Acute Gastrointestinal Injury in Polytrauma: Special Attention to Elderly Patients.

Background: Acute gastrointestinal injury (AGI) has been documented in critically ill patients, yet there remains a dearth of knowledge regarding its occurrence, predisposing factors, and outcomes in elderly polytrauma patients, a significant but overlooked population. This study aims to examine the frequency, risk factors, and clinical implications of AGI in elderly polytrauma patients. Methods: A retrospective, observational, multicenter study was carried out in two Level I trauma centers, encompassing a cohort of 1054 polytrauma patients from July 2020 to April 2022. Results: A total of 965 consecutive polytrauma patients were recruited who were divided into youth group (n=746) and elderly group (n=219). 73.5% of elderly patients after polytrauma were accompanied by AGI. An increasing ISS (OR=2.957, 95%CI: 1.285-7.714), SI (OR=2.861, 95%CI: 1.372-5.823), serum lactate (OR=2.547, 95%CI: 1.254-5.028), IL-6 (OR=1.771, 95%CI: 1.145-8.768), APTT (OR=1.462, 95%CI: 1.364-4.254) and a decreasing GCS (OR=0.325, 95%CI: 0.116-0.906) were each associated with an increasing risk of AGI in elderly polytrauma patients. Elderly polytrauma patients with AGI were presented relatively high 28-day mortality (40.4%) and super high 60-day mortality (61.2%) compared with elderly group without AGI and youth group with AGI. The area under the curve for predicting 28-day mortality in elderly polytrauma patients with AGI was 0.93 for AGI-III,IV with 96% sensitivity and 87% specificity. Conclusion: Elderly patients have a higher incidence and a worse prognosis of AGI after polytrauma. ISS, GCS, SI, serum lactate, IL-6, and APTT are identified as reliable prognostic markers to distinguish the AGI and N-AGI in elderly polytrauma patients. AGI-III,IV was the independent predictor of mortality in elderly polytrauma patients with AGI.

Trajectories of acute gastrointestinal injury grade in critically Ill children.

OBJECTIVE: To investigate the characteristics of different Acute Gastrointestinal Injury (AGI) grading trajectories and examine their impact on prognosis in the Pediatric Intensive Care Unit (PICU). METHODS: This retrospective cohort study was conducted at a large children's hospital in China. The children admitted to the PICU were included. AGI grade was assessed every other day during the initial nine days following PICU admission. RESULTS: A total of 642 children were included, of which 364 children (56.7%) exhibited varying degrees of gastrointestinal dysfunction (AGI grade ≥ 2). Based on the patterns of AGI grading over time, six groups were identified: low-stable group, low-fluctuating group, medium-decreasing group, medium-increasing group, high-decreasing group, high-persistent group. The high-persistent group accounted for approximately 90% of all recorded deaths. Compared to low-stable group, both the medium-increasing and high-persistent groups exhibited positive correlations with length of stay in PICU (PICU LOS) and length of stay (LOS). Compared to low-stable group, the five groups exhibited a negative correlation with the percentage of energy received by enteral nutrition (EN), as well as the protein received by EN. CONCLUSION: This study identified six distinct trajectory groups of AGI grade in critically ill children. The pattern of AGI grade trajectories over time were associated with EN delivery proportions and clinical outcomes.

Restraint Stress-Induced Neutrophil Inflammation Contributes to Concurrent Gastrointestinal Injury in Mice.

