Influence of bile and pancreatic secretions on the size of the intestinal villi in the rat

Objective evaluation of blood flow in the small-intestinal villous: quantification of findings from dynamic endoscopy with concomitant narrow-band imaging

BACKGROUND AND AIMS

 We have previously shown that the increase in blood flow volume in jejunum villi after spraying of 10 % dextrose solution correlates with pancreatic exocrine function (PEF). The aim of this study was to establish an objective method to evaluate the amount of jejunum villous blood flow using a novel image analysis system.

PATIENTS AND METHODS

 The subjects were 26 patients who underwent upper gastrointestinal endoscopy with a newly developed small intestine endoscope (SIF-Y0007, Olympus, Tokyo, Japan). By defining the ratio of capillary occupancy in each villus at levels from 1 to 5, villous blood flow was evaluated subjectively on the villous blood flow scale (VBFS). Objective evaluation was performed based on luminance analysis. The morphological opening process was used to make images with leveled brightness. A histogram was prepared from the luminance information and the standard deviation was determined and defined as SDOV (Standard Deviation calculated from a histogram made by luminance analysis Of Villi). PEF was evaluated by measuring the BT-PABA (N-benzoyl-L-tyrosyl-p-aminobenzoic acid) excretion rate.

RESULTS

 There was a significant positive correlation between VBFS and SDOV ( P  < 0.0001, ρ = 0.5882). SDOV was also positively correlated with PEF ( P  = 0.0004, ρ = 0.6421).

CONCLUSIONS

 SDOV is a new objective index for evaluation of blood flow volume in jejunum villi. SDOV may be useful in clinical practice to estimate PEF and for clarification of the mechanisms underlying the functional correlation between the pancreas and small intestine.

Functional Correlation Between the Pancreas and the Small Intestine in Humans: The First Evaluation Using a Newly Developed Enteroscopy

OBJECTIVES

The aim of this study is to evaluate a functional correlation between the pancreas and the small intestine and the association of this relationship with nutritional status, using magnifying enteroscopy.

METHODS

The subjects were adults aged 20 years or older who underwent upper gastrointestinal endoscopy. An endoscope was inserted into the jejunum, and 10% glucose was sprayed under magnifying observation to evaluate changes in blood flow in the villous capillary network. Mucosal biopsy was performed before and after spraying to evaluate the incretin response in the jejunal mucosa.

RESULTS

A total of 124 patients participated in the study. There was a positive correlation between villous blood flow change and exocrine pancreas function (R = 0.4337, P < 0.0001). Changes of gastric inhibitory polypeptide and glucagon-like peptide messenger RNAs in biopsy samples were positively correlated with endocrine pancreas function in 88 patients without treatment for diabetes (R = 0.4314, P = 0.0012; R = 0.4112, P = 0.0081). In patients with lower villous blood flow change and decreased pancreatic exocrine function, the prognostic nutritional index were significantly lower (P = 0.0098), compared with other patients.

CONCLUSIONS

This study provides the first evidence of a close functional correlation between the pancreas and the small intestine.

Loop ileostomy-mediated fecal stream diversion is associated with microbial dysbiosis

Loop ileostomy is an effective procedure to protect downstream intestinal anastomoses. Ileostomy reversal surgery is often performed within 12 months of formation but is associated with substantial morbidity due to severe post-surgical complications. Distal ileum is deprived of enteral nutrition and rendered inactive, often becoming atrophied and fibrotic. This study aimed to investigate the microbial and morphological changes that occur in the defunctioned ileum following loop ileostomy-mediated fecal stream diversion. Functional and defunctioned ileal resection tissue was obtained at the time of loop-ileostomy closure. Intrapatient comparisons, including histological assessment of morphology and epithelial cell proliferation, were performed on paired samples using the functional limb as control. Mucosal-associated microflora was quantified via determination of 16S rRNA gene copy number using qPCR analysis. DGGE with Sanger sequencing and qPCR methods profiled microflora to genus and phylum level, respectively. Reduced villous height and proliferation confirmed atrophy of the defunctioned ileum. DGGE analysis revealed that the microflora within defunctioned ileum is less diverse and convergence between defunctioned microbiota profiles was observed. Candidate Genera, notably Clostridia and Streptococcus, reduced in relative terms in defunctioned ileum. We conclude that Ileostomy-associated nutrient deprivation results in dysbiosis and impaired intestinal renewal in the defunctioned ileum. Altered host-microbial interactions at the mucosal surface likely contribute to the deterioration in homeostasis and thus may underpin numerous postoperative complications. Strategies to sustain the microflora before reanastomosis should be investigated.

The Pathogenesis of Resection-Associated Intestinal Adaptation

After massive small-bowel resection, the remnant bowel compensates by a process termed adaptation. Adaptation is characterized by villus elongation and crypt deepening, which increases the capacity for absorption and digestion per unit length. The mechanisms/mediators of this important response are multiple. The purpose of this review is to highlight the major basic contributions in elucidating a more comprehensive understanding of this process.

Investigation of Morphological and Functional Changes in the Small Intestine With Pancreatic Disease

OBJECTIVES

The aim of this study was to investigate the relationship between pancreas and small intestine evaluating the endoscopic and histopathologic findings of the proximal small intestine in pancreatic diseases.

METHODS

Fifty patients (18 patients with chronic pancreatitis, 17 patients with pancreatic cancer, 15 control subjects) underwent enteroscopy using a prototype enteroscope. The villous height of the jejunum on bioptic specimens was measured, and the mean values of the villi were compared among the 3 groups. Exocrine function was calculated by the pancreatic function diagnostic test, and the correlation between the recovery rate of p-aminobenzoic acid and the villous height was assessed. Finally, the distribution of the K cells secreting glucose-dependent insulinotropic polypeptide and the L cells secreting glucagon-like peptide 1 in the duodenum and jejunum was investigated using immunohistochemistry for glucose-dependent insulinotropic polypeptide and glucagon-like peptide 1.

RESULTS

The mean villous height in chronic pancreatitis (328 ± 67 μm) was significantly lower than that in pancreatic cancer (413 ± 57 μm) and control subjects (461 ± 97 μm) (P = 0.004 and P < 0.0001, respectively). A positive correlation was found between the recovery rate of p-aminobenzoic acid and the villous height (r = 0.52, P = 0.0001). The presence of K and L cells was verified in the duodenum and the jejunum.

CONCLUSIONS

Close relationship between pancreas and small intestine was demonstrated.

Pancreatic and pancreatic-like microbial proteases accelerate gut maturation in neonatal rats

OBJECTIVES

Postnatal gut maturation in neonatal mammals, either at natural weaning or after precocious inducement, is coinciding with enhanced enzymes production by exocrine pancreas. Since the involvement of enzymes in gut functional maturation was overlooked, the present study aimed to investigate the role of enzymes in gut functional maturation using neonatal rats.

