Gastrointestinal Tract Complications Research Articles

Use of Physician Education and Computer Alert to Improve Targeted Use of Gastroprotection Among NSAID Users

Gastrointestinal (GI) hemorrhage accounts for 200-400,000 admissions in the United States annually. Around 50% of patients with bleeding ulcer have used aspirin and/or nonsteroidal anti-inflammatory drugs (NSAIDs). Misoprostol and proton pump inhibitors (PPIs) may reduce NSAID-related upper GI tract complications in high-risk patients, but their targeted use may be suboptimal. To determine the impact of physician education, a computer alert, or both on the targeted use of GI prophylaxis in high-risk patients discharged from hospital. To target high-risk patients, we studied cardiology telemetry and coronary care unit (CCU) services. Every 4th wk, 8 different residents managed these patients. Over a 32-wk period, residents were assigned to one of the four 8-wk groups sequentially: Group I: control; Group II: physician education, consisting of a 10-min tutorial on risk factors for NSAID-related GI complications; Group III: computer alert; and Group IV: combination of tutorial and computer alert. We reviewed all patients admitted to these cardiology services during the study period. Exclusion criteria included discharge on no ulcerogenic medications, incomplete discharge data, and inpatient death. Patients readmitted during the study period were not re-counted. Medical records were reviewed for discharge medications, past medical history, demographics, admission and discharge diagnoses, hospital days, and the Charlson comorbidity index. Other indications for acid suppression were documented. A chi(2) test was used to determine independence among all four groups. We enrolled 721 patients, of whom 120 (16.7%) were excluded. The remaining 601 were divided by physician intervention group and risk for NSAID-related GI complications. In total, 270 of 601 (45%) patients were discharged home on appropriate gastroprotection. The overall use of gastroprotection increased from 43 to 61% with the combination of an electronic alert and physician education (P < 0.001); among PPI-naïve patients, the rate increased from 26% to 55% (P < 0.0001). When stratified by known risk factors for GI complications of NSAIDs, the odds of receiving a gastroprotective prescription among PPI-naïve patients was 1.6 with education alone, 1.8 with electronic alert alone, and 2.9 with the combination (P < 0.0001). The combination of a computer alert and brief physician education led to an increase in the use of gastroprotection among NSAID users at the time of discharge from hospital. This effect was most evident among high-risk, PPI-naïve patients. Combining physician education and a computer alert appears to have an additive effect.

The Burden of Varicella Complications Before the Introduction of Routine Varicella Vaccination in Germany

The true burden of varicella complications in Germany is not known. We investigated the incidence and pattern of varicella complications in children and adolescents using 3 independent surveillance sources. Prospective nationwide surveillance in all pediatric hospitals through the German Pediatric Surveillance Unit [Erhebungseinheit für Seltene Pädiatrische Erkrankungen in Deutschland (ESPED)] was used to ascertain hospitalized varicella cases in children <or=16 years of age between January 2003 and December 2004. In the federal state, North-Rhine Westphalia (NRW), a practice sentinel network [European Diabetes Study Group (EURODIAB)] and pediatric hospital based International Statistical Classification of Diseases and Related Health Problems, 10th Revision (ICD-10) surveillance were additionally used to refine incidence estimates via capture-recapture methodology. A total of 918 hospitalized varicella patients (male-to-female: 55%/45%) with a median age of 3.3 years (interquartile range, 1.4-5.2) and a median hospital stay of 5 days (interquartile range, 3-8) were reported. Varicella associated complications occurred in 80% of the hospitalizations, most frequently being neurologic (25.4%), skin infectious (23.2%), and gastrointestinal tract complications (15.0%). Most hospitalizations (77%) occurred in previously healthy children. A predisposing condition existed in 207 children (23%): immunosuppression 7%, atopic dermatitis 7%, and other underlying chronic conditions 9%. Severity of varicella complications was related to increasing age and immunosuppression. Permanent or possible sequelae were reported in 15 (1.7%) and 78 (8.7%) of all children, respectively; 10 children died. Capture-recapture analyses yielded an incidence of 14.1 (95% confidence interval, 9.7-18.6) varicella hospitalizations/100,000 children, corresponding to 1996 (95% confidence interval, 1363-2629) varicella-related hospitalizations per year in Germany. These data show that the severity of varicella complications in healthy children has been previously underestimated.

