[Effect of clonidine on oro-cecal transit time in normal man]

The aim of our study was to explore the effect of clonidine on the mouth to caecum transit time in healthy man. Hydrogen-breath test, using lactulose 10 g, was carried out in 10 healthy male volunteers, in double-blind conditions and in random sequences of medications, placebo or clonidine (0.3 mg per os). Clonidine increased the mouth to caecum transit time significantly (p = 0.013): from 85 +/- 12 min. (with placebo) to 139 +/- 16 min. (mean +/- SE). This study suggests that the antidiarrheal action of clonidine is due, at least in part, to effect on motility of the proximal gut.

[Indications of enteral nutrition in inflammatory bowel diseases]

Enteral nutrition may have two-fold value in the treatment of intestinal inflammatory disorders. On one hand it constitutes a simple, inexpensive and effective method of nutritional assistance, which is very useful in medical and surgical contexts since malnutrition is frequently observed in combination with these disorders. It that case, it consists of a polymer type mixture of nutrients generally administered as a supplement to oral feeding. Moreover, as is the case with total parenteral nutrition, it makes it possible to control progressive attacks of Crohn's disease in 80 to 90% of cases. This therapeutic action has only been demonstrated for elementary enteral nutrition alone and by putting the digestive system "at rest" it represents one of the primary factors. In the same way, a remission may be obtained in corticosteroid resistant or dependent forms of this disease as well as the weaning of the patient from or a reduction in dosage of corticosteroids. Its prolonged, discontinuous administration in children with below normal height and weight appears as promising. However, as with all current treatments used for this disorder, it does not radically alter the progressive course of Crohn's disease.

[Crohn's disease and enteral feeding: comparative nutritional efficacy of elemental and polymeric nutritive mixtures]

The nutritional development with three types of enteral diets during 28 days, was compared in 45 patients with malnutrition presenting an active Crohn's disease. Enteral feeding consisted of a polymeric mixture (Realmentyl) administered in addition to a normal oral diet in 11 patients; the same mixture was administered alone exclusively to 9 patients, and an elemental diet (Vivonex HN) administered exclusively to 25 patients. The total caloric intake reached, in the three groups, the mean values of 60.2, 36.9 and 33.8 kcal/kg of ideal weight/day, respectively. 33 patients also received steroids. At the end of 28 days of enteral diet, the improvement in the weight and the anthropometric measurements (muscle circumference, triceps skinfold) was significantly more marked (gain of 6.5 kg) with the supplemental polymeric mixture than with exclusive enteral diet, polymeric diet (+/- 2.0 kg) or basic (+1.2 kg). Transferrin and albumin plasma levels increased in all 3 groups, but much faster with the exclusive elemental feeding, in spite of a higher urinary urea excretion in these patients. The overall nutritional development was significantly better with supplemental polymeric feeding, and was identical in the two other groups. These results confirm that the supplemental polymeric enteral feeding is more effective, from the nutrition standpoint. With an exclusive enteral feeding, the nutritional result is appreciably the same, whether the mixture consists of polymers or basic elements.

[The overwhelmed intestine syndrome]

We studied 54 patients who, after small intestinal resection, developed a massive protracted diarrhea with a daily fecal loss greater than 2 kg, status we defined as the "overwhelmed intestine syndrome" (OIS). Median length of residual small bowel was 120 cm, 19 patients had a definitive stoma (jejunostomy, n = 9; colostomy, n = 10), 26 patients had a provisional jejunostomy. Fecal weight greater than 2 kg was related to enteral hyperalimentation (greater than 3,500 Kcal) in 19 patients (induced OIS) and was clearly independent in 16 others who had fecal weight over 3 kg while receiving approximately 2,000 Kcal (obligatory OIS); the last 19 patients had fecal weight between 2 and 3 kg during normoalimentation. Hypocalcemia and hypomagnesemia were common in the three groups. The other complications were seen mostly in patients with obligatory OIS: in those patients, parenteral nutrition was maintained in 9 cases out of 16 (vs. 0 in other groups), nutritional gain was scanty, sodium equilibrium was difficult to obtain in spite of a large sodium intake (380 mmol/day), hospitalization lasted several months and autonomy via the enteral route could not be achieved in 7 out of the 9 patients with definitive short bowel (vs. 0 in other groups). This study shows that the OIS is an unique functional entity. Complications and prognosis are dependent on the obligatory or induced pattern of the syndrome. Only patients with obligatory OIS require definitive home parenteral nutrition.

