Acute pancreatitis(AP)has varying severity,and moderately severe and severe AP has prolonged hospitalization and requires multiple interventions.These patients are at risk of malnutrition.There is no proven pharmacoth...Acute pancreatitis(AP)has varying severity,and moderately severe and severe AP has prolonged hospitalization and requires multiple interventions.These patients are at risk of malnutrition.There is no proven pharmacotherapy for AP,however,apart from fluid resuscitation,analgesics,and organ support,nutrition plays an important role in the management of AP.Oral or enteral nutrition(EN)is the preferred route of nutrition in AP,however,in a subset of patients,parenteral nutrition is required.EN has various physiological benefits and decreases the risk of infection,intervention,and mortality.There is no proven role of probiotics,glutamine supplementation,antioxidants,and pancreatic enzyme replacement therapy in patients with AP.展开更多
BACKGROUND Platelet transfusion in acute variceal bleeding(AVB)is recommended by few guidelines and is common in routine clinical practice,even though the effect of thrombocytopenia and platelet transfusion on the out...BACKGROUND Platelet transfusion in acute variceal bleeding(AVB)is recommended by few guidelines and is common in routine clinical practice,even though the effect of thrombocytopenia and platelet transfusion on the outcomes of AVB is unclear.AIM To determine how platelet counts,platelets transfusions,and fresh frozen plasma transfusions affect the outcomes of AVB in cirrhosis patients in terms of bleeding control,rebleeding,and mortality.METHODS Prospectively maintained database was used to analyze the outcomes of cirrhosis patients who presented with AVB.The outcomes were assessed as the risk of rebleeding at days 5 and 42,and risk of death at day 42,considering the platelet counts and platelet transfusion.Propensity score matching(PSM)was used to compare the outcomes in those who received platelet transfusion.Statistical comparisons were done using Kaplan-Meier curves with log-rank tests and Coxproportional hazard model for rebleeding and for 42-d mortality.RESULTS The study included 913 patients,with 83.5%men,median age 45 years,and Model for End-stage Liver Disease score 14.7.Platelet count<20×10^(9)/L,20-50×10^(9)/L,and>50×10^(9)/L were found in 23(2.5%),168(18.4%),and 722(79.1%)patients,respectively.Rebleeding rates were similar between the three platelet groups on days 5 and 42(13%,6.5%,and 4.7%,respectively,on days 5,P=0.150;and 21.7%,17.3%,and 14.4%,respectively,on days 42,P=0.433).At day 42,the mortality rates for the three platelet groups were also similar(13.0%,23.2%,and 17.2%,respectively,P=0.153).On PSM analysis patients receiving platelets transfusions(n=89)had significantly higher rebleeding rates on day 5(14.6%vs 4.5%;P=0.039)and day 42(32.6%vs 15.7%;P=0.014),compared to those who didn't.The mortality rates were also higher among patients receiving platelets(25.8%vs 23.6%;P=0.862),although the difference was not significant.On multivariate analysis,platelet transfusion and not platelet count,was independently associated with 42-d rebleeding.Hepatic encephalopathy was independently associated with 42-d mortality.CONCLUSION Thrombocytopenia had no effect on rebleeding rates or mortality in cirrhosis patients with AVB;however,platelet transfusion increased rebleeding on days 5 and 42,with a higher but nonsignificant effect on mortality.展开更多
Chronic pancreatitis is a chronic fibro-inflammatory disorder of the pancreas,resulting in recurrent abdominal pain,diabetes mellitus,and malnutrition.It may lead to various other complications such as pseudocyst form...Chronic pancreatitis is a chronic fibro-inflammatory disorder of the pancreas,resulting in recurrent abdominal pain,diabetes mellitus,and malnutrition.It may lead to various other complications such as pseudocyst formation,benign biliary stricture,gastric outlet obstruction;and vascular complications like venous thrombosis,variceal and pseudoaneurysmal bleed.Development of varices is usually due to chronic venous thrombosis with collateral formation and variceal bleeding can easily be tackled by endoscopic therapy.Pseudoaneurysmal bleed can be catastrophic and requires radiological interventions including digital subtraction angiography followed by endovascular obliteration,or sometimes with a percutaneous or an endoscopic ultrasound-guided approach in technically difficult situations.Procedure-related bleed is usually venous and mostly managed conservatively.Procedure-related arterial bleed,however,may require radiological interventions.展开更多