Complications Related to Surgical Treatment of Intervertebral Disc Disease in Dogs

After intervertebral disk surgery we often have to deal with various complications (seizures, gastrointestinal tract (GIT) ulcerations, cystitis, and surgical wound healing problems). These complications may lead to the death of the patient. We performed clinical and laboratory investigations in 161 dogs with an intervertebral disc disease. After that, we performed a cranial (n = 31), caudal (n = 125) or both (n = 5) types of myelography at the same time, and surgery - ventral slot decompression (SLOT) (n = 18) or hemilaminectomy (n = 143). During the postsurgical period we observed seizures, GIT complications, cystitis, and surgical wound healing problems or even death of the patients. These complications appeared to be related to the lesion site, the degree of clinical signs and the type of surgical procedure. In our study we found a higher incidence of seizures after cranial myelography, higher incidence of gastrointestinal (GI) complications particularly in paraplegic dogs, and a higher risk of death in patients after the SLOT surgery. The occurrence of cystitis was not significant (p = 0.5524, p = 0.1655, respectively). We consider seizures, GI ulcerations, and death the most frequent complications after intervertebral disc surgery. Their incidence depends on the lesion site and the degree of neurologic symptoms.

Laparotomy for Acute Complications of Gastrointestinal Metastases from Lung Cancer: Is it a Worthwhile or Futile Effort?

Complications of gastrointestinal tract (GIT) metastases from lung cancer are rare and the optimal management remains controversial. Whereas some authors advocate a nonoperative policy due to the poor prognosis, others recommend aggressive surgery as it offers effective palliation. The aim of this study is to present our experience with nine patients who underwent a laparotomy for complications of GIT metastases and to determine their outcome. Between 1995 and 2005, nine patients who underwent a laparotomy for complications of pathologically proven GIT metastases secondary to lung cancer were retrospectively reviewed. All patients were male with a median age of 63 years (range, 40-70 years) at initial presentation. The sites of symptomatic GIT metastases include the ileum (n = 3), jejunum (n = 3), cecum (n = 1), duodenum (n = 2) and stomach (n = 2) and the patients presented with obstruction (n = 2), hemorrhage (n = 3), intussusception (n = 3) and perforation (n = 1). The median time of symptomatic GIT metastases from initial presentation was 2 months (range, 0-8 months) and the histological subtypes of the lung cancer were squamous cell carcinoma (n = 3), large cell carcinoma (n = 3), adenocarcinoma (n = 1), pleomorphic carcinoma (n = 1) and pleomorphic with adenocarcinoma (n = 1). All patients underwent an exploratory laparotomy and the definitive surgical procedure was dependent on the site and extent of disease. These included a small bowel resection with primary anastomosis (n = 5), a subtotal gastrectomy with an extended right hemicolectomy (n = 1), a gastrojejunostomy (n = 1), a right hemicolectomy (n = 1), and an ulcerectomy with under-running of ulcers (n = 1). Eight of the nine patients (89%) recovered from surgery and were then discharged from hospital at a median time of 9.5 days (range, 6-24 days). All these eight patients survived for more than 30 days and the median survival was 6 months (range, 2-13 months). Four of the 8 patients (50%) lived for more than 6 months and all eight patients died of advanced metastatic lung cancer with multiple sites of metastases at the time of death. Gastrointestinal tract metastases should always be considered in the differential diagnosis of lung cancer patients presenting with an acute abdomen. Aggressive surgical treatment is worthwhile in a selected group of patients as it provides effective palliation.