[Malnutrition in chronic radiation enteritis. Study of 100 patients]

The nutritional condition of 100 patients with radiation chronic enteritis was studied and compared with that of a consecutive series of 80 patients hospitalized for digestive disorders. The parameters which were measured (body weight, muscular measurement, triceps skinfold creatinine/height index, albumin, transferrin, cholesterol, lymphocytosis), were all significantly lower in patients with radiotherapy enteritis. Anthropometric parameters and lymphocytes were the most affected. The severity of the denutrition was unrelated to the duration of the radiotherapy, the presence of an associated post-radiotherapy involvement of the colon or the urinary tract, a neoplastic recurrence, possible past-history of small bowel surgery; on the contrary, it was related to the extension of actinic lesions on the small bowel and to the presence of subocclusive manifestations. The subsequent evolution at 6 months was most often complicated or unfavorable in patients presenting a severe denutrition. Therefore, denutrition is frequent and severe in the course of post-radiotherapy chronic enteritis and is associated with a more guarded prognosis.

[New forms of 5-aminosalicylate in inflammatory intestinal lesions]

5 aminosalicylate (5 ASA) represents the active fraction of Salazopyrin. Various preparations, 5 ASA-based, are currently already marketed in the world. Some are reserved for the treatment of distal sites of inflammatory bowel diseases, in the form of enemas and suppositories. The others are used orally by preserving the Salazopyrin structure and its azoic link, like di-ASA (Dipentum) or by coating 5 ASA to allow its release in the distal bowel (Asacol, Claversal, Salofalk, Pentasa). In haemorrhagic recto-colitis, these various preparations have, in the whole, a similar effectiveness to that of Salazopyrin in controlling moderately active forms or in keeping the patient in remission. In Crohn's disease, proof of their activity has not yet been established. The major advantage of these new derivatives rests in their use on patients who do not tolerate or are allergic to Salazopyrin since they are quite well tolerated except for the occurrence of diarrhea.

[Exclusive elemental enteral diet in cortico-resistant and cortico-dependent forms of Crohn's disease]

The aim of this study was to investigate the value of elemental diet in steroid-resistant and steroid-dependent Crohn's disease. Elemental diet (Vivonex HN, 39.4 +/- 9.2 kcal/kg/d) was delivered through a nasogastric tube at a constant rate. Twenty therapeutic periods lasting from 20 to 74 days (median, 32 days) were undertaken in 18 patients. Elemental diet was well tolerated. Mean values of hemoglobin, serum albumin, and serum transferrin increased significantly through the therapeutic period; body weight and anthropometric data did not change significantly. The short-term response to elemental diet was excellent in 11 cases, demonstrated by achievement of clinical remission and steroid withdrawal; six patients had an incomplete remission and remained slightly active or had to be maintained under low dose steroids; three patients did not respond to therapy and had to be operated upon. During the follow-up (6-30 months), 8 patients out of 17 had a relapse. Relapse was controlled by medical therapy in 5 cases and led to surgery in the 3 other cases. We conclude that elemental diet, as total parenteral nutrition, is an effective therapy of steroid-resistant and steroid-dependent Crohn's disease. However, elemental diet does not prevent relapse.

[Aid to decision for nutritional support in chronic digestive diseases]

In patients with chronic gastro-intestinal disease, deciding whether or not to provide nutritional support is difficult. The aim of the present study was to develop an objective index to help clinicians to decide which patients should be treated with nutritional support. Two hundred and two patients were studied prospectively. Seventy-one had an inflammatory bowel disease, 51, a malabsorption syndrome, 59, an esophagogastric disorder, and 21, a pancreatic disease. On admission, nutritional status was assessed by anthropometric and biological measurements, and spontaneous oral caloric intake. Clinical assessment of the nutritional condition was performed by an independent observer. Using discriminant analysis, collected data were correlated to the therapeutic outcome of the patient during the 15 days after admission, i. e. whether or not they received nutritional support. Clinical global assessment proved to be the most discriminant variable: 83 p. 100 of the patients were correctly classified. This variable was deleted from further analysis to obtain an objective index, calculated with four variables: mid-arm muscle circumference, body weight, serum albumin, and caloric oral intake expressed as kcal X IBW kg-1 X day-1. The index classified correctly 84 p. 100 of the patients. This study demonstrates that subjective clinical assessment is the best variable to decide whether or not a gastrointestinal patient should receive nutritional support. We suggest that this index might be of help in these situations.

