title: Relative adrenal insufficiency in severe acute variceal and non-variceal bleeding: influence on outcomes.
abstract: OBJECTIVE
  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.
  
  
  METHODS
  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.
  
  
  RESULTS
  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).
  
  
  CONCLUSIONS
  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.
authors: 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.
authors: Isabel
authors: I
authors: Graupera
authors: 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.
authors: Oana
authors: O
authors: Pavel
authors: Gastrointestinal Bleeding Unit, Department of Gastroenterology, Hospital de la Santa Creu i Sant Pau, Barcelona Autonomous University, Barcelona, Spain.
authors: Virginia
authors: V
authors: Hernandez-Gea
authors: Gastrointestinal Bleeding Unit, Department of Gastroenterology, Hospital de la Santa Creu i Sant Pau, Barcelona Autonomous University, Barcelona, Spain.
authors: Alba
authors: A
authors: Ardevol
authors: Department of Endocrinology, Hospital de la Santa Creu i Sant Pau, Barcelona Autonomous University, Barcelona, Spain.|Centro de Investigación Biomédica en Red de Enfermedades Raras (CIBER-ER), Barcelona, Spain.
authors: Susan
authors: S
authors: Webb
authors: Department of Clinical Biochemistry, Hospital de la Santa Creu i Sant Pau, Barcelona Autonomous University, Barcelona, Spain.
authors: Eulalia
authors: E
authors: Urgell
authors: Gastrointestinal Bleeding Unit, Department of Gastroenterology, Hospital de la Santa Creu i Sant Pau, Barcelona Autonomous University, Barcelona, Spain.
authors: Alan
authors: A
authors: Colomo
authors: Gastrointestinal Bleeding Unit, Department of Gastroenterology, Hospital de la Santa Creu i Sant Pau, Barcelona Autonomous University, Barcelona, Spain.
authors: Jordina
authors: J
authors: Llaó
authors: Gastrointestinal Bleeding Unit, Department of Gastroenterology, Hospital de la Santa Creu i Sant Pau, Barcelona Autonomous University, Barcelona, Spain.
authors: Mar
authors: M
authors: Concepción
authors: 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.
authors: Càndid
authors: C
authors: Villanueva
mesh_terms: D000208:Acute Disease; D000309:Adrenal Insufficiency / Q000453:epidemiology* / Q000473:pathology; D000368:Aged; D000369:Aged, 80 and over; D001707:Biopsy, Needle; D002423:Cause of Death; D015897:Comorbidity; D016001:Confidence Intervals; D016099:Endoscopy, Gastrointestinal / Q000379:methods; D004932:Esophageal and Gastric Varices / Q000453:epidemiology* / Q000473:pathology; D005260:Female; D006471:Gastrointestinal Hemorrhage / Q000453:epidemiology* / Q000473:pathology; D006801:Humans; D015994:Incidence; D008103:Liver Cirrhosis / Q000453:epidemiology / Q000473:pathology; D016015:Logistic Models; D008297:Male; D008875:Middle Aged; D015999:Multivariate Analysis; D011379:Prognosis; D011446:Prospective Studies; D018570:Risk Assessment; D012720:Severity of Illness Index; D013030:Spain; D018709:Statistics, Nonparametric; D016019:Survival Analysis