Upper gastrointestinal bleeding in an open-access dedicated unit.

The open-access high dependency bleeding unit in Aberdeen admits all patients with suspected gastrointestinal bleeding from a stable adult population of 468,000. The aim is to reduce mortality, morbidity and hospital stay, and create a prospective whole community database. An agreed management protocol is based on prompt resuscitation and early diagnosis. From October 1991 to September 1993 there were 1,602 consecutive admissions with suspected upper or lower gastrointestinal haemorrhage. Bleeding was confirmed in 1,098 of 1,324 patients with presumed upper gastrointestinal haemorrhage, (117 bleeding episodes per 100,000 per year). The overall 30-day mortality was 3.9%, with all deaths attributable to significant concurrent illness. Mortality from peptic ulcer bleeding was 5.3%, with an operation rate of 17% and surgical mortality of 8%. Rapid diagnosis allowed 48% of 523 patients with trivial bleeds to be discharged after a median stay of 24 hours. Centralised expertise and equipment is the essence of the unit's success. The interests of patient care are better served, nursing skills are better developed and teaching opportunities better structured. The major improvement in clinical care, welcomed by hospital colleagues, management and general practitioners, makes the unit an indispensable part of acute medical provision.

The role of an open-access bleeding unit in the management of colonic haemorrhage. A 2-year prospective study.

BACKGROUND: Major colonic haemorrhage poses difficult diagnostic and therapeutic problems and, in contrast to upper gastrointestinal bleeding, has no generally accepted plan of management. METHODS: We report community-based prospective data accumulated over 2 years (1991-93) on 1602 patients referred to an open-access bleeding unit with suspected gastrointestinal haemorrhage. RESULTS: Of 278 (17%) admissions with suspected lower GI haemorrhage, 252 were confirmed. Forty-eight per cent were defined as "significant' bleeds, with a decrease in haemoglobin and cardiovascular compromise. Of 102 significant bleeds in subjects more than 60 years old, 29% rebled, and 12.6% required emergency surgery. Diverticular disease (24%) was the commonest diagnosis, with tumours, infective colitis, and inflammatory colitis each at 10%. The overall 30-day mortality for colonic bleeding was 5.1% (13 of 252), with only 1 death occurring in the group less than 60 years old. CONCLUSIONS: This study provides a unique database for the natural history of colonic bleeding and its management within the setting of a specialized bleeding unit.

Estimation of body composition from bioelectrical impedance of body segments: comparison with dual-energy X-ray absorptiometry.

In twenty-eight healthy subjects, ten men and eighteen women, with a range in body mass index (BMI) of 17.9-31.6 kg/m2 and an age range 20-60 years, body composition was estimated by dual-energy X-ray absorptiometry (DEXA), skinfold anthropometry (SFA) and bioelectrical impedance analysis (BIA) of the 'whole body' and body segments. In thirteen subjects muscle mass was also estimated by 24 h urinary creatinine excretion. The relationship between fat-free mass (FFM) determined by DEXA and the impedance index of each body segment (calculated as length2/impedance (Z)) was analysed. The strongest correlation was between FFM (DEXA) and height2/'whole-body' Z (ZW) (r 0.97 for the combined sexes, standard error of estimate (SEE) 2.72 kg). Separate prediction equations were found to be necessary for males and females when estimating FFM from BIA measurement of the arm (for men, r 0.93, SEE 1.98 kg; for women, r 0.75, SEE 2.87 kg). Muscle mass derived from 24 h creatinine excretion showed weak correlation with FFM (DEXA) (r 0.57, P = 0.03) and no correlation with FFM (SFA). FFM (SFA) correlated well with both FFM (DEXA) (r 0.96, SEE = 3.12 kg) and with height2/ZW (r 0.92, SEE 4.52 kg). Measurement of the impedance of the arm offers a simple method of assessing the composition of the whole body in normal individuals, and it appears comparable with other methods of assessment.

Cerebral function analyzing monitor and visual evoked potentials as a noninvasive method of detecting cerebral dysfunction in patients with acute hepatic and renal failure treated with intermittent machine hemofiltration.