METHODS

Suckling rats (Rattus norvegicus) were instagastrically gavaged with porcine pancreatic enzymes (Creon), microbial-derived amylase, protease, lipase and mixture thereof, while controls received α-lactalbumin or water once per day during 14-16 d of age. At 17 d of age the animals were euthanized and visceral organs were dissected, weighed and analyzed for structural and functional properties. For some of the rats, gavage with the macromolecular markers such as bovine serum albumin and bovine IgG was performed 3 hours prior to blood collection to assess the intestinal permeability.

RESULTS

Gavage with the pancreatic or pancreatic-like enzymes resulted in stimulated gut growth, increased gastric acid secretion and switched intestinal disaccharidases, with decreased lactase and increased maltase and sucrase activities. The fetal-type vacuolated enterocytes were replaced by the adult-type in the distal intestine, and macromolecular transfer to the blood was declined. Enzyme exposure also promoted pancreas growth with increased amylase and trypsin production. These effects were confined to the proteases in a dose-dependent manner.

CONCLUSION

Feeding exogenous enzymes, containing proteases, induced precocious gut maturation in suckling rats. This suggests that luminal exposure to proteases by oral loading or, possibly, via enhanced pancreatic secretion involves in the gut maturation of young mammals.

Animal models of gastrointestinal and liver diseases. Animal models of infant short bowel syndrome: translational relevance and challenges

Intestinal failure (IF), due to short bowel syndrome (SBS), results from surgical resection of a major portion of the intestine, leading to reduced nutrient absorption and need for parenteral nutrition (PN). The incidence is highest in infants and relates to preterm birth, necrotizing enterocolitis, atresia, gastroschisis, volvulus, and aganglionosis. Patient outcomes have improved, but there is a need to develop new therapies for SBS and to understand intestinal adaptation after different diseases, resection types, and nutritional and pharmacological interventions. Animal studies are needed to carefully evaluate the cellular mechanisms, safety, and translational relevance of new procedures. Distal intestinal resection, without a functioning colon, results in the most severe complications and adaptation may depend on the age at resection (preterm, term, young, adult). Clinically relevant therapies have recently been suggested from studies in preterm and term PN-dependent SBS piglets, with or without a functional colon. Studies in rats and mice have specifically addressed the fundamental physiological processes underlying adaptation at the cellular level, such as regulation of mucosal proliferation, apoptosis, transport, and digestive enzyme expression, and easily allow exogenous or genetic manipulation of growth factors and their receptors (e.g., glucagon-like peptide 2, growth hormone, insulin-like growth factor 1, epidermal growth factor, keratinocyte growth factor). The greater size of rats, and especially young pigs, is an advantage for testing surgical procedures and nutritional interventions (e.g., PN, milk diets, long-/short-chain lipids, pre- and probiotics). Conversely, newborn pigs (preterm or term) and weanling rats provide better insights into the developmental aspects of treatment for SBS in infants owing to their immature intestines. The review shows that a balance among practical, economical, experimental, and ethical constraints will determine the choice of SBS model for each clinical or basic research question.

Effects on gut properties in exocrine pancreatic insufficient (EPI) pigs, being growth retarded due to pancreatic duct ligation at 7 weeks but not at 16 weeks of age

PURPOSE

Exocrine pancreatic insufficiency (EPI) induced in young pigs by pancreatic duct ligation (PDL) early after weaning result in total growth deprivation while it has little effect in somewhat older pigs. The main objective was to study effects of EPI on gut structure and function in littermate pigs underwent to PDL at different age.

MATERIAL/METHODS

Pigs, duct-ligated at either 7 (2 weeks post-weaning, PDL-7) or 16 weeks of age (PDL-16), and euthanized at an age of 21-23 weeks together with un-operated littermates were studied. The intestinal in vitro permeability was studied in separate PDL-pigs and compared to un-operated.

RESULTS

Morphometric analysis showed gut mucosal atrophy in the PDL-7 as compared to PDL-16 pigs, while no differences in mucosal disaccharidase activities. The intestinal permeability for different-sized markers was significantly increased in the PDL-pigs compared to the un-operated controls. Analyses of the intestinal digesta showed a total lack of pancreatic enzymes in all PDL-pigs, while instead new, as yet unidentified, enzyme-activities appeared.

CONCLUSIONS

All EPI-pigs, independent of age at PDL-operation, displayed adaptive gut changes, however the EPI-pigs operated early after weaning appeared more sensitive, probably related to their gut maturity and possibly explaining the growth arrest seen in these pigs.

Comparative study of jejunal and colonic alterations between gastrojejunoduodenal and gastrocoloduodenal interposition in dogs

BACKGROUND

The intestinal interpositions are important in various operations of the digestive tract. However, they are capable to produce serious immediate and late complications.

AIM

To compare clinical and surgical outcomes, as well as intestinal pathological findings, in dogs submitted to jejunum and colon interposition.

METHODS

Forty male mongreal dogs were immunized and dewormed, between 36 and 72 months old and weighting from 6 to 16 kg divided into two groups of 20 (G1=gastrojejunoduodenal and G2=gastrocoloduodenal). They were anesthetized and submitted to laparotomy with jejunum and colon interposition between the gastric antrum and the duodenum. On the 120th postoperative day, a relaparotomy was performed with removal of the jejunun/colon segments for evaluation. The segments were processed using Bouin and tissue were stained with H&E for histological analysis. Clinical and surgical outcomes analyzed were weight, diarrhea, fistula, infection, suture dehiscence and incisional hernia. The pathological analysis involved neutrophilic infiltration, increase in number of goblet cells and villous and crypts hypotrophy. Mann-Whitney and Fisher Exact tests were used for groups comparisons.

RESULTS

Dogs that underwent gastrocoloduodenal interposition had a higher weight loss (p<0.05) and more diarrhea (p<0.001). Clinically, controlled fistula rates were 20% in G1 and 100% in G2. Complications occurred in 20% in G1 and in all animals in G2 (p<0.001). Pathological alterations were also more prevalent in G2 (p<0.001).

CONCLUSION

There is a high morbidity and complication rates involving intestine interposition and higher in G2 where colon segments were used.

Stimulating effect of pancreatic-like enzymes on the development of the gastrointestinal tract in piglets

Use of nutritional components from the milk and eventually from the solid feed relates to the growth and development of gastrointestinal tract (GIT). We studied the effect of pancreatic-like enzymes [porcine pancreatic enzymes (Creon) or microbial-derived amylase, protease, and lipase] on GIT morphology and lipid absorption in suckling piglets. Both enzyme preparations, in low or high dose, were fed via a stomach tube twice a day for 7 d starting at 8 d of age and controls received vehicle, n = 6. The day after treatments ended, lipid absorption was tested after which pigs were euthanized and GIT was examined. Enzyme cocktails, irrespective of their origin, increased (P < 0.001) triglyceride level in blood. Enzyme preparation affected (P < 0.001) small intestinal mucosal thickness, villi length, and crypt depth and (P < 0.01) mitotic division of enterocytes. In addition, the external administration of pancreatic enzymes stimulated pancreatic growth as observed by increased (P < 0.05) mitotic division of pancreatic cells. The study revealed that pancreatic or pancreatic-like enzymes of microbial origin administrated in the early postperinatal period enhance GIT development and may be used to better prepare the GIT of piglets for milk use and weaning.

