Treatment Of Acute Gastrointestinal Bleeding Research Articles

Transarterial Embolization for Active Gastrointestinal Bleeding: Predictors of Early Mortality and Early Rebleeding.

Background: The aim of this study was to determine predictive factors of early mortality and early rebleeding (≤30 days) following transarterial embolization (TAE) for treatment of acute gastrointestinal bleeding. Methods: All consecutive patients admitted for acute gastrointestinal bleeding to the interventional radiology department in a tertiary center between January 2012 and January 2022 were included. Exclusion criteria were patients: (1) aged < 18-year-old, (2) referred to the operation room without TAE, (3) treated for hemobilia, (4) with mesenteric hematoma, (5) lost to follow-up within 30 days after the procedure. We evaluated pre and per-procedure clinical data, biological data, outcomes, and complications. Results: Sixty-eight patients were included: 55 (80.9%) experienced upper gastrointestinal bleeding and 13 (19.1%) lower gastrointestinal bleeding. Median age was 69 (61−74) years. There were 49 (72%) males. Median hemoglobin was 7.25 (6.1−8.3) g/dL. There were 30 (50%) ulcers. Coils were used in 46 (67.6%) procedures. Early mortality was 15 (22.1%) and early rebleeding was 17 (25%). In multivariate analysis, hyperlactatemia (≥2 mmol/L) were predictive of early mortality (≤30 days). A high number of red blood cells units was associated with early rebleeding. Conclusion: This study identified some predictive factors of 30-day mortality and early rebleeding following TAE. This will assist in patient selection and may help improve the management of gastrointestinal bleeding.

Economic evaluation of tranexamic acid for the treatment of acute gastrointestinal bleeding: a cost-effectiveness analysis using data from the HALT-IT randomised controlled trial

ObjectiveTo perform an economic evaluation of tranexamic acid (TXA) versus no-TXA, in addition to current clinical practice, for acute gastrointestinal bleeding, using the results of the HALT-IT trial (NCT01658124), a...

Disorders of the Blood Coagulation System in Patients with Infectious Endocarditis

Infectious endocarditis is a disease which is still hard to diagnose and treat. The success of the proposed ther-apy depends not only on the surgical correction of the heart disease, but also on effective perioperative management of this group of patients. In most cases, patients have a long history of drug treatment and compromised status of all organs and systems. Coagulation disorders in patients with infectious endocarditis are one of the main links which lead to the patient’s death, despite advances in therapeutic and surgical treatment. Since the development of infectious endocarditis is based on thrombo-inflammatory lesions of the endocardium as a result of the interaction of microorganisms and modifiers of the blood coagulation system, the appointment of effective anticoagulant therapy in the postoperative period becomes one of the important tasks in resuscitation. The need to maintain balance between the coagulation and anticoagulation systems of hemostasis requires constant monitoring of the coagulation system and careful administration of anticoagulants.&#x0D; The aim. To demonstrate an example of an alternative scheme of anticoagulant therapy in a patient with postopera-tive gastrointestinal bleeding after cardiac surgery for infectious endocarditis.&#x0D; Materials and methods. We present a clinical case of treatment of acute gastrointestinal bleeding in the early post-operative period in a patient after cardiac surgery for infectious aortic valve endocarditis. The 56-year-old patient K. was taken to the National Amosov Institute of Cardiovascular Surgery of the NAMS of Ukraine by ambulance with a diagnosis: Infectious endocarditis of the aortic and mitral valves. Combined aortic defect with a predominance of insufficiency, mitral regurgitation, tricuspid insufficiency. Pulmonary arterial hypertension. Degree II respiratory failure. Ischemic heart disease: non-Q-wave myocardial infarction (as of October 29, 2020), RCA stenting (November 2, 2020), post-infarction atheroscle-rotic cardiosclerosis. Degree III hypertension, stage 2, risk 4. Heart failure 2B, functional class III. A salvage cardiac surgery was performed: aortic valve replacement. Mitral and tricuspid valve plastics. On day 2 of the postoperative period, against the background of anticoagulant therapy prescribed according to international recommendations, gastrointestinal bleeding developed. Anticoagulant therapy regimen was adjusted. The proposed scheme of hemostasis control allowed to normalize the blood parameters and to avoid blood loss. On day 10 of the postoperative period, standard scheme of anticoagulant ther-apy could be renewed, and the patient was transferred to the therapeutic department under the supervision of cardiologist.&#x0D; Conclusions. The proposed variant of anticoagulant therapy in the postoperative period in a patient operated on for infectious endocarditis created the conditions for normalization of hemostasis. Complete withdrawal of anticoagulants and transfer of patients to a continuous infusion of heparin under the control of APTT with a target value allows not only to control the risk of bleeding, but also to prevent thrombosis.

