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Mikaelyan KA, Krylov KY, Petrova MV, Shestopalov AE. [Intestine morphology and microbiocenosis changes in critically ill patients in neurosurgery]. ZHURNAL VOPROSY NEĬROKHIRURGII IMENI N. N. BURDENKO 2021; 85:104-110. [PMID: 33560626 DOI: 10.17116/neiro202185011104] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
In recent years, the effect of critical conditions on intestine and the role of such changes in maintenance and progression of systemic disorders are of particular attention. This issue is relevant in critically ill neurosurgical patients too. Intestine morphology and microbiome changes in these patients represent a wide field for researches in intensive care and prevention of secondary damage to other organs and systems. This review ensures a current approach to the problem of intestine morphology and microbiome changes in critically ill neurosurgical patients. We reviewed the data from clinical studies and experiments reproducing a critical condition in animals. Most publications are indexed in the PubMed, e-library, Google Scholar databases. We also analyzed the data from NEJM, JAMA, Lancet, Critical Care and other issues. The manuscript contains an overview of 44 foreign and 13 domestic references; over 50% of researches were published within the past 5 years. Searching depth was over 50 years.
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Affiliation(s)
- K A Mikaelyan
- Russian Peoples' Friendship University, Moscow, Russia
| | - K Yu Krylov
- Pirogov Russian National Research Medical University, Moscow, Russia
| | - M V Petrova
- Russian Peoples' Friendship University, Moscow, Russia
| | - A E Shestopalov
- Federal Research Clinical Center of Intensive Care and Rehabilitation, Lytkino, Russia
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2
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Abstract
PURPOSE OF REVIEW To provide a comprehensive update of diagnosis and treatment of gastrointestinal dysmotility in the critically ill, with a focus on work published in the last 5 years. RECENT FINDINGS Symptoms and clinical features consistent with upper and/or lower gastrointestinal dysmotility occur frequently. Although features of gastrointestinal dysmotility are strongly associated with adverse outcomes, these associations may be because of unmeasured confounders. The use of ultrasonography to identify upper gastrointestinal dysmotility appears promising. Both nonpharmacological and pharmacological approaches to treat gastrointestinal dysmotility have recently been evaluated. These approaches include modification of macronutrient content and administration of promotility drugs, stool softeners or laxatives. Although these approaches may reduce features of gastrointestinal dysmotility, none have translated to patient-centred benefit. SUMMARY 'Off-label' metoclopramide and/or erythromycin administration are effective for upper gastrointestinal dysmotility but have adverse effects. Trials of alternative or novel promotility drugs have not demonstrated superiority over current pharmacotherapies. Prophylactic laxative regimens to prevent non-defecation have been infrequently studied and there is no recent evidence to further inform treatment of established pseudo-obstruction. Further trials of nonpharmacological and pharmacological therapies to treat upper and lower gastrointestinal dysmotility are required and challenges in designing such trials are explored.
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3
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O’Grady J, Murphy CL, Barry L, Shanahan F, Buckley M. Defining gastrointestinal transit time using video capsule endoscopy: a study of healthy subjects. Endosc Int Open 2020; 8:E396-E400. [PMID: 32118112 PMCID: PMC7035031 DOI: 10.1055/a-1073-7653] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/23/2019] [Accepted: 11/11/2019] [Indexed: 12/13/2022] Open
Abstract
Background and study aims Determining the etiology and location of gastrointestinal motility disorders can be challenging. A range of investigations targeting specific areas of gastrointestinal transit are available, but many provide clinical data for a given gastrointestinal region alone or for non-specific whole gut transit, and are otherwise of limited use. Video capsule endoscopy allows endoscopic visualisation of the entire gastrointestinal tract, and may also provide more specific data for regional transit time abnormalities. Patients and methods Data from video capsules ingested by 71 ambulatory healthy subjects were recorded and analyzed to determine gastric and small bowel transit times in the fasting state. Results Median, and interquartile range (IQR), gastric transit time was 22 (10-48) minutes, and median (IQR) small bowel transit time was 198.5 (157-240.5) minutes. Conclusion These data, for the first time to our knowledge, provide references for gastrointestinal transit times among healthy ambulatory subjects using video capsule endoscopy. This potentially strengthens clinical use of video capsule endoscopy in the investigation of patients with suspected gastrointestinal motility disorders.