Coronavirus disease 2019(COVID-19)has affected patients with pre-existing chronic liver disease(CLD)in various ways.The maximum impact was seen on patients with underlying cirrhosis who have shown to have poor clinica...Coronavirus disease 2019(COVID-19)has affected patients with pre-existing chronic liver disease(CLD)in various ways.The maximum impact was seen on patients with underlying cirrhosis who have shown to have poor clinical outcomes in the form of increased risk of hepatic decompensation,acute-onchronic liver failure,and even mortality.It is of paramount importance to identify various factors which are associated with unfavorable outcomes for prognostication and making informed management strategy.Many factors have been evaluated in different studies in patients with underlying CLD.Some of these factors include the severity of underlying chronic liver disease,comorbid conditions,age,and severity of COVID-19.Overall,the outcomes are not favorable in patients with cirrhosis as evidenced by data from various studies.The main purpose of this review is to identify the predictors of adverse clinical outcomes including mortality in patients with CLD for risk stratification,prognostication,and appropriate clinical management.展开更多
The small intestine is an uncommon site of gastro-intestinal(GI)bleeding;however it is the commonest cause of obscure GI bleeding.It may require multiple blood transfusions,diagnostic procedures and repeated hospitali...The small intestine is an uncommon site of gastro-intestinal(GI)bleeding;however it is the commonest cause of obscure GI bleeding.It may require multiple blood transfusions,diagnostic procedures and repeated hospitalizations.Angiodysplasia is the commonest cause of obscure GI bleeding,particularly in the elderly.Inflammatory lesions and tumours are the usual causes of small intestinal bleeding in younger patients.Capsule endoscopy and deep enteroscopy have improved our ability to investigate small bowel bleeds.Deep enteroscopy has also an added advantage of therapeutic potential.Computed tomography is helpful in identifying extra-intestinal lesions.In cases of difficult diagnosis,surgery and intra-operative enteroscopy can help with diagnosis and management.The treatment is dependent upon the aetiology of the bleed.An overt bleed requires aggressive resuscitation and immediate localisation of the lesion for institution of appropriate therapy.Small bowel bleeding can be managed by conservative,radiological,pharmacological,endoscopic and surgical methods,depending upon indications,expertise and availability.Some patients,especially those with multiple vascular lesions,can re-bleed even after appropriate treatment and pose difficult challenge to the treating physician.展开更多
文摘Acute pancreatitis(AP)has varying severity,and moderately severe and severe AP has prolonged hospitalization and requires multiple interventions.These patients are at risk of malnutrition.There is no proven pharmacotherapy for AP,however,apart from fluid resuscitation,analgesics,and organ support,nutrition plays an important role in the management of AP.Oral or enteral nutrition(EN)is the preferred route of nutrition in AP,however,in a subset of patients,parenteral nutrition is required.EN has various physiological benefits and decreases the risk of infection,intervention,and mortality.There is no proven role of probiotics,glutamine supplementation,antioxidants,and pancreatic enzyme replacement therapy in patients with AP.
