Massive variceal bleeding caused by scuba diving

Decompression Illness in a Scuba Diver With Significant Esophageal Injury

Scuba divers are at risk of decompression illness, of which arterial gas embolism is the most feared consequence. Severe complications involving the gastrointestinal tract are rare. In this report, we describe a case of an experienced scuba diver who was forced to rapidly ascend because of a mechanical failure. His course was complicated by severe esophageal mucosal injury including multiple ulcerations. Although he improved clinically, an esophageal stricture subsequently formed, which required dilation. This seems to be the first case report of significant esophageal injury resulting from decompression illness in a scuba diver.

Physical exercise in cirrhotic patients: Towards prehabilitation on waiting list for liver transplantation. A systematic review and meta-analysis

BACKGROUND

Early survival after Liver Transplantation (LT) is reduced among sarcopenic patients. Despite, Adapted Physical Activity (APA) before LT is rarely proposed for the risk to impair portal hypertension and its resulting complications.

OBJECTIVES

To assess the effects of APA program in adults affected by End Stage Liver Disease (ESLD) on hospital stay, 1-year mortality and morbidity after LT, adverse events (Primary outcomes). Secondary outcomes were changes in VO2 peak, muscle morphology, 6minutes walking distance test (6MWD), Body Mass Index (BMI), MELD, CHILD score and Hepatic Venous Pressure Gradient (HVPG).

SEARCH METHODS

MEDLINE, EMBASE, Google Scholar and the Cochrane Library database were explored for randomized clinical trials (RCT).

DATA COLLECTION AND ANALYSIS

Data were collected by one review author on the type of study, participants, treatments used for primary and secondary outcomes. Review Manager 5.2 was used for the analysis.

MAIN RESULTS

Four RCT with 81 patients were included. Primary outcomes: no severe adverse event was observed, but no published data were available on hospital stay or mortality after LT.

SECONDARY OUTCOMES

CHILD, MELD and BMI were not worsened by physical activity. No significant muscle diameter, 6MWD and VO2 peak changes were observed after exercise. Significant reduction in HVPG in the treatment group was observed in a single study (MD-2.5mmHg; 95%CI [-04.76, -0.24]; P=0.03).

AUTHORS' CONCLUSIONS

Knowledge in this field is still at an early stage. Evidence derived from small trials of medium quality on ESLD patients suggests that APA is safe, without increasing portal hypertension. Further research is very likely to have an important impact on our confidence in the intervention effect.

Acute ischemic colitis secondary to air embolism after diving

Ischemic colitis (IC) secondary to air embolism from decompression sickness or barotrauma during diving is an extremely rare condition. After extensive review of the available literature, we found that there has been only one reported case of IC secondary to air embolism from diving. Although air embolization from diving and the various medical complications that follow have been well documented, the clinical manifestation of IC from an air embolism during diving is very rare and thus far unstudied. Common symptoms of IC include abdominal pain, bloody or non-bloody diarrhea or nausea or vomiting or any combination. Emergency physicians and Critical Care specialists should consider IC as a potential diagnosis for a patient with the above-mentioned symptoms and a history of recent diving. We report a case of IC from air embolism after a routine dive to 75 feet below sea level in a 53-year-old White female who presented to a community Emergency Department complaining of a 2-day history of diffuse abdominal pain and nausea. She was diagnosed by colonoscopy with biopsies and treated conservatively with antibiotics, bowel rest, and a slow advancement in diet.

Decreased levels of PAI-1 and alpha2-antiplasmin contribute to enhanced fibrinolytic activity in divers

BACKGROUND

There are a number of reported cases of decompression sickness (DCS) with haemorrhages. These cases have not been sufficiently investigated and thus bleeding complications could not be directly correlated to the enhanced fibrinolysis.

OBJECTIVES

The effect of hyperbaric exposition and decompression on the main components of fibrinolytic system has been measured.

METHODS

Two groups of 25 male divers each were subjected to hyperbaric exposures to the pressure of either 400 kPa - group I - or 700 kPa - group II followed by a staged decompression. The divers were monitored for clinical symptoms of DCS and checked for Doppler-detected venous gas bubbles. Venous blood was drawn from divers before exposition and 15 min after decompression. The concentrations and activities of t-PA and PAI-1 as well as concentrations of PAP and alpha2-antiplasmin and activity of factor XIIa were measured.

RESULTS

In all groups of divers no cases of DCS as well as detectable gas bubbles were noted. We observed elevated concentration of PAP, decreased concentration of alpha2-AP, decreased PAI-1 concentration and activity. There were no significant changes in factor XIIa activity as well as of t-PA concentration and activity.

CONCLUSIONS

Hyperbaric exposition and decompression induce activation of fibrinolysis, even in the absence of detectable gas bubbles. Fibrinolytic activity increases mainly due to decrease of PAI-1 concentration and activity. Further clinical trials are necessary for the estimation of the importance of activation of fibrinolysis with decreased level of PAI-1 and alpha2-AP as a possible risk factor for bleeding in divers.