Embolization for acute gastrointestinal bleeding

Purpose: To retrospectively evaluate the clinical success and complication rates following interventional embolization for treatment of acute gastrointestinal bleeding (GIB) at a tertiary care centre. The secondary purpose was to evaluate results of practice change whereby multiphase CT angiography was requested prior to conventional angiograms.&#x0D; Methods: A retrospective chart review and analysis of 38 patients undergoing Interventional Radiology guided embolization for acute GIB was performed. Clinical success was defined as patient stability 30 days’ post embolization and complications included subsequent bleeding requiring endoscopy, surgery or additional embolization, or death.&#x0D; Results: Overall clinical success rate was 86.8% (33/38). Complications included 14 patients (36.8%) experiencing continued bleeding, 6 patients (15.8%) requiring repeat endoscopic evaluation, 8 patients (21.1%) requiring surgery, 3 patients (7.9%) requiring repeat embolization, and 4 deaths (10.5%). These results were not inferior to clinical success rates reported in the literature for GIB regardless of location. Positive predictive value for multiphase CT angiogram was 92.3% and the negative predictive value was 57.1%.&#x0D; Conclusions: Interventional angiography and embolization is an effective treatment for GIB with the most common complication being recurrent bleeding which may require additional endoscopic evaluation, surgical intervention or additional embolization. Clinical success and complication rates at this centre are similar to those reported in the literature. Continued evaluation of the utility of multiphase CT angiography prior to conducting embolization should be considered to determine its impact on rates of negative angiogram studies.

No role for tranexamic acid in the treatment of acute gastrointestinal bleeding

The HALT-IT Trial has shown that tranexamic acid does not improve outcome in acute gastrointestinal bleeding and may instead increase the risk of complications . Tranexamic acid (TXA) is an...

Clinical approach to the patient with acute gastrointestinal bleeding.

Gastrointestinal bleeding (GIB) is a very common condition at all ages, with high rates of morbidity and mortality, especially in case of acute presentation. The optimal management of acute GIB requires a timely overview of vital signs and clinical presentation to stabilize the patient if necessary and set up the most adequate diagnostic and therapeutic approach, based on the suspected etiology. Endoscopy plays a major role both in diagnosis and treatment of acute GIB, as allows the application of several hemostasis techniques during the diagnostic session, which should preferably be performed within 24 hours from the acute event. The hemostasis technique should be chosen based on type, etiology of the bleeding and the operator preference and expertise. Nevertheless, several challenging cases need the cooperation of radiology especially in the diagnostic phase, and even in the therapeutic phase for those bleedings in which medical and endoscopic techniques have failed. Imaging diagnostic techniques include mainly CT angiography, scintigraphy with labeled erythrocytes and arteriography. This last technique plays also a therapeutic role in case arterial embolization is needed. Only those patients in which the previous techniques have failed, both in diagnosis and treatment, are candidates for emergency surgery. (www.actabiomedica.it)

Modern methods of diagnosis and treatment of acute gastrointestinal bleeding of various etiology

Aim. Analysis of the treatment results in patients with gastrointestinal bleeding with the use of endoscopic and surgical methods of hemostasis.Methods. Analysis of the treatment results in 421 patients with acute gastrointestinal bleeding from the urgent surgical department of City Clinical Hospital №7 of Kazan was conducted.Results. Endoscopic methods of hemostasis in bleeding from the upper gastrointestinal tract (argon plasma coagulation, combined prolonged infiltration hemostasis with the use of 6% solution of polyglucin with mafusol, irrigation with the solution «Hemolab», ligation of the esophageal veins and Danis stent implantation) were applied to 404 patients. All patients simultaneously received conservative treatment. When using the methods of endoscopic hemostasis mentioned above in patients with bleeding from upper gastrointestinal tract the efficiency was achieved in 87.9% of cases. It was the highest when using combined endoscopic methods. Recurrent acute bleeding was diagnosed in 30 (7.1%) cases. Majority of the patients with recurrent bleeding suffered from gastric ulcer and/or duodenal ulcer (21 patients). In all 30 patients with recurrent bleeding surgical intervention with the author’s technique was performed.Conclusion. The efficacy of endoscopic methods of hemostasis in bleeding from the upper gastrointestinal tract, especially their combined use, was revealed; differentiated approach to the use of endoscopic and surgical techniques of hemostasis depending on the source of bleeding and its intensity is required.