Necrotizing enterocolitis in a 850 gram infant receiving sorbitol-free sodium polystyrene sulfonate (Kayexalate): clinical and histopathologic findings

We report a 27-week, 850 g infant with severe Streptococcus group B sepsis and life-threatening hyperkalemia due to progressive anuria. On the fourth day of life, after he failed treatment with diuretics, salbutamol, insulin, calcium gluconate and sodium bicarbonate, he was treated with sorbitol-free Kayexalate enemas. Potassium level slowly decreased from 9.2 mmol/l to normal level along with a recovery of normal urine output. On the 11th day of life, clinical and radiological signs of a perforated necrotizing enterocolitis (NEC) occurred and the patient required surgical intestinal resection. Histologic examination of the ileum specimen revealed areas of necrosis with fibrosis and giant cell reaction to a nonpolarizable material consistent with sodium polystyrene sulfonate. Usually, Kayexalate is suspended in hyperosmolar sorbitol solutions and the elevated osmolarity seems to be responsible for hemorrhagic colitis, transmural necrosis and definitely NEC. Our case report shows that Kayexalate per se, and not necessarily suspended in sorbitol, can lead to gastrointestinal tract complications and NEC in preterm infants.

Clinical implications of cyclooxygenase-2 inhibitors

The mechanism underlying the efficacy of nonsteroidal anti-inflammatory drugs (NSAIDs) is suppression of the activity of cyclooxygenase (COX). It has been surmised that selective COX-2 inhibitors can inhibit only the production of prostaglandin (PG) related to inflammation but not PG related to physiological functions. However, COX-2 is present in some tissues with physiological function. It has been established that selective COX-2 inhibitors are safer with respect to upper gastrointestinal tract complications than traditional nonselective NSAIDs. Furthermore, selective COX-2 inhibitors are effective in suppressing familial adenomatous polyposis. In contrast, recent studies have shown that selective COX-2 inhibitors and non-selective NSAIDs increase the cardiovascular risk. In Japan, celecoxib, a selective COX-2 inhibitor, was approved for clinical use in 2007. In this review, we outline the benefits and advantages of selective COX-2 inhibitors and suggest how best to use NSAIDs in daily clinical practice.

Role of amyloidosis in determining the prognosis of dialyzed patients with rheumatoid arthritis

The role of secondary amyloidosis in determining the prognosis of dialyzed patients with rheumatoid arthritis (RA) was examined in 22 patients with a mean age of 60.1 years included 21 renal amyloidosis. RA duration until the start of dialysis was 19.5 +/- 7.2 years and the observation period after introduction 27.1 +/- 26.4 months. Of the 14 dead cases, four died due to sepsis, three due to gastrointestinal tract bleeding, two due to congestive heart failure, and eight cases died within 5 months after starting dialysis. When comparing the eight survivors and the nine non-survivors who died within 2 years after the start of dialysis, the former patients showed significantly higher serum albumin, and lower electrocardiogram score and cardiothoracic ratios at the time of introduction to dialysis. The careful prevention and treatment of infection, cerebrovascular and/or gastrointestinal tract complications seem to be necessary to improve the prognosis of RA patients after the initiation of renal replacement therapy.

Consensus Development Conference on the Use of Nonsteroidal Anti-Inflammatory Agents, Including Cyclooxygenase-2 Enzyme Inhibitors and Aspirin

Consensus Development Conference on the Use of Nonsteroidal Anti-Inflammatory Agents, Including Cyclooxygenase-2 Enzyme Inhibitors and Aspirin

Laparoscopic vs. Open Surgery for Diverticular Disease: A Meta-Analysis of Nonrandomized Studies

