Aggressive Intravenous Fluid Research Articles

Comparative effectiveness of aggressive intravenous fluid resuscitation with lactated Ringer's solution and rectal indomethacin therapy in the prevention of pancreatitis after endoscopic retrograde cholangiopancreatography: a double blind randomised controlled clinical trial.

IntroductionThere is growing evidence indicating the aggressive intravenous fluid resuscitation (IVFR) can decrease the rate of pancreatitis; however, to the best of our knowledge it has not been well studied in a post-endoscopic retrograde cholangiopancreatography (post-ERCP) setting.AimTo compare the effects of aggressive IVFR and rectal indomethacin (RI) in preventing pancreatitis after ERCP.Material and methodsThis is a double blind randomised controlled clinical trial on 186 patients undergoing ERCP in Ahvaz, Iran. The inclusion criteria were ERCP for standard clinical indications such as choledocholithiasis, bile duct leak, and biliary obstruction. The IVFR group (n = 62) received a bolus of 20 ml/kg of body weight lactated Ringer’s solution (LRS) immediately after ERCP, followed by 3 ml/kg/h maintenance for 8 h. The RI group (n = 62) received 50 mg rectal indomethacin immediately before procedure and 12 h after ERCP. The control group (n = 62) did not receive any treatment.ResultsPost-ERCP pancreatitis in IVFR, rectal indomethacin, and control groups occurred in 8 (12.9%), 16 (25.8%), and 20 (32.3%) patients (p = 0.036). Pancreatic pain was reported in 13 (21%), 21 (33.9%), and 27 (43.5%) patients in the IVFR, RI, and control group (p = 0.046). The serum amylase level increased over 24 h after intervention in all three groups. The mean serum amylase level 8 h after intervention in the IVFR patients was lower than the RI and control groups.ConclusionsIntravenous fluid resuscitation with LRS was more effective in preventing post-ERCP pancreatitis in comparison to the rectal indomethacin and control group.

Post ERCP Pancreatitis: A Endoscopist’s Night Mare! An Insight with Literature Review

Post ERCP pancreatitis is a serious complication that, at the minimum, prolongs hospital stay and, in rare cases, causes serious morbidity and death. The potential for risk reduction has therefore been the matter of extensive research. Rectal Non-Steroidal Anti-Inflammatory Drugs (NSAIDs) were found to be appropriate for clinical use. Pancreatic Duct (PD) stent placement is currently considered the standard of care in high-risk cases where PD entered by guide wire multiple time and contrast injection in to PD. Failure attempt at PD stenting is disastrous. In cases of pancreatic branch duct injuries caused by the PGW combination of PD stenting and rectal NSAIDs should b used because PD stenting alone may not be effective. Sublingual nitroglycerin and bolus-administered somatostatin were found to be promising agents for whom confirmatory research is needed. Additional research required to justify use to prevention of PEP for topical epinephrine, aggressive intravenous fluids and ulinastatin.

Preventing Post-ERCP Pancreatitis: IV Fluids to the Rescue?

Pilot study data suggest a possible role for aggressive intravenous (IV) fluid resuscitation in preventing post–endoscopic retrograde

Annals for Educators - 4 October 2016

<i>Annals</i> for Educators - 4 October 2016

Acute Pancreatitis Following Trans-arterial Chemo-embolization for Hepatocellular Carcinoma

Introduction: Trans-arterial chemo-embolization (TACE) is a time-tested and proven modality of treatment for non-resectable hepatocellular carcinoma (HCC). Acute pancreatitis (AP) is a rare complication following TACE with an incidence of 1.7-2% in patients undergoing selective and super-selective embolization. It usually presents within 24 hours of the procedure. We present to you one such case. Case. Patient is a 54-year old male with a history of ethanol abuse, hepatitis C, currently on Harvoni and hepatocellular carcinoma. Patient underwent first TACE on 11/24/2015 with no post-procedure complications. Patient had good response with repeat computerize tomography (CT) showing slight decrease in liver lesion. Patient underwent second TACE on 05/18/2016. Given the positive response to previous treatment using the right hepatic artery, decision was made to continue with right hepatic artery TACE. Patient was noticed to be unable to remain still despite aggressive sedation throughout the procedure. The catheter was repositioned distally multiple times due to patient motion. Post-treatment injection demonstrated stasis in the right hepatic artery. Overnight, he developed worsening abdominal pain with nausea and vomiting. On physical examination, patient was tachycardic, afebrile, with non-distended, diffusely tender abdomen, with normal bowel sounds. Laboratory investigations showed elevated lipase (2939 U/L), slight elevation of alkaline phosphatase (188 U/L) with normal alanine transaminase and asparate transaminase. In view of patient meeting 2 out of 3 criteria for AP, patient was started on aggressive intravenous fluids and other supportive management. Patient responded well to the treatment with complete resolution of symptoms after 24 hours of initiation of treatment. Discussion. Various theories have been proposed regarding the pathogenesis of post-TACE AP. These include embolization, intra and extra-pancreatic arterial ischemia, drug reflux and arterial malformations. Drug reflux seems to be the most probable cause of AP in our patient. We recommend performing serum lipase in any patient complaining of worsening abdominal pain, nausea, vomiting within 24 hours post procedure to assess for AP and differentiate from post-TACE syndrome. Management of post-TACE AP is the same as other types of AP.

