Saccharomyces boulardii does not stimulate mucosal hyperplasia after intestinal resection in the rat

BACKGROUND

Polyamines have been shown to be important regulators of the intestinal adaptation process after massive bowel resection. Saccharomyces boulardii is yeast that has the ability to synthesize polyamines. Therefore. S. boulardii may be useful in the treatment of short bowel syndrome.

METHODS

Twenty 150-g male Sprague-Dawley rats were subjected to 80% jejunoileal resection. Another 20 animals received transection and closure and served as pair fed controls. One half of the resected rats and one half of the controls were given S. boulardii 25 mg/day.

RESULTS

After 2 weeks, mucosal mass (mg/cm bowel) did not differ between treated and non-treated animals despite the presence of a marked resection effect. Mucosal DNA, protein, and sucrase activity likewise did not differ. Subsequently, the experiment was repeated four times the original dose (100 mg/day) and found comparable results. In the proximal bowel, mucosal mass was 92+/-6 mg/cm in treated animals versus 107+/-8 mg/cm in untreated rats. In the distal small bowel, comparable values were 85+/-5 mg/cm and 88+/-4 mg/cm. Again, mucosal DNA, protein, and sucrase activity levels paralleled these results.

CONCLUSIONS

Although S. boulardii may stimulate polyamine synthesis, it does not seem to be helpful in augmenting gut adaptation in this animal model of short bowel syndrome.

X-linked neonatal diabetes mellitus, enteropathy and endocrinopathy syndrome is the human equivalent of mouse scurfy

To determine whether human X-linked neonatal diabetes mellitus, enteropathy and endocrinopathy syndrome (IPEX; MIM 304930) is the genetic equivalent of the scurfy (sf) mouse, we sequenced the human ortholog (FOXP3) of the gene mutated in scurfy mice (Foxp3), in IPEX patients. We found four non-polymorphic mutations. Each mutation affects the forkhead/winged-helix domain of the scurfin protein, indicating that the mutations may disrupt critical DNA interactions.

Role of lipid emulsions in cholestasis associated with long-term parenteral nutrition in children

BACKGROUND

In children who depend on long-term parenteral nutrition (PN), liver disease is a major complication that may lead to end-stage liver failure requiring liver transplantation.

METHODS

This retrospective study investigated the influence of lipid emulsions on cholestasis onset in children receiving long-term total parenteral nutrition (TPN) with lipids. Ten children who presented with a total of 23 episodes of cholestasis, associated in 13 cases with thrombocytopenia, were studied.

RESULTS

Changes in the lipid delivery preceded these complications in more than half the cases. The temporary decrease in lipid administration led to normalization of bilirubin in 17 episodes.

CONCLUSIONS

These data suggest that lipid supply is one of the risk factors for PN-associated cholestasis. The link between cholestasis and the reticuloendothelial system overload needs to be better understood. Prevention of cholestasis might include the decrease in the lipid load. When cholestasis occurs, lipid supply should be temporarily stopped, especially in the case of associated thrombocytopenia.

Central venous catheter-related infections in children on long-term home parenteral nutrition: incidence and risk factors

BACKGROUND AND AIMS

This study aimed to assess the incidence and etiology of central venous catheter (CVC) infections in children on home parenteral nutrition (HPN).

METHODS

207 CVC-years were studied retrospectively in 47 children on HPN, aged 8.1+/-5.0 years.

RESULTS

125 CVC were used (means: 2.6 CVC/patient and 21 months utilization/CVC). Half of the hospitalizations (162) were due to proven CVC-related infections. The mean infection incidence was 2. 1/1000 HPN days. The total population divided in two groups below and above this value: group one including 24 children, incidence < or = 2.1 per 1000 days (mean: 0.83) and group two including 23 children, incidence >2.1 per 1000 days (mean: 4.3). No differences were found between the two groups in terms of underlying disease, presence of ostomies, age at the time of HPN onset, or micro-organisms responsible. The only differences (p<0.05) were the mean duration of HPN (longer in group one) and the delay between HPN onset and the first infection (longer in group one).

