Risk factors and their interactive effects on severe acute pancreatitis complicated with acute gastrointestinal injury

BACKGROUND There are many risk factors for severe acute pancreatitis(SAP)complicated with acute gastrointestinal injury(AGI),but few reports on the interaction between these risk factors.AIM To analyze the risk factors for SAP complicated with AGI and their interactive effects.METHODS We selected 168 SAP patients admitted to our hospital between December 2019 and June 2022.They were divided into AGI group and non-AGI group according to whether AGI was present.Demographic data and laboratory test data were compared between the two groups.The risk factors for SAP with concomitant AGI were analyzed using multifactorial logistic regression,and an analysis of the interaction of the risk factors was performed.RESULTS The percentage of patients with multiple organ dysfunction syndrome,acute physiological and chronic health scoring system II(APACHE II)score,white blood cell count and creatinine(CRE)level was higher in the AGI group than in the non-AGI group.There was a statistically significant difference between the two groups(P<0.05).Logistic regression analysis indicated that an APACHE II score>15 and CRE>100μmol/L were risk factors for SAP complicating AGI.The interaction index of APACHE II score and CRE level was 3.123.CONCLUSION An APACHE II score>15 and CRE level>100μmol/L are independent risk factors for SAP complicated with AGI,and there is a positive interaction between them.

Severity of acute gastrointestinal injury grade is a good predictor of mortality in critically ill patients with acute pancreatitis

BACKGROUND Gastrointestinal(GI)dysfunction is a common and important complication of acute pancreatitis(AP),especially in patients with severe AP.Despite this,there is no consensus means of obtaining a precise assessment of GI function.AIM To determine the association between acute gastrointestinal injury(AGI)grade and clinical outcomes in critically ill patients with AP.METHODS Patients with AP admitted to our pancreatic intensive care unit from May 2017 to May 2019 were enrolled.GI function was assessed according to the AGI grade proposed by the European Society of Intensive Care Medicine in 2012,which is mainly based on GI symptoms,intra-abdominal pressure,and feeding intolerance in the first week of admission to the intensive care unit.Multivariate logistic regression analysis was performed to assess the association between AGI grade and clinical outcomes in critically ill patients with AP.RESULTS Among the 286 patients included,the distribution of patients with various AGI grades was 34.62%with grade I,22.03%with grade II,32.52%with grade III,and 10.84%with grade IV.The distribution of mortality was 0%among those with grade I,6.35%among those with grade II,30.11%among those with grade III,and 61.29%among those with grade IV,and AGI grade was positively correlated with mortality(χ2=31.511,P<0.0001).Multivariate logistic regression analysis showed that age,serum calcium level,AGI grade,persistent renal failure,and persistent circulatory failure were independently associated with mortality.Compared with the Acute Physiology and Chronic Health Evaluation II score(area under the curve:0.739 vs 0.854;P<0.05)and Ranson score(area under the curve:0.72 vs 0.854;P<0.01),the AGI grade was more useful for predicting mortality.CONCLUSION AGI grade is useful for identifying the severity of GI dysfunction and can be used as a predictor of mortality in critically ill patients with AP.

Acute gastrointestinal injury in critically ill patients with COVID-19 in Wuhan,China