[Continuous enteral feeding of the gastrectomized patient with malnutrition]

The development of nutritional parameters, anthropometric and biologic, under polymeric continuous gastro-intestinal feeding, was followed during 3 to 7 weeks in a group of 10 gastrectomised patients with malnutrition and compared with a group of 10 patients with malnutrition secondary to intake deficiencies and receiving the same treatment. Body weight, mid-arm muscle circumference, triceps skinfold and serum transferrin increased significantly from the beginning to the end of the gastro-intestinal feeding in both groups, and in a comparable fashion. Continuous gastro-intestinal feeding is therefore an effective treatment of malnutrition in the gastrectomised patient. The response obtained, as far as nutrition is concerned, may be compared to that of the patient with malnutrition secondary to intake deficiencies.

[Malabsorption in alcoholic cirrhosis]

21 patients with alcoholic cirrhosis were worked up for malabsorption. In three patients, the fecal weight was over 200 g/24 h; three had a steatorrhea over 6 g/24 h and in four the creatorrhea was over 2 g/24 h. The D-xylose test was abnormal 4 times out of 18, but these 4 patients presented an ascites. Alpha-1-antitrypsin clearance was increased in 1 out of 9 patients. The Lundh test demonstrated in 5 out of 8 cases an external pancreatic insufficiency, but without any relation with the fecal losses. The 4 patients with malabsorption showed signs of malnutrition (anthropometric criteria). In the course of an alcoholic cirrhosis, malabsorption seems therefore infrequent, dissociated, and only observed in patients with signs of malnutrition.

[Biermer's disease and selective IgA deficiency. Apropos of a case]

The authors report a case of pernicious anaemia in a 41-year old white man; this case has particular features: rise in mean corpuscular volume, neurological manifestation 8 and 2 years respectively before diagnosis, association with selective IgA deficiency. Relations between pernicious anaemia and immunoglobulin deficiency are discussed.

[Role of the prevalvular terminal ileum in fecal losses in ileostomized patients]

Fecal losses of water, electrolytes, fat and nitrogen were studied retrospectively in 42 cases (40 patients). To assess the role of the terminal ileum, patients were classified into 2 groups according to the length of resected and/or excluded ileum before the ileocecal junction; group I (n = 17; length less than or equal to 15 cm) and group II (n = 25; length ranging from 15 to 50 cm). In group I, fecal weight and fecal output of sodium, fat and nitrogen were (mean for 24 h) 544 g, 63 mmol, 6.5 g (6.4 p. 100 of ingesta), 2.94 respectively. In group II, fecal outputs were higher; (mean for 24 h) 862 g, 112 mmol, 10.9 g (14.2 p. 100 of ingesta), 4.2 respectively. These differences were statistically significant for fecal weight and fecal output of sodium (p less than 0.001) and for fecal output of fat when expressed as percentage of ingesta (p less than 0.02). These results show that the length of terminal ileum is a major determinant in fecal losses after ileostomy; therefore, it appears to be of major importance to preserve this segment of ileum as much as possible during ileocolic surgery.

Compensatory enteral hyperalimentation for management of patients with severe short bowel syndrome

In order to evaluate the effects of an unrestricted, compensatory, enteral hyperalimentation in patients with short bowel syndrome, we retrospectively selected from 128 consecutive patients with extensive small bowel resection a group of 25 who developed under this regimen a massive protracted diarrhea (fecal weight 2005-6188 g/day). All the patients but one were weaned from parenteral nutrition by the eighth day after admission. Although fecal weight increased in relation to the increase of the enteral intake, there was a significant gain of body weight, serum-albumin, and creatinine-height index and an improved fluid and electrolyte balance through the period of hospitalization. By contrast, 18 of the 25 patients developed hypocalcemia and/or hypomagnesemia. After discharge (median follow-up, three years), most patients resumed normal social activity. It is concluded that exclusively enteral hyperalimentation can stabilize most patients with severe short bowel syndrome even in the case of massive fecal losses.