CONCLUSIONS

This study does not highlight any risk factors for CVC infection. However, early CVC infections after HPN onset appear to predict a bad prognosis.

Intestinal transplantation: indications, results and strategy

The term 'intestinal failure' is now often used to describe gastrointestinal function insufficient to satisfy body nutrient and fluid requirements. The first recognized condition of intestinal failure was short bowel syndrome. Severe motility disorders such as chronic intestinal pseudo-obstruction syndrome in children as well as congenital intractable intestinal mucosa disorders are also forms of intestinal failure, because no curative treatment for these diseases is yet available. Parenteral nutrition and home parenteral nutrition remain the mainstay of therapy for intestinal failure, whether it is partial or total, provisional or permanent. However, some patients develop complications while receiving standard therapy for intestinal failure and are considered for intestinal transplantation. Indeed, recent advances in immunosuppressive treatment and the better monitoring and control of acute rejection have brought intestinal transplantation into the realm of standard treatment for intestinal failure. Although it has been used in humans for the past two decades, this procedure has had a slow learning curve. According to the current results, this challenging procedure may be performed in children or adults, only under certain conditions.

[Iodine nutrition in the infant. Committee on Nutrition of the French Society of Pediatrics]

Iodine is a trace element essential for the synthesis of thyroid hormones. It is present in the human body in minute amounts (15-20 mg in adults). The thyroid is very sensitive to iodine deficiency in newborns and infants because of its very low iodine content. Daily iodine requirements in humans vary from 40 micrograms in neonates to 150 micrograms in adults. Iodine deficiency represents the first cause of avoidable mental deficiency in developed countries; it has not yet disappeared in Europe, especially in the East, where it is responsible for a high prevalence of goiter. Iodine deficiency during pregnancy increases the risk of neonatal transient hypothyroidism, with a high recall rate in programs of systematic screening for congenital hypothyroidism. Data available in France suggest that screening for iodine deficiency should be performed during pregnancy, and that the minimal iodine concentration in formula milk should be increased to 10 micrograms/100 kcal for term infants and 20 micrograms/100 kcal for premature infants. Iodine deficiency is ideally prevented by the use of iodized salt. Because of the risk of iodine overexposure and secondary transient hypothyroidism, the use of iodinated antiseptics must be avoided in premature babies and neonates as well as in pregnant and lactating women. The fight against iodine deficiency, associated with oral stable preventive iodine administration, decreases sharply the risk of thyroid cancer in case of nuclear exposure, by diminishing thyroid uptake of iodine radioactive isotopes.

[Management of chronic constipation in the infant]

Constipation is a common symptom of various pathologies with dysfunction of the intestinal motricity which largely differ in their expression and severity. However chronic idiopathic constipation is by far the most frequent condition. Only constipations associated with symptoms such as poor nutritional status, failure to thrive, signs of upper intestinal tract obstruction (gross abdominal distention), or showing resistance to the usual therapeutic approach, justify investigations looking for an organic disease, mainly Hirschsprung disease. Treatment of chronic idiopathic constipation requires, first to evacuate the fecal mass, then to prevent its reconstitution mainly by dietetic measures, regular large hydration, stool modifying therapy, daily bowel habit, and regular physical activities; in addition it is important that clear and reassuring explanations be given to the parents.

Long-term efficacy and safety of a new olive oil-based intravenous fat emulsion in pediatric patients: a double-blind randomized study

BACKGROUND

A new intravenous lipid emulsion (ILE) prepared from a mixture of soybean and olive oils contains only long-chain triacylglycerols, with a low proportion (20%) of polyunsaturated fatty acids and 60% monounsaturated fatty acids.

OBJECTIVE

The goal of this randomized, double-blind clinical trial was to assess in children the efficacy and safety of this new ILE compared with a control group receiving a soybean-oil emulsion.