BACKGROUND The coronavirus disease 2019(COVID-19)is spreading rapidly around the world.Most critically ill patients have organ injury,including acute respiratory distress syndrome,acute kidney injury,cardiac injury,or liver dysfunction.However,few studies on acute gastrointestinal injury(AGI)have been reported in critically ill patients with COVID-19.AIM To investigate the prevalence and outcomes of AGI in critically ill patients with COVID-19.METHODS In this retrospective study,demographic data,laboratory parameters,AGI grades,clinical severity and outcomes were collected.The primary endpoints were AGI incidence and 28-d mortality.RESULTS From February 10 to March 102020,83 critically ill patients out of 1314 patients with COVID-19 were enrolled.Seventy-two(86.7%)patients had AGI during hospital stay,of these patients,30 had AGI gradeⅠ,35 had AGI gradeⅡ,5 had AGI gradeⅢ,and 2 had AGI gradeⅣ.The incidence of AGI gradeⅡand above was 50.6%.Forty(48.2%)patients died within 28 days of admission.Multiple organ dysfunction syndrome developed in 58(69.9%)patients,and septic shock in 16(19.3%)patients.Patients with worse AGI grades had worse clinical variables,a higher incidence of septic shock and 28-d mortality.Sequential organ failure assessment(SOFA)scores(95%CI:1.374-2.860;P<0.001),white blood cell(WBC)counts(95%CI:1.037-1.379;P=0.014),and duration of mechanical ventilation(MV)(95%CI:1.020-1.340;P=0.025)were risk factors for the development of AGI gradeⅡand above.CONCLUSION The incidence of AGI was 86.7%,and hospital mortality was 48.2%in critically ill patients with COVID-19.SOFA scores,WBC counts,and duration of MV were risk factors for the development of AGI gradeⅡand above.Patients with worse AGI grades had a higher incidence of septic shock and 28-d mortality.

Electroacupuncture in Treatment of Acute Gastrointestinal Injury in Patients with Severe Traumatic Brain Injury:A Multicenter Randomized Controlled Trial

Objective: To evaluate whether electroacupuncture(EA) would improve gastrointestinal function and clinical prognosis in patients with severe traumatic brain injury(TBI) complicocted by acute gastrointestinal injury(AGI). Methods: This multicenter, single-blind trial included patients with TBI and AGI admitted to 5Chinese hospitals from September 2018 to December 2019. A total of 500 patients were randomized to the control or acupuncture groups using a random number table, 250 cases in each group. Patients in the control group received conventional treatment, including mannitol, nutritional support, epilepsy and infection prevention, and maintenance of water, electrolytes, and acid-base balance. While patients in the acupuncture group received EA intervention at bilateral Zusanli(ST 36), Shangjuxu(ST 37), Xiajuxu(ST 39), Tianshu(ST 25), and Zhongwan(RN 12) acupoints in addition to the conventional treatment, 30 min per time, twice daily,for 7 d. The primary endpoint was 28-d mortality. The secondary endpoints were serum levels of D-lactic acid(D-lac), diamine oxidase(DAO), lipopolysaccharide(LPS), motilin(MTL) and gastrin(GAS), intra-abdominal pressure(IAP), bowel sounds, abdominal circumference, AGI grade, scores of gastrointestinal failure(GIF),Glasgow Coma Scale(GCS), Acute Physiology and Chronic Health Evaluation(APACHE Ⅱ), Sequential Organ Failure Assessment(SOFA), and Multiple Organ Dysfunction Syndrome(MODS), mechanical ventilation time,intense care unit(ICU) stay, and the incidence of hospital-acquired pneumonia. Results: The 28-d mortality in the acupuncture group was lower than that in the control group(22.80% vs. 33.20%, P<0.05). Compared with the control group, the acupuncture group at 7 d showed lower GIF, APACHE Ⅱ, SOFA, MODS scores, D-lac,DAO, LPS, IAP, and abdominal circumference and higher GCS score, MTL, GAS, and bowel sound frequency(all P<0.05). In addition, the above indices showed simillar changes at 7 d compared with days 1 and 3 in the EA group(all P<0.05). Conclusion: Early EA can improve gastrointestinal function and clinical prognosis in patients with severe TBI complicated by AGI.(Registration No. ChiCTR2000032276)

Evaluation of clinical application of ESICM acute gastrointestinal injury grading system： a single-center observational study