[Does continuous enteral nutritional deficiencies in digestive system diseases? Results of a longitudinal study of 92 consecutive patients treated for 3 to 7 weeks]

In order to assess the effectiveness and potential limitations of continuous enteral nutrition (CEN) to correct denutrition related to underlying digestive diseases, 10 nutritional criteria were measured weekly in 92 under-nourished patients fed with CEN for a 3-7 week period. All the patients received a standard non-elemental diet providing a mean daily energy intake of 52.8 kcal/kg BW (36.5 kcal/kg BW by tube feeding and 16.3 kcal/kg BW orally). The influence of preexisting intestinal malabsorption, hypercatabolic status, and post-radiation or inflammatory bowel disease was studied by an a posteriori classification of patients in one of the six following groups: I (no limiting factor), II (malabsorption), III (catabolic disease), IV (catabolic disease and malabsorption), V (colitis), VI (enteritis). During CEN, 8 patients had transient and one had persistent vomiting while 3 developed bronchopneumonia. Gains in body weight, triceps skinfold, midarm muscle circumference, creatinine-height index, urinary sodium and serum transferrin were significant as early as the 2nd week of CEN. Serum albumin and cholesterol, hemoglobin, and total count of lymphocytes were not significantly affected. Sixty-five patients (71 per cent) had an objective nutritional improvement and mean spontaneous oral intake increased from 17.8 to 28.7 kcal/kg BW per day. Significant increase of oral intake and objective nutritional improvement were observed in each group, but a longer period of CEN was necessary to achieve this result in groups II, IV and VI.(ABSTRACT TRUNCATED AT 250 WORDS)

[Urinary lithiasis secondary to intestinal diseases]

Urinary stones are much more common in subjects with intestinal diseases than in the general population. The chemical composition of the stones depends on the type of intestinal disease. In diarrhoeas with loss of water and electrolytes (inflammatory colitis and, chiefly, ileostomy), the urine is acid and concentrated and the stones are composed of uric acid. Extensive lesions of the ileum or wide resections of the small bowel increase the intestinal absorption of oxalates and expose the patients to oxalate stones. Treatment, which must be preventive, is based upon a knowledge of the pathophysiology of urolithiasis.

[Chronic radiation enteritis. I. Intestinal malabsorption. Anatomo-functional correlates]

Intestinal malabsorption was studied in 51 cases (46 patients) with radiological and/or operative evidence of small bowel radiation injury. At the time of the study, 23 patients had not been operated on (MED patients), and 28 had undergone previous small-intestinal by-pass or resection (BP/R patients). Fecal analysis data (n = 51), and results of alpha-1-antitrypsin clearance (n = 24), and of D-xylose (n = 37), folic acid (n = 20) and Schilling (n = 27) absorption tests were compared to the extent and severity of small-intestinal damage assessed radiologically and/or operatively. Mean fecal weight was 311 g/24 h in MED patients and 1,190 g/24 h in BP/R patients. Sixty-five, 43, 86, and 82 p. 100 of MED patients, and 93, 77, 93, and 85 p. 100 of BP/R patients, respectively presented increased fecal weight, sodium, lipid, and nitrogen. In MED patients, there was a significant relationship between the extent and severity of small-intestinal damage and fecal weight, lipid, and nitrogen. In BP/R patients, fecal data were related to those calculated from the site and the extent of the intestinal resection. Fecal losses tended to be more abundant when the residual intestine was severely damaged. Alpha-1-antitrypsin clearance (mean 37 ml/24 h) was increased in 8 out of 9 MED patients and in 11 out of 15 BP/R patients. Its value was not related to the extent and severity of small-intestinal damage.(ABSTRACT TRUNCATED AT 250 WORDS)

[Chronic radiation enteritis. II. General consequences and prognostic factors]

We have studied 54 patients (age 19-83 years) with radiological and/or operative evidence of small bowel radiation injury, in order to assess clinical and biological features, final outcome, and prognostic factors of late radiation enteropathy; 23 of them had undergone previous small-intestinal by-pass or resection. During initial treatment (first 6 months), the patients received symptomatic medical treatment and 17 had a 3-6 week continuous enteral alimentation; 15 were operated on. At entry, 51 out of 54 complained of diarrhea, 32 had repeated vomiting and abdominal pain, 43 were undernourished (36 had lost more than 20 p. 100 of their normal weight, 27 had profound anorexia, 29 had hypo-albuminemia of less than 30 milligrams). Anemia was present in 30 patients. Seventy six and 88 p. 100, respectively, had hypocalcemia and hypomagnesemia, with clinical symptoms in 14 cases. Fourteen patients, 12 of whom had undergone intestinal by-pass or resection, had biological hepatic abnormalities. Six patients died during initial treatment and 5 during follow-up; the actuarial survival rate was 72 p. 100 at four years (65 p. 100 for the unoperated patients, and 79 p. 100 for those previously operated on). Carcinoma was the cause of death in 5 cases. Social activity and state of nutrition were satisfactory in 22 out of the 32 patients seen in 1982 with 6-96 months (mean 29 months) follow-up.(ABSTRACT TRUNCATED AT 250 WORDS)