DESIGN

Eighteen children received for 2 mo 24% of nonprotein energy (1.80 g kg (-)(1) d(-)(1)) either as the new ILE or a soybean oil-based emulsion. Assessments were performed on days -30, 0, 30, and 60 and the changes (day 60 - day 0) assessed by analysis of variance.

RESULTS

There were no significant differences in triacylglycerol, apolipoproteins A-I and B, or HDL cholesterol between the 2 groups, whereas total and LDL cholesterol were higher in the soybean oil group on day 60. The pattern of 20:4n-6 in erythrocyte membranes did not change significantly, nor did the ratio of 20:3n-9 to 20:4n-6. On day 60, 18:1n-9 was significantly higher in the olive oil group, the ratio of Sigma(n)-6 > C(18) + 18:3n-6 to 18:2n-6 was 2.20 +/- 0.09 in the olive oil group and 1.33 +/- 0.16 in the soybean-oil group, and Sigma(n)-3 > C(18) was 3.83 +/- 0.30 in the olive oil group and 4. 03 +/- 0.33 in the soybean-oil group. The peroxidation index was lower after the olive oil treatment.

CONCLUSIONS

The olive oil-based emulsion was well tolerated, maintained a normal EFA status, and may be more suitable for prevention of lipid peroxidation than the soybean-oil-based emulsion.

Intestinal transplantation in children: preliminary experience in Paris

From November 1994 to November 1998, 20 children (2.5 to 14 years) received a jejunoileal graft alone (SBTx; n = 10) or in combination with the liver (SBLTx; n = 10 and/or the right colon (5 SBTx). Indications were intractable diarrhea of infancy (n = 8), short bowel syndrome (n = 6), extensive Hirschsprung disease (n = 4), and chronic intestinal pseudoobstruction (n = 2). Immunosuppression included tacrolimus, methylprednisolone, and azathioprine. Current follow-up ranges from 6 to 54 months. Five patients died (3 SBTx) within the first 2 months. Acute liver rejection occurred in 5 patients during the first 2 months. Sixteen episodes of intestinal rejection during the first 3 months in 11 patients (8 in 4 SBTx) were successfully treated in all but 3 by increasing tacrolimus dose and/or a 3-day methyprednisolone bolus or required antilymphoglobulins in 3 cases. Surgical complications occurred 8 times after SBLTx and 3 after SBTx. Infectious complications were more frequent in SBLTx recipients. Reversible Epstein-Barr virus-related posttransplant lymphoproliferative disease occurred in 3 recipients. Five presented cytomegalovirus infection. The SB graft was removed in 5 recipients (3 chronic rejection). All patients were started with oral and/or enteral feeding from the 7th postoperative day by using either normal food or protein hydrolysate diet. Currently, 10 of 11 children (8 SBLTx) achieved digestive autonomy after 5 to 30 weeks. All recipients gained weight; however, growth velocity remained reduced during the first 6 months because of the steroid therapy. Overall graft and patient survival is higher after SBLTx. Intestinal transplantation is indicated for patients with permanent intestinal failure. However, because parenteral nutrition is generally well tolerated, even for long periods, each indication for transplantation must be weighed carefully in terms of risk and quality of life.

[Protein requirements in children during states of stress. Committee on Nutrition of the French Society of Pediatrics]

Acute and chronic stress conditions affecting critically ill children are characterized by severe protein breakdown and growth failure. This paper describes the disorders of protein metabolism, and gives recommendations for protein and energy intakes during stress conditions in children.

[Can intestinal transplantation constitute treatment for intestinal failure?]