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Affiliation(s)
- John O’Grady
- APC Microbiome Ireland, University College Cork, National University of Ireland, Cork, Ireland,Department of Medicine, Cork University Hospital, National University of Ireland, Cork, Ireland
| | - Clodagh L. Murphy
- APC Microbiome Ireland, University College Cork, National University of Ireland, Cork, Ireland,Department of Medicine, Cork University Hospital, National University of Ireland, Cork, Ireland
| | - Lillian Barry
- Centre for Gastroenterology, Mercy University Hospital, Cork, Ireland
| | - Fergus Shanahan
- APC Microbiome Ireland, University College Cork, National University of Ireland, Cork, Ireland,Department of Medicine, Cork University Hospital, National University of Ireland, Cork, Ireland
| | - Martin Buckley
- Centre for Gastroenterology, Mercy University Hospital, Cork, Ireland
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4
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Tominaga K, Sato H, Yokomichi H, Tsuchiya A, Yoshida T, Kawata Y, Mizusawa T, Yokoyama J, Terai S. Variation in small bowel transit time on capsule endoscopy. ANNALS OF TRANSLATIONAL MEDICINE 2020; 8:348. [PMID: 32355792 PMCID: PMC7186741 DOI: 10.21037/atm.2020.02.40] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Background Small bowel motility remains inadequately understood because of the complex and various functions as well as its anatomical position. The aimed of the study was to investigate the small bowel transit time (SBTT) of capsule endoscopy (CE) and to analyze the clinical factors affecting SBTT. Methods SBTT was analyzed in patients who underwent small bowel CE. Factors contributing to SBTT and CE retention were investigated. Results Among 397 patients enrolled in this study, 336 (84.6%) completed CE. The mean SBTT (± standard deviation) was 282.1±132.2 min. According to the univariate and multivariate analyses, aging and small bowel stenosis extended SBTT. In 38 patients who underwent multiple CE studies, considerable variation in SBTT were observed [mean of standard deviations (SDs) =97.97 min, SD of the SDs =81.99 min]. CE retention was observed in 61 patients (13.3%), and it was statistically associated to small bowel lesion. Conclusions Aging and small bowel stenosis were associated with longer SBTT. Furthermore, SBTT analyzed by CE should be interpreted carefully considering the intra-individual differences in SBTT.
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Affiliation(s)
- Kentaro Tominaga
- Division of Gastroenterology and Hepatology, Niigata University Medical and Dental Hospital, Niigata, Japan
| | - Hiroki Sato
- Division of Gastroenterology and Hepatology, Niigata University Medical and Dental Hospital, Niigata, Japan
| | - Hiroshi Yokomichi
- Department of Health Sciences, School of Medicine, University of Yamanashi, Yamanashi, Japan
| | - Atsunori Tsuchiya
- Division of Gastroenterology and Hepatology, Niigata University Medical and Dental Hospital, Niigata, Japan
| | - Tomoaki Yoshida
- Division of Gastroenterology and Hepatology, Niigata University Medical and Dental Hospital, Niigata, Japan
| | - Yuzo Kawata
- Division of Gastroenterology and Hepatology, Niigata University Medical and Dental Hospital, Niigata, Japan
| | - Takeshi Mizusawa
- Division of Gastroenterology and Hepatology, Niigata University Medical and Dental Hospital, Niigata, Japan
| | - Junji Yokoyama
- Division of Gastroenterology and Hepatology, Niigata University Medical and Dental Hospital, Niigata, Japan
| | - Shuji Terai
- Division of Gastroenterology and Hepatology, Niigata University Medical and Dental Hospital, Niigata, Japan
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Abstract
PURPOSE OF REVIEW Gastrointestinal dysmotility occurs frequently in the critically ill. Although the causes underlying dysmotility are multifactorial, both pain and its treatment with exogenous opioids are likely causative factors. The purpose of this review is to describe the effects of pain and opioids on gastrointestinal motility; outline the rationale for and evidence supporting the administration of opioid antagonists to improve dysmotility; and describe the potential influence opioids drugs have on the intestinal microbiome and infectious complications. RECENT FINDINGS Opioid drugs are frequently prescribed in the critically ill to alleviate pain. In health, opioids cause gastric dysmotility, yet the evidence for this in critical illness is inconsistent and limited to observational studies. Administration of opioid antagonists may improve gastrointestinal motility, but data are sparse, and these agents cannot be recommended outside of clinical trials. Although critical illness is associated with alterations in the microbiome, the extent to which opioid administration influences these changes, and the subsequent development of infection, remains uncertain. SUMMARY Replication of clinical studies from ambulant populations in critical care is required to ascertain the independent influence of opioid administration on gastrointestinal motility and infectious complications.