We monitored the effect of 7 intermittent machine hemofiltration treatments in 4 patients with fulminant hepatic failure who had progressed to grade IV coma and developed acute oliguric renal failure. Prior to treatment the processed EEG showed excess slow wave activity, and the latency of the later visual evoked potentials (N2 and P2) was delayed. Following treatment there was a further increase in both EEG slow wave activity and latency of the N1, N2, and P2 potentials. Intracranial pressure increased from a median of 8 mm Hg (2-12, range) to 14 (8-28) following treatment, p < 0.05. There was a correlation between intracranial pressure and all of the later visual evoked potentials, for N3 r = 0.71, for P1 r = 0.39, and P2 r = 0.74, all p < 0.05. Although there appeared to be a good correlation between intracranial pressure and the noninvasive electrophysiological recordings, there were major changes in intracranial pressure, cerebral perfusion pressure, and cerebrospinal fluid pH during the first hour of treatment, during which time there were no discernable changes in EEG or evoked potentials. In this study, non-invasive neurophysiological methods were not found to be reliable as invasive methods in assessing acute, minute-by-minute changes in cerebral metabolism but these methods may have a role in the longer term in assessing patient prognosis.

Are patients with primary biliary cirrhosis hypermetabolic? A comparison between patients before and after liver transplantation and controls.

Wasting is common in end-stage primary biliary cirrhosis and causes concern in patients facing liver transplantation. We have quantified resting metabolic rate and diet-induced thermogenesis in seven patients with primary biliary cirrhosis, in seven patients after liver transplantation who had previously been diagnosed as having primary biliary cirrhosis and in seven controls. Resting metabolic rate was elevated in the primary biliary cirrhosis group (4.44 +/- 0.81 kJ/hr/kg body wt; mean +/- S.D.) compared with the post-liver-transplantation group (3.39 +/- 0.40 kJ/hr/kg body wt) (p less than 0.005) and compared with control subjects (3.65 +/- 0.23 kJ/hr/kg body wt) (p less than 0.01). A highly significant relationship was found between the severity of liver disease in the primary biliary cirrhosis group, as assessed by Child-Pugh score, and the resting metabolic rate group (r = 0.93; p less than 0.005). After a liquid meal (41 kJ/kg body wt), the metabolic rate increased, with similar peak changes from baseline occurring in all three groups. However, the rise persisted significantly longer in the primary biliary cirrhosis patients, and thus the integrated mean postprandial energy expenditure over the 4-hr postprandial observation period was greater in the primary biliary cirrhosis group than in the other two groups (p less than 0.001).(ABSTRACT TRUNCATED AT 250 WORDS)

Hodgkin's disease presenting as liver abscesses.

A patient is reported who presented with sterile hepatic abscesses which proved to be the first manifestation of Hodgkin's disease. He failed to improve with antibiotic treatment but responded to combined chemotherapy. Liver involvement as the first sign of Hodgkin's disease is rare. Liver abscesses due to Hodgkin's disease seem to be previously unreported.

Serum hyaluronate as a marker of hepatic derangement in acute liver damage.

Twenty patients with paracetamol(acetaminophen)-induced acute liver damage of varying severity were studied longitudinally with assessment of clinical state, standard liver function tests and radiometric hyaluronate (HYA) assay (Pharmacia). In patients (n = 6) who developed coma, HYA rose rapidly with clinical deterioration to reach a median value of 27,510 micrograms/l, 7 days post-ingestion, which was significantly higher (p less than 0.005) than in patients (n = 7) who exhibited only marked derangement of liver function tests without evidence of encephalopathy, HYA median value of 3240 micrograms/l. These peak values showed no correlation to the peak values of serum alanine aminotransferase (ALT). A third group of patients (n = 7) who were treated with N-acetyl cysteine, did not exhibit any evidence of liver failure and showed no significant rise in levels of HYA or ALT. The data demonstrate that HYA is a rapidly changing marker of liver derangement which appears to follow the clinical course of the patient. The increase to extremely high levels in patients with hepatic encephalopathy, suggests that there is a reversible defect in the hepatic endothelial cell HYA receptor, possibly due to endothelial cell damage or release of toxins from the necrotic liver.

Platelet activation in nocturnal asthma.

Platelet activation may be a factor in the bronchial hyperresponsiveness that characterises asthma. As hyperresponsiveness is increased at night, changes in platelet activation over 24 hours were related to the diurnal changes in peak expiratory flow and plasma catecholamine concentrations in five subjects with asthma and five normal subjects. The effect of muscarinic receptor blockade with intravenous atropine at 0400 hours on these measurements was also studied. Platelet activation, assessed as the ration of beta thromboglobulin to platelet factor 4, was highest when the peak expiratory flow rate was at its lowest in the asthmatic subjects. There was no correlation between platelet activation and plasma catecholamine concentrations. Intravenous atropine did not alter the ratio of beta thromboglobulin to platelet factor 4, suggesting that parasympathetic activity is not the cause of the increased platelet activation at night.