Hemospray: a novel therapeutic option in the management of acute upper gastrointestinal bleeding

Early endoscopic diagnosis and endoscopic therapy are very important in cases of acute gastrointestinal bleeding. Hemospray is an inorganic powder with hemostatic properties recently proposed for the treatment of acute gastrointestinal bleeding. The aim of the authors was to report the first Hungarian experience obtained with Hemospray in patients with acute gastrointestinal bleeding. During a 14-month period 10 acute upper gastrointestinal bleeder patients were treated endoscopically with Hemospray in 11 settings. In 5 patients previous endoscopic hemostatic methods failed and in the remaining 5 patients Hemospray was administrated as a first-line therapy. Primary hemostasis was achieved in 9 of the 10 patients treated with Hemospray. Two patients died during hospitalization (uncontrolled arterial bleeding in one patient and hepatic encephalopathy in the other one patient). Primary hemostasis and hemodynamic stability were achieved in each of the 4 patients who had thrombopenia. Hemospray as a rescue therapy may ensure primary hemostasis in severe acute gastrointestinal bleeding even in cases with thrombopenia.

Outcomes in Bloodless Medicine Patients With Acute Gastrointestinal Bleeding

Introduction: Red blood cell transfusion is often indicated in acute gastrointestinal bleeding (GIB), but some patients refuse blood transfusion for personal or religious reasons. Limited data exists regarding the clinical management and outcomes in this population. We describe the in-hospital mortality and endoscopic outcomes of patients with overt GIB. Methods: A single center retrospective cohort study was performed using the clinical database of the Bloodless Medicine Referral Center at a university-affiliated hospital. Inclusion criteria were age 18 years or older, inpatient admission between January 2007 and January 2014, an ICD-9 diagnosis code for GIB, and documented refusal of blood transfusion. Results: Ninety-two patients (63% female, 37% male) met inclusion criteria. Mean age was 68 years (range 20-97) with a median length of stay of 5 days (range 0-48 days). A source of bleeding was documented in 86% of patients (35% upper, 51% lower, and 14% undetermined). For medical therapy, 76% received intravenous iron, 75% received erythropoietin, and 30% received aminocaproic acid. In-hospital mortality was 8.6%. Fifty-two patients (56%) underwent endoscopy (45% EGD, 30% colonoscopy, and 25% both). In the endoscopy group, mean admission hemoglobin was 9.2 g/dL (range 4.5-14.7), mean nadir hemoglobin was 7.8 g/dL (range 3.5-14.3) and in-hospital mortality was 1.9%. A source of bleeding was identified on endoscopy in 61% of patients. Of the 40 patients who did not undergo endoscopy, mean admission hemoglobin was 8.9 g/dL (range 3.5-14.9), mean nadir hemoglobin was 7.3 g/dL (range 3-13.2), and in-hospital mortality was 17.5%. Conclusion: In carefully selected Bloodless Medicine patients, endoscopy is safe and effective in the evaluation and treatment of acute GIB.

PTU-029 The Use Of Endoclot™ Therapy In The Endoscopic Management Of Gastrointestinal Bleeding

IntroductionEndoclot™ is a non-toxic topical haemostatic powder consisting of absorbable modified polymers. We previously described our early experience using Endoclot™ as an adjunct haemostatic endoscopic therapy in 6 patients undergoing...