This study was designed to compare outcomes between laparoscopic and open surgery for patients with diverticular disease by using meta-analytic techniques. Comparative studies published between 1996 and 2004 of open vs. laparoscopic surgery for diverticular disease were included. The end points that were evaluated are operative and functional outcomes and adverse events. A random effects model was used during analysis of these outcomes; heterogeneity was assessed and sensitivity analysis was performed to account for bias in patient selection. Twelve nonrandomized studies, incorporating 19,608 patients, were included in the analysis. One study with 18,444 patients accounted for 94.5 percent of the total sample. Laparoscopic surgery resulted in reduced infective (odds ratio, 0.61; P = 0.01), pulmonary (odds ratio, 0.4; P < 0.001), gastrointestinal tract (odds ratio, 0.75; P = 0.03), and cardiovascular complications (odds ratio, 0.28; P = 0.0008) with no significant heterogeneity. Operative time was longer with laparoscopic surgery (weighted mean difference, 67.59; P = 0.04), and length of stay was significantly shorter (weighted mean difference, -3.81; P < 0.0001); however, these outcomes demonstrated significant heterogeneity. These results remained significant throughout all the sensitivity analyses except when evaluating high-quality studies (when the study with 18,444 patients was excluded), in which only blood loss and length of stay were significantly in favor of the laparoscopic group. The results for patients selected for laparoscopic surgery compared with open surgery for diverticular disease are equivalent with a potential reduction in complications and hospital stay. Laparoscopic surgery for diverticular disease performed by appropriately experienced surgeons in the elective setting may be safe and feasible; because of the potential of significant bias arising from the included studies, a randomized, controlled trial is recommended.

Infectious complications of the gastrointestinal tract in the allogeneic BMT patient

Infectious complications of the gastrointestinal tract in the allogeneic BMT patient

Cardiac Surgery in Octogenarians

Outcome differences in octogenarians vs patients younger than 80 years undergoing coronary artery bypass grafting or valve surgery can be analyzed to isolate the effect of age alone on morbidity and mortality. Eight-year hospitalization cohort study. Physicians, nurses, and perfusionists prospectively collected data on 225 variables. Community hospital. A consecutive sample of 7726 patients undergoing coronary artery bypass grafting or valve surgery between October 1, 1993, and February 28, 2001. There were 9 main outcomes of interest: mortality, length of hospital stay, gastrointestinal tract complications, neurologic complications, pulmonary complications, renal complications, return to intensive care unit, intraoperative complications, and reoperation to treat bleeding. We controlled for 16 potential confounding variables to isolate outcome differences according to age. Of 7726 patients who fit the inclusion criteria, 522 were octogenarians. Compared with nonoctogenarians, octogenarians had a significantly higher New York Heart Association functional classification, higher incidence of hypertension, and underwent a greater number of coronary artery bypass grafting plus valve surgical procedures (P<.05). They also had significantly lower body surface area, fewer total number of grafts used, less history of tobacco use, and less abnormal left ventricular hypertrophy, and there were fewer nonwhite patients and fewer men. At multivariate analysis, octogenarians had a higher risk for death (relative risk [RR], 1.72; 95% confidence interval [CI], 1.52-1.83), longer hospital stay (RR, 1.03; 95% CI, 1.01-1.04), more neurologic complications (RR, 1.51; 95% CI, 1.26-1.67), and were more likely to undergo a reoperation to treat bleeding (RR, 1.49; 95% CI, 1.09-1.72). Univariate analyses revealed no difference between octogenarians and nonoctogenarians for diabetes mellitus, urgency of procedure, prior myocardial infarction, time since last myocardial infarction, cerebrovascular history, chronic obstructive pulmonary disease, or pump time. Age alone has been shown to influence outcomes after cardiac bypass or valve surgery. Octogenarians undergoing cardiac surgery have more comorbidities and higher mortality even after controlling for 16 potential confounding variables, compared with nonoctogenarians.

Risk of hospitalization for upper gastrointestinal tract complications associated with non-selective non-steroidal anti-inflammatory drugs in Malaysia: a retrospective case control study