Improved bioavailability from a spironolactone beta-cyclodextrin complex.

The relative bioavailabilty of spironolactone from a complex with beta-cyclodextrin has been evaluated. Capsules containing 100 mg micronised spironolactone powder were compared with 100 mg spironolactone beta-cyclodextrin complex in 8 healthy volunteers by a single dose, double blind, crossover pharmacokinetic study. Subjects were randomly allocated to each preparation and crossed over after 2 weeks. Relative bioavailability was assessed by the measurement of serum canrenone concentrations. The mean relative bioavailability of the spironolactone cyclodextrin complex, compared to the micronised spironolactone powder, was 233%. Statistical analysis (Wilcoxon signed rank test) revealed that this difference was significant with a mean area under the serum concentration time curve of 3.90 and 1.88 mg.h.l-1 for the complex and micronised spironolactone powder, respectively. Four of the volunteer also received a 100 mg spironolactone tablet (Aldactone) under identical conditions. Pharmacokinetic analysis revealed that the mean relative bioavailability of the spironolactone beta cyclodextrin complex and micronised powder when compared with spironolactone tablets (Aldactone) was 252% and 124%, respectively. There was no change in the canrenone elimination half lives of each subject.

Treatment of metastatic Vipoma by liver transplantation.

We report the first case of metastatic Vipoma treated by orthotopic liver transplantation. A woman with explosive secretory diarrhea causing hypokalemic acidosis was diagnosed as having a vasoactive intestinal peptide secreting tumor with widespread hepatic metastases. The symptoms were initially controlled for 9 months with increasing doses of long-acting somatostatin analogue (Sandostatin, Sandoz Ltd, UK). Alpha interferon was not tolerated, causing an acute paranoid psychosis. Eventually orthotopic liver transplantation was performed with the removal of the primary tumor from the distal pancreas. Postoperatively, complications were associated with the distal pancreatectomy. The patient has no evidence of tumor recurrence on imaging or serum VIP level 12 months posttransplantation.

Morbidity and mortality due to cerebral edema complicating the treatment of severe leptospiral infection.

Although neurological signs and symptoms are well described in leptospiral infections, cerebral edema has not been reported previously. We have encountered two patients with severe leptospiral infection, associated with multisystem involvement, who developed cerebral edema. Both patients were in acute oligoanuric renal failure, one being treated by acetate hemodialysis and the other by hemofiltration. Grand mal seizures developed in both patients, followed by respiratory, then cardiac arrest, as a consequence of dialytic therapy. Only one patient could be resuscitated and he was left with a hemiparesis. Cerebral edema may develop in patients with severe leptospiral infections consequent to treatments used in the management of renal failure.

Invalidity of hand heating as a method to arterialize venous blood.

We have assessed in normal subjects the validity of using hand heating to obtain "arterialized" venous blood by biochemical comparison of results for "arterialized" venous and true arterial (radial artery) blood samples. The heating regimen involved placing one hand in an air-heated box at 45-50 degrees C for 45 min. This method produced blood that was "arterialized" for lactate, PCO2, HbO2, and Hb but not for ammonia or PO2; it had no effect on determinations of pyruvate or glucose in plasma. Despite using a lower air temperature than previous workers, we observed thermal injury in one volunteer. Further, there was considerable between-subject variation in the effect of hand heating on blood gases. This suggests that blood gases should be measured in the "arterialized" samples at regular intervals from the start of hand heating in each patient to determine whether maximal "arterialization" has been achieved, to avoid making misleading biochemical measurements. Given the wide range in degree of observed "arterialization," we question the validity of this method.

Pneumococcal Waterhouse-Friderichsen syndrome despite a normal spleen.

A previously fit 56 year old female presented with a rapidly progressive and fatal pneumococcal septicaemia with disseminated intravascular coagulation. Post-mortem studies confirmed a Waterhouse-Friderichsen syndrome and revealed an anatomically normal spleen; intracellular diplococci were seen within splenic macrophages providing evidence of normal splenic function. This appears to be only the second case of Waterhouse-Friderichsen syndrome due to pneumococcal septicaemia in a patient with a normal spleen.