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Deane AM, Chapman MJ, Reintam Blaser A, McClave SA, Emmanuel A. Pathophysiology and Treatment of Gastrointestinal Motility Disorders in the Acutely Ill. Nutr Clin Pract 2018; 34:23-36. [PMID: 30294835 DOI: 10.1002/ncp.10199] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
Gastrointestinal dysmotility causes delayed gastric emptying, enteral feed intolerance, and functional obstruction of the small and large intestine, the latter functional obstructions being frequently termed ileus and Ogilvie syndrome, respectively. In addition to meticulous supportive care, drug therapy may be appropriate in certain situations. There is, however, considerable variation among individuals regarding what gastric residual volume identifies gastric dysmotility and would encourage use of a promotility drug. While the administration of either metoclopramide or erythromycin is supported by evidence it appears that, dual-drug therapy (erythromycin and metoclopramide) reduces the rate of treatment failure. There is a lack of evidence to guide drug therapy of ileus, but neither erythromycin nor metoclopramide appear to have a role. Several drugs, including ghrelin agonists, highly selective 5-hydroxytryptamine receptor agonists, and opiate antagonists are being studied in clinical trials. Neostigmine, when infused at a relatively slow rate in patients receiving continuous hemodynamic monitoring, may alleviate the need for endoscopic decompression in some patients.
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Affiliation(s)
- Adam M Deane
- Intensive Care Unit, Royal Melbourne Hospital, University of Melbourne, Parkville, Australia
| | - Marianne J Chapman
- Discipline of Acute Care Medicine, University of Adelaide, Adelaide, Australia.,Department of Critical Care Services, Royal Adelaide Hospital, Adelaide, Australia
| | - Annika Reintam Blaser
- Department of Anaesthesiology and Intensive Care, University of Tartu, Tartu, Estonia.,Center of Intensive Care Medicine, Lucerne Cantonal Hospital, Lucerne, Switzerland
| | - Stephen A McClave
- Department of Medicine, University of Louisville, Louisville, Kentucky, USA
| | - Anton Emmanuel
- Department of Neuro-Gastroenterology, University College London, London, UK
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7
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Hakimian S, Jawaid S, Guilarte-Walker Y, Mathew J, Cave D. Video capsule endoscopy as a tool for evaluation of obscure overt gastrointestinal bleeding in the intensive care unit. Endosc Int Open 2018; 6:E989-E993. [PMID: 30083589 PMCID: PMC6075946 DOI: 10.1055/a-0590-3940] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/04/2017] [Accepted: 02/21/2018] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND AND STUDY AIMS Video capsule endoscopy (VCE) is a minimally invasive tool that helps visualize the gastrointestinal tract from the esophagus to the right colon without the need for sedation or preparation. VCE is safe with very few contraindications. However, its role and safety profile in the intensive care unit (ICU) population have not been reported. The aim of this study is to evaluate the safety, efficacy, and feasibility of VCE use in ICU patients. PATIENTS AND METHODS We conducted a single-center retrospective observational study of patients who underwent VCE for evaluation of obscure overt gastrointestinal bleeding in the ICU between 2008 and 2016. RESULTS This study included 48 patients who were admitted to the UMass Memorial Medical Center ICUs for gastrointestinal bleeding. VCE was successfully completed in 43/48 (90 %) patients. The entire length of small bowel could be evaluated in 75 % and the source of bleeding was identified in 44 % of the patients. The most commonly identified source of bleeding included small bowel angioectasias, duodenal erosions/ulcers, and small bowel polyps. No major complications could be attributed to the VCE. Only 1 capsule was retained after 2 wk; however, there was no incidence of bowel obstruction, perforation, or capsule aspiration. CONCLUSIONS This observational retrospective study demonstrates that VCE may be a safe, feasible, and effective diagnostic tool in evaluation of gastrointestinal bleeding in the ICU population with few complications. VCE may be a safe diagnostic prelude and be a guide to the correct therapeutic procedure if needed, in the context of patients who are seriously ill.