Psychological stress increases risk of gastrointestinal tract diseases. However, the mechanism behind stress-induced gastrointestinal injury is not well understood. The objective of our study is to elucidate the putative mechanism of stress-induced gastrointestinal injury and develop an intervention strategy. To achieve this, we employed the restraint stress mouse model, a well-established method to study the pathophysiological changes associated with psychological stress in mice. By orally administering gut-nonabsorbable Evans blue dye and monitoring its plasma levels, we were able to track the progression of gastrointestinal injury in live mice. Additionally, flow cytometry was utilized to assess the viability, death, and inflammatory status of splenic leukocytes, providing insights into the stress-induced impact on the innate immune system associated with stress-induced gastrointestinal injury. Our findings reveal that neutrophils represent the primary innate immune leukocyte lineage responsible for stress-induced inflammation. Splenic neutrophils exhibited elevated expression levels of the pro-inflammatory cytokine IL-1, cellular reactive oxygen species, mitochondrial burden, and cell death following stress challenge compared to other innate immune cells such as macrophages, monocytes, and dendritic cells. Regulated cell death analysis indicated that NETosis is the predominant stress-induced cell death response among other analyzed regulated cell death pathways. NETosis culminates in the formation and release of neutrophil extracellular traps, which play a crucial role in modulating inflammation by binding to pathogens. Treatment with the NETosis inhibitor GSK484 rescued stress-induced neutrophil extracellular trap release and gastrointestinal injury, highlighting the involvement of neutrophil extracellular traps in stress-induced gastrointestinal inflammation. Our results suggest that neutrophil NETosis could serve as a promising drug target for managing psychological stress-induced gastrointestinal injuries.

Ferroptosis, Inflammation, and Microbiome Alterations in the Intestine in the Göttingen Minipig Model of Hematopoietic-Acute Radiation Syndrome.

Hematopoietic acute radiation syndrome (H-ARS) involves injury to multiple organ systems following total body irradiation (TBI). Our laboratory demonstrated that captopril, an angiotensin-converting enzyme inhibitor, mitigates H-ARS in Göttingen minipigs, with improved survival and hematopoietic recovery, as well as the suppression of acute inflammation. However, the effects of captopril on the gastrointestinal (GI) system after TBI are not well known. We used a Göttingen minipig H-ARS model to investigate captopril's effects on the GI following TBI (60Co 1.79 or 1.80 Gy, 0.42-0.48 Gy/min), with endpoints at 6 or 35 days. The vehicle or captopril (0.96 mg/kg) was administered orally twice daily for 12 days, starting 4 h post-irradiation. Ilea were harvested for histological, protein, and RNA analyses. TBI increased congestion and mucosa erosion and hemorrhage, which were modulated by captopril. GPX-4 and SLC7A11 were downregulated post-irradiation, consistent with ferroptosis at 6 and 35 days post-irradiation in all groups. Interestingly, p21/waf1 increased at 6 days in vehicle-treated but not captopril-treated animals. An RT-qPCR analysis showed that radiation increased the gene expression of inflammatory cytokines IL1B, TNFA, CCL2, IL18, and CXCL8, and the inflammasome component NLRP3. Captopril suppressed radiation-induced IL1B and TNFA. Rectal microbiome analysis showed that 1 day of captopril treatment with radiation decreased overall diversity, with increased Proteobacteria phyla and Escherichia genera. By 6 days, captopril increased the relative abundance of Enterococcus, previously associated with improved H-ARS survival in mice. Our data suggest that captopril mitigates senescence, some inflammation, and microbiome alterations, but not ferroptosis markers in the intestine following TBI.

Prognostic Value of Acute Gastrointestinal Injury Combined with Disease Severity Scores in Critically Ill Patients.

Background: Critically ill patients are at high risk of multiple organ failure syndrome (MODS) and gastrointestinal (GI) injury and dysfunction, which are associated with increased mortality rates. The acute gastrointestinal injury (AGI) scale has shown promise in assessing GI dysfunction. However, the combined utility of AGI with established disease severity scores remains unclear. This study aimed to investigate the performance of AGI in conjunction with modified nutritional risk in critically ill (mNUTRIC), sequential organ failure assessment (SOFA), and acute physiology and chronic health evaluation II (APACHE II) scores for predicting mortality in critically ill patients. Materials and methods: A retrospective cross-sectional study was conducted in the intensive care unit (ICU) from May 2021 to December 2021. Demographic and clinical data were collected, including AGI grade, mNUTRIC score, SOFA score, APACHE II score, and mortality. Results: Among 93 critically ill patients, AGI was observed in 47.3% of cases, and the in-hospital mortality rate was 30.1%. The area under the curve (AUC) for AGI in predicting in-hospital mortality was 0.67 [95% confidence interval (CI), 0.56, 0.79; p = 0.008], similar to the AUCs of SOFA, APACHE II, and mNUTRIC scores. The combination of AGI with mNUTRIC, APACHE II, or SOFA scores improved the predictive performance compared with AGI alone. Conclusion: The AGI grade, in conjunction with disease severity scores, such as mNUTRIC, SOFA, and APACHE II scores, shows promise in predicting mortality in critically ill patients. Integrating AGI into evaluating critically ill patients can enhance prognostic accuracy. How to cite this article: Hai PD, Tot NH, Thao LT, Khoa Q, Thien DH. Prognostic Value of Acute Gastrointestinal Injury Combined with Disease Severity Scores in Critically Ill Patients. Indian J Crit Care Med 2024;28(6):575-580.