Short bowel syndrome: how short is too short?

Short bowel syndrome (SBS) is the most common cause of intestinal failure. This article discusses the prognostic factors that predict weaning from parenteral nutrition in SBS. The article also delineates an approach to enteral feeding in SBS.

Influência de válvulas artificiais sobre a morfometria intestinal de ratos

OBJETIVO: Avaliar o papel de válvulas artificiais constituídas por seromiotomias circunferenciais duplas no comprimento dos vilos, no diâmetro do intestino delgado e no peso de ratos. MÉTODO: Foram utilizados 40 ratos, distribuídos em quatro grupos. Os animais do Grupo R foram submetidos à ressecção de 50% do intestino delgado, sem criação de válvulas. No Grupo RV associaram duas válvulas à ressecção intestinal. No Grupo V foram criadas duas válvulas, sem ressecção intestinal. O Grupo C forneceu a altura normal dos vilos. A eutanásia deu-se entre o décimo e o 14º dia pós-operatórios. RESULTADOS: Houve aumento no comprimento dos vilos nos grupos R, RV e V. Comparado ao Grupo R, o comprimento dos vilos nos grupos RV e V foi semelhante nos segmentos proximal e distal. No Grupo RV, os vilos do segmento proximal tiveram comprimento superior ao do distal. No Grupo V, o comprimento dos vilos do segmento proximal foi menor que do distal. A alça intestinal teve diâmetro maior que no pré-operatório no Grupo R e nos segmentos proximal à primeira válvula e distal à segunda, dos grupos RV e V. A ressecção intestinal levou à perda ponderal nos grupos R e RV, sem diferença entre os grupos. No Grupo V houve ganho de peso, significativo quando comparado aos grupos R e RV. Apesar de não impedirem a perda ponderal em animais submetidos à ressecção, as válvulas não determinaram perda superior à da ressecção isolada. CONCLUSÃO: Essas válvulas parecem influenciar positivamente a adaptação intestinal e podem ser incluídas entre as técnicas de reabilitação intestinal cirúrgica, isoladamente ou precedendo intervenções de alongamento do intestino.

Expansion of intestinal stem cells associated with long-term adaptation following ileocecal resection in mice

Sustained increases in mucosal surface area occur in remaining bowel following massive intestinal loss. The mechanisms responsible for expanding and perpetuating this response are not presently understood. We hypothesized that an increase in the number of intestinal stem cells (ISC) occurs following intestinal resection and is an important component of the adaptive response in mice. This was assessed in the jejunum of mice 2-3 days, 4-5 days, 6-7 days, 2 wk, 6 wk, and 16 wk following ileocecal resection (ICR) or sham operation. Changes in ISC following ICR compared with sham resulted in increased crypt fission and were assayed by 1) putative ISC population (SP) by flow cytometry, 2) Musashi-1 immunohistochemistry, and 3) bromodeoxyuridine (BrdU) label retention. Observed early increases in crypt depth and villus height were not sustained 16 wk following operation. In contrast, long-term increases in intestinal caliber and overall number of crypts per circumference appear to account for the enhanced mucosal surface area following ICR. Flow cytometry demonstrated that significant increases in SP cells occur within 2-3 days following resection. By 7 days, ICR resulted in marked increases in crypt fission and Musashi-1 immunohistochemistry staining. Separate label-retention studies confirmed a 20-fold increase in BrdU incorporation 6 wk following ICR, confirming an overall increase in the number of ISC. These studies support that expansion of ISC occurs following ICR, leading to an overall increase number of crypts through a process of fission and intestinal dilation. Understanding the mechanism expanding ISCs may provide important insight into management of intestinal failure.

Intestine-specific ablation of mouse atonal homolog 1 (Math1) reveals a role in cellular homeostasis

BACKGROUND & AIMS

Math1 (Atoh1) is a basic helix-loop-helix transcription factor important for intestinal secretory cell differentiation. We hypothesized that Math1 is important in cell fate commitment, and therefore mediates proliferative homeostasis and the adaptive response following intestinal resection in the adult intestine.

METHODS

We generated mice with an intestine-specific mosaic deletion of Math1 (Math1(Delta intestine)) using the Cre/loxP system. Histologic analysis in adult Math1(Delta intestine) and wild-type littermates at baseline and following small bowel resection or sham surgery was performed.

RESULTS

We observed loss of Paneth, goblet, and enteroendocrine cells in Math1-null crypts. In addition, aberrant activation of the Math1 promoter occurred in absorptive enterocytes derived from Math1-null crypts, suggesting a change in cell fate. Proliferation was increased but apoptosis unchanged in Math1-mutant crypts compared to adjacent wild-type crypts. Math1(Delta intestine) mice and wild-type littermates displayed similar physiologic adaptive responses to small bowel resection as measured by changes in body weight and ileal wet weight. In contrast, Math1-mutant crypts displayed a blunted adaptive response compared to adjacent wild-type crypts.

CONCLUSIONS

We show that Math1 is essential for adult intestinal secretory cell production, and in its absence cells destined to a secretory phenotype instead adopt an absorptive phenotype. Subtle abnormalities of proliferation within Math1-null crypts in Math1(Delta intestine) mice were identified, together with a substantial defect in the adaptive response of Math1-null crypts following small bowel resection. Our results suggest that Math1 is critical for both cell fate determination within the intestinal epithelium and for regulation of the response to intestinal resection.

Rapid expansion of intestinal secretory lineages following a massive small bowel resection in mice

Following massive small bowel resection (SBR) in mice, there are sustained increases in crypt depth and villus height, resulting in enhanced mucosal surface area. The early mechanisms responsible for resetting and sustaining this increase are presently not understood. We hypothesized that expansion of secretory lineages is an early and sustained component of the adaptive response. This was assessed in the ileum by quantitative morphometry at 12 h, 36 h, 7 days, and 28 days and by quantitative RT-PCR of marker mRNAs for proliferation and differentiated goblet, Paneth cell, and enterocyte genes at 12 h after 50% SBR or sham operation. As predicted, SBR elicited increases of both crypt and villus epithelial cells, which were sustained though the 28 days of the experiment. Significant increases in the overall number and percentage of both Paneth and goblet cells within intestinal epithelium occurred by 12 h and were sustained up to 28 days after SBR. The increases of goblet cells after SBR were initially observed within villi at 12 h, with marked increases occurring in crypts at 36 h and 7 days. Consistent with this finding, qRT-PCR demonstrated significant increases in the expression of mRNAs associated with proliferation (c-myc) and differentiated goblet cells (Tff3, Muc2) and Paneth cells (lysozyme), whereas mRNA associated with differentiated enterocytes (sucrase-isomaltase) remained unchanged. From these data, we speculate that early expansion of intestinal secretory lineages within the epithelium of the ileum occurs following SBR, possibly serving to amplify the signal responsible for initiating and sustaining intestinal adaptation.