A Case of Necrotising Pancreatitis Following Ampullary Biopsy

Acute pancreatitis is a rare, but potential complication of ampullary biopsy. Most patients will recover without major complications. However, 20% of patients will develop a moderate or severe acute pancreatitis with local or systemic complications or organ failure. The patients who develop organ failure or infected necrosis face an increased mortality rate of 30%. To the best of authors knowledge this case represents one of four published articles that reports acute pancreatitis as a complication of ampullary manipulation.Figure 1Figure 2A 72 year old male with a past medical history of recurrent ampullary adenomas presented for a routine EGD and colonoscopy. Patient was discharged home and the ampullary biopsies showed no abnormalities. Later that day, the patient presented to the emergency department with acute epigastric pain that radiated to his back with nausea and vomiting. He was hemodynamically stable and afebrile on arrival. He was tender to palpation but exhibited no signs of peritonitis. Initial lab tests showed lipase >2250. Liver function tests, leukocyte count and lipid panel were all within normal limits. He does not drink, take any medications, or have any other risk factor that could potentially be a cause of his pancreatitis. Thus, he was diagnosed with acute pancreatitis secondary to EGD with ampullary biopsy. The patient's epigastric pain did not improve the first 4 days after conservative management with aggressive intravenous fluids and pain control. He started spiking fevers with no known source. A CT abdomen was done and it showed that the patient had developed necrotizing pancreatitis and was started on cefepime and metronidazole. His course was further complicated by non-cardiogenic pulmonary edema which improved after fluids were stopped and a trial of furosemide. He clinically improved and was discharged on day 8 to resume Ciprofloxacin and Metronidazole for a total 21 days.Figure 1Figure 2This case reflects one of four case reports of patients developing acute pancreatitis following ampullary biopsy, three of which also developed pancreatic necrosis. Physicians should be aware of acute pancreatitis as a rare but potential complication of endoscopy with ampullary biopsy. If patients do develop acute pancreatitis, it is essential to manage them with adequate fluid resuscitation and to remain vigilant for signs of necrotizing pancreatitis which has a very high mortality rate.

Heart Failure with Reduced Ejection Fraction Is Associated with Worse Outcomes in Patients Hospitalized with Acute Pancreatitis: Results of a Nationwide Analysis

Introduction: Heart failure with reduced ejection fraction (HFrEF) is associated with worse outcomes in various medical conditions. Smaller studies have suggested worse clinical outcomes in patients with acute pancreatitis (AP) and HFrEF resulting from the challenge of the required aggressive intravenous fluid administration in states of volume overload. Therefore, the aim of this study was to explore the impact of HFrEF on AP outcomes. Methods: This was a retrospective cohort study using the 2013 National Inpatient Sample, the largest publically available inpatient database in the US. All patients with ICD-9 CM codes for a diagnosis of AP were included. There were no exclusion criteria. The primary outcome was in-hospital mortality. Secondary outcomes were morbidity measured by intensive care unit (ICU) admission, shock and multi-organ failure; resource utilization measured by abdominal CT scan, abdominal ultrasound (US), total parenteral nutrition (TPN) use; length of hospital stay (LOS) and total hospitalization charges. Patients were classified as having HFrEF and not having HFrEF using ICD-9 CM codes. Using multivariate regression analysis, Odds ratios and means were adjusted for age, sex, race, median income in the patient's zip code, Charlson Comorbidity Index, hospital region, urban location, size and teaching status. Results: A total of 274,774 patients with acute pancreatitis were included in the study, 3,010 (1.1%) of whom had a diagnosis of HFrEF. Mean age was 51 years and 49% were female. The overall in-hospital mortality rate was 0.8% (0.7% on patients without HFrEF, 4.2% in patients with HFrEF). Table 1 shows all adjusted odds ratios, adjusted means and p values. On multivariate analysis, patients with HFrEF had increased mortality rates (OR:1.97, 95%CI:1.23-3.15,p < 0.01) when compared to patients without HFrEF. Looking at morbidity, patients with HFrEF had higher odds of shock, ICU admission, and multiorgan failure at a statistically significant level. For resource utilization, both groups had similar odds of abdominal imaging and TPN use. However, patients with HFrEF displayed modestly higher lengths of hospital stay compared to patients without HFrEF.Table 1Conclusion: HFrEF is associated with increased risk of mortality and morbidity in patients hospitalized with AP. Additionally, despite not differing in additional hospitalization charges, HFrEF affects resource utilization in patients with AP, as measured by increased additional LOS.