Synergizing Survival: Uniting Acute Gastrointestinal Injury Grade and Disease Severity Scores in Critical Care Prognostication.

How to cite this article: Patnaik RK, Karan N. Synergizing Survival: Uniting Acute Gastrointestinal Injury Grade and Disease Severity Scores in Critical Care Prognostication. Indian J Crit Care Med 2024;28(6):529-530.

Low-dose nafamostat mesilate ameliorates tissue injury and inhibits 5-hydroxytryptamine synthesis in the rat intestine after methotrexate administration.

We aimed to clarify the effect of nafamostat mesilate (nafamostat) on intestinal mucositis as well as the potentiation of intestinal 5-hydroxytryptamine (5-HT) dynamics induced by methotrexate, an anti-cancer drug, in rats. Rats received intraperitoneal methotrexate at 12.5 mg/kg/day for 4 days. In addition, 1, 3, or 10 mg/kg/day of nafamostat was given subcutaneously for 4 days. Ninety-six hours after the first administration of methotrexate, jejunal tissues were collected for analysis. The results showed that 1 mg/kg, but not 3 or 10 mg/kg, of nafamostat significantly ameliorated the methotrexate-induced body weight loss. Moreover, 1 mg/kg of nafamostat significantly improved methotrexate-induced mucositis, including villus atrophy. Nafamostat (1 mg/kg) significantly inhibited the methotrexate-induced mRNA expression of pro-inflammatory cytokines and cyclooxygenase-2, as well as methotrexate-induced 5-HT content and tryptophan hydroxylase (TPH) activity. In addition, it tended to inhibit the number of anti-TPH antibody-positive cells and significantly inhibited the number of anti-substance P antibody-positive cells. These findings suggest that low-dose nafamostat ameliorates tissue injury and 5-HT and substance P synthesis in methotrexate-induced mucositis. Nafamostat may be a novel therapeutic strategy for the prevention and treatment of mucositis as well as 5-HT- and/or substance P-related adverse effects in cancer chemotherapy.

Incidence and influencing factors of acute gastrointestinal injury after cardiac surgery.

BACKGROUND: To investigate the incidence and influencing factors of acute gastrointestinal injury (AGI) after cardiac surgery. METHODS: A total of 346 cases receiving treatment in the Intensive Care Unit (ICU) of the Department of Cardiovascular Surgery in our hospital from January 2021 to December 2021 were enrolled and their basic information was collected, including age, gender, height, weight, past medical history, Nutrition Risk Screening 2002, Body Mass Index (BMI), total operation duration, stay in ICU, preoperative blood routine examination results, complete biochemical examination, diamine oxidase (DAO) on Day 1, D-lactic acid index, a postoperative gastrointestinal condition, other postoperative complications and death during hospitalization. Moreover, logistic regression analysis was performed to identify the independent risk factors influencing the incidence of AGI after cardiac surgery. RESULTS: The incidence and mortality of AGI after cardiac surgery were 10.40% (36/346) and 25% (9/36), respectively. A dichotomous logistic regression multivariate analysis revealed that DAO on Day 1 (odd ratio = 1.062, p = 0.006) and stay in ICU (odd ratio = 1.192, p < 0.001) were independent risk factors of AGI after cardiac surgery, and total protein is a protective factor (odd ratio = 0.914, p = 0.012). CONCLUSIONS: Factors influencing AGI after cardiac surgery have been determined in this study. Our data suggest that patients with AGI after cardiac surgery have a decreased preoperative total protein, and elevated DAO on Day 1. Total protein and DAO on Day 1 were found to be correlated with AGI.

Evaluation of gastrointestinal tract injury within 1 year of surgery for pelvic organ prolapse.