Aims: To assess the association between non-steroidal anti-inflammatory drug (NSAID) use and upper gastrointestinal (GI) tract-related hospitalizations and to evaluate inpatient healthcare resource utilization associated with these complications in Malaysia. Methods: A retrospective case control study was performed using medical records of patients admitted to two Malaysian hospitals during 1999 and 2000. Cases were identified based on mode of presentation at hospital admission. One control was identified for each case, matched by age, sex and admission date. NSAID exposure was determined by drug use during one year prior to admission. Conditional logistic regression analysis was used to determine the association between NSAID use and upper GI complications, adjusting for predictors. Results: The 273 cases were significantly more likely to have used NSAIDs in the year prior to hospitalization than controls (27.8%vs. 6.2% of patients; P < 0.0001). Conditional logistic regression analysis adjusting for other predictors showed that the odds of being hospitalized for upper GI tract complications were 4.1 times higher among NSAID users than non-users (95% CI = 1.88–9.12). Other risk factors for GI-related hospitalizations were a history of upper GI tract complications (OR = 5.8, 95% CI = 1.28–26.53), use of gastroprotective agents (OR = 5.3, 95% CI = 1.67–16.79), and use of antacids (OR = 5.0, 95% CI = 2.10–11.91) in the previous year. Conclusion: This study demonstrated that NSAID exposure was significantly higher among patients hospitalized for GI-related complications than for other reasons, indicating that NSAID use is an independent risk factor for upper GI tract complications in this Malaysian sample.

Duodenal Obstruction after Elective Abdominal Aortic Aneurysm Repair: A Case Report

Gastrointestinal tract complications after abdominal aortic aneurysm (AAA) repair are well known. The reported frequency ranges from 6.6% to 21%. However, the incidence of duodenal obstruction following AAA has probably been underestimated. This report concerns a 78-year-old male who was admitted for elective repair of an infrarenal AAA. On the ninth postoperative day, the patient presented with large quantities of bile-stained vomitus despite passing flatus per rectum. Metoclopramide and ranitidine were given under the initial impression of paralytic ileus. However, the upper gastrointestinal obstruction persisted, and on day 12, computerized tomography (CT) revealed marked distension of the gastric tube and duodenum, down to the level of the third portion, with abrupt change of caliber at the point of the superior mesenteric artery (SMA). SMA syndrome was diagnosed. After nasogastric tube aspiration, parenteral nutrition, and 11 days of conservative treatment, abdominal CT and upper gastrointestinal series showed no apparent duodenal obstruction. The patient was discharged on the 29th postoperative day; follow-up abdominal CT 4 months later was unremarkable.

Prevention and treatment of gastrointestinal complications in patients on mechanical ventilation.

There exists a complex, dynamic interaction between mechanical ventilation and the splanchnic vasculature that contributes to a myriad of gastrointestinal tract complications that arise during critical illness. Positive pressure-induced splanchnic hypoperfusion appears to play a pivotal role in the pathogenesis of these complications, the most prevalent of which are stress-related mucosal damage, gastrointestinal hypomotility and diarrhea. Furthermore, characteristics of the splanchnic vasculature make the gastrointestinal tract vulnerable to adverse effects related to positive pressure ventilation. While most of these complications seen in mechanically ventilated patients are reflections of altered gastrointestinal physiology, some may be attributed to medical interventions instituted to treat critical illness. Since maintenance of normal hemodynamics cannot always be achieved, pharmacologic prophylactic therapy has become a mainstay in the prevention of gastrointestinal complications in the intensive care unit. Improved understanding of the systemic effects of mechanical ventilation and greater application of lung-protective ventilatory strategies may potentially minimize positive pressure-induced reductions in splanchnic perfusion, systemic cytokine release and, consequently, reduce the incidence of gastrointestinal complications associated with mechanical ventilation. Herein, we discuss the pathophysiology of gastrointestinal complications associated with mechanical ventilation, summarize the most prevalent complications and focus on preventive strategies and available treatment options for these complications. The most common causes of gastrointestinal hemorrhage in mechanically ventilated patients are bleeding from stress-related mucosal damage and erosive esophagitis. In general, histamine H(2) receptor antagonists and proton pump inhibitors prevent stress-related mucosal disease by raising the gastric fluid pH. Proton pump inhibitors tend to provide more consistent pH control than histamine H(2) receptor antagonists. There is no consensus on the drug of choice for stress ulcer prophylaxis with several meta-analyses providing conflicting results on the superiority of any medication. Prevention of erosive esophagitis include careful use of nasogastric tubes and institution of strategies that improve gastric emptying. Many mechanically ventilated patients have gastrointestinal hypomotility and diarrhea. Treatment options for gastrointestinal motility are limited, thus, preventive measures such as correction of electrolyte abnormalities and avoidance of medications that impair gastrointestinal motility are crucial. Treatment of diarrhea depends on the underlying cause. When associated with Clostridium difficile infection antibacterial therapy should be discontinued, if possible, and treatment with oral metronidazole should be initiated.More studies are warranted to better understand the systemic effects of mechanical ventilation on the gastrointestinal tract and to investigate the impact of lung protective ventilatory strategies on gastrointestinal complications.

