Comparison of the efficacy of octreotide, vasopressin, and omeprazole in the control of acute bleeding in patients with portal hypertensive gastropathy: a controlled study

Pro/con debate: octreotide has an important role in the treatment of gastrointestinal bleeding of unknown origin?

Whether it is the primary reason for admission or a complication of critical illness, upper gastrointestinal bleeding is commonly encountered in the intensive care unit. In this setting, in the absence of endoscopy, intensivists generally provide supportive care (transfusion of blood products) and acid suppression (such as proton pump inhibitors). More recently, octreotide (a somatostatin analogue) has been used in such patients. However, its precise role in patients with upper gastrointestinal bleeding is not necessarily clear and the drug is associated with significant costs. In this issue of Critical Care, two expert teams debate the merits of using octreotide in non-variceal upper gastrointestinal bleeding.

Case Report: Octreotide as an Adjunct to Embolisation in the Management of Recurrent Bleeding Upper Gastrointestinal Metastases from Primary Renal Cell Cancer

The recommended treatment for patients with severe bleeding from upper gastrointestinal (GI) metastases is embolisation. We report a case in which despite adequate embolisation major haemorrhage from renal cell carcinoma (RCC) gastric metastases continually recurred. During a severe bleed refractory to embolisation octreotide was used to control and prevent further bleeding. No further episodes of severe haemorrhage occurred over the following 23 months since starting treatment. Octreotide has been observed to be effective both in the acute management of persistent haemorrhage and in prevention of subsequent haematemesis from GI metastatic RCC.

A multicentred clinical comparative study on curative effect and safety of acetic octreotide in treatment of esophageal varices bleeding

AIM: To evaluate curative effect and safety of acetic octreotide in the treatment of esophageal varices blee-ding (EVB) in comparison with octreotide (Sandostatin).

METHODS: EVB patients were randomly and double-blinded assigned into acetic octreotide group (n = 70) and Sandostatin group (n = 66). Both kinds of drugs were dissolved in normal saline and then given to the patients at the rate of 50 mg/h for 48 h. The amount of bleeding and vital signs of all the patients were observed and comparatively analyzed.

RESULTS: The frequencies and amount of hemateme-sis, the excreted frequencies and amount of black feces were significantly different before and after treatment with both kinds of drugs (P <0.05), but there was no marked difference between the two groups (P >0.05). The vital signs such as heart rate, systolic and diastolic blood pressure as well as symptoms of nausea, swirling, heart-throb, sweatiness, and thirst were notably improved after treatment (P <0.05), but there was still no obvious difference between the two groups (P >0.05). Adverse drug reaction was also different between the two groups 1.43% (1.43% vs 1.52%, P >0.05). The total effective rates in acetic octreotide and Sandostatin group were 97.14% and 92.42%, respectively (P >0.05).

CONCLUSION: Acetic octreotide is safe and effective in the treatment of EVB, and its effect is not significan-tly different from Sandostatin's.

High-dose vasopressin is not superior to norepinephrine in septic shock*

OBJECTIVE

We examined the effects of arginine vasopressin, when substituted for norepinephrine as a vasopressor in septic shock, on global and hepatosplanchnic hemodynamic and oxygen transport variables.

DESIGN

Experimental study.

SETTING

Intensive care unit.

SUBJECTS

Twelve septic shock patients.

INTERVENTIONS

Norepinephrine was replaced by vasopressin in a dose sufficient to keep mean arterial blood pressure constant. Blood flow, oxygen delivery, and oxygen consumption of the hepatosplanchnic region (calculated by a hepatic venous catheter technique using the Fick principle during continuous infusion of indocyanine green), global hemodynamics (by thermodilution), and gastric regional PCO2 gap (by air tonometry) were calculated during infusion of norepinephrine (mean, 0.56 microg.kg-1.min-1; range, 0.18-1.1 microg.kg-1.min-1) and again 2 hrs after replacement by vasopressin (mean, 0.47 IU/min; range, 0.06-1.8 IU/min).

MEASUREMENTS AND MAIN RESULTS

Cardiac index decreased significantly from 3.8 +/- 1.3 to 3.0 +/- 1.1 L.min-1.m-2, heart rate decreased from 96 +/- 14 to 80 +/- 16 min-1 (p <.01), and global oxygen uptake decreased from 248 +/- 67 to 218 +/- 75 mL/min (p <.05). Absolute splanchnic blood flow tended to increase, although not significantly, whereas fractional splanchnic blood flow increased from 10.8 +/- 7.6 to 25.9 +/- 16.6% of cardiac output (p <.05). Gastric regional PCO2 gap increased from 17.5 +/- 26.6 to 36.5 +/- 26.6 mm Hg (p <.01).

CONCLUSION

Vasopressin, in doses sufficient to replace the vasopressor norepinephrine, had mixed effects in septic shock patients. Hepatosplanchnic blood flow was preserved during substantial reduction in cardiac output. An increased gastric PCO2 gap suggests that the gut blood flow could have been redistributed to the disadvantage of the mucosa. Based on these limited data, it does not appear beneficial to directly replace norepinephrine with vasopressin in septic shock.

Diagnosis of portal hypertensive gastropathy

Portal hypertensive gastropathy is a relatively recently described entity that is an important cause of bleeding in portal hypertension. This article focuses on the endoscopic diagnosis of portal hypertensive gastropathy, including a review of different proposed scoring systems, and briefly examines the epidemiology, pathogenesis, and treatment of portal hypertensive gastropathy.