal hemoglobin oxygenation and of organ oxygen uptake. CONCLUSION: These data suggest that exogenously added adrenomedullin protects ileum mucosa by diminishing alpha-toxin-induced microcirculatory disturbances. Further investigations will have to clarify the therapeutic potential of adrenomedullin in sepsis-related gut dysfunction.

Adrenomedullin↗

PubMed1999

Mycophenolate mofetil, microemulsion cyclosporine, and prednisone as primary immunosuppression for pediatric liver transplant recipients.

Triple immunosuppressive therapy using mycophenolate mofetil (MMF), microemulsion cyclosporine (me-CsA), and prednisone offers the potential for potent immunosuppression without intravenous drug therapy or anti-T-cell antibody induction therapy. This report describes the application of an immunosuppressive protocol (CNp) using MMF, me-CsA, and prednisone as primary immunosuppression for pediatric liver transplant recipients at the University of California at San Francisco. From August 1995 through December 1996, 26 children (17 boys, 9 girls) aged 1 month to 16 years (mean +/- standard deviation, 58 +/- 62 months; median, 31 months) underwent liver transplantation at our institution, receiving CNp as primary immunosuppression. Posttransplantation renal function, incidence of leukopenia, and drug tolerance within the group receiving CNp as primary immunosuppression were compared with those of 19 children who received primary immunosuppression consisting of azathioprine, oil-based gel-encapsulated cyclosporine, and prednisone with anti-T-cell antibody induction therapy at the same institution from October 1993 through July 1995. No significant difference was observed between immunosuppressive protocols in serum creatinine level or incidence of leukopenia requiring medical therapy during the first year posttransplantation. Whereas gastrointestinal symptoms were observed in approximately 30% of CNp recipients during initial immunotherapy, tolerance of CNp primary immunotherapy was routinely achieved by the dose reduction of MMF. At 1 year posttransplantation, 20 children (77%) remained on CNp primary immunotherapy, 5 children (19%) were receiving tacrolimus-based immunotherapy secondary to rejection, and 1 patient (4%) converted to tacrolimus-based immunotherapy secondary to persistent gastrointestinal intolerance. In conclusion, CNp provides an alternative immunosuppressive protocol that eliminates the necessity of intravenous and induction immunosuppressive therapy with no increased incidence of posttransplantation renal dysfunction or leukopenia and is well tolerated in children.

Adolescent↗

PubMed1998

Outcome of patients with cirrhosis requiring intensive care unit support: prospective assessment of predictors of mortality.

Determinants of outcome and the utility of the Child-Pugh score and the acute physiology and chronic health evaluation (APACHE) II score as predictors of outcome were prospectively assessed in 54 consecutive patients with cirrhosis requiring intensive care unit (ICU) management. Overall mortality in the ICU was 43% (23/54). Child-Pugh scores did not differ between survivors or nonsurvivors (12.8 versus 12.3, P = 0.26), however APACHE II scores (P = 0.007), acute physiology scores (P = 0.006), and Karnofsky scores (P = 0.001) were significant predictors of outcome. By univariate analysis, requirement of mechanical ventilation analysis (P = 0.001), duration of mechanical ventilation (P = 0.001), pulmonary infiltrates (P = 0.0001), infections (P = 0.047), gastrointestinal bleeding (P = 0.005), and serum creatinine >1.5mg/dl (P = 0.0005) were significantly associated with mortality. By logistic regression analysis only pulmonary infiltrates (P = 0.0001) and renal dysfunction (P = 0.041) were independent predictors of mortality. When controlled for the severity of illness (APACHE II scores), the mortality in patients with cirrhosis caused by alcohol was significantly lower than that in patients with liver disease not caused by alcohol (P = 0.01). Our study not only identified predictors of poor outcome in patients with cirrhosis requiring ICU care but also provided data that may have implications for optimal timing for transplantation.

APACHE↗

PubMed2005

Bleeding induced by SSRIs.

Selective Serotonin Reuptake Inhibitors (SSRIs) have been accused of causing bleeding problems as a side effect. Theories about the mechanism are still being discussed. We report a case, presenting bleeding problems, during sertraline treatment. The SSRIs are widely used to treat depression and many other psychiatric disorders. Their lower severity of side effects and being markedly safer in overdose are some of the reasons of their preference as primary choice in most of the cases. Besides their common side effects like, agitation, headache, insomnia, weight gain or loss, and sexual dysfunction, SSRIs also have been suspected of increasing the risk of bleeding. A population-based cohort study supported the hypothesis of an increased risk of upper gastrointestinal bleeding during the use of SSRIs, and they also indicated that this effect is potentiated with concurrent use of NSAIDs or low-dose aspirin. We would like to report our recent experience with one patient who was on sertraline, 50 mg/day.

Adult↗

PubMed1993

Medical complications of head injury.

There are many common and significant medical complications of head injury. These include (1) cardiovascular problems such as hyperdynamic state, myocardial injury, and dysrhythmias; (2) respiratory changes such as neurogenic pulmonary edema, hypoxia, abnormal ventilatory patterns, pulmonary infections, and pulmonary emboli secondary to deep vein thrombosis; (3) consumption coagulopathy; (4) water and electrolyte derangements--hypo- and hypernatremia; (5) hypothalamic/pituitary dysfunction--syndrome of inappropriate secretion of antidiuretic hormone and diabetes insipidus; (6) increased general metabolism with loss of immunocompetence, respiratory compromise, and complications of decreased activity; (7) gastrointestinal difficulties, particularly stress gastritis; and (8) infectious problems including those related to contamination from open wounds and foreign bodies such as monitors.

Cardiovascular Diseases↗