Outcome and predictive factors of successful transarterial embolization for the treatment of acute gastrointestinal hemorrhage

Transarterial embolization (TAE) is an effective procedure for the treatment of acute gastrointestinal bleeding (GIB). Factors associated with clinical success have not been well delineated. To evaluate the technical and clinical successes of TAE for acute GIB in order to identify factors influencing clinical success and in-hospital mortality. This was a retrospective study of 70 consecutive patients with GIB who underwent angiography and embolization between January 2004 and December 2011. The technical success rate, clinical success rate, and in-hospital mortality were calculated by percentage. Clinical parameters, angiographic, and embolization data were assessed for factors influencing clinical success and in-hospital survival using univariate and multivariate analysis. Statistical significance was set at P value <0.05. The technical success rate was 98.6%. The primary clinical success rate was 71.4% and the secondary clinical success rate after repeat embolization was 78.6%. Bowel infarction was the most serious complication of three (4.3%) patients. Failure to achieve 30-day hemostasis can be predicted in patients who have one or more of the following factors: hemoglobin concentration <8 g/dL (P = 0.004), coagulopathy (P = 0.005), upper GIB (P = 0.02), contrast extravasation (P = 0.012), and more than one embolized vessel (P = 0.005). In-hospital survival is affected by the amount of transfused packed red blood cells before embolization (P = 0.008) and post-embolization bowel infarction (P = 0.005). TAE is a feasible and effective management of acute GIB with high technical and clinical success rates. The factors influencing clinical success include hemoglobin concentration, coagulopathy, upper GIB, contrast extravasation, and more than one embolized vessel. The number of units of transfused packed red blood cells and post-embolization bowel infarction are important factors associated with in-hospital mortality.

PWE-046 Early Clinical Experience of Endoclot™ in the Treatment of Acute Gastro-Intestinal Bleeding

IntroductionEndoClot™ is a new novel haemostatic powder for the treatment of gastrointestinal bleeding. We report our initial experiences of EndoClot™ as an adjunct haemostatic therapy. This is the first UK...

Over-the-scope clip (OTSC) represents an effective endoscopic treatment for acute GI bleeding after failure of conventional techniques

Through-the-scope clips are commonly used for endoscopic hemostasis of gastrointestinal (GI) bleeding, but their efficacy can be suboptimal in patients with complex bleeding lesions. The over-the-scope clip (OTSC) could overcome the limitations of through-the-scope clips by allowing compression of larger amounts of tissue, allowing a more efficient hemostasis. We analyzed the use of OTSC in a consecutive case series of patients with acute GI bleeding unresponsive to conventional endoscopic treatment modalities. In a retrospective analysis of prospectively collected data in tertiary referral centers, patients undergoing emergency endoscopy for severe acute nonvariceal GI bleeding were treated with the OTSC after failure of conventional techniques. All patients underwent repeat endoscopy 2-4 days after the procedure. Data analysis included primary hemostasis, complications, and 1-month follow-up clinical outcome. During a 10-month period, 30 patients entered the study consecutively. Bleeding lesions unresponsive to conventional endoscopic treatment (saline/adrenaline injection and through-the-scope clipping) were located in the upper and lower GI tract in 23 and 7 cases, respectively. Primary hemostasis was achieved in 29 of 30 cases (97 %). One patient with bleeding from duodenal bulb ulcer required emergent selective radiological embolization. Rebleeding occurred in two patients 12 and 24 h after the procedure; they were successfully treated with conventional saline/adrenaline endoscopic injection. OTSC is an effective and safe therapeutic option for severe acute GI bleeding when conventional endoscopic treatment modalities fail.

Treatment of Nonvariceal Gastrointestinal Hemorrhage by Transcatheter Embolization

Purpose. To investigate the sensitivity of mesenteric angiography, technical success of hemostasis, clinical success rate, and complications of transcatheter embolization for the treatment of acute nonvariceal gastrointestinal hemorrhage. Material and Methods. A retrospective review of 200 consecutive patients who underwent mesenteric arteriography for acute nonvariceal gastrointestinal hemorrhage between February 2004 and February 2011 was done. Results. Of 200 angiographic studies, 114 correctly revealed the bleeding site with mesenteric angiography. 47 (41%) patients had upper gastrointestinal hemorrhage and 67 (59%) patients had lower gastrointestinal hemorrhage. Out of these 114, in 112 patients (98%) technical success was achieved with immediate cessation of bleeding. 81 patients could be followed for one month. Clinical success was achieved in 72 out of these 81 patients (89%). Seven patients rebled. 2 patients developed bowel ischemia. Four patients underwent surgery for bowel ischemia or rebleeding. Conclusion. The use of therapeutic transcatheter embolization for treatment of acute gastrointestinal hemorrhage is highly successful and relatively safe with 98% technical success and 2.4% postembolization ischemia in our series. In 89% of cases it was definitive without any further intervention.