Treatment of exertional rhabdomyolysis in athletes: a systematic review.

Exertional rhabdomyolysis (ER) is the breakdown of skeletal muscle tissue following intense physical activity that results in impairment of the cell membrane, which allows intracellular contents to be released into the bloodstream. Signs and symptoms include myalgia, myoglobinuria and increased creatine kinase (CK) levels. Athletes are vulnerable to this condition due to their increased level of physical activity. The severity and effects of this condition vary between individuals; however, all athletes are at risk of significant muscle damage, renal failure and perhaps death if not recognized and treated quickly. Effective methods for treatment and return to activity following this condition should be established. The objective of this review was to identify effective treatment methods associated with ER in athletes. Adult and adolescent patients (15 years of age and older) in the athletic population who have been diagnosed with ER. Fluid resuscitation/replacement or other treatment methods that aim to improve CK levels and decrease myoglobinuria and treat ER. Due to the absence of randomized control trials, the quantitative component of the review considered descriptive studies, case series and individual case reports for inclusion. CK and myoglobinuria levels. length of hospital stay; length of time from diagnosis to premorbid levels of physical activity. A comprehensive search of the following databases with no date limitation was conducted: CINAHL, PubMed, ProQuest, Embase, SPORTDiscus and Physical Education Index. Results were limited to those available in English. Two independent reviewers evaluated the retrieved articles for methodological quality using the standardized critical appraisal instrument from the Joanna Briggs Institute Meta-Analysis of Statistics and Review Instruments. Data were extracted from the articles by two independent reviewers using the standardized Joanna Briggs Institute extraction tool. Narrative and tabular synthesis. Fourteen studies with a combined total of 53 participants were included. Aggressive intravenous (IV) fluid resuscitation was found to be the most commonly utilized treatment method for decreasing CK levels and resolving myoglobinuria. The addition of compounds within the IV fluid varied between studies. Due to the types of included studies and variation in reported treatment methods and outcomes for ER among athletes, effectiveness of treatment could not be determined. The limited evidence available indicates that IV fluid replacement, specifically normal saline, is the most commonly reported treatment for decreasing CK levels and myoglobinuria following ER. It appears that normal saline may be combined with other compounds including sodium bicarbonate, sodium chloride or potassium chloride to achieve reduction of CK levels and myoglobinuria. Clinically, early IV fluid replacement appears to be delivered at a rate of approximately 400 ml/hour, with adjustments ranging between 200 and 1000 ml/hour, depending on severity and volume states. Hospitalization time varies, depending on severity of condition, and return to activity is widely inconsistent among the athletic population.

Clinico-biochemical and surgical evaluation of omaso-abomasal volvulus in cattle

The aim of the present study was to determine and characterize the clinical, hematological, biochemical parametersand outcome in cows suffering from Omaso-abomasal volvulus (OAV). Animals data were obtained from medicalrecords of 60 adult dairy cattle suffering from OAV (Clinic for Ruminants, Justus-Liebig-University, Germany).For each case, history, age, results of clinical examination, hematological and biochemical findings were recordedand analyzed. Ages of animals were between 2.3 and 8 years, (mean 4.8). Compared with the respective normalrange, there were significant increases of the heart rate, hematocrit, total bilirubin, urea blood, concentrations ofbicarbonate and base excess. Serum chloride and potassium were significantly decreased in the majority of cows.In this study, dehydration, metabolic alkalosis, hypochloremia, hypokalemia and circulatory insufficiency werethe major common findings in cows with Omasum-abomasal volvulus. Excessive stretching of the abomasal walland long lasting strangulations at the torsion-sites must be avoided (surgery should be performed as soon afterdiagnosis of AOV as possible) and correction of these conditions with aggressive intravenous fluid therapy isnecessary before the surgical intervention for correction of the hematobiochemical alterations