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Affiliation(s)
- Shahrad Hakimian
- Department of Medicine, UMass Memorial Medical Center, Worcester, MA,Corresponding author Shahrad Hakimian, MD UMass Memorial Medical CenterDepartment of Internal Medicine55 Lake Avenue NorthWorcesterMA 01655United States+1-508-8563981
| | - Salmaan Jawaid
- Division of Gastroenterology, UMass Memorial Medical Center, Worcester, MA
| | - Yurima Guilarte-Walker
- Division of Data Sciences and Technology, Information Technology, UMass Medical School, Worcester, MA
| | - Jomol Mathew
- Division of Data Sciences and Technology, Information Technology, UMass Medical School, Worcester, MA
| | - David Cave
- Division of Gastroenterology, UMass Memorial Medical Center, Worcester, MA
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8
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Ladopoulos T, Giannaki M, Alexopoulou C, Proklou A, Pediaditis E, Kondili E. Gastrointestinal dysmotility in critically ill patients. Ann Gastroenterol 2018; 31:273-281. [PMID: 29720852 PMCID: PMC5924849 DOI: 10.20524/aog.2018.0250] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/28/2017] [Accepted: 01/30/2018] [Indexed: 12/17/2022] Open
Abstract
Gastrointestinal (GI) motility disorders are commonly present in critical illness. Up to 60% of critically ill patients have been reported to experience GI dysmotility of some form necessitating therapeutic intervention. It has been attributed to various factors, related to both the underlying disease and the therapeutic interventions undertaken. The assessment of motility disturbances can be challenging in critically ill patients, as the available tests used to detect abnormal motility have major limitations in the setting of an Intensive Care Unit. Critically ill patients with GI dysmotility require a multifaceted treatment approach that addresses multiple causes and utilizes multiple pharmacological pathways. In this review, we discuss the pathophysiology, assessment and management of GI dysmotility in critically ill patients.
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Affiliation(s)
- Theodoros Ladopoulos
- Department of Intensive Care Medicine, University Hospital of Heraklion, Medical School, University of Crete, Heraklion, Crete, Greece
| | - Maria Giannaki
- Department of Intensive Care Medicine, University Hospital of Heraklion, Medical School, University of Crete, Heraklion, Crete, Greece
| | - Christina Alexopoulou
- Department of Intensive Care Medicine, University Hospital of Heraklion, Medical School, University of Crete, Heraklion, Crete, Greece
| | - Athanasia Proklou
- Department of Intensive Care Medicine, University Hospital of Heraklion, Medical School, University of Crete, Heraklion, Crete, Greece
| | - Emmanuel Pediaditis
- Department of Intensive Care Medicine, University Hospital of Heraklion, Medical School, University of Crete, Heraklion, Crete, Greece
| | - Eumorfia Kondili
- Department of Intensive Care Medicine, University Hospital of Heraklion, Medical School, University of Crete, Heraklion, Crete, Greece
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Grønlund D, Poulsen JL, Sandberg TH, Olesen AE, Madzak A, Krogh K, Frøkjaer JB, Drewes AM. Established and emerging methods for assessment of small and large intestinal motility. Neurogastroenterol Motil 2017; 29. [PMID: 28086261 DOI: 10.1111/nmo.13008] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/05/2016] [Accepted: 11/11/2016] [Indexed: 12/13/2022]
Abstract
BACKGROUND Gastrointestinal symptoms are common in the general population and may originate from disturbances in gut motility. However, fundamental mechanistic understanding of motility remains inadequate, especially of the less accessible regions of the small bowel and colon. Hence, refinement and validation of objective methods to evaluate motility of the whole gut is important. Such techniques may be applied in clinical settings as diagnostic tools, in research to elucidate underlying mechanisms of diseases, and to evaluate how the gut responds to various drugs. A wide array of such methods exists; however, a limited number are used universally due to drawbacks like radiation exposure, lack of standardization, and difficulties interpreting data. In recent years, several new methods such as the 3D-Transit system and magnetic resonance imaging assessments on small bowel and colonic motility have emerged, with the advantages that they are less invasive, use no radiation, and provide much more detailed information. PURPOSE This review outlines well-established and emerging methods to evaluate small bowel and colonic motility in clinical settings and in research. The latter include the 3D-Transit system, magnetic resonance imaging assessments, and high-resolution manometry. Procedures, indications, and the relative strengths and weaknesses of each method are summarized.