Transarterial treatment of acute gastrointestinal bleeding: Prediction of treatment failure by clinical and angiographic parameters

BackgroundAcute gastrointestinal bleeding (GIB) is a life-threatening abdominal emergency and can be treated by transarterial embolization (TAE). Rehemorrhage and poor outcome are associated with several clinical factors. This study investigated the clinical and angiographic parameters associated with treatment failure for patients with acute GIB undergoing TAE. MethodsSixty-seven patients who had angiographic evidence of contrast extravasation and who received subsequent TAE were included in this study. Treatment failure was defined as continuous or recurrent bleeding that required surgery within 7 days after the bleeding episode and/or death within 1 month. Univariate and multivariate logistic regression was applied to analyze the clinical and angiographic parameters affecting treatment failure. ResultsPatients were divided into two groups: success (n = 35, 52.3%) and failure (n = 32, 47.7%). In the failure group, 22 patients (68.9%) re-bled and then received surgery. With the aid of angiographic localization, 68.2% (15 of 22 patients) survived after surgery. The other 10 patients who did not receive surgery died within 30 days. Several clinical and angiographic parameters analyzed by multivariate analysis were associated with treatment failure (p < 0.05), including presence of coagulopathy [odds ratio (OR), 14.7], number of supplying arteries >1 (OR, 13.2), and a distance of >5 cm (OR, 6.3) during TAE. ConclusionAngiographic parameters associated with treatment failure in patients undergoing TAE are established when the number of supplying arteries is >1, and a distance of >5 cm. Patients with these risk factors should be watched carefully for recurrence in the post-procedural period.

Acute Gastrointestinal Bleeding: Emerging Role of Multidetector CT Angiography and Review of Current Imaging Techniques

Acute gastrointestinal bleeding is a common cause of hospitalization, morbidity, and mortality in the United States. The evaluation and treatment of acute gastrointestinal bleeding are complex and often require a multispecialty approach involving gastroenterologists, surgeons, internists, emergency physicians, and radiologists. The multitude of pathologic processes that can result in gastrointestinal bleeding, the length of the gastrointestinal tract, and the often intermittent nature of gastrointestinal bleeding further complicate patient evaluation. In addition, there are multiple imaging modalities and therapeutic interventions that are currently being used in the evaluation and treatment of acute gastrointestinal hemorrhage, each with its own strengths and weaknesses. Initial experience indicates that multidetector computed tomographic angiography is a promising first-line modality for the time-efficient, sensitive, and accurate diagnosis or exclusion of active gastrointestinal hemorrhage and may have a profound impact on the evaluation and subsequent treatment of patients who present with acute gastrointestinal bleeding.

On-Call Treatment of Acute Gastrointestinal Hemorrhage

Urgent treatment of gastrointestinal bleeding is multidisciplinary and often variable by institution. In general, medical management is the first-line therapy for both upper and lower gastrointestinal hemorrhage. In severe upper gastrointestinal hemorrhage, endoscopy is performed prior to other interventions as it is often both diagnostic and therapeutic. Embolization is performed for refractory arterial bleeding. Transjugular portosystemic shunt insertion may be performed to treat refractory variceal bleeding although its use at night is controversial. The treatment algorithm for lower gastrointestinal bleeding is less clear but in general, severe bleeding is handled in the interventional suite by superselective embolization and less severe bleeding is initially treated by endoscopy after an 8- to 12-hour bowel prep. This article will summarize the current approach in my hospital for treating patients with acute gastrointestinal hemorrhage.

Emergency department capsule endoscopy for acute gastrointestinal bleeding: A randomized pilot study