Background In 2012,the working group on abdominal problems of the European Society of Intensive Care Medicine （ESICM） proposed a definition and also guidelines for the grading system and treatment of acute gastrointestinal injury （AGI）.Until now,clinical reports on this topic have not been available,and the practicality of using the AGI grading system requires further validation in the clinic.Therefore,we conducted this study to evaluate the feasibility of utilizing the current AGI grading system in a clinical environment,and to provide evidence for its usefulness in assessing the severity and prognosis of critically ill patients with gastrointestinal dysfunction.Methods A total of 133 patients were examined for the presence or absence of AGI,their scores on the Acute Physiology and Chronic Health Evaluation （APACHE） Ⅱ and Lausanne Intestinal Failure Estimation （LIFE） test,and 28 days mortality.The presence and severity of AGI was based on guidelines provided by the ESICM.The patients were assigned to a NOAGI group （n=50） or an AGI group （n=83）.The AGI group was then further divided into three subgroups,consisting ofAGI Ⅰ （risk group,n=38）,AGI Ⅱ （gastrointestinal dysfunction group,n=33） and AGI Ⅲ＋AGI Ⅳ （gastrointestinal failure group,n=12）.These subgroups were then compared for differences in AGI indicators.Results There were no statistically significant differences between the AGI group and the NO-AGI group in terms of age,gender,APACHE Ⅱ score or LIFE score （P ＞ 0.05）; however,the two groups showed a significant difference in their respective rates of 28 days mortality （32.5％ in the AGI group vs.8.0％ in the NO-AGI group （P ＜ 0.05））.Patients in the three AGI subgroups showed significant differences in their 28 d mortality rates,APACHE Ⅱ,and LIFE scores.AGI grading system showed strong positive correlations with APACHE Ⅱ and LIFE scores （P ＜ 0.05）.Conclusions The currentAGI grading system can be used to identify and evaluate gastrointestinal dysfunction in critically ill patients,and also to provide a preliminary assessment regarding the prognosis for patients with different grades of AGI.

Heparanase inhibition leads to improvement in patients with acute gastrointestinal injuries induced by sepsis

BACKGROUND Patients with sepsis are at high risk for acute gastrointestinal injury(AGI),but the diagnosis and treatment of AGI due to sepsis are unsatisfactory.Heparanase(HPA)plays an important role in septic AGI(S-AGI),but its specific mechanism is not completely understood,and few clinical reports are available.AIM To explore the effect and mechanism of HPA inhibition in S-AGI patients.METHODS In our prospective clinical trial,48 patients with S-AGI were randomly assigned to a control group to receive conventional treatment,whereas 47 patients were randomly assigned to an intervention group to receive conventional treatment combined with low molecular weight heparin.AGI grade,sequential organ failure assessment score,acute physiology and chronic health evaluation II score,D-dimer,activated partial thromboplastin time(APTT),anti-Xa factor,interleukin-6,tumour necrosis factor-α,HPA,syndecan-1(SDC-1),LC3B(autophagy marker),intestinal fatty acid binding protein,D-lactate,motilin,gastrin,CD4/CD8,length of intensive care unit(ICU)stay,length of hospital stay and 28-d survival on the 1^(st),3^(rd) and 7^(th) d after treatment were compared.Correlations between HPA and AGI grading as well as LC3B were compared.Receiver operator characteristic(ROC)curves were generated to evaluate the diagnostic value of HPA,intestinal fatty acid binding protein and D-lactate in S-AGI.RESULTS Serum HPA and SCD-1 levels were significantly reduced in the intervention group compared with the control group(P<0.05).In addition,intestinal fatty acid-binding protein,D-lactate,AGI grade,motilin,and gastrin levels and sequential organ failure assessment score were significantly decreased(P<0.05)in the intervention group.However,LC3B,APTT,anti-Xa factor,and CD4/CD8 were significantly increased(P<0.05)in the intervention group.No significant differences in interleukin-6,tumour necrosis factor-α,d-dimer,acute physiology and chronic health evaluation II score,length of ICU stay,length of hospital stay,or 28-d survival were noted between the two groups(P>0.05).Correlation analysis revealed a significant negative correlation between HPA and LC3B and a significant positive correlation between HPA and AGI grade.ROC curve analysis showed that HPA had higher specificity and sensitivity in diagnosis of S-AGI.CONCLUSION HPA has great potential as a diagnostic marker for S-AGI.Inhibition of HPA activity reduces SDC-1 shedding and alleviates S-AGI symptoms.The inhibitory effect of HPA in gastrointestinal protection may be achieved by enhanced autophagy.

