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Steroid therapy in alcoholic hepatitis: when enough is enough ▸

Without specific treatment, up to 50% of patients with severe alcoholic hepatitis will die within two months. Although the efficacy of corticosteroid therapy in reducing mortality from alcoholic hepatitis has been demonstrated in some randomised placebo controlled trials, meta-analyses have drawn conflicting conclusions. One of the concerns of treating patients with 40 mg of prednisolone for 28 days is that of susceptibility to infection, which is a frequent cause of mortality in this group. Therefore, early identification of those who would not benefit from steroid therapy would be clinically helpful.

Mathurin et al included 238 patients with histologically proven alcoholic hepatitis and a discriminant function of ⩾32 treated with steroids in the analysis. Overall, 73% of patients had a reduction in bilirubin after seven days of steroid therapy compared with that at the time of onset of treatment. Ninety five per cent of those who had this early response to steroid therapy continued to improve at the end of therapy (day 28). At six months, 83% of those who had an early fall in bilirubin levels survived compared with 23% of non-responders. The authors recommend that steroid therapy should be withdrawn in those who fail to show an early response. Physicians should be persuaded to consider a “seven day steroid trial” in patients with severe alcoholic hepatitis as this appears to be a safer approach. Measurement of serum bilirubin at the end of a week’s treatment is a useful guide to further management as well as prognosis.

An NSAID a day helps keep gastric cancer away ▸

The cyclooxygenase 2 gene is overexpressed in many gastrointestinal malignancies, and non-steroidal anti-inflammatory drug (NSAID) use has been shown to reduce the risk of colorectal and oesophageal adenocarcinoma. The potential chemoprotective effect of NSAIDs on gastric cancer is uncertain, as observational studies have given conflicting results. Wang et al have performed an excellent systematic review that has synthesised these data and suggested that subjects with gastric cancer are less likely to be taking NSAIDs than non-cancer controls (odds ratio 0.78; 95% confidence interval 0.69–0.87). The reduced risk of gastric cancer was observed for both aspirin and non-aspirin NSAID users.

The authors are rightly cautious about their results, as observational studies are prone to confounding and bias, which can be magnified in a meta-analysis. They also note that there is asymmetry in the results, suggesting publication bias or related quality issues. Furthermore, the most important chemopreventative strategy to reduce gastric cancer mortality is likely to be population Helicobacter pylori screening and treatment. Nevertheless, this work provides further evidence of the possible protective effect of NSAIDs on upper gastrointestinal malignancy. Clinical trials to evaluate the impact of NSAIDs in reducing gastrointestinal malignancy may be warranted.

Intravenous fluids: a double edged sword ▸

For patients undergoing major gastrointestinal surgery, conventional management is to keep them well hydrated in the immediate postoperative period, often in response to expected rather than actual losses of fluid. However, fluid overload has been shown to be associated with a decrease in muscle oxygen tension, a delay in recovery of gastrointestinal function, and also with increased complications and reduced survival. The aim of this study was to compare the effect of a restricted perioperative intravenous fluid regimen (aimed at maintaining preoperative body weight) with a standard regimen (well hydrated and resembling everyday practice) in patients undergoing elective colorectal resection.

This was a randomised observer blinded trial which took place in eight Danish hospitals and included 140 patients. The restricted intravenous fluid regimen was associated with a statistically significant reduction in postoperative complications (33% v 51%; p = 0.013). The numbers of both cardiopulmonary (7% v 24%; p = 0.007) and tissue healing complications (16% v 31%; p = 0.04) were markedly reduced. More patients died in the standard group but this was not statistically significant (4.7% v 0%; p = 0.12). This study has shown that giving surplus fluids may not only be unnecessary but might be harmful. As indicated in the editorial by Kenneth Kudsk in the same issue of Annals of Surgery, “intravenous fluids, the most commonly used drug in the hospital, are a double edged sword”.

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