OBJECTIVE: To identify the incidence and risk factors of gastrointestinal injury (GITI) related to pelvic organ prolapse (POP) surgery. METHODS: Women who underwent POP surgery between 2000 and 2020 were identified in the Premier Healthcare Database. The primary outcome was GITI, defined as small or large bowel injury or repair, and fistula or fistula repair. Differences between patients with and without GITI were evaluated, and a multivariable regression was performed to determine independent predictors of GITI. RESULTS: We identified 563,661 index POP surgeries in female patients aged 18 years and older. Of these, 4582 (0.8%) had a bowel injury code within 1 year of index POP surgery. Patients who experienced GITI were more likely to be younger (49.9 ± 12.8 vs 50.9 ± 13.7), and receive surgery with a surgeon who performed less than 12 surgeries per year (48% vs 42%). Most GITI was diagnosed in the same month (73.4%) and same hospital encounter (54%) as index POP surgery. After adjusting for confounders, lysis of adhesions (aOR = 2.03, 95% CI: 1.48-2.72) and perioperative hematoma/hemorrhage (aOR = 2.87, 95%C I: 1.70-4.59) were strongly associated with GITI, while having surgery with a surgeon performing > 50 POP surgeries per year (aOR = 0.66, 95%C I: 0.59-0.75 and concomitant obliterative procedures (aOR = 0.48, 95% CI: 0.34-0.65) were associated with a lower probability of GITI. CONCLUSIONS: The rate of GITI after POP surgery is less than 1%, and injuries are commonly diagnosed and treated in the same month as index surgery. High-volume surgeons and obliterative procedures may be protective against GITI.

Gastrointestinal Complications After Transesophageal Echocardiography for Mitral Valve Transcatheter Edge-to-Edge Repair: Insights From a Large Contemporary Cohort.

OBJECTIVES: Transesophageal echocardiography-related complications (TEE-RC) are higher in structural heart interventions than in traditional operative settings. In mitral valve transcatheter edge-to-edge repair (MV-TEER), the incidence of TEE-RC may be higher than in other structural interventions. However, existing reports are limited and robust data evaluating TEE safety in this patient population are lacking. The authors sought to describe the incidence and risk factors of upper gastrointestinal injuries after TEE in patients undergoing MV-TEER. DESIGN: A retrospective observational study. SETTING: A single tertiary academic hospital. PARTICIPANTS: A total of 442 consecutive patients who underwent MV-TEER, specifically with MitraClip, between December 2015 and March 2022. INTERVENTIONS: Transesophageal echocardiography was performed intraoperatively to guide all MV-TEERs. MEASUREMENTS AND MAIN RESULTS: The study's primary goal was to investigate an association between TEE procedure duration and TEE-RC risk. The contribution of demographic risk factors and intraprocedural characteristics also was investigated. Transesophageal echocardiography-RCs were observed in 17 out of 442 patients (3.8%). Dysphagia was the most common TEE-RC (n = 9/17, 53%), followed by new gastroesophageal reflux (n = 6/17, 35%) and odynophagia (n = 3/17, 18%). There were no esophageal perforations or upper gastrointestinal bleeds. History of dysphagia was the only variable associated with TEE-RCs (p = 0.008; n = 9 [2.1%] v n = 3 [18%]), with a relative risk of 8.67 (95% CI 2.57, 29.16). The TEE procedure duration was not statistically different between the 2 groups (46 minutes [39-64] in TEE-RCs v 49 minutes [36-77] in no complications). CONCLUSION: In patients undergoing MV-TEER, TEE-RCs are uncommon, and major complications are rare. The authors' outcomes reflect those of a high-volume referral center with TEEs performed by cardiac anesthesiologists.

The Role of Activating Transcription Factor 3 in Metformin's Alleviation of Gastrointestinal Injury Induced by Restraint Stress in Mice.