The management of patients with intestinal failure has benefited from progress in parenteral nutrition (PN), especially home-based parental nutrition. Intestinal transplantation is now possible and in some conditions, constitutes the logical treatment option. Since 1985, more than 300 small-bowel grafts have been performed, involving the isolated small bowel with or without the colon (45%), the liver + small bowel (40%) or several organs (15%). 2/3 of recipients were under 20 years of age, and indications were short-bowel syndrome (64%), severe intractable diarrhea (13%), abdominal cancer (13%), or chronic intestinal pseudo-obstruction syndrome (8%). 51% of patients survived > 2 years after the graft. Patient and graft survival depends on the type of immunosuppression, i.e. Cyclosporine or FK 506. The results must be interpreted carefully as they represent the first experience in numerous centers using different immuno-suppressive protocols, without any randomization. The results from the largest of these centers more closely reflect the current situation and may exceed a 70% 2-year survival rate. Functional grafts lead to gastrointestinal autonomy (weaning of PN) while maintaining satisfactory nutritional status and normal growth in childhood. Intestinal transplantation is theoretically indicated for all patients permanently or persistently dependent on PN. However, as PN is generally well tolerated, even for long periods, each indication for transplantation must be carefully weighed up in terms of the iatrogenic risk and quality of life. When PN has reached its limits, especially those associated with vascular, infectious, hepatic or metabolic complications, intestinal transplantation must be undertaken. Transplantation of the small bowel alone remains the first option, as combined liver-small bowel grafting is only indicated in case of life-threatening progressive cirrhogenic liver disease.

Intestinal transplantation

Intestinal transplantation might become the alternative to definitive parenteral nutrition in patients with permanent intestinal failure. Indeed, recent advances in immunosuppressive treatment and better monitoring and control of acute rejection have brought intestinal transplantation into the realms of standard treatment of intestinal failure. This procedure may be performed in adult or paediatric patients under certain conditions. This short review focuses on the current clinical results and indications for intestinal transplantation and discusses the strategy regarding this challenging procedure.

Up-to-date evolution of small bowel transplantation in children with intestinal failure

PURPOSE

The aim of the authors was to report an up-to-date review of their experience with 26 intestinal transplantations in children since 1987.

METHODS

A retrospective study was conducted of 26 patients with a mean age of 5 years (range, 0.3 to 14 years). Three groups were isolated. In group A (1987 to 1990), seven patients received nine isolated intestinal transplants for short bowel syndrome. Immunosuppression therapy consisted of cyclosporine, aziathioprine, and corticosteroids. In group B (1994-current), nine patients received nine isolated intestinal transplants for short bowel syndrom (n = 2), intestinal pseudoobstruction (n = 2), neonatal intractable diarrhea (n = 3), and Hirschsprung' disease (n = 1); hepatic biopsy results showed weak cholestasis or fibrosis. In group C (1994-current), 10 patients received 10 combined liver-small bowel transplants for short bowel syndrome (n = 3), neonatal intractable diarrhea (n = 4), and Hirschsprung' disease (n = 3); hepatic cirrhosis related to total parenteral nutrition (TPN) was shown in all cases. Groups B and C received immunosupressive treatment consisting of tacrolimus, aziathioprine, and corticosteroids. Posttransplant follow-up included intestinal biopsies of the small bowel twice a week and more frequently or combined with liver biopsy if rejection was suspected.

RESULTS

Overall patient survival (PS) and graft survival (GS) are 61% (16 of 26) and 50% (13 of 26), respectively. In group A, severe intestinal allograft rejection occurred in six patients leading to graft removal (GS, 11%). Five patients died of TPN complications after graft removal (PS, 28%). One survivor is off TPN, and one currently is waiting for a second graft. In group B, six patients survived (PS, 66%). Causes of death include hepatic failure (n = 1), renal and liver failure (n = 1), and systemic infection (n = 1). Severe intestinal allograft rejection occurred in five patients, which neccessitated aggressive immunosuppression (antilymphocyte serum) leading to an incomplete functional recovery of the graft. Only two patients currently are off TPN. In group C, eight patients survived (PS, 80%) all of which are currently off TPN. One patient died during the procedure, and one died of severe systemic infection. Intestinal graft rejection occurred in six patients; rejection of the liver allograft occurred in five patients, yet all rejections were weak and successfully treated by corticosteroids (GS, 80%).

