Abstract
Secondary sclerosing cholangitis in critically ill patients (SC-CIP) is a rare cholestatic liver disease triggered by long-term intensive care treatment. The aim of this study was to evaluate the frequency and characteristics of gastrointestinal bleeding in SC-CIP. Patients with diagnosed SC-CIP were retrospectively identified and compared to a control group of patients with cardiac surgery and intensive care treatment but without the development of SC-CIP. Fifty-three patients with SC-CIP and 19 controls were included in the study. The frequency of gastrointestinal bleeding was 30% in SC-CIP (16 patients) and 5% in the control group (1 patient) (p = 0.03). Bleeding occured in the mean 13 months after admission to an intensive care unit in SC-CIP, three patients (19%) suffered bleeding during intensive care treatment. Three SC-CIP patients (19%) had cirrhosis at the time of bleeding, five (31%) had splenomegaly, and four (25%) received oral anticoagulation. In SC-CIP, 13 bleedings were identified in the upper gastrointestinal tract, two in the lower, and one remained unknown. The most common reasons for bleeding were gastroduodenal ulcers. In total, 80% of patients needed blood units, and one death due to bleeding occurred in SC-CIP. In conclusion, gastrointestinal bleeding is a frequent complication in patients with SC-CIP. Whether the liver disease itself or cofactors cause the susceptibility for bleeding remains unclear.
Highlights
The diagnosis of sclerosing cholangitis in critically ill patients (SC-CIP) was established by clinical suspicion and by typical cholangiographic findings, including irregular intrahepatic bile ducts with strictures, prestenotic dilations, bile duct rarefication, and biliary casts on magnetic resonance cholangiopancreatography (MRCP), on endoscopic retrograde cholangiopancreatography (ERCP), or with liver biopsy
Fifty-three patients with SC-CIP and 19 controls were included in the analysis
Long-term intensive care unit (ICU) treatment as the main driver for the high rate of bleeding in our cohort is conceivable, but only three patients suffered bleeding during ICU treatment and the total rate of 30% in SC-CIP is twice as high as previously reported in critically ill patients in a study from the pre-pump inhibitors (PPI) era [12]
Summary
Long-term intensive care treatment with invasive ventilation and hemodynamic support may lead to secondary sclerosing cholangitis in critically ill patients (SC-CIP), a relatively rare chronic cholestatic liver disease. It occurs in patients without prior known liver pathology and predominantly in patients after polytrauma or cardiovascular surgery and with pre-existing internal pathologies [1,2,3]. Other than hepatocytes, which receive perfusion from the portal vein and the hepatic arteries, blood flow for the biliary epithelium is supplied solely by branches of the hepatic arteries This makes the biliary tree more vulnerable to ischemic injury [6,7].
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