title: Critical illness-related corticosteroid insufficiency in patients with cirrhosis and variceal bleeding.
abstract: OBJECTIVE
  Relative adrenal insufficiency (AI) occurs in patients with cirrhosis with sepsis, but not with variceal bleeding. We evaluated adrenal function in cirrhotic patients with and without bleeding.
  
  
  METHODS
  Twenty cirrhotic patients with variceal bleeding were evaluated using the short synacthen test (SST) and 10 using the low-dose synacthen test (LDSST) followed by SST. The control group included 60 stable cirrhotic patients, assessed by LDSST (n = 50) or SST (n = 10), and 14 healthy volunteers. AI was diagnosed using SST, based on peak cortisol levels ≤ 18 μg/dL in nonstressed patients or Δmax <9 μg/dL or a total cortisol level <10 μg/dL in stressed patients with variceal bleeding-the current criteria for critical illness-related corticosteroid insufficiency. Using LDSST, diagnosis was based on peak concentrations of cortisol ≤ 18 μg/dL in nonstressed patients and <25 μg/dL (or Δmax <9 μg/dL) in patients with variceal bleeding. We evaluated patients with levels of serum albumin >2.5 g/dL, to indirectly assess cortisol binding.
  
  
  RESULTS
  All healthy volunteers had normal results from LDSSTs and SSTs. Patients with variceal bleeding had higher median baseline concentrations of cortisol (15.4 μg/dL) than stable cirrhotic patients (8.7 μg/dL, P = .001) or healthy volunteers (10.1 μg/dL, P = .01). Patients with variceal bleeding had higher median peak concentrations of cortisol than stable cirrhotic patients (SST results of 32.7 vs 21 μg/dL, P = .001; LDSST results of 9.3 vs 8.1 μg/dL; nonsignificant), with no differences in Δmax in either test. These differences were greater with variceal bleeding than in stable cirrhotic patients with AI. Subanalysis of patients with albumin levels >2.5 g/dL did not change these differences.
  
  
  CONCLUSIONS
  Cirrhotic patients with variceal bleeding have AI. Despite higher baseline concentrations of serum cortisol and subnormal Δmax values, they did not have adequate responses to stress, and therefore had critical illness-related corticosteroid insufficiency.
authors.affiliation: Department of Gastroenterology, University Hospital of Patras, Patras, Greece. chtriantos@hotmail.com
authors.forename: Christos K
authors.initials: CK
authors.lastname: Triantos
authors.forename: Michel
authors.initials: M
authors.lastname: Marzigie
authors.forename: Giuseppe
authors.initials: G
authors.lastname: Fede
authors.forename: Marina
authors.initials: M
authors.lastname: Michalaki
authors.forename: Dimitra
authors.initials: D
authors.lastname: Giannakopoulou
authors.forename: Konstantinos
authors.initials: K
authors.lastname: Thomopoulos
authors.forename: Matteo
authors.initials: M
authors.lastname: Garcovich
authors.forename: Maria
authors.initials: M
authors.lastname: Kalafateli
authors.forename: Aris
authors.initials: A
authors.lastname: Chronis
authors.forename: Venetsana
authors.initials: V
authors.lastname: Kyriazopoulou
authors.forename: Eleni
authors.initials: E
authors.lastname: Jelastopoulou
authors.forename: Vasiliki
authors.initials: V
authors.lastname: Nikolopoulou
authors.forename: James
authors.initials: J
authors.lastname: O'Beirne
authors.forename: Andrew K
authors.initials: AK
authors.lastname: Burroughs
mesh_terms: D000305:Adrenal Cortex Hormones / Q000172:deficiency*; D000328:Adult; D000368:Aged; D016638:Critical Illness; D005260:Female; D006471:Gastrointestinal Hemorrhage / Q000150:complications*; D006801:Humans; D006854:Hydrocortisone / Q000097:blood; D008103:Liver Cirrhosis / Q000150:complications*; D008297:Male; D008875:Middle Aged
chemical_list: D000305:Adrenal Cortex Hormones; D006854:Hydrocortisone