ESPEN Guidelines on Parenteral Nutrition: gastroenterology

Multivariate analysis of factors associated with the successful prediction of initial blind placement of a nasointestinal tube in the stomach based on X-ray imaging: a retrospective, single-center study

BACKGROUND

Patients in the intensive care unit (ICU) are highly susceptible to malnutrition, and while enteral nutrition via nasogastric tube is the preferred method, there is a risk of inadvertent reflux and aspiration. Therefore, clinicians have turned to nasointestinal tubes (NET) for enteral nutrition as an alternative option. But the precise localization of NET presents an ongoing challenge. We proposed an innovative approach to provide a valuable reference for clinicians involved in NET placement.

METHOD

Data were obtained retrospectively from the medical records of adult patients with a high risk of aspiration or gastric feeding intolerance who had a NET placed in the ICU of Zhejiang Provincial People's Hospital between October 1, 2017, and October 1, 2023. The collected data were subjected to statistical analysis using SPSS and R software.

RESULT

There were 494 patients who met the inclusion and exclusion criteria. The first-pass success rate was 81.4% (n = 402). The success of a patient's initial NET placement was found to be associated with Angle SPC and Distance CP, as determined by univariate analysis (25.6 ± 16.7° vs. 41.9 ± 18.0°, P < 0.001; 40.0 ± 26.2 mm vs. 62.0 ± 31.8 mm, P < 0.001, respectively). By conducting a multivariate regression analysis, we identified a significant association between pyloric types and the success rate of placing NET (OR 29.559, 95%CI 14.084-62.038, P < 0.001).

CONCLUSION

Angle SPC, Distance CP, and the type of pylorus are independently associated with successful initial placement of NET. Besides, patients with the outside type of pylorus (OP-type) exhibit a higher rate of initial placement success.

Baseline Characteristics of Adult Patients Treated and Never Treated with Teduglutide in a Multinational Short Bowel Syndrome and Intestinal Failure Registry

The Short Bowel Syndrome (SBS) Registry (NCT01990040) is a multinational real-world study evaluating the long-term safety of teduglutide in patients with SBS and intestinal failure (SBS-IF) in routine clinical practice. This paper describes the study methodology and baseline characteristics of adult patients who have (ever-treated) or have never (never-treated) received teduglutide. A total of 1411 adult patients (679 ever-treated; 732 never-treated) were enrolled at 124 sites across 17 countries. The mean (standard deviation [SD]) age at enrollment was 55.4 (15.46) years, and 60.2% of patients were women. Crohn's disease was the most common cause of major intestinal resection in both ever-treated (34.1%) and never-treated patients (20.4%). A similar proportion of ever-treated and never-treated patients had a prior history of colorectal polyps (2.7% vs. 3.6%), whereas proportionally fewer ever-treated patients reported a history of colorectal cancer (1.8% vs. 6.2%) or any malignancy (17.7% vs. 30.0%) than never-treated patients. Never-treated patients received a numerically greater mean (SD) volume of parenteral nutrition and/or intravenous fluids than ever-treated patients (12.4 [8.02] vs. 10.1 [6.64] L/week). Ever-treated patients received a mean teduglutide dosage of 0.05 mg/kg/day. This is the first report of patient baseline characteristics from the SBS Registry, and the largest cohort of patients with SBS-IF to date. Overall, ever-treated and never-treated patients had similar baseline characteristics. Differences between treatment groups may reflect variations in patient selection and degree of monitoring.

Stability of individualized neonatal parenteral nutrition admixtures with fish oil and high calcium content

Introduction

Introduction: the stability of total parenteral nutrition admixtures for neonates (TPNAn) has been questioned in relation to the interaction between calcium and fish oil emulsions. Aim: the aim of this study was to check the stability (particle size < 1 µm) of different individualized TPNAn prepared with fish-oil emulsion and containing calcium at concentrations ranging from 10 to 20 mmol/L. Methods: admixtures analyzed: twelve different formulations with SMOFlipid® 20 % (conserved for 24 h and for 96 h), three formulations with Lipoplus® 20 % (conserved for 96 h) and three formulations with SMOFlipid® 20 % with Multi-12K1® Pediatric (conserved for 96 h). Two bags were compounded for each formulation and conservation period. Measurements on each admixture bag: particle standardized diameter by laser diffraction technique and pH by a calibrated pH-meter. Data analysis with mixed linear regression models. Results: maximum particle size was < 0.8 µm for all investigated admixtures. Lipid concentration of 5 g/L and sodium and potassium concentration of 100 mmol/L slightly increased the proportion of particles > 0.6 µm. Ninety six hours storage also increased the percentage of particles > 0.6 µm (+0.143 ± 0.07; p = 0.038) but did not influence other parameters. No association with calcium composition was observed. Amino acid content was inversely correlated with pH (-0.83; p < 0.0001). Conclusions: the studied individualized parenteral nutrition admixtures for newborns that contain fish oil emulsions and meet cation requirements are stable for at least 96 hours.