New growth factor therapies aimed at improving intestinal adaptation in short bowel syndrome

Short bowel syndrome (SBS) is used to describe a condition of malabsorption and malnutrition resulting from the loss of absorptive area following massive small bowel resection. The key to improved clinical outcome after massive small bowel resection is the ability of the residual bowel to adapt. Although still in experimental stages, a major goal in the management of SBS may be the augmented use of growth factors to promote increased adaptation. A number of growth factors have been implicated in promoting the adaptation process. The best-described growth factors are reviewed: glucagon-like peptide-2 (GLP-2), epidermal growth factor (EGF), and growth hormone (GH). This article reviews the ability of recombinant GLP-2, EGF and GH to modulate structural and functional aspects of intestinal adaptation following small bowel resection. Although these growth factors have shown promise, small sample size, inconsistent measurement parameters and uncontrolled study designs have hampered the acquisition of strong data advocating the use of growth factor treatment for SBS. Multicenter trials using well-defined outcome measures to assess clinical efficacy are needed to direct the clinical indications, timing and duration of therapy and assess potential risks associated with growth factor therapies.

Intestinal Adaptation in Short Bowel Syndrome

Short bowel syndrome occurs when there is insufficient length of the small intestine to maintain adequate nutrition and/or hydration status without supplemental support. This syndrome most frequently occurs following extensive surgical resection of the intestine, and the extent of adaptation depends on the anatomy of the resected bowel and the amount of bowel remaining. Following resection, the intestinal tissue undergoes morphologic and functional changes to compensate for the lost function of the resected bowel. These changes are mediated by multiple interactive factors, including intraluminal and parenteral nutrients, gastrointestinal secretions, hormones, cytokines, and growth factors, many of which have been well characterized in animal models. The amount of small bowel remaining is the most important predictor of adaptive potential; neither structural nor functional adaptative changes have been demonstrated in humans or animal models with more extreme resections resulting in an end-jejunostomy. The current understanding of these processes has led to the recent use of supplemental hormones, such as growth hormone and glucagon-like peptide 2, in intestinal rehabilitation programs and may lead to the development of pharmacologic agents designed to augment the innate adaptive response.

Surgical therapy for short bowel syndrome

Patients with short bowel syndrome (SBS) suffer tremendous morbidity secondary to prolonged hospitalization and chronic parenteral nutrition (TPN). Overall, the majority of infants will adapt and ultimately become independent of TPN, but this process may require many months or years. Reasons for continued TPN dependency include bowel dysmotility, bacterial overgrowth, insufficient adaptation, or very short bowel length. It is this subpopulation of patients who may benefit from surgical procedures that optimize intestinal adaptation and increase the mucosal absorptive surface area. The goal of this review article is to summarize the process of intestinal adaptation and then to outline the surgical principles and techniques available to surgeons who treat this complicated group of patients.

Long-term parenteral nutritional support and intestinal adaptation in children with short bowel syndrome: a 25-year experience

OBJECTIVE

To analyze the outcome of children with short bowel syndrome (SBS) who required long-term parenteral nutrition (PN).

STUDY DESIGN

Retrospective analysis of children (n=78) with SBS who required PN >3 months from 1975 to 2000.

STATISTICS

univariate analysis, Kaplan-Meier method, and Cox proportional regression model were used.

RESULTS

We identified 78 patients. Survival was better with small bowel length (SBL) >38 cm, intact ileocecal valve (ICV), intact colon, takedown surgery after ostomy (all P <.01), and primary anastomosis (P <.001). PN-associated early persistent cholestatic jaundice (P <.001) and SBL of <15 cm (P <.01) were associated with a higher mortality. Intestinal adaptation was less likely if SBL <15 cm (P <.05), ICV was removed, colonic resection was done (both P <.001), >50% of colon was resected (P <.05), and primary anastomosis could not be accomplished (P <.01). Survival was 73% (57), and 77% (44) of survivors had intestinal adaptation.

CONCLUSIONS

SBL, intact ICV, intestinal continuity, and preservation of the colon are important factors for survival and adaptation. Adaptation usually occurred within the first 3 years. Need for long-term PN does not preclude achieving productive adulthood. Patients with ICV even with <15 cm of SBL and patients with SBL >15 cm without ICV have a chance of intestinal adaptation.

Intestinal rehabilitation and the short bowel syndrome: part 1

The management of patients with intestinal failure due to short bowel syndrome (SBS) is complex, requiring a comprehensive approach that frequently necessitates long-term, if not life-long, use of parenteral nutrition (PN). Despite tremendous advances in the provision of PN over the past three decades, which have allowed significant improvements in the survival and quality of life of these patients, this mode of nutritional support carries with it significant risks to the patient, is very costly and, ultimately, does not attempt to improve the function of the remaining bowel. Intestinal rehabilitation refers to the process of restoring enteral autonomy and, thus, allowing freedom from parenteral nutrition, usually by means of dietary, medical, and, occasionally, surgical strategies. While recent investigations have focused on the use of trophic substances to increase the absorptive function of the remaining gut, whether intestinal rehabilitation occurs as a consequence of enhanced bowel adaptation or is simply a result of an optimized, comprehensive approach to the care of these patients remains unclear. In Part 1 of this review, an overview of SBS and pathophysiological considerations related to the remaining bowel anatomy in these patients will be provided. Additionally, a review of intestinal adaptation and factors that may enhance the adaptive process, focusing on evidence derived from animal studies, will also be discussed. In Part 2, relevant data on the development of intestinal adaptation in studies involving humans will be reviewed as will the general management of SBS. Lastly, the potential benefits of a multidisciplinary intestinal rehabilitation program in the care of these patients will also be discussed.