Metformin is one of the most commonly used drugs for type 2 diabetes mellitus. In addition to its anti-diabetic property, evidence suggests more potential applications for metformin, such as antiaging, cellular protection, and anti-inflammation. Studies have reported that metformin activates pathways with anti-inflammatory effects, enhances the integrity of gut epithelial tight junctions, and promotes a healthy gut microbiome. These actions contribute to the protective effect of metformin against gastrointestinal (GI) tract injury. However, whether metformin plays a protective role in psychological-stress-associated GI tract injury remains elusive. We aim to elucidate the potential protective effect of metformin on the GI system and develop an effective intervention strategy to counteract GI injury induced by acute psychological stress. By monitoring the levels of GI-nonabsorbable Evans blue dye in the bloodstream, we assessed the progression of GI injury in live mice. Our findings demonstrate that the administration of metformin effectively mitigated GI leakage caused by psychological stress. The GI protective effect of metformin is more potent when used on wild-type mice than on activating-transcription-factor 3 (ATF3)-deficient (ATF3-/-) mice. As such, metformin-mediated rescue was conducted in an ATF3-dependent manner. In addition, metformin-mediated protection is associated with the induction of stress-induced GI mRNA expressions of the stress-induced genes ATF3 and AMP-activated protein kinase. Furthermore, metformin treatment-mediated protection of CD326+ GI epithelial cells against stress-induced apoptotic cell death was observed in wild-type but not in ATF3-/- mice. These results suggest that metformin plays a protective role in stress-induced GI injury and that ATF3 is an essential regulator for metformin-mediated rescue of stress-induced GI tract injury.

Screening of radiation gastrointestinal injury biomarkers in rat plasma by high-coverage targeted lipidomics.

INTRODUCTION: In the event of radiological accidents and cancer radiotherapies in the clinic, the gastrointestinal (GI) system is vulnerable to ionizing radiation and shows GI injury. Accessible biomarkers may provide means to predict, evaluate, and treat GI tissue damage. The current study investigated radiation GI injury biomarkers in rat plasma. MATERIAL AND METHODS: High-coverage targeted lipidomics was employed to profile lipidome perturbations at 72 h after 0, 1, 2, 3, 5, and 8 Gy (60Co γ-rays at 1 Gy/min) total-body irradiation in male rat jejunum. The results were correlated with previous plasma screening outcomes. RESULTS: In total, 93 differential metabolites and 28 linear dose-responsive metabolites were screened in the jejunum. Moreover, 52 lipid species with significant differences both in jejunum and plasma were obtained. Three lipid species with linear dose-response relationship both in jejunum and plasma were put forth, which exhibited good to excellent sensitivity and specificity in triaging different exposure levels. DISCUSSION: The linear dose-effect relationship of lipid metabolites in the jejunum and the triage performance of radiation GI injury biomarkers in plasma were studied for the first time. CONCLUSION: The present study can provide insights into expanded biomarkers of IR-mediated GI injury and minimally invasive assays for evaluation.

Establishment and evaluation of a prediction model for acute gastrointestinal injury in patients with prolonged disorder of consciousness.

OBJECTIVE: To establish a prediction model for acute gastrointestinal injury (AGI) in patients with prolonged disorder of consciousness (pDOC) and to evaluate and apply the prediction model.  METHODS: The clinical data of 165 patients with pDOC admitted to the hyperbaric oxygen department from January 2021 to December 2021 were retrospectively reviewed, and the patients were divided into an AGI group (n = 91) and an N-AGI group (n = 74) according to whether AGI occurred. A prediction model was built by fitting multiple independent influencing factors through logistic regression. The receiver operating characteristic (ROC) curve was used to evaluate the predictive value of the model, the Hosmer-Lemeshow (H-L) test was used to evaluate the goodness-of-fit of the model, and the ROC curve and calibration curve were drawn to evaluate the predictive performance. A nomogram was plotted to visualize the prediction model. RESULTS: According to the multivariate logistic regression analysis results, the prediction model was finally constructed with the CRS-R score, DAO, PCT, ALB, and I-FABP, and a nomogram was generated. The area under the ROC curve (AUC) of the prediction model was 0.931, the sensitivity was 83.5%, and the specificity was 93.2%. The data were divided into 5 groups for the H-L test (χ2 = 2.54, P = 0.468 > 0.05) and into 10 groups for the H-L test (χ2 = 9.98, P = 0.267 > 0.05). A calibration curve was drawn based on the test results, indicating that the prediction model has a good goodness-of-fit and good prediction stability. CONCLUSION: The prediction model for AGI in pDOC patients constructed in this study can be used in clinical practice and is helpful to predict the occurrence of AGI in pDOC patients.

