The effects of medium-chain triglycerides in the short bowel syndrome. Increased glucose and water transport

Effects of high-fat diet on liver injury after small bowel resection

BACKGROUND

The optimal regimen for enteral nutritional support in the management of children with short bowel syndrome (SBS) is not well characterized. A high fat, enteral diet is theoretically beneficial due to increased caloric density and enhanced structural adaptation. We therefore sought to determine the long-term effects of a high fat diet (HFD) on liver injury, a common complication of SBS, compared to a standard chow (SC) diet.

METHODS

Using a parenteral nutrition-independent model of resection-associated liver injury, C57BL/6 mice underwent a sham operation or a 50% or 75% proximal small bowel resection (SBR). Mice in each group were then fed either a HFD (35% kcal fat) or SC (13% kcal fat). At post-operative week 15, markers of liver injury were quantified.

RESULTS

Liver triglyceride levels were increased from 7- to 19-fold in mice on the HFD compared to mice fed SC in the sham, 50%, and 75% resection groups. Serum ALT (2.2-fold increase in 75% resected mice compared to sham controls) and AST (2.0- and 2.7-fold increases in 50% and 75% resected mice, respectively) levels as well as fibrotic liver staining were elevated only in resected mice fed a HFD.

CONCLUSION

Long-term enteral feeding of HFD in our murine SBS model is associated with hepatic steatosis and liver injury. Our observation that liver steatosis and injury occur independent of parenteral nutrition suggests that enteral feeding composition and magnitude of intestinal loss may make a significant contribution to intestinal failure-associated liver disease.

Nutritional Therapy in Adult Short Bowel Syndrome Patients with Chronic Intestinal Failure

Intestinal failure (IF) is the reduction of gut function below the minimum necessary for the absorption of macronutrients and/or water and electrolytes, such that parenteral support (PS) is required to maintain health and/or growth. This article critically revises the gaps in and evidence for providing general nutritional therapy recommendations in the Short Bowel Syndrome-IF population. It addresses the need for an individualized approach, aiming to reduce or even eliminate the need for PS, and emphasizes a need to focus on effects of dietary interventions on the quality of life of these patients.

Caprylic acid and medium-chain triglycerides inhibit IL-8 gene transcription in Caco-2 cells: comparison with the potent histone deacetylase inhibitor trichostatin A

1. Medium-chain triglyceride (MCT) is often administered to patients with Crohn's disease (CD) or short-bowel syndrome. However, little is known about the effects of medium-chain fatty acids (MCFAs) and MCT on intestinal inflammation. In this study we examined whether caprylic acid, one of the MCFAs, and MCT suppress IL-8 secretion by differentiated Caco-2 cells. 2. We found for the first time that caprylic acid and MCT suppress IL-8 secretion by Caco-2 cells at the transcriptional level when precultured together for 24 h. We also tried to clarify the mechanism of IL-8 gene inhibition by examining the activation of NF-kappaB and other transcription factors by electrophoretic mobility shift assay (EMSA), and found that caprylic acid did not modulate their activation. 3. The result of dual-luciferase assay using Caco-2 cells transfected with IL-8 promoter/luciferase reporter plasmid revealed that caprylic acid inhibited the activation of IL-8 promoter. 4. Similar results were observed when cells were precultured with the well-known potent histone deacetylase inhibitor trichostatin A (TSA). 5. We examined the state of H4 acetylation in IL-8 promoter using the technique known as chromatin immunoprecipitation (Chr-IP). TSA rapidly induced H4 acetylation in IL-8 promoter chromatin, whereas caprylic acid did not. These results suggest that the inhibition of IL-8 gene transcription induced by caprylic acid and TSA does not necessarily require the marked suppression of transcription factors, and the mechanism of inhibition of IL-8 gene transcription may be different between caprylic acid and TSA.

Management of patients with a short bowel

There are two common types of adult patient with a short bowel, those with jejunum in continuity with a functioning colon and those with a jejunostomy. Both groups have potential problems of undernutrition, but this is a greater problem in those without a colon, as they do not derive energy from anaerobic bacterial fermentation of carbohydrate to short chain fatty acids in the colon. Patients with a jejunostomy have major problems of dehydration, sodium and magnesium depletion all due to a large volume of stomal output. Both types of patient have lost at least 60 cm of terminal ileum and so will become deficient of vitamin B₁₂. Both groups have a high prevalence of gallstones (45%) resulting from periods of biliary stasis. Patients with a retained colon have a 25% chance of developing calcium oxalate renal stones and they may have problems with D (-) lactic acidosis. The survival of patients with a short bowel, even if they need long-term parenteral nutrition, is good.