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Affiliation(s)
- D Grønlund
- Mech-Sense, Department of Gastroenterology and Hepatology, Aalborg University Hospital, Aalborg, Denmark.,Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| | - J L Poulsen
- Mech-Sense, Department of Gastroenterology and Hepatology, Aalborg University Hospital, Aalborg, Denmark.,Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| | - T H Sandberg
- Mech-Sense, Department of Gastroenterology and Hepatology, Aalborg University Hospital, Aalborg, Denmark
| | - A E Olesen
- Mech-Sense, Department of Gastroenterology and Hepatology, Aalborg University Hospital, Aalborg, Denmark.,Department of Clinical Medicine, Aalborg University, Aalborg, Denmark.,Department of Drug Design and Pharmacology, University of Copenhagen, Copenhagen, Denmark
| | - A Madzak
- Mech-Sense, Department of Radiology, Aalborg University Hospital, Aalborg, Denmark
| | - K Krogh
- Neurogastroenterology Unit, Department of Hepatology and Gastroenterology, Aarhus University Hospital, Aarhus, Denmark
| | - J B Frøkjaer
- Department of Clinical Medicine, Aalborg University, Aalborg, Denmark.,Mech-Sense, Department of Radiology, Aalborg University Hospital, Aalborg, Denmark
| | - A M Drewes
- Mech-Sense, Department of Gastroenterology and Hepatology, Aalborg University Hospital, Aalborg, Denmark.,Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
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10
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Peters JH, Wierdsma NJ, Beishuizen A, Teerlink T, van Bodegraven AA. Intravenous citrulline generation test to assess intestinal function in intensive care unit patients. Clin Exp Gastroenterol 2017; 10:75-81. [PMID: 28496350 PMCID: PMC5417678 DOI: 10.2147/ceg.s121100] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/22/2023] Open
Abstract
Background Assessment of a quantifiable small intestinal function test is cumbersome. Fasting citrulline concentrations have been proposed as a measure of enterocyte function and elaborated into a citrulline generation test (CGT), which is applicable only when glutamine is administered orally. CGT is an oral test, limiting its use, for example, in critically ill patients. Objective Assessment of normative values and feasibility of an intravenously performed CGT in intensive care unit (ICU) patients with presumed gastrointestinal motility disturbances, especially when performed intravenously. Design CGT reference values were determined in 16 stable ICU patients using two different CGT methods, namely following either enteral or intravenous glutamine administration and both with simultaneous arterial and venous plasma citrulline sampling at six time-points. Plasma amino acid analysis was performed using reverse-phase high-performance liquid chromatography. Results The median total generation of citrulline in 90 min (CGT iAUCT90) was markedly higher with arterial citrulline sampling compared with venous citrulline sampling, being 724±585 and 556±418 µmol/L/min for enteral glutamine, respectively (p=0.02) and 977±283 and 769±231 µmol/L/min for intravenous glutamine, respectively (p=0.0004). The median slope (time-dependent increase) for plasma arterial and venous citrulline during the CGT was 0.20±0.16 and 0.18±0.12 µmol/L/min for enteral glutamine, respectively (p=0.004) and 0.22±0.16 and 0.19±0.05 µmol/L/min for intravenous glutamine, respectively (p=0.02). Conclusion Intravenous glutamine administration combined with arterial plasma citrulline sampling yielded the least variation in CGT characteristics in stable ICU patients. A 2-point measurement test had comparable test characteristics as a 6-point measurement CGT and seems promising.