Study objectives: For more than 30 years, the first step in diagnosis or treatment of acute gastrointestinal bleeding has been upper endoscopy/enteroscopy (EGD) and colonoscopy. Approximately 80% of patients do not have a source of bleeding detected, possibly because the source of bleeding is outside the range of EGD or colonoscopy or because the bleeding has already stopped by the time the procedure is performed. We conduct a pilot study to obtain preliminary information on whether capsule endoscopy can improve detection of a source of acute gastrointestinal bleeding in the emergency department (ED) setting. Methods: The study was performed in a community teaching hospital with 30,000 ED visits per year. Twenty-four patients were randomized to either early (capsule endoscopy in the ED before conventional investigations) or late (capsule endoscopy after conventional evaluation completed) in a 2:1 ratio. Diagnostic information from the capsule endoscopy was provided to the primary care physician as soon as the physician could be reached. Additional evaluation was performed at the discretion of the primary care physician. Results: Of the 138 patients screened during a 6-month period, 24 met our inclusion criteria (nonhematemesis acute gastrointestinal bleeding) and signed consent. On presentation to the ED, the 2 groups were similar in age, sex, initial blood pressure, hematocrit level, and use of anticoagulants, aspirin, and nonsteroidal anti-inflammatory drugs. Twenty-one (88%) of 24 patients were taking anticoagulants or antiplatelet agents. Within 24 hours of enrollment, 12 (75%) of 16 patients in the early capsule endoscopy group had a presumptive source of bleeding capsule endoscopy (10), EGD (1), or colonoscopy (1) versus 3 (38%) of 8 patients (EGD [3]) in the late capsule endoscopy group ( P =.099). Median time to presumptive diagnosis by any modality was 19 hours in the early capsule endoscopy group versus 35 hours in the late capsule endoscopy group ( P =.06). Overall, active bleeding was detected by capsule endoscopy in 13 (54%) of 24 patients, 2 (11%) of 17 by EGD, and zero (0%) of 13 by colonoscopy. Capsule endoscopy provided minimal or no useful data in 4 (17%) of 24 patients because of failure to swallow the capsule (1) or gastric retention (3). Conclusion: In this pilot study, there was a strong trend to a significant increase in detection and decrease in time to detection of a presumptive source of bleeding when capsule endoscopy was performed in the ED setting.

Superselective Embolization with Microcoil in Acute Gastrointestinal Hemorrhage

Purpose: To evaluate the efficacy and safety of superselective arterial embolization using the microcoil in acute gastrointestinal hemorrhage. Materials and Methods: We evaluated 11 of 42 patients who had undergone diagnostic angiography and tran-scatheter arterial embolization due to acute gastrointestinal hemorrhage and subsequently underwent superselective arterial embolization using the microcoil. Nine were males and two were females, and their age ranged from 33 to 70 (mean, 51) years. The etiologies were bleeding ulcer (n=5), pseudoaneurysm from pancreatitis (n=3), and postoperative bleeding (n=3). The symptoms were melena, hematemesis, and hematochezia, and the critical signs were decreased hemoglobin and worsening of vital signs. All patients underwent superselective embolization using the microcatheter and microcoil. Results: Bleeding occurred in the gastroduodenal artery (n=5), inferior pancreaticoduodenal artery (n=2), left gastric artery (n=2), right hepatic artery (n=1), and ileal branch of the superior mesenteric artery (n=1). All cases were treated succesfully, without complications. In one case in which there was bleeding in the right he-patic artery, reembolization with a microcoil was needed because of persistent melena. During follow up, three patients died from complications arising underlying diseases, namely disseminated intravascular coagulopathy, chronic renal failure, and adult respiratory distress syndrome. Procedural complications, such as ischemia or infarction were not noted. Conclusion: Superselective arterial embolization using the microcoil is a safe and effective method for the treatment of acute gastrointestinal bleeding, and does not lead to complications.

A CASE OF RHABDOMYOLYSIS ASSOCIATED WITH A USE OF INTRAVENOUS VASOPRESSIN

We report a case of rhabdomyolysis associated with a continuous infusion of vasopressin (VP) used in the treatment of acute gastrointestinal bleeding. A 68-year-old man with alcoholic liver cirrhosis was admitted to the hospital because of massive anal bleeding. Endoscopy showed no active bleeding site in the esophagus, stomach, duodeum and colon. Bleeding from the small intestine was suspected and an open laparotomy was performed. During surgery, no bleeding point was found and portal vein pressure was 30mmHg. After the operation, gastrointestinal bleeding continued, and a continuous intravenous VP infusion was started at a rate of 0.2U/min. Ten hours after administration of VP, skin mottling in the lower extremitis were noted. The serum myoglobin level was 17, 100ng/ml. Rhabdomyolysis due to VP was diagnosed, and the VP infusion was suspended. But because of exacerbation of the gastrointestinal bleeding, VP infusion was resumed at a rate of 0.1U/min. Transjugular intrahepatic portosystemic shunt (TIPS) was performed and portal vein pressure was markedly reduced after TIPS. But the skin mottling extended to the truncus. The patient died of multiple organ failure and sepsis. As far as we could review, only seven cases of rhabdomyolysis associated with a continuous infusion of vasopressin have been reported.