Glucagon-Like Peptide-2 and Intestinal Adaptation: An Historical and Clinical Perspective

Of the many models of intestinal adaptation, the structural and functional changes seen in the residual small bowel following jejunectomy or ileectomy are the most predictable and best studied. There are three major mechanisms for these adaptive phenomena: changes in i) luminal nutrition, ii) pancreatico-biliary secretions and iii) hormonal factors. Observations in a unique patient with an "enteroglucagon"-secreting tumor of the kidney associated with massive small bowel enlargement, provided the strongest evidence, at that time (>30 y ago), in favor of hormonal factors. When the patient's renal tumor was removed, the markedly increased circulating concentrations of the glucagon-like peptide (now presumed to be GLP-2) returned to normal-as did her intestinal anatomy. Subsequent studies showed that there are increased tissue and plasma enteroglucagon (and recently GLP-2) levels in many animal models of intestinal adaptation. This, and anecdotal evidence from three other case reports, coupled with contemporary studies of GLP-2, strongly suggest that this glucagon-like peptide is a potent, but not the sole, enterotrophin.

Effect of ileocolonic transposition on gut morphology, gene expression, and function

Intestinal morphology and expression of brush border enzymes can be dramatically altered by nutrient composition and position along the longitudinal gut axis. In contrast, endocrine gene expression appears to be relatively "imprinted" and is not significantly altered by positional changes. The purpose of our study was to assess the effects of transposing the ileum into the colonic position on intestinal morphology, gene expression, and enzyme activity. For this study, male Sprague-Dawley rats underwent either transposition of an approximately 8-cm segment of distal ileum into the colonic position or sham operation. Rats were sacrificed 2 months after operation and transposed or sham ileum was assessed. We found that transposition of the ileum to the colonic position resulted in no change in the ileal mucosal architecture. Furthermore, no change in the expression of the endocrine genes neurotensin and PYY or the apoptotic genes was detected. Although sucrase-isomaltase activity was decreased in the transposed ileum, this decrease did not achieve statistical significance. These results demonstrate that the ileum can be successfully interposed into the colonic position. In this location, the ileum functions normally without changes in the villus morphology or gene expression pattern despite the change in position and composition of the luminal content.

Luminal nutrient signals for intestinal adaptation in pythons

Python intestine responds rapidly to luminal nutrients by increasing mass and upregulating nutrient transport. Candidates for luminal signals triggering those responses include mechanical stimulation, single or several dietary nutrients, and endogenous secretions. To identify signals, we infused into the python's small intestine either a nonnutrient solution (saline) or a single- or multinutrient solution. Python intestine failed to respond trophically or functionally to luminal infusions of saline, glucose, lipid, or bile. Infusion of amino acids and peptides, with or without glucose, induced an intermediate response. Infusion of nutritionally complete liquid formula or natural diet induced full intestinal response. Intact meals triggered full intestinal responses without pancreatic or biliary secretions, whereas direct cephalic and gastric stimulation failed to elicit any response. Hence neither physical stimulation (cephalic, gastric, or intestinal) nor the luminal presence of glucose, lipids, or bile can induce intestinal response; instead, a combination of nutrients is required (even without pancreaticobiliary secretions), the most important being amino acids and peptides. This is understandable because pythons, as carnivores, have a high-protein diet.

Enhancing bowel adaptation in short bowel syndrome

Malabsorption of both nonessential and essential nutrients, fluid, and electrolytes will, if not compensated for by increased intake, lead to diminished body stores and to subclinical and eventually clinical deficiencies. By definition, intestinal failure prevails when parenteral support is necessary to maintain nutritional equilibrium. After intestinal resection, adaptation, a progressive recovery from the malabsorptive disorder, may be seen. Research has focused on optimizing remnant intestinal function through dietary or pharmacologic interventions. In this review, factors responsible for the morphologic and functional changes in the adaptive processes are described. Results of clinical trials employing either growth hormone and glutamine or glucagon-like peptide-2 in short bowel patients are presented.

Intestinal adaptation in short bowel syndrome

Regaining enteral autonomy after extensive small bowel resection is dependent on intestinal adaptation. This adaptational process is characterized by hyperplastic growth of the remaining gut, which is accompanied by both an increase of cell division at the level of the crypt cells and by an increased rate of programmed cell death (apoptosis). Apart from the absorptive function, the small bowel also has a barrier function and plays an important role in interorgan metabolism. Also, these functions are greatly affected by a massive intestinal resection and subsequent recovery by intestinal adaptation. This review aims to give an overview of the debilitating effects of massive intestinal resection on gut function and subsequently discusses intestinal adaptation and possible factors stimulating adaptation.

Intestinal adaptation: structure, function, and regulation

After massive small bowel resection (SBR), the remnant intestine undergoes an adaptive process characterized by increases in wet weight, protein and DNA content, villus height and crypt depth, and absorptive surface area. These changes are the result of a proliferative stimulus that increases crypt cell mitosis and augments cellular progression along the villus axis. Functionally, there is upregulation of the Na(+)/glucose cotransporter, Na(+)/H(+) exchanger, and other enzymes involved in intestinal digestion and absorption. These physiologic events are a compensatory response to the sudden loss of digestive and absorptive capacity by the remnant intestine. A major consequence of inadequate intestinal adaptation is lifelong dependence on parenteral nutrition, which results ultimately in cholestatic liver dysfunction. Furthermore, adaptation may be associated with changes in intestinal permeability and an increased risk of bacterial translocation and sepsis. Several mediators thought to be integral to the postresection adaptive response have been proposed, including luminal nutrients, gastrointestinal secretions, and humoral factors. A thorough understanding of intestinal adaptation will be essential in the rational development of new and innovative therapies that amplify this complex but important process.

An open trial of octreotide long-acting release in the management of short bowel syndrome

OBJECTIVES

The aim of this study was to assess the effects of the long-acting release (LAR) depot octreotide preparation Sandostatin LAR Depot on stool water and electrolyte losses, fecal fat excretion, and GI transit in patients with short bowel syndrome.

METHODS

We performed a 15-wk, prospective, open-label study of intramuscular (i.m.) Sandostatin LAR Depot, 20 mg, at 0, 3, 7, and 11 wk. Balance studies were performed before and at the end of the 15-wk study. Baseline and posttreatment measurements of body weight, stool fat, sodium and potassium, and gastric and small bowel transit of a radiolabeled egg meal were compared by paired analysis.

RESULTS

We studied eight patients with short bowel syndrome (five women and three men; mean age 52 yr, range 37-72 yr) who had been TPN dependent for a mean of 11.8 yr (range 1.5-22 yr). The underlying diagnoses were Crohn's disease (n = 6), intestinal ischemia (n = 1), and resection for carcinoid tumor (n = 1). Treatment with Sandostatin LAR Depot significantly increased small bowel transit time (p = 0.03). Changes in body weight, urine volume, stool weight, fecal fat excretion, stool sodium and potassium excretion, or gastric emptying rate were highly variable, and no overall significance was observed.

CONCLUSIONS

Sandostatin LAR Depot for 15 wk significantly prolonged small bowel transit time. Body weight and stool parameters in response to Sandostatin LAR Depot treatment needs to be assessed further in multicenter studies assessing dose, frequency of administration, and a larger sample size.