Acute Pancreatitis in the Setting of Normal Serum Pancreatitic Enzyme Levels

There have been many reports of acute pancreatitis with normal serum amylase levels but acute pancreatitis with normal serum lipase levels is exceedingly rare. This is not uncommon given that amylase has a relatively short half-life of about ten hours with normalization in about three to five days while lipase may remain elevated for up to two weeks. A 44 year-old male with a past medical history of hypertension and diabetes mellitus presented to the Emergency Department complaining of nausea with non-bloody and non-bilious emesis, non-bloody diarrhea, epigastric pain, anorexia and chills for the past several days. The epigastric pain is sharp and radiates to the back. It is aggravated with food intake and lying supine. The patient admits to using alcohol every weekend and consumes several beers each session. His last alcohol intake was about one week prior. He denies tobacco or illicit drug use.His vitals on admission were notable for a fever of 101.5 degrees Fahrenheit and sinus tachycardia. The physical exam was notable for dry mucous membranes and severe epigastric tenderness with guarding.The remainder of the exam was unremarkable. His complete blood count and basic metabolic panel were within normal limits. Liver function tests were only notable for an elevated gammaglutamyl transpedtidase and an elevated lactate dehydrogenase. Serum amylase and lipase levels were found to be within normal limits. A lipid panel including triglycerides was also found to be within normal limits. A chest x-ray showed a small left-sided pleural effusion. The patient was admitted to the medicine service for the inability to tolerate oral intake and treatment for acute gastroenteritis.On day three of hospitalization, the patient was still not able to tolerate oral intake, developed worsening abdominal pain and a low grade fever. Repeat blood work revealed a white blood cell count of 15,300 cells per microliter. A Computed Tomography (CT) scan of the abdomen and pelvis with intravenous and oral contrast was pursued and showed extensive pancreatic edema and peripancreatic stranding consistent with acute pancreatitis. No pseudocysts or calcifications were seen. A repeat serum amylase and lipase were within normal limits. Based on clinical presentation and radiological findings, the diagnosis of acute pancreatitis was made. The patient was started on aggressive intravenous fluid hydration, pain management and bowel rest, with improvement in symptoms. On day five of hospitalization the patient was able to tolerate a regular diet with almost complete resolution of his epigastric pain. Clinical symptoms and radiological findings are all that is needed to make the diagnosis of acute pancreatitis and medical care providers should not exclude this diagnosis based on normal serum levels of amylase and lipase enzymes as they can normalize early on in the course of this disease.

Aggressive Intravenous Fluid Management in Acute Pancreatitis

Aggressive Intravenous Fluid Management in Acute Pancreatitis

Effect of 3% hypertonic saline as early fluid resuscitation in pediatric septic shock