CONCLUSIONS

Intestinal transplantation is a valid therapeutic option for children with definitive intestinal failure and not only for short bowel syndrome. Tacrolimus improves graft and patient survival (group A v group B). The lower severity of graft rejection in combined liver-small bowel transplantation improves functional results of intestinal transplantation in children without additional mortality or morbidity (group B vgroup C).

Chronic intestinal pseudoobstruction syndrome: clinical analysis, outcome, and prognosis in 105 children. French-Speaking Group of Pediatric Gastroenterology

Our aim was to collect a large number of cases to characterize clinical presentation, outcome, and prognosis of chronic intestinal pseusoobstruction in children. We conducted a retrospective multicenter study that included children treated for chronic intestinal pseusoobstruction defined as recurrent episodes of intestinal obstruction with no mechanical obstruction, excluding Hirschsprung's disease. In all, 105 children, 57 boys and 48 girls, were studied, including five familial forms. Prenatal diagnosis was made in 18 patients. Eighty patients were less than 12 months old at onset; the disease began at birth for 37 patients. The most frequent signs were abdominal distension, vomiting, and constipation. Megacystis was noted in myopathies (7 cases), neuropathies (10 cases) and unclassified forms (13 cases). For all but three cases (two patients with CMV infection, one with Munchhausen-by-proxy syndrome), the associated diseases and disorders could not account for chronic intestinal pseusoobstruction as a secondary disorder. At least one full-thickness biopsy from the digestive tract was studied for 99 patients. The diagnosis recorded was visceral neuropathy in 58 cases, visceral myopathy in 17 cases, and uncertain or normal biopsy results in 24 cases. Seventy-eight children were fed intravenously, and only 18 were able to be fed orally throughout their illness. Seventy-one patients underwent surgery during their illness, and 217 surgical procedures, a mean of 3 per patient, were performed. Ostomy was the most performed procedure. Follow-up continued in 89 patients for 3 months to 16 years (mean 85 months). Forty-two patients were still fed by parenteral (39 patients) or enteral nutrition (3 patients) at the time of the study. Eleven patients died between the age of 1 month and 14 years 7 months.

Chronic intestinal pseudo-obstruction syndrome in pediatric patients

The aim of this study was to report the presentation and outcome of 22 consecutive children (13 female) who presented with a syndrome of chronic intestinal pseudo-obstruction with or without urinary tract involvement. We analyse the main clinical and histopathological features and discuss therapeutic management. Ten patients had signs of intestinal obstruction at birth, in which 6 presented antenatally with megacystis on ultrasound. Six children presented with constipation and/or obstruction between 1 and 6 months of age and in 6 other patients diagnosis was made between the ages of 1 and 12 years. There was a family history in 4 patients. Investigations showed diffusely dilated gut on x-ray with slow transit on small bowel follow through. Absent or abnormal motor migrating complex with low amplitude contractions were demonstrated on duodeno-jejunal manometry in 12/13. Megacystis occurred in 15/21 and megaureter in 2/21. Full thickness biopsies (n = 22) revealed involvement of muscle layers in 8, and abnormal myenteric plexus on histochemistry in 13. In 1, the biopsies were inconclusive. Recurrent urinary tract infections occurred in all with structural urinary tract abnormality and most had bacterial overgrowth. Severe recurrent episodes of obstruction which required parenteral nutrition (PN) occurred in all patients. Drugs were unhelpful and decompression ileostomies or colostomies were performed in 20/22. Five children died from sepsis (n = 3) or sudden death. Eleven patients remain partially or totally dependent on PN despite decompression ileostomy in 10/11. Six patients underwent colectomy and ileorectal pull-through, 2 of which remain on long-term PN, while the others are totally orally fed. Despite careful histological study pointing to 2 main forms, myopathy and neuropathy, the etiology of primary intestinal pseudoobstruction syndromes remains unknown. It may present antenatally while most of the time the gut and the urinary tract are diffusely involved. The condition has a high morbidity with a percentage requiring long-term PN. Although the mortality rate is high (23%), careful treatment of urinary tract infections and bacterial overgrowth, decompression surgery and judicious use of PN allows survival to adult life.