Colonic digestion and absorption of energy from carbohydrates and medium-chain fat in small bowel failure

Gut function and the degree of intestinal insufficiency or failure in short bowel patients can be quantified with respect to wet weight and energy absorption by the use of balance studies. This enables the physician to distinguish patients with extreme intestinal failure inconsistent with the restoration of intestinal autonomy by dietary manipulation from short bowel patients with borderline gut failure in whom dietary manipulations may result in the weaning from parenteral support. A high-carbohydrate, low long-chain fat diet and a diet where long-chain fat has been replaced by medium-chain triglycerides increase absorption of energy in patients with small bowel failure, provided that they have a preserved colon in continuity. This is due to the ability of the colonic flora to ferment carbohydrates malabsorbed in the small bowel to the short-chain fatty acids (SCFAs). These SCFAs are easily absorbed across the colonic mucosa resulting in a salvage of carbohydrate energy that otherwise would have been lost in feces. In contrast, long-chain fatty acids are not absorbed by the colon, and long-chain fat malabsorbed in the small bowel of short bowel patients are not retained in the large bowel. Recent work has indicated that the water soluble medium-chain fatty acids are effectively absorbed in the large bowel similar to the SCFAs. This may explain an almost complete absorption of medium-chain triglycerides in short bowel patients, even in patients with virtually no absorption of long-chain fat, and why this only occurs in patients with a colon in continuity. Manipulation of the dietary fat:carbohydrate ratio is much less efficacious in short bowel patients with no colonic function, and the use of medium-chain triglycerides has no proven effect on overall energy absorption from short bowel patients without a large bowel in continuity. Hence, the colon has increasingly important digestive functions as small bowel failure proceeds, not only when it comes to absorption of water and sodium, but also of energy from carbohydrates and medium-chain fat.

Influence of dietary fat on nutritive utilization of protein in intestinally resected rats

The effects of different types of dietary fat on the digestive and metabolic utilization of protein were studied in rats with 50% resection of the distal small intestine and in sham-operated controls one month after surgery. The digestive utilization of protein was not significantly affected in intact animals when olive oil was replaced by butter as the dietary source of fat. In resected rats given either type of diet the apparent digestibility coefficient of protein declined significantly in comparison to intact controls. Intestinal resection decreased the retention of nitrogen significantly in rats given olive oil. The replacement of 2/3 of the dietary supply of olive oil with 1/3 medium chain triglycerides and 1/3 sunflower seed oil improved the metabolic utilization of protein in comparison to resected rats fed olive oil or butter as the only source of dietary fat. However, the addition of ursodeoxycholic acid to the diet containing equal parts of olive oil, medium chain triglycerides and sunflower seed oil failed to improve the metabolic utilization of protein in comparison to that seen in rats given olive oil only. Serum concentrations of total protein, urea and creatinine, albeit with slight changes in the first, remained within normal limits. Despite the lower retention of nitrogen in resected rats, these animals maintained homeostasis without resorting to muscular protein.

Influence of medium chain triglycerides and vitamin D3 on digestive and metabolic utilization of protein in rats with intestinal resection

The effects of different types of diet and resecting 50% of the distal small intestine on the digestive and metabolic utilization of protein were studied in resected rats and sham-operated controls. Nutritional parameters were analyzed at 1 and 3 months postsurgery. Intestinal resection led to a deterioration in digestive utilization of protein, which improved with time (3 months postsurgery). A qualitative change in the dietary fat source from 100% olive oil to equal parts of medium chain triglycerides, sunflower seed oil and olive oil and this same diet supplemented with vitamin D3 favoured digestive utilization of protein as recorded 1 month after surgery. However, the beneficial effects were maintained at 3 months only in resected rats given dietary fat in the form of 100% olive oil.

Neonatal parenteral nutrition with medium-chain triglycerides: rationale for research

With the advances in technology stable fat emulsions containing medium-chain triglycerides (MCT) became available. Intravenous MCT are readily utilizable energy source because they reach the liver rapidly and their medium-chain fatty acids (MCFA) are oxidized through carnitine-independent mechanisms. However the MCFA can also be deviated to alternative oxidation pathways which results in urinary excretion of metabolites. The metabolic effects of intravenous MCT containing fat emulsions are discussed and emphasis is given in the possible role of these fats in parenteral nutrition of preterm infants, who are carnitine depleted. Directions of future research are speculated.