Effects of anastomosis of tissue-engineered neointestine to native small bowel

BACKGROUND

Our laboratory is investigating the tissue engineering of small intestine using intestinal epithelial organoid units seeded onto highly porous biodegradable polymer matrices. This study investigated the effects of anastomosis of tissue-engineered intestine to native small bowel alone or combined with small bowel resection on neointestinal regeneration.

METHODS

Intestinal epithelial organoid units harvested from neonatal Lewis rats were seeded onto biodegradable polymer tubes and implanted into the omentum of adult Lewis rats as follows: (1) implantation alone (n = 9); (2) implantation followed by anastomosis to native small bowel at 3 weeks (n = 11); and (3) implantation after small bowel resection and anastomosis to native small bowel at 3 weeks (n = 8). All constructs were harvested at 10 weeks and examined by histology. Morphometric analysis of the neomucosa was obtained using a computer image analysis program.

RESULTS

Cyst development was noted in all animals. All anastomoses were patent at 10 weeks. Histology revealed the development of a vascularized tissue with a neomucosa lining the lumen of the cyst with invaginations resembling crypt-villus structures. Morphometric analysis demonstrated significantly greater villus number, villus height, crypt number, crypt area, and mucosal surface length in groups 2 and 3 compared with group 1, and significantly greater villus number, villus height, crypt area, and mucosal surface length in group 3 compared with group 2 (P < 0.05, ANOVA, Tukey test).

CONCLUSION

Intestinal epithelial organoid units transplanted on biodegradable polymer tubes can regenerate into complex tissue resembling small intestine. Anastomosis to native small bowel combined with small bowel resection and anastomosis alone contribute significant regenerative stimuli for the morphogenesis and differentiation of tissue-engineered neointestine.

Gastrointestinal responses to a panel of lectins in rats maintained on total parenteral nutrition

Total parenteral nutrition (TPN) causes atrophy of gastrointestinal epithelia, so we asked whether lectins that stimulate epithelial proliferation can reverse this effect of TPN. Two lectins stimulate pancreatic proliferation by releasing CCK, so we asked whether lectins that stimulate gastrointestinal proliferation also release hormones that might mediate their effects. Six rats per group received continuous infusion of TPN and a once daily bolus dose of purified lectin (25 mg. rat-1. day-1) or vehicle alone (control group) for 4 days via an intragastric cannula. Proliferation rates were estimated by metaphase arrest, and hormones were measured by RIAs. Phytohemagglutinin (PHA) increased proliferation by 90% in the gastric fundus (P < 0.05), doubled proliferation in the small intestine (P < 0.001), and had a small effect in the midcolon (P < 0.05). Peanut agglutinin (PNA) had a minor trophic effect in the proximal small intestine (P < 0.05) and increased proliferation by 166% in the proximal colon (P < 0.001) and by 40% in the midcolon (P < 0.001). PNA elevated circulating gastrin and CCK by 97 (P < 0.05) and 81% (P < 0.01), respectively, and PHA elevated plasma enteroglucagon by 69% and CCK by 60% (both P < 0.05). Only wheat germ agglutinin increased the release of glucagon-like peptide-1 by 100% (P < 0.05). PHA and PNA consistently reverse the fall in gastrointestinal and pancreatic growth associated with TPN in rats. Both lectins stimulated the release of specific hormones that may have been responsible for the trophic effects. It is suggested that lectins could be used to prevent gastrointestinal atrophy during TPN. Their hormone-releasing effects might be involved.

Successful anastomosis between tissue-engineered intestine and native small bowel

BACKGROUND

Previous work from this laboratory has shown that isolated intestinal epithelial organoid units on porous biodegradable polymer scaffolds formed vascularized cysts lined by a neomucosa. The purpose of this study was to demonstrate anastomosis between tissue-engineered intestine and the native small bowel and to observe the effect of this anastomosis on cyst growth.

METHODS

Intestinal epithelial organoid units from neonatal Lewis rats were seeded onto porous biodegradable polymer tubes made of polyglycolic acid, and they were implanted into the omentum of adult male Lewis rats. Three weeks after implantation, the unit-polymer constructs were anastomosed in a side-to-side fashion to the native jejunum in 20 rats (group 1). The other 18 rats were closed without anastomosis (group 2). All 38 tissue-engineered constructs were harvested 10 weeks after implantation. Four rats underwent upper gastrointestinal (GI) study before they were killed.

RESULTS

The rats in group 1 increased their body weights equal to those in group 2, and there was no statistically significant difference between the two groups. Upper GI examinations revealed no evidence of either bowel stenosis or obstruction at the anastomotic site. Grossly, the patency of the anastomosis was 90% and the lumen of the cyst was visualized by the upper GI study. At the second operation, there was no significant difference in the size of the cysts in either group: however, at the time the rats were killed, the length of the cysts in group 1 was significantly longer than that in group 2 (P<0.05 using Mann-Whitney U test). Histological examination showed that cysts after anastomosis were lined by a neomucosa in continuity to native small bowel across the anastomotic site and also demonstrated crypt-villus structures. Morphometric study demonstrated that cysts in group 1 had significantly greater villus number, height, and surface length than did those in group 2.

CONCLUSIONS

Anastomosis between tissue-engineered intestine and native small bowel resulted in no complications after the operation, kept a high patency rate, and maintained mucosal continuity between the tissue-engineered intestine and native small bowel. Furthermore, anastomosis had a positive effect on cyst size and development of the mucosa in the tissue-engineered intestine.

Creation of a caecostoma in mice as a model of an enterocutaneous fistula

In the past, physiological, oncological and pharmaceutical investigations led to the development of different models of enterocutaneous fistulas. For a few years, fistula models were also created to investigate the efficacy of minimal invasive therapies in closing these fistulas. As most experimental surgical procedures are difficult to perform and are often combined with a high mortality or spontaneous closure rate, a new model in mice was developed with the aim of avoiding these disadvantages. Twenty mice, divided into two groups of 10 animals each, had a caecostoma created surgically. The two groups differed regarding the technique of creating the stoma. All animals survived and gained weight during a postoperative period of 4 months. The operation was easy to perform and lasted no longer than about 30 min. Neither a spontaneous closure of the fistula nor any prior death of animals occurred. In conclusion, because of its simplicity and low complication rate, the presented model of an enterocutaneous fistula may offer an interesting alternative to other models for a variety of indications.