The mainstay of therapy in patients with septic shock is early and aggressive intravenous fluid resuscitation. However the type of intravenous fluid that would be ideal for managing septic shock has been intensely debated. In this study, the authors observed the effects of 3% hypertonic saline solution compared with normal saline solution as early fluid resuscitation in children with septic shock. In this prospective study, 44 septic shock children seen in the intensive care unit (ICU) of the Children's Hospital Affiliated to Capital Institute of Pediatrics were enrolled from January 2012 to January 2014, of whom 33 were male and 11 were female. Patients were randomly divided into two groups: normal saline group (NS group, 24 patients) and 3% hypertonic saline group (HS group,20 patients). There were no significant differences between the 2 groups of patients in age, gender, pediatric critical illness score (PCIS), oxygenation index (OI = PaO2/FiO2), arterial lactate, initial hemodynamic parameters, serum sodium and treatment at time of admission. Patients in NS group received normal saline guided by standard therapy. Those in HS group received 6 ml/kg 3% hypertonic saline as a single bolus over 10 min to 15 min with a maximum of 2 boluses and other standard therapy. Heart rate (HR), mean arterial blood pressure (MAP), arterial lactate, oxygenation index, urine output, serum sodium, lactate clearance rate, PCIS, fluid infusion volume, vasoactive - inotropic score, mechanical ventilation time , as well as incidence of multiple organ dysfunction syndrome (MODS), and 28 days in - hospital mortality were recorded for all patients. (1) HR, MAP in both groups were significantly higher after infusion than those on admission. There were no significant difference in HR and MAP at 1h, 3h, 6h and 24h after infusion between NS group and HS group. (2) OI in HS group was significantly higher than that on admission at 3 hours after infusion [(321. 8 ± 50. 7) vs. (296. 5 ± 58. 2) mmHg, t = -2. 50, P = 0. 018 ]), and it was significantly higher at 24 hours after infusion in NS group (325. 7 ± 62. 6) vs. (304. 2 ± 70. 4) mmHg, t = -2.60, P=0.016]. There were no significant differences in OI at 1h, 3h, 6h and 24h after infusion between NS group and HS group. (3) At 1 hour after infusion, serum sodium in HS group was significantly higherthan that in NS group [(138.3 ± 3.8)vs. (135.0 ± 3.5) mmol/L, t=8.77, P=0.005], and then no significant difference at 3h, 6h and 24h after infusion between two groups. (4) At 6 hours and 24 hours after treatment, fluid infusion volume in HS group was markedly less than that in NS group [6 h: (39. 2 13. 9) vs. (60. 8 ± 22. 4) ml/kg, t = 14. 21, P =0. 000; 24 h: (102. 9 ± 27. 7) vs. (130. 6 ± 33. 2 ) ml/kg, t= 8. 85, P = 0. 005]. Urine output had not significant different between the two groups. (5) There were no significant differences in 24h PCIS, 24h lactate clearance rate, vasoactive - inotropic score and mechanical ventilation time between the two groups. The incidence of MODS (80. 0% in HS group, 70. 0% in NS group) and mortality rate(5. 0% in HS group, 8. 3% in NS group) were similar in both groups. The 3% hypertonic saline was effective as resuscitation fluid in pediatric septic shock with respect to restoration of hemodynamic stability without obvious side effects. Hypertonic saline could more rapidly improve oxygenation and need less fluid infusion volume compared with normal saline.

Improving care through standardization

There is clear evidence that standardizing care in medicine improves outcomes. Despite this, care of many medical conditions in pediatrics is not standardized and varies considerably between providers. Management of children with acute pancreatitis (AP) is one example where there is a total lack of standardization of initial care. In adults with acute pancreatitis, initial aggressive intravenous (IV) fluid administration and early initiation of enteral nutrition are associated with better outcomes. Both are now recommended in guidelines for management of AP by the American College of Gastroenterology. Currently there are no such recommendations for the pediatric age group. The type and rate of IV fluid administration given to children is highly variable and onset of enteral nutrition often is delayed for prolonged periods. In this issue of The Journal, Szabo et al address the issue of initial management of children with mild AP. Based on a survey, they first documented that treatment of such children at their institution was highly variable. In order to have a more standardized approach to care they devised and implemented an admission order set in the electronic medical record (EMR) that provided recommendations for the type and rate of IV fluid administration and initiation of enteral nutrition upon admission for all children with mild AP. Outcomes for children treated prior to the EMR-based order set was compared with that of children treated using this standardized protocol. In essence, they demonstrated that early “aggressive” IV fluid administration and enteral nutrition are safe and associated with a decrease in length of hospital stay and rate of progression to severe pancreatitis. Although the design of this study does not allow us to assume that this should now be the standard of care for all children with mild AP, the apparent improvement in outcome is noteworthy and deserves further study. Perhaps more important is that this study once again demonstrates the potential value of standardizing care for children with medical conditions. Article page 397▶ Early Enteral Nutrition and Aggressive Fluid Resuscitation are Associated with Improved Clinical Outcomes in Acute PancreatitisThe Journal of PediatricsVol. 167Issue 2PreviewTo determine whether recommendations for treatment of acute pancreatitis (AP) in adults impact the outcomes of pediatric AP. Full-Text PDF

Early Enteral Nutrition and Aggressive Fluid Resuscitation are Associated with Improved Clinical Outcomes in Acute Pancreatitis