Outcomes of bowel program in spinal cord injury patients with neurogenic bowel dysfunction

In this study, we aimed to determine gastrointestinal problems associated with neurogenic bowel dysfunction in spinal cord injury patients and to assess the efficacy of bowel program on gastrointestinal problems and the severity of neurogenic bowel dysfunction. Fifty-five spinal cord injury patients were included in this study. A bowel program according to the characteristics of neurogenic bowel dysfunction was performed for each patient. Before and after bowel program, gastrointestinal problems（constipation, difficult intestinal evacuation, incontinence, abdominal pain, abdominal distension, loss of appetite, hemorrhoids, rectal bleeding and gastrointestinal induced autonomic dysreflexia） and bowel evacuation methods（digital stimulation, oral medication, suppositories, abdominal massage, Valsalva maneuver and manual evacuation） were determined. Neurogenic bowel dysfunction score was used to assess the severity of neurogenic bowel dysfunction. At least one gastrointestinal problem was identified in 44（80%） of the 55 patients before bowel program. Constipation（56%, 31/55） and incontinence（42%, 23/55） were the most common gastrointestinal problems. Digital rectal stimulation was the most common method for bowel evacuation, both before（76%, 42/55） and after（73%, 40/55） bowel program. Oral medication, enema and manual evacuation application rates were significantly decreased and constipation, difficult intestinal evacuation, abdominal distention, and abdominal pain rates were significantly reduced after bowel program. In addition, mean neurogenic bowel dysfunction score was decreased after bowel program. An effective bowel program decreases the severity of neurogenic bowel dysfunction and reduces associated gastrointestinal problems in patients with spinal cord injury.

针灸治疗急性胃肠损伤的系统评价和meta分析

Objective:To systematically review the clinical therapeutic effect of acupuncture on acute gastrointestinal injury(AGI)in critically ill patients.Methods:The randomized control trials of acupuncture for AGI in critically ill patients were retrieved from the databases,from inception to the cutoff date in August,2021,including China National Knowledge Infrastructure(CNKI),Wanfang,VIP,China Biology Medicine disc(CBM),PubMed,Science Direct and Cochrane Library.Simultaneously,the accomplished and published RCTs were further searched from American clinical trial registry platform(https://clinicaltrials.gov)and Chinese clinical trial registry platform(www.chictr.org.cn).Two researchers extracted the data and performed the quality evaluation of the eligible articles independently.The meta-analysis was undertaken,by using RevMan 5.4.Results:Totally,15 papers were included,involving 1316 patients.The results of meta-analysis showed that after treated with acupuncture,the differences were statistical significance as compared with the routine treatment group in the score of the second edition of Acute Physiology and Chronic Health Evaluation(APACHEII)(MD=-1.98,95%CI[-3.23,-0.73],P=0.002),gastrointestinal dysfunction score(MD=-0.33,95%CI[-0.41,-0.24],P<0.00001),the intra-abdominal pressure(mmHg)(MD=-2.74,95%CI[-3.81,-1.67],P<0.00001),intensive care unit(ICU)length of stay(MD=-3.15,95%CI[-5.99,-0.30],P<0.00001)and fatality rate in 28-day(RR=0.57,95%CI[0.39,0.85],P=0.006)in critically ill patients with AGI,respectively.Conclusion:The limited available evidence suggests that acupuncture relieves clinical symptoms and poor prognosis in the critically ill patients with AGI,thus,it is one of the potential therapies to AGI.Hence,acupuncture should be recommended into the regimen of AGI in critically ill patients and more highquality and multi-central trials can be undertaken in the further.