Short bowel syndrome in pediatric patients

The treatment of infants and children with short bowel syndrome aims at restoring the intestinal continuity and at improving the physiological process of gut adaptation. Mucosal hyperplasia allows the remaining gut to ensure an adequate digestion and an absorption process leading to intestinal autonomy. During the period of adaptation, appropriate parenteral and/or enteral feeding must be directed at maintaining an optimal nutritional status. Delay of intestinal autonomy depends on the characteristics of the residual intestine: length, presence of the ileocecal valve and colon, and motor function. Bacterial overgrowth compromises intestinal adaptation and increases the risk of liver disorders. Few patients will remain long-term dependent on parenteral nutrition. All approaches aimed at achieving intestinal autonomy should be tried: use of trophic factors, intestinal tapering, and lengthening. In a few residual patients, permanent intestinal failure or extreme short bowel syndrome require intestinal transplantation.

Short bowel syndrome

This article discusses the causes, prognosis, and management of short bowel syndrome. Attempts to enhance intestinal adaptation with trophic factors and surgical treatment options, including small bowel transplantation, are discussed.

Dying enterocytes downregulate signaling pathways converging on Ras: rescue by protease inhibition

Organ and cell cultures of the small intestine serve as excellent in vitro models for programmed cell death (PCD). Cells cultured in serum-free, minimal medium rapidly died, as evidenced by histological changes, internucleosomal DNA cleavage, and TdT-mediated dUTP nick end labeling. Cell death was pervasive, although nonepithelial cells within the fibrovascular villus core were spared. PCD did not require a functional p53 gene. Serine and cysteine protease inhibitors, but not FCS, suppressed it. Relative to structural and functional proteins, dying enterocytes rapidly downregulated Ras-convergent proteins, including epidermal growth factor receptor, Erb-B2, and the son of sevenless guanine nucleotide exchangers. Reductions in the steady-state levels of both protein and mRNA were observed. These reductions were prevented by a combination of death-defying serine and caspase inhibitors, indicating a requirement for the initiation of death. Thus, during catastrophic PCD, intestinal epithelial cells delete cell surface signaling pathways responsible for Ras activation.

A simplified procedure for studies of intestinal immunity in rabbits

As interest in the development of oral vaccines continues to rise, alternative animal models for studies of mucosal immunity are needed. The present study examines a simplified procedure for delivering antigen to rabbit Peyer's patches via an indwelling cannula. The cannula was placed 3-4 cm proximal to the Peyer's patch, and was used to deliver four weekly doses of the potent mucosal immunogen, cholera toxin (CT). Anti-CT specific fecal secretory IgA (S-IgA), serum IgG and serum IgA were found in essentially equal amounts in rabbits with cannulas and in rabbits fitted with Thiry-Vella (T-V) isolated ileal loops. In contrast to animals with T-V loops, the intestinal flora of animals with cannulas contained less bacterial overgrowth with Pseudomonas sp. Further, the villus architecture remained histologically normal in appearance and there were fewer post-surgical complications associated with this technique than with T-V loops. This simplified technique should allow wider use of rabbits in studies of mucosal immunity.

Growth and propagation of normal rat intestinal epithelial cells

A combination of mild proteolytic digestion and selective growth stimulation has been used to isolate and propagate adult rat intestinal epithelial cells with a finite life span. Growth of these cells on a variety of matrices and on mesenchymal cells has resulted in the expression of brush border enzymes including sucrase-isomaltase, aminopeptidase N, and alkaline phosphatase. Examination of the cells at the electron microscopic level has revealed that although these cells express key brush border enzymes, they do not have a fully formed brush border. These findings suggest that the expression of brush border enzymes and structural proteins represent distinct stages of enterocyte differentiation that are under separate transcriptional and temporal control.

Intestinal morphology and cytokinetics in pancreatic insufficiency. An experimental study in the rat

Intraluminal pancreatic enzymes influence intestinal function, adaptation, and susceptibility to injury. These effects may be mediated partly through changes in the rate of epithelial cell turnover. We assessed intestinal morphology and cytokinetics in a rat model of exocrine pancreatic insufficiency that does not alter anatomic relationships or animal growth. Pancreatic duct occlusion was performed by applying metal clips on both sides along the common bile duct. Control animals underwent sham-operation with exposure and manipulation of the pancreas without duct occlusion. Twelve days later, pulse labeling with tritiated thymidine was performed, and mitotic arrest was induced with colcemid. Groups of animals were sacrificed at 0 and 2 hr after colcemid injection. Specimens for histopathology, morphometry, and autoradiography were obtained from duodenum, proximal jejunum, distal jejunum, and ileum. Labeling index, grain counts, mitoses per crypt, cells per crypt, cells per villus, crypt depth, villus height, and number of goblet cells per villus were used as end points. Pancreatic duct occlusion resulted in increased labeling index across intestinal segments relative to sham-operated controls (P < 0.01) and increased labeling index and mitotic rate in distal compared to proximal intestine (P < 0.05). Grain-count histograms were similar in the two experimental groups. There were no significant morphologic differences between pancreatic duct-occluded animals and controls. Exocrine pancreatic insufficiency increases crypt cell proliferation in distal small intestine but does not alter the duration of S phase. These changes are most likely due to an increase in the size of the proliferative compartment and may be partly responsible for changes in small bowel function and response to injury.

Increases in nup475 and c-jun are early molecular events that precede the adaptive hyperplastic response after small bowel resection

OBJECTIVE

The authors determined whether increases of nup475 and c-jun gene expression occur after small bowel resection and whether these changes are specific to the gut.

SUMMARY BACKGROUND DATA

Massive small bowel resection (SBR) is characterized by adaptive proliferation of the remaining gut mucosa; the molecular signals responsible for this adaptive hyperplasia are unknown. Increases in the "immediate-early genes" nup475 and c-jun are noted in some proliferating tissues; however, alterations in the expression of these genes have not been described in the gut after SBR.

METHODS

Rats underwent either a 70% proximal SBR or intestinal transection with reanastomosis (SHAM) and were then killed over a time course (0.5, 2, and 24 hours). The ileum, duodenum, colon, and kidneys were removed and RNA was extracted for Northern hybridization.

RESULTS

The authors found that steady-state mRNA levels of both nup475 and c-jun were increased 81% and 62%, respectively, in the ileal remnant at 2 hours in rats after SBR compared with the SHAM group. In addition, nup475 was increased 101% in the duodenum at 24 hours and 31% in the colon at 0.5 hours in rats after SBR. In contrast, neither gene was increased in the kidney.

CONCLUSIONS

Increases in steady-state levels of nup475 and c-jun are limited to the gut after SBR, and the timing and magnitude of these changes differ, depending on the gut segment. Finally, the rapid and nutrient-independent increases of nup475 and c-jun suggest an important role for these genes as early molecular signals that participate in the adaptive hyperplasia occurring in the gut remnant after SBR.

Role of bombesin on gut mucosal growth

OBJECTIVE

The authors examined the effects of exogenous bombesin (BBS) on gut mucosal growth in chow-fed rats and the mucosal regeneration after gut atrophy brought about by feeding an elemental diet and after intestinal injury produced by methotrexate (MTX).