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Affiliation(s)
- Job Hc Peters
- Department of Gastroenterology and Hepatology, Red Cross Hospital, Beverwijk
| | - Nicolette J Wierdsma
- Department of Nutrition and Dietetics, VU University Medical Center, Amsterdam.,Department of Gastroenterology, Small Bowel Disease Unit, VU University Medical Center, Amsterdam
| | - Albertus Beishuizen
- Department of Intensive Care, VU University Medical Center, Amsterdam.,Department of Intensive Care, Intensive Care Center, Medisch Spectrum Twente, Enschede
| | - Tom Teerlink
- Department of Clinical Chemistry, Metabolic Laboratory, VU University Medical Center, Amsterdam
| | - Ad A van Bodegraven
- Department of Gastroenterology, Small Bowel Disease Unit, VU University Medical Center, Amsterdam.,Department of Gastroenterology, Geriatrics, Intensive Care and Internal Medicin (Co-MIK), Zuyderland MC, Heerlen-Sittard-Geleen, the Netherlands
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Abstract
Acute gastrointestinal injury (AGI) is common in critical illness and negatively affects outcome. A variety of definitions have been used to describe AGI, which has led to clinical confusion and hampered comparison of research studies across institutions. An international working group of the European Society of Intensive Care Medicine was convened to standardize definitions for AGI and provide current evidence-based understanding of its pathophysiology and management. This disorder is associated with a wide variety of signs and symptoms and may be difficult to detect, therefore a high index of suspicion is warranted.
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Affiliation(s)
- Robert W Taylor
- Department of Critical Care Medicine, Mercy Hospital St. Louis, Suite 4006B, St Louis, MO 63141, USA.
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12
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Abstract
PURPOSE OF REVIEW Gastrointestinal dysmotility and dysfunction underlie our difficulties in providing adequate nutrition by the enteral route to our critically ill patients. RECENT FINDINGS Recent studies have quantified gastric emptying and nutrient absorption. Slow gastric emptying is common and probably mediated by cholecystokinin and reduced active ghrelin concentrations. The cause of impaired nutrient absorption is not yet fully understood but may be related to small intestinal blood flow and/or mucosal factors. The absorption of the different macronutrients may be affected in different ways both by critical illness and by therapies. A better understanding of this may optimize the design of nutrient formulations in the future. New treatment modalities for gastrointestinal dysfunction are being investigated and include small intestinal feeding, nonpharmacological options such as acupuncture, and drugs including novel motilin receptor agonists, and opioid antagonists. SUMMARY We are gradually developing a better understanding of how the gut works during critical illness, which has implications for optimizing the delivery of nutrition and thereby improving nutritional and clinical outcomes.
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Affiliation(s)
- Marianne J Chapman
- Department of Critical Care Services, Royal Adelaide Hospital, Adelaide, South Australia, Australia.
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13
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Motility disorders of the upper gastrointestinal tract in the intensive care unit: pathophysiology and contemporary management. J Clin Gastroenterol 2012; 46:449-56. [PMID: 22469641 DOI: 10.1097/mcg.0b013e31824e14c1] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Upper gastrointestinal (GI) dysmotility, an entity commonly found in the intensive care unit setting, can lead to insufficient nutrient intake while increasing the risk of infection and mortality. Further, overcoming the altered motility with early enteral feeding is associated with a reduced incidence of infectious complications in intensive care unit patients. Upper GI dysmotility in critical care patients is a common occurrence, and there are many causes for this problem, which affects a very heterogenous population with a multitude of underlying medical abnormalities. Therefore, it is of utmost importance to identify this widespread problem and subsequently institute a proper therapy as rapidly as possible. Prokinetic pharmacotherapies are currently the mainstay for the management of disordered upper GI motility. Future therapies, aimed at the underlying pathophysiology of this complex problem, are under investigation. These aim is to reduce the side effects of the currently available options, while improving on nutrition delivery in the critically ill. This review discusses the pathophysiology, clinical manifestations, diagnosis, and treatment of upper GI motility disturbances in the critically ill.
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14
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Rauch S, Krueger K, Turan A, You J, Roewer N, Sessler DI. Use of wireless motility capsule to determine gastric emptying and small intestinal transit times in critically ill trauma patients. J Crit Care 2012; 27:534.e7-12. [PMID: 22300488 DOI: 10.1016/j.jcrc.2011.12.002] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2011] [Revised: 11/22/2011] [Accepted: 12/06/2011] [Indexed: 12/22/2022]
Abstract
PURPOSE The purpose of this study is to use a novel wireless motility capsule to compare gastric emptying and small bowel transit times in critically ill trauma patients and healthy volunteers. MATERIALS AND METHODS We evaluated gastric emptying, small bowel transit time, and total intestinal transit time in 8 critically ill trauma patients. These data were compared with those obtained in 87 healthy volunteers from a separate trial. Data were obtained with a motility capsule that wirelessly transmitted pH, pressure, and temperature to a recorder attached to each subject's abdomen. RESULTS The gastric emptying time was significantly longer in critically ill patients (median, 13.9; interquartile range [IQR], 6.6-48.3 hours) than in healthy volunteers (median, 3.0; IQR, 2.5-3.9 hours), P < .001. The small bowel transit time in critically ill patients was significantly longer than in healthy volunteers (median, 6.7 hours; IQR, 4.4-8.5 hours vs median, 3.8 hours; IQR, 3.1-4.7 hours), P = .01. Furthermore, the capsules passed after 10 (IQR, 8.5-13) days in the critical care group and 1.2 (IQR, 0.9-1.9) days in healthy volunteers (P < .001). CONCLUSIONS Both gastric emptying and small bowel transit were delayed in critically ill trauma patients.
