title: Critical illness-related corticosteroid insufficiency in cirrhotic patients with acute gastroesophageal variceal bleeding: risk factors and association with outcome*.
abstract: OBJECTIVE
  Critical illness-related corticosteroid insufficiency can adversely influence the prognosis of critically ill patients. However, its impact on the outcomes of patients with cirrhosis and acute gastroesophageal variceal bleeding remains unknown. We evaluated adrenal function using short corticotropin stimulation test in patients with cirrhosis and gastroesophageal variceal bleeding. The main outcomes analyzed were 5-day treatment failure and 6-week mortality.
  
  
  METHODS
  Prospective observational study.
  
  
  METHODS
  Ten-bed gastroenterology-specific medical ICU at a 3,613-bed university teaching hospital in Taiwan.
  
  
  METHODS
  Patients with liver cirrhosis and acute gastroesophageal variceal bleeding.
  
  
  METHODS
  None.
  
  
  RESULTS
  We evaluated adrenal function using short corticotropin stimulation test in 157 episodes of gastroesophageal variceal bleeding in 143 patients with cirrhosis. Critical illness-related corticosteroid insufficiency occurred in 29.9% of patients. The patients with critical illness-related corticosteroid insufficiency had higher rates of treatment failure and 6-week mortality (63.8% vs 10.9%, 42.6% vs 6.4%, respectively; p < 0.001). The cumulative rates of survival at 6 weeks were 57.4% and 93.6% for the critical illness-related corticosteroid insufficiency group and normal adrenal function group, respectively (p < 0.001). The cortisol response to corticotropin was inversely correlated with Model for End-Stage Liver Disease and Child-Pugh scores and positively correlated with the levels of high-density lipoprotein and total cholesterol. Hypovolemic shock, high-density lipoprotein, platelet count, and bacterial infection at inclusion are independent factors predicting critical illness-related corticosteroid insufficiency, whereas critical illness-related corticosteroid insufficiency, Model for End-Stage Liver Disease score, hypovolemic shock, hepatocellular carcinoma, and active bleeding at endoscopy are independent factors to predict treatment failure. Multivariate analysis also identified Model for End-Stage Liver Disease score, hypovolemic shock, and bacterial infection at inclusion as independent factors associated with 6-week mortality.
  
  
  CONCLUSIONS
  Critical illness-related corticosteroid insufficiency is common in cirrhotic patients with acute gastroesophageal variceal bleeding and is an independent factor to predict 5-day treatment failure.
authors.affiliation: 1Division of Digestive Therapeutic Endoscopy, Chang Gung Memorial Hospital, Chang Gung University, Taipei, Taiwan. 2Division of Gastroenterology, Department of Medicine, Taipei Veterans General Hospital, Faculty of Medicine, National Yang-Ming University, Taipei, Taiwan. 3Division of Endocrinology, Chang Gung Memorial Hospital, Chia-Yi, Taiwan. 4Division of Critical Care Nephrology, Chang Gung Memorial Hospital, Taipei, Taiwan. 5Division of Gastroenterology, Chang Gung Memorial Hospital, Chia-Yi, Taiwan.
authors.forename: Ming-Hung
authors.initials: MH
authors.lastname: Tsai
authors.forename: Hui-Chun
authors.initials: HC
authors.lastname: Huang
authors.forename: Yun-Shing
authors.initials: YS
authors.lastname: Peng
authors.forename: Yung-Chang
authors.initials: YC
authors.lastname: Chen
authors.forename: Ya-Chung
authors.initials: YC
authors.lastname: Tian
authors.forename: Chih-Wei
authors.initials: CW
authors.lastname: Yang
authors.forename: Jau-Min
authors.initials: JM
authors.lastname: Lien
authors.forename: Ji-Tseng
authors.initials: JT
authors.lastname: Fang
authors.forename: Cheng-Shyong
authors.initials: CS
authors.lastname: Wu
authors.forename: Fa-Yauh
authors.initials: FY
authors.lastname: Lee
mesh_terms: D000302:Adrenal Cortex / Q000378:metabolism*; D000304:Adrenal Cortex Function Tests; D000328:Adult; D000368:Aged; D015897:Comorbidity; D016638:Critical Illness / Q000401:mortality*; D004932:Esophageal and Gastric Varices / Q000453:epidemiology / Q000401:mortality*; D005260:Female; D006471:Gastrointestinal Hemorrhage / Q000453:epidemiology / Q000401:mortality*; D006801:Humans; D007362:Intensive Care Units; D008103:Liver Cirrhosis / Q000453:epidemiology / Q000401:mortality*; D008297:Male; D008875:Middle Aged; D011446:Prospective Studies; D012307:Risk Factors; D012720:Severity of Illness Index; D013624:Taiwan