Gastroenterology Critical Care

Overview
Pratt DS, Epstein SK. Recent advances in critical care gastroenterology.  Am J Respir Crit Care Med. 2000; 161:1417-20. Excellent update focusing on new approaches to the management of acute variceal hemorrhage, acute colonic pseudo-obstruction, and severe necrotizing pancreatitis. http://www.ncbi.nlm.nih.gov/pubmed/10806132?ordinalpos=1&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVDocSum

Gastrointestinal Bleeding/Anemia
Cook D, Guyatt G, Marshall J, et al. A comparison of sucralfate and ranitidine for the prevention of upper gastrointestinal bleeding in patients requiring mechanical ventilation. N Engl J Med 1998;338:791-7. Multicenter, placebo-controlled RCT found patients receiving ranitidine had significantly lower rates of clinically important GI bleeding than patients receiving sucralfate. There was a trend toward less VAP in the sucralfate group. http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=9504939

Cook DJ, Fuller HD, Guyatt GH, et al. Risk factors for gastrointestinal bleeding in critically ill patients. N Engl J Med 1994;330:377-81. Study found coagulopathy and respiratory failure were the two primary risk factors for clinically important bleeding (3.7% risk if any risk factor present). Use of enteral feeding was not protective. Some high-risk patients (burns, recent diagnosis of PUD etc.) received prophylaxis. http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=8284001
See also Rivers et al. under Sepsis.

Hepatology
Marrero J, Martinez FJ, Hyzy R. Advances in critical care hepatology. Am J Respir Crit Care Med 2003; 168:1421-6. Excellent concise review of the evaluation and management of fulminant hepatic failure, ascites, hepatorenal syndrome, hepatic encephalopathy, and hepatic dysfunction in sepsis. http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=14668256

Garcia-Tsao, Sanyal A, Grace N, et al. Practice Guidelines Committee of the American Association for the Study of Liver Diseases and the Practice Parameters Committee of the American College of Gastroenterology.  Prevention and management of gastroesophageal varices and variceal hemorrhage in cirrhosis.  Am J Gastroenterol 2007;102:2086–2102.  Thorough update of the current practice guidelines for the treatment of varicies, including use of antibiotics, octreotide, and IV PPI in the intensive care setting.  http://www.ncbi.nlm.nih.gov/pubmed/17879356?ordinalpos=1&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVDocSum

Sort P, Navasa M, Arroyo V, et al. Effect of intravenous albumin on renal impairment and mortality in patients with cirrhosis and spontaneous bacterial peritonitis. N Engl J Med 1999;341:403-9. RCT found addition of albumin to cefotaxime vs. antibiotic alone in above population preserved renal function and reduced mortality. Study does not provide information on volume resuscitation in the antibiotic-alone group, however, making it less clear whether albumin has additional benefit beyond what could be achieved with aggressive IVF. http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=10432325

Pancreatitis