• Christos K Triantos, Michel Marzigie, Giuseppe Fede, Marina Michalaki, Dimitra Giannakopoulou, Konstantinos Thomopoulos, Matteo Garcovich, Maria Kalafateli, Aris Chronis, Venetsana Kyriazopoulou, Eleni Jelastopoulou, Vasiliki Nikolopoulou, James O'Beirne, and Andrew K Burroughs.
• Department of Gastroenterology, University Hospital of Patras, Patras, Greece. chtriantos@hotmail.com
• Clin. Gastroenterol. Hepatol. 2011 Jul 1; 9 (7): 595-601.

Background & AimsRelative adrenal insufficiency (AI) occurs in patients with cirrhosis with sepsis, but not with variceal bleeding. We evaluated adrenal function in cirrhotic patients with and without bleeding.MethodsTwenty cirrhotic patients with variceal bleeding were evaluated using the short synacthen test (SST) and 10 using the low-dose synacthen test (LDSST) followed by SST. The control group included 60 stable cirrhotic patients, assessed by LDSST (n = 50) or SST (n = 10), and 14 healthy volunteers. AI was diagnosed using SST, based on peak cortisol levels ≤ 18 μg/dL in nonstressed patients or Δmax <9 μg/dL or a total cortisol level <10 μg/dL in stressed patients with variceal bleeding-the current criteria for critical illness-related corticosteroid insufficiency. Using LDSST, diagnosis was based on peak concentrations of cortisol ≤ 18 μg/dL in nonstressed patients and <25 μg/dL (or Δmax <9 μg/dL) in patients with variceal bleeding. We evaluated patients with levels of serum albumin >2.5 g/dL, to indirectly assess cortisol binding.ResultsAll healthy volunteers had normal results from LDSSTs and SSTs. Patients with variceal bleeding had higher median baseline concentrations of cortisol (15.4 μg/dL) than stable cirrhotic patients (8.7 μg/dL, P = .001) or healthy volunteers (10.1 μg/dL, P = .01). Patients with variceal bleeding had higher median peak concentrations of cortisol than stable cirrhotic patients (SST results of 32.7 vs 21 μg/dL, P = .001; LDSST results of 9.3 vs 8.1 μg/dL; nonsignificant), with no differences in Δmax in either test. These differences were greater with variceal bleeding than in stable cirrhotic patients with AI. Subanalysis of patients with albumin levels >2.5 g/dL did not change these differences.ConclusionsCirrhotic patients with variceal bleeding have AI. Despite higher baseline concentrations of serum cortisol and subnormal Δmax values, they did not have adequate responses to stress, and therefore had critical illness-related corticosteroid insufficiency.Copyright © 2011 AGA Institute. Published by Elsevier Inc. All rights reserved.

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