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Affiliation(s)
- Stefan Rauch
- Department of Anesthesiology, University of Würzburg, Germany.
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15
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Chapman MJ, Nguyen NQ, Deane AM. Gastrointestinal dysmotility: clinical consequences and management of the critically ill patient. Gastroenterol Clin North Am 2011; 40:725-39. [PMID: 22100114 DOI: 10.1016/j.gtc.2011.09.003] [Citation(s) in RCA: 45] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/21/2023]
Abstract
Gastrointestinal dysmotility is a common feature of critical illness, with a number of significant implications that include malnutrition secondary to reduced feed tolerance and absorption, reflux and aspiration resulting in reduced lung function and ventilator-associated pneumonia, bacterial overgrowth and possible translocation causing nosocomial sepsis. Prokinetic agent administration can improve gastric emptying and caloric delivery, but its effect on nutrient absorption and clinical outcomes is, as yet, unclear. Postpyloric delivery of nutrition has not yet been demonstrated to increase caloric intake or improve clinical outcomes.
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Affiliation(s)
- Marianne J Chapman
- Department of Critical Care Services, Royal Adelaide Hospital, North Terrace, Adelaide, South Australia.
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16
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Deane AM, Summers MJ, Zaknic AV, Chapman MJ, Di Bartolomeo AE, Bellon M, Maddox A, Russo A, Horowitz M, Fraser RJL. Glucose absorption and small intestinal transit in critical illness. Crit Care Med 2011; 39:1282-8. [PMID: 21336122 DOI: 10.1097/ccm.0b013e31820ee21f] [Citation(s) in RCA: 52] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
OBJECTIVES Although enteral nutrition is standard care for critically ill patients, nutrient absorption has not been quantified in this group and may be impaired due to intestinal dysmotility. The objectives of this study were to measure small intestinal glucose absorption and duodenocecal transit and determine their relationship with glycemia in the critically ill. DESIGN Prospective observational study of healthy and critically ill subjects. SETTING Tertiary mixed medical-surgical adult intensive care unit. SUBJECTS Twenty-eight critically ill patients and 16 healthy subjects were studied. MATERIALS AND MAIN RESULTS: Liquid feed (100 kcal/100 mL), labeled with Tc-sulfur colloid and including 3 g of 3-O-methylglucose, was infused into the duodenum. Glucose absorption and duodenocecal transit were measured using the area under the 3-O-methylglucose concentration curve and scintigraphy, respectively. Data are median (range). RESULTS AND DISCUSSION Glucose absorption was reduced in critical illness when compared to health (area under the concentration curve: 16 [1-32] vs. 20 [14-34] mmol/L·min; p = .03). Small intestinal transit times were comparable in patients and healthy subjects (192 [9-240] vs. 168 [6-240] min; p = .99) and were not related to glucose absorption. Despite higher fasting blood glucose concentrations (6.3 [5.1-9.3] vs. 5.7 [4.6-7.6] mmol/L; p < .05), the increment in blood glucose was sustained for longer in the critically ill (Δ glucose at t = 60; 1.9 [-2.1-5.0] mmol/L vs. -0.2 [-1.3-2.3] mmol/L; p < .01). CONCLUSIONS Critical illness is associated with reduced small intestinal glucose absorption, but despite this, the glycemic response to enteral nutrient is sustained for longer.
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Affiliation(s)
- Adam M Deane
- National Health and Medical Research Council of Australia Centre for Clinical Research Excellence in Nutritional Physiology and Outcomes, Adelaide, South Australia, Australia.