SUMMARY BACKGROUND DATA

Bombesin is one of many gastrointestinal peptides implicated in the regulation of gut mucosal growth. Although BBS is known to stimulate growth of normal pancreatic tissue, the trophic effect of BBS on gut mucosa is less clear and its exact role in gut mucosal regeneration and repair is not known.

METHODS

Rats were fed a regular chow diet (control) or an elemental diet plus either saline or BBS (10 micrograms/kg). In another experiment, rats fed a chow diet and treated with saline or BBS were given MTX (20 micrograms/kg) or a single intraperitoneal injection. In all experiments, small and large bowel mucosa and pancreas were removed and analyzed for BBS-mediated proliferation.

RESULTS

Bombesin produced significant mucosal proliferation of the small bowel at day 14, but not at day 7, in rats fed regular chow. In contrast, BBS treatment for 7 days produced significant proliferation in both the atrophic and injured gut mucosa of rats given elemental diet or MTX.

CONCLUSIONS

Bombesin may be an important enterotrophic factor for normal mucosal proliferation and may be clinically beneficial as an agent to restore or maintain gut mucosa during periods of atrophy or injury.

Bombesin stimulates mucosal growth in jejunal and ileal Thiry-Vella fistulas

OBJECTIVE

The authors determined whether the trophic effects of bombesin (BBS) on the small bowel mucosa are mediated by either nonluminal factors or endogenous luminal secretion.

SUMMARY BACKGROUND DATA

The gut hormone bombesin stimulates growth of small bowel mucosa. The mechanisms responsible for this trophic effect are not known.

METHODS

Rats underwent construction of a Thiry-Vella fistula (TVF) of either the jejunum or ileum. On postoperative day 10, the two groups were subdivided to receive either saline (control) or bombesin (10 micrograms/kg, subcutaneously, three times a day). After 14 days, rats were killed and the TVF was removed. The mucosa was scraped and weighed, and DNA and protein content was determined.

RESULTS

Bombesin significantly increased mucosal weight and DNA and protein content of both the jejunal and ileal TVF compared with the control rats.

CONCLUSIONS

Bombesin-mediated stimulation of small bowel mucosal growth is mediated by factors that are independent of luminal contents and pancreaticobiliary secretion. Bombesin may prove to be an important enterotrophic factor for gut mucosal proliferation.

Bombesin improves survival from methotrexate-induced enterocolitis

OBJECTIVE

The authors determined whether bombesin could improve survival from methotrexate (MTX)-induced enterocolitis.

SUMMARY BACKGROUND DATA

Bombesin prevents gut mucosal atrophy, which is produced by feeding rats an elemental diet. Administration of MTX produces a lethal enterocolitis in rats fed an elemental diet.

METHODS

On treatment day 0, 60 rats were divided randomly into three groups and fed an elemental diet (Vivonex TEN, Sandoz, Minneapolis, MN) as the only source of nutrition. Groups were subdivided further to receive either saline or bombesin (10 micrograms/kg, subcutaneously, three times a day) beginning either on day 0 or day 14. Methotrexate (20 mg/kg, intraperitoneally) was given to all rats 14 days after the start of an elemental diet.

RESULTS

Bombesin prevented the mucosal atrophy in the ileum produced by the elemental diet and significantly decreased mortality in rats given MTX (whether given as a pretreatment or at the time of MTX administration).

CONCLUSION

Bombesin significantly improved survival in a lethal model of MTX-induced enterocolitis, possibly by maintaining gut mucosal structure. Administration of bombesin to patients receiving chemotherapy may be clinically useful in preventing the severe enterocolitis induced by various chemotherapeutic agents.

Adaptation of enteroendocrine cells in response to jejunal-ileal transposition in the rat

BACKGROUND/AIMS

Enteroendocrine cell subpopulations are uniquely distributed along the crypt-villus and cephalocaudal axes of the small intestine. These regional differences in enteroendocrine cell expression, which are maintained in spite of rapid turnover of the epithelium, serve as descriptive markers of physiological differences along the length of the bowel. This study aimed to determine the influence of luminal contents on the maintenance of regional differentiation patterns of enteroendocrine and enterocytic phenotypes.

METHODS

Sections of jejunum and ileum were surgically transposed in rats, leaving the innervation and blood supply to the transposed segments intact. The animals were killed 1, 4, and 8 weeks after surgery. Enteroendocrine cell subpopulations and enterocytic cell markers were studied immunohistochemically.

RESULTS

No change in regional expression patterns was seen in response to the altered luminal environment by any of the enterocytic markers and four of the five enteroendocrine cell subpopulation markers. Eight weeks after surgery, the number of gastrin-expressing enteroendocrine cells increased in ileal segments transplanted proximally.

CONCLUSIONS

Although luminal signals can affect intestinal stem cells to alter their proliferation rates, the luminal environment has only limited effects on the regional-specific expression of enteroendocrine or enterocytic products.

Differential cell kinetics in the ileum and colon of germfree rats

Our aim was to study the cell kinetics and epithelial structure in the ileum and colon of conventional and germfree AGUS rats by means of a classic stathmokinetic technique. A slight hyperplasia was observed in the villi of germfree animals (p < 0.05), associated with a comparatively short cell cycle time. The crypt cell production rate was reduced in the colon of germfree rats (p < 0.05), and their crypts contained fewer cells than those of conventional animals (p < 0.05). It is concluded that intraluminal bacteria influence cell proliferation in the colon. The absence of microflora prolongs the cell cycle time and reduces the proliferative activity in the colonic crypts, which contributes to a steady state that is different from that of conventional animals.

Small intestinal mucosa changes, including epithelial cell proliferative activity, of children receiving total parenteral nutrition (TPN)

We examined the small intestinal histology disaccharidase activities as well as the incorporation of [3H]thymidine into DNA of biopsies maintained in organ culture from seven children (ages 9 months to 5 years) receiving total parenteral nutrition (TPN). Three children suffered from inflammatory bowel disease and received TPN for one month (short term). Four required long-term TPN (> 9 months) for short-bowel syndrome. DNA was extracted from the samples following serial precipitation with perchloric acid. Results were compared to those from 22 age-matched children investigated for abdominal pain or chronic diarrhea. Short-term TPN resulted in slightly lower lactase, sucrase, and palatinase activities that were not statistically different from controls. Long-term TPN resulted in focal mild villus atrophy and a decrease in disaccharidase activity in two patients. Biopsies from long-term TPN patients incorporated less thymidine compared to those of controls (P < 0.001) when data was expressed per total biopsy (3.6 +/- 1.1 vs. 8.4 +/- 1.1 fmol) or per milligram of tissue (1.0 +/- 0.12 vs 2.7 +/- 0.7 fmol). The above data are in general agreement with the hypoplastic effect of TPN in animals. However, in children, much longer periods of TPN are required to realize the changes.