Essential fatty acid deficiency and postresection mucosal adaptation in the rat

The effect of short-term (biochemical) and long-term (clinical) essential fatty acid (EFA) deficiency on mucosal adaptation was studied in a surgical model of short bowel syndrome. Rats fed an EFA-deficient diet for 4 wk had biochemical evidence of EFA deficiency (hepatic and red blood cell triene to tetraene ratios greater than 0.4). Resected animals (70% proximal jejunoileal resection) receiving an EFA-deficient diet had a significantly impaired intestinal mucosal hyperplasia response in all remaining small bowel segments compared with resected controls. The effect of refeeding a control diet to clinically EFA-deficient resected rats was also evaluated. Short-term refeeding (2 wk) of a control diet resulted in a significant return toward normal tissue triene to tetraene ratios. Concomitantly, refed animals had significantly greater mucosal adaptation in the remaining duodenal/jejunal segment compared with resected animals maintained on an EFA-deficient diet postoperatively. These experiments underscore the dynamic nature of tissue EFA status and the importance of fatty acids in the normal compensatory mechanisms of mucosal adaptation after resection.

Augmentation of postresection mucosal hyperplasia by plerocercoid growth factor (PGF). Analog of human growth hormone

Postresection villus hyperplasia is a major compensatory mechanism in the short-bowel patient. Substances capable of augmenting postresection mucosal hyperplasia could have therapeutic implications. Human growth hormone (hGH) and human growth hormone releasing factor (hGHRF) stimulate growth of the gastrointestinal tract; however, the diabetogenic actions of growth hormone limit its usefulness in clinical practice. Plerocercoid larvae of the tapeworm Spirometra mansonoides produce an analog of hGH void of diabetogenic side effects. We assessed effects of plerocercoid growth factor (PGF) on mucosal adaptation following 70% proximal jejunoileal resection in young rats. Mucosal weight, DNA, protein, and total sucrase activity per centimeter of bowel were increased in resected PGF-treated animals compared to resected controls. We conclude PGF augments intrinsic postresection mucosal hyperplasia following extensive intestinal resection.

Effect of high percentage medium-chain triglyceride diet on mucosal adaptation following massive bowel resection in rats

Patients undergoing massive small bowel resection for a variety of conditions develop severe nutrient malabsorption which gradually improves through mucosal hyperplasia in the remaining small intestine. Following massive small bowel resection, patients are generally fed elemental diets, often containing high concentrations of medium-chain triglycerides. We evaluated the effect of high percentage medium-chain triglyceride feeding on mucosal adaptation following massive small bowel resection in rats. Twenty 150-g Sprague-Dawley rats were subjected to 60% jejunoileal resection. Another 20 animals received sham operations. One-half of each group were fed a diet containing 83% of the fat as medium-chain triglycerides, the remainder were fed a diet containing 40% medium-chain triglycerides. Animals were pair-fed for 2 wk and subsequently killed. The remaining bowel was removed and unidirectional glucose and leucine uptake were measured using isolated sacs. Mucosal wet weight, protein, and sucrase content were determined. Animals fed medium-chain triglycerides demonstrated decreased mucosal weight in the proximal bowel, decreased mucosal sucrase activity in the proximal bowel, and decreased mucosal leucine uptake in the distal bowel. While medium-chain triglycerides offer an advantage to patients with short bowel syndrome because they are easily absorbed, they may not stimulate the same degree of mucosal adaptation following resection as long-chain triglyceride feedings.

Correction of the malabsorption of the preterm infant with a medium-chain triglyceride formula

After receiving milk-based formula for one week, 16 preterm infants, weighing 1,300 to 1,800 gm, were fed two isocaloric formulas containing either medium-chain or long-chain triglycerides for 15 days; the alternate formula was given for a second period of identical duration. While receiving MCT, the infants had greater (P smaller than 0.01) percent fat absorption (83.4 leads to 97.1%) and weight gain (7.5 leads to 11.5 gm/kg/100 calories). Because metabolic acidosis occurred with the LCT formula, the chloride content was adjusted to that of the MCT were confirmed and, in addition, there was a higher (P smaller than .01) percent retention of nitrogen (67.3 leads to 82.1).