Laparoscopic nephrectomy in the markedly obese living renal donor

Objectives. To determine whether laparoscopic living donor nephrectomy is safe and efficacious in markedly obese renal donors. Methods. From 1996 to 1999, 431 laparoscopic living donor nephrectomies were performed. The markedly obese group consisted of 41 patients with a body mass index (BMI) greater than 35. Forty-one controls with a BMI less than 30 were matched to the obese donors by sex, age, race, and date of surgery. Results. The markedly obese and control groups were closely matched in sex, race, age, serum creatinine level, creatinine clearance, HLA match to recipient, side of donated kidney, and experience level of the surgeons. The obese patients had a BMI range of 35.2 to 53.9 (mean 39.3), and the control patients had a BMI range of 18.4 to 29.0 (mean 24.3). Donor operations in the markedly obese were significantly longer by an average of 40 minutes. The greater intraoperative blood loss and longer extraction incision length seen in the markedly obese did not reach statistical significance. More and larger laparoscopic ports were used in the markedly obese. Obese donors were more likely to require conversion from laparoscopic nephrectomy to open nephrectomy than ideal-sized donors. The postoperative recovery of the gastrointestinal tract, hospitalization time, analgesic requirements, and total complications were equal in the two groups, although the obese donors’ complications tended to be cardiopulmonary problems. The recipient graft function was equivalent between the two groups. Conclusions. Laparoscopic living donor nephrectomy is more difficult to perform in the markedly obese but is associated with an equivalent donor morbidity and recipient renal outcome.

Association between nonsteroidal anti-inflammatory drugs and upper gastrointestinal tract bleeding/perforation: an overview of epidemiologic studies published in the 1990s.

In the last decades, studies have estimated the upper gastrointestinal tract bleeding/perforation (UGIB) risk associated with individual nonsteroidal anti-inflammatory drugs (NSAIDs). Later analyses have also included the effect of patterns of NSAID use, risk factors for UGIB, and modifiers of NSAID effect. Systematic review of case-control and cohort studies on serious gastrointestinal tract complications and nonaspirin NSAIDs published between 1990 and 1999 using MEDLINE. Eighteen original studies were selected according to predefined criteria. Two researchers extracted the data independently. Pooled relative risk estimates were calculated according to subject and exposure characteristics. Heterogeneity of effects was tested and reasons for heterogeneity were considered. Advanced age, history of peptic ulcer disease, and being male were risk factors for UGIB. Nonsteroidal anti-inflammatory drug users with advanced age or a history of peptic ulcer had the highest absolute risks. The pooled relative risk of UGIB after exposure to NSAIDs was 3.8 (95% confidence interval, 3.6-4.1). The increased risk was maintained during treatment and returned to baseline once treatment was stopped. A clear dose response was observed. There was some variation in risk between individual NSAIDs, though these differences were markedly attenuated when comparable daily doses were considered. The elderly and patients with a history of peptic ulcer could benefit the most from a reduction in NSAID gastrotoxicity. Whenever possible, physicians may wish to recommend lower doses to reduce the UGIB risk associated with all individual NSAIDs, especially in the subgroup of patients with the greatest background risk.

COLONIC PERFORATION ASSOCIATED WITH SLOW‐RELEASE DICLOFENAC SODIUM

SUMMARYUpper gastrointestinal tract complications due to non‐steroidal anti‐inflammatory drugs are well recognised. However, adverse effects on large intestinal mucosa are less common and less well recognised, even though they carry a significant morbidity and mortality. Here we report a case of colonic perforation in a healthy woman without any underlying colonic pathology associated with ingestion of slow release diclofenac sodium. (Int J Clin Pract 2000; 54(5): 338‐339)

Risk of hospitalization for upper gastrointestinal tract bleeding associated with ketorolac, other nonsteroidal anti-inflammatory drugs, calcium antagonists, and other antihypertensive drugs.

