Respiratory Trials·org

Topic

Gastroenterology in critical care

GI bleeding, stress ulcer prophylaxis, and liver failure.

Stress ulcer prophylaxis works. Pantoprazole cut clinically important upper gastrointestinal bleeding from 3.5% to 1.0% in ventilated patients, with no effect on mortality in either direction (REVISE). Which agent is used matters far less — proton pump inhibitors and H2 blockers gave equivalent mortality across nearly 27,000 patients (PEPTIC).

Transfuse less in gastrointestinal bleeding. A restrictive threshold improved survival and reduced rebleeding (Villanueva 2013), plausibly because transfusion raises portal pressure. Tranexamic acid does not work here, despite working in trauma and obstetric haemorrhage: no reduction in death from bleeding and more venous thromboembolism (HALT-IT).

In liver disease, albumin with an antibiotic prevents renal failure and death in spontaneous bacterial peritonitis (Sort 1999) — one of the clearest indications for albumin anywhere. Early TIPS almost abolished rebleeding in high-risk variceal bleeding (Early TIPS). Terlipressin reverses hepatorenal syndrome in a third of patients and causes respiratory failure (CONFIRM), which is why volume status governs who is offered it.

Acute liver failure

Trial Year Therapy Effect Finding
CRRT in acute liver failure registry cohort 2018 Continuous renal replacement therapy Continuous renal replacement therapy lowered ammonia and was associated with better transplant-free survival; intermittent therapy was associated with worse
NAC in non-paracetamol ALF 2009 N-acetylcysteine N-acetylcysteine improved transplant-free survival in early non-paracetamol liver failure only

Stress ulcer prophylaxis

Trial Year Therapy Effect Finding
REVISE 2024 Pantoprazole Pantoprazole cut clinically important gastrointestinal bleeding from 3.5% to 1.0%
PEPTIC 2020 Proton pump inhibitor Mortality was similar with either default agent, though the proton pump inhibitor strategy trended higher and reduced gastrointestinal bleeding

Albumin in spontaneous bacterial peritonitis

Trial Year Therapy Effect Finding
Sort 1999 1999 Intravenous albumin Albumin with antibiotics prevented renal failure and death in spontaneous bacterial peritonitis

Antifibrinolytics in gastrointestinal bleeding

Trial Year Therapy Effect Finding
HALT-IT 2020 Tranexamic acid Tranexamic acid did not reduce death from gastrointestinal bleeding and caused more clots

Hepatorenal syndrome

Trial Year Therapy Effect Finding
CONFIRM 2021 Terlipressin Terlipressin reversed hepatorenal syndrome in a third of patients, at the cost of respiratory failure

Transfusion in gastrointestinal bleeding

Trial Year Therapy Effect Finding
Villanueva 2013 2013 Restrictive transfusion strategy Transfusing less in upper gastrointestinal bleeding improved survival

Variceal bleeding

Trial Year Therapy Effect Finding
Early TIPS 2010 Early transjugular intrahepatic portosystemic shunt Early TIPS almost abolished rebleeding and improved survival in high-risk variceal bleeding

Key references

Guidelines, standards and reviews for this topic.