Acute gastrointestinal injury in critically ill children: Impact on clinical outcome.

AIM: To estimate acute gastrointestinal injury (AGI) in critically ill children and association of its severity with mortality. METHODS: In a prospective cohort study, critically ill children (1 month-18 years) were enrolled. Gastrointestinal symptoms over the first week of admission were classified into AGI grades 1 through 4, using a paediatric adaptation of European Society of Intensive Care Medicine AGI definitions. Performance of AGI grades in predicting 28-day mortality was evaluated. RESULTS: Of 151 children enrolled, 71 (47%, 95% confidence interval (CI): 38.9-55.3%) developed AGI, with AGI grades 1, 2, 3 and 4 in 22.5%, 15.9%, 6.6% and 2%, respectively. The 28-day mortality progressively increased with AGI grade 0 (15%), 1 (35%), 2 (50%), 3 (70%), through 4 (100%), P < 0.001. Association of AGI grades with 28-day mortality was significant even after adjustment for disease severity, age and nutritional status (odds ratio (OR) = 2.152, 95% CI: 1.455, 3.184). Among AGI grades, and paediatric logistic organ dysfunction-2 score components, cardiovascular (OR = 1.525, 95% CI: 1.142, 2.037) and haematological (OR = 1.719, 95% CI: 1.067, 2.772) components of paediatric logistic organ dysfunction-2 score and AGI grades (OR = 1.565, 95% CI: 1.001, 2.449) showed significant association with 28-day mortality. CONCLUSIONS: Nearly half of the critically ill children developed AGI. AGI grades were independently associated with increased mortality, and mortality progressively increased with AGI grade.

P-Selectin is a Critical Factor for Platelet-Mediated Protection on Restraint Stress-Induced Gastrointestinal Injury in Mice.

Psychological stress is associated with increased risk of gastrointestinal (GI) tract diseases. Evidence indicated that platelets facilitate GI tissue repair in intestinal anastomosis models. However, whether platelets are involved in native mechanism of the rescue of stress-induced GI injury for maintaining the GI homeostasis remains elusive. Because P-selectin-deficient (Selp-/-) mice displayed higher stress-induced GI injury compared to the wild-type (Selp+/+) mice, and P-selectin is specifically expressed in platelets, we hypothesize that P-selectin-expressing platelets play a protective role in the rescue of stress-induced GI injury. Our goal is to clarify the putative protective role of platelets in a GI system, thereby develop a feasible intervention strategy, such as platelet transfer, to overcome stress-induced GI injury. Through monitoring the plasma levels of GI-nonabsorbable Evans blue dye to reveal the progression course of GI injury in live mice, we found that intravenous treatments of purified platelets ameliorated stress-induced GI leakage. The transfer of platelets from wild-type mice was more potent than from Selp-/- mice in the rescue of stress-induced-GI leakage in the recipients. As such, platelet transfer-mediated rescue was conducted in a P-selectin dependent manner. Additionally, platelet-mediated protection is associated with corrections of stress-induced aberrant GI mRNA expressions, including tight junctions claudin 3 and occludin, as well as stress-induced genes activating transcription factor 3 and AMP-activated protein kinase, after the transfer of wild-type platelets into wild-type and Selp-/- mice. Furthermore, the stress-induced apoptosis of CD326+ GI epithelial cells was rescued by the transfer of wild type, but not P-selectin-deficient platelets. These results suggest that platelet plays a protective role for maintaining the GI homeostasis during stress in vivo, and that P-selectin is a molecular target for managing stress-induced GI tract injury.

Angiopoietin-2 Is an Early Predictor for Acute Gastrointestinal Injury and Intestinal Barrier Dysfunction in Patients with Acute Pancreatitis.