To determine whether recommendations for treatment of acute pancreatitis (AP) in adults impact the outcomes of pediatric AP. Adult guidelines regarding early management of AP were implemented through an admission order set at Cincinnati Children's Hospital Medical Center at the beginning of the year 2014. Recommendations included administering high rates of intravenous fluid (IVF) within 24 hours of admission and enteral nutrition within 48 hours of admission. A retrospective chart review of AP admissions before and after the implementation of the recommendations was undertaken. Outcomes studied were: hospital length of stay, intensive care unit transfer rates, development of severe AP, pulmonary complications, and readmission rates post discharge from the hospital. The study included 201 patients. Children who received feeds within the first 48 hours and received greater than maintenance IVF within 24 hours had a shorter length of stay, less intensive care unit admissions and severe AP rates compared with the patients who remained nil per os during the first 48 hours and received lower rates of IVF. Our data support that early enteral nutrition and early aggressive IVF improve outcomes of pediatric AP.

Outcome after Implementation of Sepsis Guideline in the Emergency Department of a University Hospital in Hong Kong

Introduction Internationally, standard care of patients with severe sepsis consists of early detection, early antimicrobial therapy, and aggressive intravenous fluid therapy to maintain tissue oxygenation and perfusion. In this retrospective study, we aimed to examine the management of patients with severe sepsis in a local university hospital emergency department before and after the implementation of a sepsis management guideline. Method We collected data on the management and outcome of patients during a three-month period before the implementation of a sepsis guideline (October-December 2009). We then collected similar data one year after the implementation (October-December 2010). Key sepsis management areas and in-hospital mortality rates were compared, as were length of resuscitation, three-month mortality rate, hospital length of stay (LOS) and intensive care unit (ICU) LOS. Results Data from 115 patients were collected in the pre-implementation group, while data on 102 patients were collected for the post-implementation group. There were more patients with hypoperfusion in the post-implementation cohort (25.2% vs. 40.2%, p=0.019). There was no difference in background characteristics, average lactate value, average MAP or number of hypotensive patients between the two groups. Significantly more antibiotics were given after the intervention (13.0% vs. 23.5%, p=0.045) and more patients had a lactate level measured (43.0% vs. 73.5%; p&lt;0.001). There was a trend towards better survival for a subgroup of patients with hypoperfusion (48.0% vs. 29.2%, p=0.060). Conclusions Implementation of a sepsis guideline leads to more antibiotics being given and more lactate measurement in the emergency department. (Hong Kong j.emerg.med. 2015;22:163-171)

Acute pancreatitis: update on management.

Acute pancreatitis is a common acute surgical condition associated with high morbidity and mortality in severe cases. New guidelines for management have recently been published by the American College of Gastroenterology and by the International Association of Pancreatology in collaboration with the American Pancreatic Association. The main differences between the new and previous versions of the guidelines relate to the use of endoscopic retrograde cholangiopancreatography (ERCP) and the addition of the new severity category of 'moderately severe acute pancreatitis' All patients with pancreatitis should have its cause determined by features of the history, results of laboratory tests (liver function tests, serum calcium triglyceride levels) and findings on transabdominal ultrasound. Those with idiopathic pancreatitis should have endoscopic ultrasound as a first-line investigation. Acute pancreatitis should be managed with aggressive hydration with intravenous fluids and fasting. Oral feeding can be recommenced in mild pancreatitis once pain and nausea and vomiting have resolved. Patients with mild biliary pancreatitis should have a laparoscopic cholecystectomy during their index admission. In addition to aggressive intravenous fluid resuscitation and fasting, patients with severe pancreatitis should have enteral feeding (nasoenteric or nasogastric feeds) commenced 48 hours after presentation. Total parenteral nutrition should be avoided where possible. All patients with organ failure or severe pancreatitis as defined by the revised version of the Atlanta classification should be managed in an intensive care setting. Patients with biliary pancreatitis and concurrent cholangitis should have endoscopic retrograde cholangiopancreatography within 24 hours of presentation.