文摘BACKGROUND Platelet transfusion in acute variceal bleeding(AVB)is recommended by few guidelines and is common in routine clinical practice,even though the effect of thrombocytopenia and platelet transfusion on the outcomes of AVB is unclear.AIM To determine how platelet counts,platelets transfusions,and fresh frozen plasma transfusions affect the outcomes of AVB in cirrhosis patients in terms of bleeding control,rebleeding,and mortality.METHODS Prospectively maintained database was used to analyze the outcomes of cirrhosis patients who presented with AVB.The outcomes were assessed as the risk of rebleeding at days 5 and 42,and risk of death at day 42,considering the platelet counts and platelet transfusion.Propensity score matching(PSM)was used to compare the outcomes in those who received platelet transfusion.Statistical comparisons were done using Kaplan-Meier curves with log-rank tests and Coxproportional hazard model for rebleeding and for 42-d mortality.RESULTS The study included 913 patients,with 83.5%men,median age 45 years,and Model for End-stage Liver Disease score 14.7.Platelet count<20×10^(9)/L,20-50×10^(9)/L,and>50×10^(9)/L were found in 23(2.5%),168(18.4%),and 722(79.1%)patients,respectively.Rebleeding rates were similar between the three platelet groups on days 5 and 42(13%,6.5%,and 4.7%,respectively,on days 5,P=0.150;and 21.7%,17.3%,and 14.4%,respectively,on days 42,P=0.433).At day 42,the mortality rates for the three platelet groups were also similar(13.0%,23.2%,and 17.2%,respectively,P=0.153).On PSM analysis patients receiving platelets transfusions(n=89)had significantly higher rebleeding rates on day 5(14.6%vs 4.5%;P=0.039)and day 42(32.6%vs 15.7%;P=0.014),compared to those who didn't.The mortality rates were also higher among patients receiving platelets(25.8%vs 23.6%;P=0.862),although the difference was not significant.On multivariate analysis,platelet transfusion and not platelet count,was independently associated with 42-d rebleeding.Hepatic encephalopathy was independently associated with 42-d mortality.CONCLUSION Thrombocytopenia had no effect on rebleeding rates or mortality in cirrhosis patients with AVB;however,platelet transfusion increased rebleeding on days 5 and 42,with a higher but nonsignificant effect on mortality.
文摘Chronic pancreatitis is a chronic fibro-inflammatory disorder of the pancreas,resulting in recurrent abdominal pain,diabetes mellitus,and malnutrition.It may lead to various other complications such as pseudocyst formation,benign biliary stricture,gastric outlet obstruction;and vascular complications like venous thrombosis,variceal and pseudoaneurysmal bleed.Development of varices is usually due to chronic venous thrombosis with collateral formation and variceal bleeding can easily be tackled by endoscopic therapy.Pseudoaneurysmal bleed can be catastrophic and requires radiological interventions including digital subtraction angiography followed by endovascular obliteration,or sometimes with a percutaneous or an endoscopic ultrasound-guided approach in technically difficult situations.Procedure-related bleed is usually venous and mostly managed conservatively.Procedure-related arterial bleed,however,may require radiological interventions.
文摘Coronavirus disease 2019(COVID-19)has affected patients with pre-existing chronic liver disease(CLD)in various ways.The maximum impact was seen on patients with underlying cirrhosis who have shown to have poor clinical outcomes in the form of increased risk of hepatic decompensation,acute-onchronic liver failure,and even mortality.It is of paramount importance to identify various factors which are associated with unfavorable outcomes for prognostication and making informed management strategy.Many factors have been evaluated in different studies in patients with underlying CLD.Some of these factors include the severity of underlying chronic liver disease,comorbid conditions,age,and severity of COVID-19.Overall,the outcomes are not favorable in patients with cirrhosis as evidenced by data from various studies.The main purpose of this review is to identify the predictors of adverse clinical outcomes including mortality in patients with CLD for risk stratification,prognostication,and appropriate clinical management.
文摘The small intestine is an uncommon site of gastro-intestinal(GI)bleeding;however it is the commonest cause of obscure GI bleeding.It may require multiple blood transfusions,diagnostic procedures and repeated hospitalizations.Angiodysplasia is the commonest cause of obscure GI bleeding,particularly in the elderly.Inflammatory lesions and tumours are the usual causes of small intestinal bleeding in younger patients.Capsule endoscopy and deep enteroscopy have improved our ability to investigate small bowel bleeds.Deep enteroscopy has also an added advantage of therapeutic potential.Computed tomography is helpful in identifying extra-intestinal lesions.In cases of difficult diagnosis,surgery and intra-operative enteroscopy can help with diagnosis and management.The treatment is dependent upon the aetiology of the bleed.An overt bleed requires aggressive resuscitation and immediate localisation of the lesion for institution of appropriate therapy.Small bowel bleeding can be managed by conservative,radiological,pharmacological,endoscopic and surgical methods,depending upon indications,expertise and availability.Some patients,especially those with multiple vascular lesions,can re-bleed even after appropriate treatment and pose difficult challenge to the treating physician.