Intravenous vitamin injections: where is the evidence?

The body needs small daily quantities of vitamins and minerals, which are usually obtained from the diet. Intravenous vitamins are used for a few serious medical conditions (eg, malabsorption syndromes with severe vitamin depletion, Wernicke's encephalopathy or critical illness). Intravenous drips containing high doses of various vitamins and minerals (eg, the so-called 'Myers' cocktail') have been promoted in popular culture to 'reduce stress', 'increase energy' or 'boost immunity', with claims that the intravenous route allows faster absorption of vitamins into the bloodstream than if they are taken orally. There is a lack of high-quality evidence to suggest that high-dose vitamin infusions are necessary or offer any health benefit in the absence of a specific vitamin deficiency or medical condition. There may be harms from taking high (non-physiological) quantities of some vitamins and minerals. Licensed forms of injectable vitamins that are prescription-only medicines should not be advertised to the public and should only be supplied and administered by appropriately qualified healthcare professionals.

ESPEN guideline on chronic intestinal failure in adults - Update 2023

BACKGROUND & AIMS

In 2016, ESPEN published the guideline for Chronic Intestinal Failure (CIF) in adults. An updated version of ESPEN guidelines on CIF due to benign disease in adults was devised in order to incorporate new evidence since the publication of the previous ESPEN guidelines.

METHODS

The grading system of the Scottish Intercollegiate Guidelines Network (SIGN) was used to grade the literature. Recommendations were graded according to the levels of evidence available as A (strong), B (conditional), 0 (weak) and Good practice points (GPP). The recommendations of the 2016 guideline (graded using the GRADE system) which were still valid, because no studies supporting an update were retrieved, were reworded and re-graded accordingly.

RESULTS

The recommendations of the 2016 guideline were reviewed, particularly focusing on definitions, and new chapters were included to devise recommendations on IF centers, chronic enterocutaneous fistulas, costs of IF, caring for CIF patients during pregnancy, transition of patients from pediatric to adult centers. The new guideline consist of 149 recommendations and 16 statements which were voted for consensus by ESPEN members, online in July 2022 and at conference during the annual Congress in September 2022. The Grade of recommendation is GPP for 96 (64.4%) of the recommendations, 0 for 29 (19.5%), B for 19 (12.7%), and A for only five (3.4%). The grade of consensus is "strong consensus" for 148 (99.3%) and "consensus" for one (0.7%) recommendation. The grade of consensus for the statements is "strong consensus" for 14 (87.5%) and "consensus" for two (12.5%).

CONCLUSIONS

It is confirmed that CIF management requires complex technologies, multidisciplinary and multiprofessional activity, and expertise to care for the underlying gastrointestinal disease and to provide HPN support. Most of the recommendations were graded as GPP, but almost all received a strong consensus.

Surgical priorities in abdominal Crohn's disease

Crohn's disease is a chronic disorder associated with a high rate of recurrence and morbidity. New therapies have been developed over the last few decades that have improved both induction of remission and lowered recurrence rates which led to improved outcomes. An overarching set of principles connects these therapies with prevention of recurrence being the top priority. To achieve the best outcomes, patients must be carefully chosen, optimized, and the correct surgery performed by an experienced and multidisciplinary team at the appropriate time. We seek to outline the current evidence-based approach to the surgical management of Crohn's disease.