Nonsteroidal anti-inflammatory drugs (NSAIDs) cause substantial morbidity and mortality from upper gastrointestinal tract disease. Ketorolac tromethamine has been singled out as an NSAID with a distinct gastrotoxicity profile. Calcium channel blockers, a class of antihypertensive drugs, have also been found to increase the risk of gastrointestinal tract bleeding. We identified 1505 patients hospitalized because of upper gastrointestinal tract bleeding and/or perforation, and we randomly sampled 20,000 controls in the source population. The adjusted relative risk (RR) for upper gastrointestinal tract bleeding and/or perforation in NSAID users compared with nonusers was 4.4 (95% confidence interval [CI], 3.7-5.3). The risk increased with higher daily doses. Ketorolac presented the highest risk (RR, 24.7; 95% CI, 9.6-63.5) and piroxicam ranked second (RR, 9.5; 95% CI, 6.5-13.8). Ketorolac was 5 times more gastrotoxic than all other NSAIDs (RR, 5.5; 95% CI, 2.1-14.4). The excess risk with ketorolac was observed with both oral and intramuscular administration and was already present during the first week of therapy. Among the various antihypertensive drug classes, beta-blockers were associated with the lowest relative risk (RR, 1.0; 95% CI, 0.7-1.4), and current use of calcium channel blockers with the highest (RR, 1.7; 95% CI, 1.3-2.1). The association with calcium channel blockers declined when adjusting for various markers of comorbidity (RR, 1.4; 95% CI, 1.1-1.8). Past use of calcium channel blockers was also associated with an increased risk (RR, 1.5; 95% CI, 1.3-1.8). The excess risk of major upper gastrointestinal tract complications associated with outpatient use of ketorolac suggests an unfavorable risk-benefit assessment compared with other NSAIDs. More data are required to reduce the uncertainty about the apparent small increased risk of upper gastrointestinal tract bleeding in patients using calcium channel blockers.

Gastrointestinal tract complications in severe acute pancreatitis

Gastrointestinal tract complications in severe acute pancreatitis

Ischemic necrotic bowel disease in thermal injury.

Gastrointestinal tract (GI) complications are a well-recognized entity following burn injury. To determine whether there was a change in the incidence and type of GI complications in individuals with thermal injuries requiring operative intervention and whether this might be related to changes in patient management. A retrospective 8-year study of patients admitted with burn injuries. A university medical center burn unit. Statistical analysis and pathological review of 2 groups of patients: those with ischemic necrotic bowel disease (INBD group) and those with other GI complications (other GI complication group), identified among 2114 patients admitted with burn injuries during an 8-year period (1988-1995). Of 2114 patients admitted with burn injuries, 19 patients were identified retrospectively as having had either INBD (n = 10) or other GI complications (n = 9). Statistical analysis showed no difference between the 2 groups in duration of hospitalization, age, sex, pneumonia, mortality, peritonitis or gastric ulcer disease, inhalation injury, ventilator use, grafting procedures, or infections. The patients in the INBD group had a statistically significant mean (+/- SD) increase in the percentage of total burn surface area compared with those in the other GI complication group (53% +/- 10% vs 22% +/- 7%; P < .02) and sepsis prior to the GI complication (32% vs 5%; P < .03). A statistically significant decrease was noted in the incidence of paralytic ileus (17% vs 69%; P < .03). Enteral nutritional support became the primary mode of treatment, and GI hemorrhage and ulcer disease decreased during this period. Patients with total burn surface area greater than 40% and sepsis were at increased risk of INBD during their hospitalization. The severity of thermal injury and systemic infection are risk factors for the development of INBD. This entity is more frequent currently because of increased survival of the more severely injured patients. Systemic infection may alter the integrity of the bowel, which becomes less "tolerant" of enteral feedings. The role of large-volume high-density enteral feedings as a usually associated event in these patients remains speculative.