BACKGROUNDS: Angiopoietin-2 (Ang-2) is a new predictor for acute pancreatitis (AP). AIMS: To assess the predictive value of Ang-2 in determining the progress of AP and the subsequent acute gastrointestinal injury (AGI). METHODS: This was a prospective study that enrolled 170 patients with AP and 100 healthy controls. Blood samples were collected within 24 h of the onset of AP. RESULTS: The majority (108) of the patients were categorized as having MAP with the rest (62) classified as suffering from SAP. Considering AGI grading, there were 118 grade 1 and 12 grade 4 patients; in grades 2 and 3, there were 20 patients each. AP was accompanied by MODS and pancreatic necrosis in 46 and 24 cases, respectively. Eighty patients were admitted to the ICU, while mortality was reported among 7.1% patients. The plasma Ang-2 levels were higher among patients with AP than in controls. A similar trend prevailed, in patients with SAP compared to those with MAP. Ang-2 was significantly increased from AGI grade 1 through to grade 4, showing a desirable positive predictive accuracy. Moreover, Ang-2 also showed strong correlations with intestinal permeability as evaluated by d-lactate (DLA), diamine oxidase (DAO), and intestinal fatty acid binding proteins (I-FABPs). Tools (Ranson and APACHE II scores, CRP), which are used more conventionally, could not effectively distinguish the various grades of AGI. Furthermore, Ang-2 predicted poor prognosis and adverse outcomes, including mortality, among patients with AP. CONCLUSIONS: This study showed Ang-2 to be an accurate early predictor for SAP, AGI, and intestinal barrier dysfunction, outperforming conventional biomarkers. Ang-2 levels also predicted the adverse outcomes and mortality due to AP.

A nationwide questionnaire survey on accidental magnet ingestion in children in Japan.

AIM: The aim is to investigate the actual situation of accidental ingestion of magnets in children in Japan and the clinical features of the resulting gastrointestinal damage. METHODS: We developed a questionnaire and sent it to 496 board-certified training hospitals nationwide. Information was collected on the number of children with accidental magnet intake from 2015 to 2017, witnesses of magnet intake, number and type of magnets, presence or absence of gastrointestinal injury, treatment, etc RESULTS: The number of cases of accidental ingestion of magnets within the study period was 104, with a median age of 2 years. About half of the incidents were unwitnessed. There were 33 cases of accidental ingestion of multiple magnets. Among them, oesophagogastroduodenoscopy was performed in 4 children and surgery in 10, and significantly invasive treatment was required in comparison with single-magnet ingestion. Gastrointestinal injury was observed in 11 cases, 10 of which were caused by multiple-magnet ingestion. All 10 of these patients underwent surgical treatment. There was no mortality. CONCLUSION: The incidence of accidental magnet ingestion in Japan is estimated to be 50-70 per year. Unwitnessed cases are not uncommon. Multiple magnet ingestion often causes gastrointestinal injury. Many cases of gastrointestinal injury are caused by ingestion of magnetic toys.

[Evaluation and Early Diagnosis of Gastrointestinal Failure in Acute Pancreatitis].

Objective To investigate the application of Acute Gastrointestinal Injury(AGI) grading in evaluating gastrointestinal failure in patients with acute pancreatitis(AP). Methods In this retrospective observational study,patients presented with moderate severe AP and severe AP in our hospital from October 2013 to October 2016 were consecutively enrolled.Logistic regression analysis and receiver operating characteristic curve were used to explore and evaluate potential predictors of gastrointestinal failure. Results A total of 202 patients were included in this study,with 90 cases(44.6%) identified as gastrointestinal failure.Survival curve showed significantly increased risk of death in patients with gastrointestinal failure(P < 0.05).Logistic regression analysis showed age(OR=1.06,95%CI:1.03-1.09,P<0.001),complaint of stopping flatus and defecation(OR=7.02,95%CI:2.08-23.66,P=0.002),increased counts of white blood cells in peripheral blood(OR=1.09,95%CI:1.02-1.17,P=0.015),decreased level of serum albumin(OR=0.93,95%CI:0.86-1.00,P=0.048),and increased level of serum creatinine at admission(OR=1.02,95%CI:1.01-1.04,P=0.001) were the independent risk factors of gastrointestinal failure.The area under curves of Acute Physiology and Chronic Health Evaluation Ⅱ (APACHE Ⅱ) and Beside Index for Severity in Acute Pancreatitis (BISAP) scores in diagnosing gastrointestinal failure were 0.999 and 0.782,respectively. Conclusions Gastrointestinal failure can remarkably increase the risk of death in patients with AP.Both APACHE Ⅱ and BISAP scores at admission are useful in diagnosing gastrointestinal failure in patients with AP.