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Antonelli M, Azoulay E, Bonten M, Chastre J, Citerio G, Conti G, De Backer D, Lemaire F, Gerlach H, Hedenstierna G, Joannidis M, Macrae D, Mancebo J, Maggiore SM, Mebazaa A, Preiser JC, Pugin J, Wernerman J, Zhang H. Year in review in Intensive Care Medicine 2009: I. Pneumonia and infections, sepsis, outcome, acute renal failure and acid base, nutrition and glycaemic control. Intensive Care Med 2010; 36:196-209. [PMID: 20057995 PMCID: PMC2816797 DOI: 10.1007/s00134-009-1742-7] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2009] [Accepted: 12/18/2009] [Indexed: 12/17/2022]
Affiliation(s)
- Massimo Antonelli
- Department of Intensive Care and Anesthesiology, Policlinico Universitario A. Gemelli, Università Cattolica del Sacro Cuore, Largo A. Gemelli, 8, 00168 Rome, Italy.
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Deane A, Chapman MJ, Fraser RJL, Horowitz M. Bench-to-bedside review: the gut as an endocrine organ in the critically ill. Crit Care 2010; 14:228. [PMID: 20887636 PMCID: PMC3219235 DOI: 10.1186/cc9039] [Citation(s) in RCA: 42] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
In health, hormones secreted from the gastrointestinal tract have an important role in regulating gastrointestinal motility, glucose metabolism and immune function. Recent studies in the critically ill have established that the secretion of a number of these hormones is abnormal, which probably contributes to disordered gastrointestinal and metabolic function. Furthermore, manipulation of endogenous secretion, physiological replacement and supra-physiological treatment (pharmacological dosing) of these hormones are likely to be novel therapeutic targets in this group. Fasting ghrelin concentrations are reduced in the early phase of critical illness, and exogenous ghrelin is a potential therapy that could be used to accelerate gastric emptying and/or stimulate appetite. Motilin agonists, such as erythromycin, are effective gastrokinetic drugs in the critically ill. Cholecystokinin and peptide YY concentrations are elevated in both the fasting and postprandial states, and are likely to contribute to slow gastric emptying. Accordingly, there is a rationale for the therapeutic use of their antagonists. So-called incretin therapies (glucagon-like peptide-1 and glucose-dependent insulinotropic polypeptide) warrant evaluation in the management of hyperglycaemia in the critically ill. Exogenous glucagon-like peptide-2 (or its analogues) may be a potential therapy because of its intestinotropic properties.
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Affiliation(s)
- Adam Deane
- Royal Adelaide Hospital, Department of Intensive Care, North Terrace, Adelaide 5000, South Australia
- University of Adelaide, Discipline of Acute Care Medicine, North Terrace, Adelaide 5000, South Australia
- NationalHealth and Medical Research Council Centre for Clinical Research Excellence in Nutritional Physiology, Interventions and Outcomes, Level 6, Eleanor Harrald Building, Frome St, Adelaide 5000, South Australia
| | - Marianne J Chapman
- Royal Adelaide Hospital, Department of Intensive Care, North Terrace, Adelaide 5000, South Australia
- University of Adelaide, Discipline of Acute Care Medicine, North Terrace, Adelaide 5000, South Australia
- NationalHealth and Medical Research Council Centre for Clinical Research Excellence in Nutritional Physiology, Interventions and Outcomes, Level 6, Eleanor Harrald Building, Frome St, Adelaide 5000, South Australia
| | - Robert JL Fraser
- NationalHealth and Medical Research Council Centre for Clinical Research Excellence in Nutritional Physiology, Interventions and Outcomes, Level 6, Eleanor Harrald Building, Frome St, Adelaide 5000, South Australia
- Investigation and Procedures Unit, Repatriation General Hospital, Daws Road, Daw Park 5041, South Australia
- University of Adelaide, Discipline of Medicine, North Terrace, Adelaide 5000, Australia
| | - Michael Horowitz
- NationalHealth and Medical Research Council Centre for Clinical Research Excellence in Nutritional Physiology, Interventions and Outcomes, Level 6, Eleanor Harrald Building, Frome St, Adelaide 5000, South Australia
- University of Adelaide, Discipline of Medicine, North Terrace, Adelaide 5000, Australia
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