Evaluation of Pharmacologic Prevention of Pancreatitis After Endoscopic Retrograde Cholangiopancreatography: A Systematic Review

There is controversy over the efficacy of pharmacologic agents for preventing pancreatitis after endoscopic retrograde cholangiopancreatography (PEP). We performed a systematic review of PEP pharmacoprevention to evaluate safety and efficacy. We performed a systematic search of the literature for randomized controlled trials (RCTs) and meta-analyses of PEP pharmacoprevention through February 2014. After identifying relevant studies, 2 reviewers each extracted information on study characteristics, clinical outcomes, and risk of bias. A research classification scale was developed to identify pharmacologic agents ready for clinical use, agents for which a confirmatory RCT should be considered a high priority, agents for which exploratory studies are still necessary, and agents for which additional research should be of low priority. Clinical and research recommendations for each agent were made by consensus after considering research classification results and other important factors such as magnitude of benefit, safety, availability, and cost. After screening 851 citations and 263 potentially relevant articles, 2 reviewers identified 85 RCTs and 28 meta-analyses that were eligible. On the basis of these studies, rectal nonsteroidal anti-inflammatory drugs were found to be appropriate for clinical use, especially for high-risk cases. Sublingual nitroglycerin, bolus-administered somatostatin, and nafamostat were found to be promising agents for which confirmatory research is warranted. Additional research was found to be required to justify confirmatory RCTs for topical epinephrine, aggressive intravenous fluids, gabexate, ulinastatin, secretin, and antibiotics. On the basis of a systematic review, NSAIDs are appropriate for use in prevention of PEP, especially for high-risk cases. Additional research is necessary to clarify the role of other pharmacologic agents. These findings could inform future research and guide clinical decision-making and policy.

A Rare Cause of Abdominal Pain, Nausea, and Vomiting: “Black” Esophagus

Introduction: A 30-year-old male with a past medical history of HIV on HAART, type 1 diabetes mellitus, end stage renal disease on chronic hemodialysis and blindness presented with two days of epigastric abdominal pain, nausea and non-bloody, non-bilious vomiting. He also endorsed odynophagia to solids. The patient was admitted to the hospital two other times within the last three months for similar complaints of abdominal pain associated with vomiting and anorexia. His symptoms were always thought to be secondary to underlying diabetic ketoacidosis and they would largely resolve with aggressive intravenous fluids and insulin. On this admission, physical examination was significant for mild epigastric tenderness. CT scan of his abdomen revealed circumferential wall thickening of the distal esophagus compatible with esophagitis. The patient underwent an EGD which showed circumferential, blackening of the distal esophagus consistent with acute esophageal necrosis. Biopsies were obtained, which revealed necro-inflammatory mucosa with multiple fungal forms consistent with Candida species. The patient was treated with intravenous esomeprazole and an oral sucralfate suspension, along with fluconazole given the findings of fungal infection on mucosal biopsy. The patient’s symptoms markedly improved. The patient was discharged home with complete resolution of his presenting symptoms to have close endoscopic follow-up at a later date. Acute esophageal necrosis, or the so-called “black esophagus,” is a rare finding first described in 1990 by Goldenberg et al, with an estimated prevalence reported in one autopsy study to be 0.2%. The exact pathogenesis remains unknown but ischemia is believed to be the main inciting event. Low-flow states such as diabetic ketoacidosis, as seen in our patient, result in hypo-perfusion of the distal esophagus, a region that is more “watershed” and less vascularized than the proximal portions of the esophagus. Treatment is largely supportive with correction of the predisposing event and better control of the underlying medical condition. Complications include esophageal perforation, mediastinitis, stricture formation and death.Figure 1: Blackening of the distal esophagus, which classically stops at the GE junction.

577 A Prospective Randomized Trial of Aggressive Hydration to Prevent Post-ERCP Pancreatitis

Pancreatitis complicates 5-15% of ERCPs and results in considerable morbidity. In pancreatitis, hypovolemia and microvascular hypoperfusion are correlated with histologic inflammation and necrosis. Our aim is to assess whether treatment with aggressive intravenous fluids during and after ERCP, which theoretically optimizes perfusion, prevents post ERCP pancreatitis (PEP).

Goal Directed Fluid Resuscitation: A Review of Hemodynamic, Metabolic, and Monitoring Based Goals

Aggressive intravenous fluid (IVF) resuscitation has been a mainstay of therapy for critically ill patients with hypotension and hypoperfusion. Recent evidence has emerged suggesting that overzealous fluid resuscitation may be associated with increased morbidity and mortality. Goal directed fluid therapies aim to exploit metabolic, hemodynamic, and monitor based parameters that may predict a response to fluid administration. The goal is to improve patient outcome by identifying patients who will benefit from IVF while avoiding excessive fluid administration to those who will not benefit.