Predictive value of transabdominal intestinal sonography in critically ill patients: a prospective observational study.

BACKGROUND: This study examined the feasibility of transabdominal intestinal ultrasonography in evaluating acute gastrointestinal injury (AGI). METHODS: A total of 116 patients were included. Intestinal ultrasonography was conducted daily within 1 week after admission to the intensive care unit. Ultrasonography indicators including intestinal diameter, changes in the intestinal folds, thickness of the intestinal wall, stratification of the intestinal wall, and intestinal peristalsis (movement of the intestinal contents) were observed to determine the acute gastrointestinal injury ultrasonography (AGIUS) score. The gastrointestinal and urinary tract sonography ultrasound (GUTS) protocol score was also calculated. During the first week of the study, the gastrointestinal failure (GIF) score was determined daily. The correlations between transabdominal intestinal scores (AGIUS and GUTS) and the GIF score were analyzed to clarify the feasibility of evaluating AGI through observation of the intestine. The utility of intestinal ultrasonography indicators in predicting feeding intolerance was investigated to improve the ability of clinicians to manage AGI. RESULTS: A total of 751 ultrasonic examinations were performed with 511 images (68%) considered to be of "good quality." AGIUS and GUTS scores differed significantly between AGI patients (GIF score 0-2) and non-AGI patients (GIF score 3-4) (p < 0.001). Both scores correlated positively with GIF score (r = 0.54, p < 0.001; r = 0.66, p < 0.001). These ultrasonography indicators could predict feeding intolerance, with an area under the receiver operating characteristic curve of 0.60 (0.48-0.71; intestinal diameter), 0.76 (0.67-0.85; intestinal folds), 0.71 (0.62-0.80; wall thickness), 0.77 (0.69-0.86; wall stratification), and 0.78 (0.68-0.88; intestinal peristalsis). Compared to patients with a normal rate of peristalsis (5-10/min), patients with abnormal peristalsis rates (< 5/min or > 10/min) have increased risk for feeding intolerance (16/83 vs. 25/33, p < 0.001). CONCLUSIONS: The transabdominal intestinal ultrasonography represents an effective means for assessing gastrointestinal injury in critically ill patients. Intestinal ultrasonography indicators, especially the degree of intestinal peristalsis, may be used to predict feeding intolerance. TRIAL REGISTRATION: ClinicalTrial.gov, NCT03589248. Registered 04 July 2018-retrospectively registered.

Multicystic encephalomalacia and gastrointestinal injury following single fetal death in first trimester and subsequent fetofetal transfusion syndrome in a monochorionic triplet pregnancy: a case report.

BACKGROUND: Monochorionic multifetal pregnancies are at increased risk of adverse perinatal outcome because of placental vascular anastomoses. We present a case of multicystic encephalomalacia and gastrointestinal injury in two surviving fetuses following single fetal death in first trimester and subsequent fetofetal transfusion syndrome in a monochorionic triplet pregnancy. CASE PRESENTATION: A 31-year-old nulliparous woman had a spontaneous monochorionic triamniotic triplet pregnancy. Three live fetuses with single placenta were seen at 8-week ultrasound scan. One fetus demised at 11 weeks and 3 days of gestation. Dilated echogenic bowel and ascites were found in one surviving fetus at 23 weeks of gestation. At 28 weeks of gestation, the pregnancy was complicated by fetofetal transfusion syndrome in which discordant amniotic fluid volumes were found. Two days later, emergency Caesarean section was performed because of worsening of fetal Doppler and biophysical profile. One baby was found to have jejunal atresia requiring surgery at 4 days old. He had periventricular leukomalacia and intracranial haemorrhage, but subsequent normal neurological development. Another baby had gastric perforation requiring surgery at 2 days old. He was confirmed to have multicystic encephalomalacia by cranial ultrasound and magnetic resonance imaging. He suffered from developmental delay, epilepsy and cerebral palsy. CONCLUSION: This case alerts the obstetricians the possible hypoxic-ischemic injury to the survivors of monochorionic triplet pregnancy after the co-triplet death in the first trimester and fetofetal transfusion syndrome. Antenatal assessment and postnatal follow-up are important for these high-risk multiple pregnancies.