Graupera Isabel, Pavel Oana, Hernandez-Gea Virginia, Ardevol Alba, Webb Susan, Urgell Eulalia, Colomo Alan, Llaó Jordina, Concepción Mar, Villanueva Càndid
Gastrointestinal Bleeding Unit, Department of Gastroenterology, Hospital de la Santa Creu i Sant Pau, Barcelona Autonomous University, Barcelona, Spain.
Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Barcelona, Spain.
Liver Int. 2015 Aug;35(8):1964-73. doi: 10.1111/liv.12788. Epub 2015 Feb 10.
BACKGROUND & AIMS: Relative adrenal insufficiency (RAI) is common in critical illness and in cirrhosis, and is related with worse outcomes. The prevalence of RAI may be different in variceal and non-variceal bleeding and whether it may influence outcomes in these settings is unclear. This study assesses RAI and its prognostic implications in cirrhosis with variceal bleeding and in peptic ulcer bleeding.
Patients with severe bleeding (systolic pressure <100 mmHg and/or haemoglobin <8 g/L) from oesophageal varices or from a peptic ulcer were included. Adrenal function was evaluated within the first 24 h and RAI was diagnosed as delta cortisol <250 nmol/L after 250 μg of i.v. corticotropin.
Sixty-two patients were included, 36 had cirrhosis and variceal bleeding and 26 without cirrhosis had ulcer bleeding. Overall, 15 patients (24%) had RAI, 8 (22%) with variceal and 7 (24%) with ulcer bleeding. Patients with RAI had higher rate of bacterial infections. Baseline serum and salivary cortisol were higher in patients with RAI (P < 0.001) while delta cortisol was lower (P < 0.001). There was a good correlation between plasma and salivary cortisol (P < 0.001). The probability of 45-days survival without further bleeding was lower in cirrhotic patients with variceal bleeding and RAI than in those without RAI (25% vs 68%, P = 0.02), but not in non-cirrhotic patients with peptic ulcer bleeding with or without RAI (P = 0.75).
The prevalence of RAI is similar in ulcer bleeding and in cirrhosis with variceal bleeding. Cirrhotic patients with RAI, but not those with bleeding ulcers, have worse prognosis.
相对性肾上腺皮质功能不全（RAI）在危重症及肝硬化患者中较为常见，且与不良预后相关。RAI在静脉曲张破裂出血和非静脉曲张破裂出血中的患病率可能不同，其是否会影响这些情况下的预后尚不清楚。本研究评估了肝硬化合并静脉曲张破裂出血及消化性溃疡出血患者中的RAI及其预后意义。
纳入因食管静脉曲张或消化性溃疡导致严重出血（收缩压<100 mmHg和/或血红蛋白<8 g/L）的患者。在最初24小时内评估肾上腺功能，静脉注射250 μg促肾上腺皮质激素后，若增量皮质醇<250 nmol/L，则诊断为RAI。
共纳入62例患者，36例为肝硬化合并静脉曲张破裂出血，26例非肝硬化患者为溃疡出血。总体而言，15例患者（24%）存在RAI，其中8例（22%）为静脉曲张破裂出血，7例（24%）为溃疡出血。RAI患者细菌感染率更高。RAI患者的基线血清和唾液皮质醇水平较高（P<0.001），而增量皮质醇水平较低（P<0.001）。血浆和唾液皮质醇之间存在良好的相关性（P<0.001）。肝硬化合并静脉曲张破裂出血且存在RAI的患者45天无再次出血存活的概率低于无RAI的患者（25%对68%，P = 0.02），但在非肝硬化消化性溃疡出血患者中，无论有无RAI，该概率无差异（P = 0.75）。
RAI在溃疡出血和肝硬化合并静脉曲张破裂出血中的患病率相似。肝硬化合并RAI的患者预后较差，但溃疡出血患者并非如此。
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