Determination of Inorganic Ions in Parenteral Nutrition Solutions by Ion Chromatography

A new, simple and sensitive ion chromatography (IC) method for the determination of sodium, potassium, magnesium, calcium and chloride in a parenteral nutrition (PN) solution was developed and validated. Before sample analysis, a sample pretreatment by calcination was applied which could totally remove interference from other constituents of the PN solution. Methanesulfonic acid (MSA) and sodium hydroxide were used as the mobile phase for the determination of cations and anions, respectively. The calibration curves showed good correlation between analyte peak area and concentration (r2 > 0.999). Detection limits ranged from 0.0001 to 0.02 mg/L and quantification limits from 0.0002 to 0.06 mg/L. Relative standard deviation (RSD) values for repeatability and inter-day precision did not exceed 1.0% and the recoveries for all analytes were between 99.1−101.1%. The robustness was verified by using an experimental design.

The Role of the Pharmacist in Selecting the Best Choice of Medication Formulation in Dysphagic Patients

Usually, the administration of drugs by feeding tube in dysphagic patients involves handling of marketing licenses outside their term, due to the lack of suitable formulations. This circumstance has put health professionals in the dilemma of choosing the formulation whose manipulation possibly does not alter the effectiveness of the drug. In this regard, a practical guide providing indications on the prescription, handling, and administration of drugs through enteral feeding tube could be of paramount utility. For this purpose, we have considered the 1047 solid oral pharmaceutical forms included in the formulary of San Paolo Hospital (Savona, Italy). From our analysis, it emerges that 95% of medicinal products are worryingly used off-label and 40% have to be managed by the hospital pharmacists without having suitable indications by either the manufacturers or by literature studies. To fill this gap, we have compiled a detailed table containing missing indications derived from pharmacist expertise and evidence-based practices, with the aim that the sharing of our procedures will contribute to make uniform pharmacological therapies from one hospital to another. This study will allow doctors to have easy access to information on drugs that can be prescribed and nurses to become familiar only with the pharmaceutical forms that can be administered.

Secondary Indicators for an Evaluation and Guidance System for Quality of Care in Inflammatory Bowel Disease Centers: A Critical Review of the Inflammatory Bowel Disease Quality of Care Center

The number of patients with inflammatory bowel disease (IBD) has increased remarkably in recent years. However, the level of health care for IBD patients varies greatly among regions of China. Standardization of health care for IBD patients is essential to improve quality of care (QoC). The mission of the IBD Quality Care Evaluation Center (IBDQCC) is to establish indicators for QoC. Since 2017, the IBDQCC has developed structure, process, and outcome indicators with the steering committee of IBD specialists and methodologists; 28 core and 13 secondary IBD QoC indicators were selected using a Delphi method. Applications for certification of IBD quality care units were made voluntarily and preliminarily screened through the IBDQCC committee. Regional units had to meet all core indicators, and units of excellence were required to meet all core indicators together with an additional 50% of secondary indicators. As of 2019 and 2020, 69 IBD units (all from tertiary referral hospitals) have been certified as regional IBD units in China. The certification of excellence of the IBD units is currently undergoing auditing. The awareness of and appreciation for QoC in IBD is increasing in China, especially through the quality control evaluation program initiated by the IBDQCC, with a higher number of IBD units applying for the next round of certification. Although secondary indicators seem to play relatively minor roles in QoC, they suggest additional requirements for high-level centers.

The Management of the Hospitalized Ulcerative Colitis Patient, the Medical-Surgical Conundrum

PURPOSE OF REVIEW

In this study we present the evidence based management for patients hospitalized for UC with a special focus on the synergic approach of the two key actors of the inflammatory bowel disease multidisciplinary team (IBD-MDT): gastroenterologist and surgeon.

RECENT FINDINGS

Focused treatment by a specialized IBD-MDT and early involvement of the colorectal surgeon in the management of hospitalized ulcerative colitis patients is advocated. The colectomy rate has not changed over the years. Moreover delayed surgery after admission is burden by increase complication and mortality. Thus, it is pivotal to identify the patients who are likely to undergo surgery, by mean of predictors of outcome, and to not prolong ineffective medical treatment. The perfect timing based on clinical close monitoring is crucial. Up to 25% of patients with ulcerative colitis (UC) may require hospitalization. The aim of admission is to evaluate severity of the disease, exclude infections and establish proper treatment while monitoring the response. During admission, the patient has to be closely observed for the possible development of toxic megacolon or perforation, which should prompt emergency colectomy. Up to 30% of UC patients will fail to respond to initial intravenous corticosteroid. Non responder or partial responder to medical therapy should be evaluated for timely surgery or could be considered for rescue medical therapy.

Small and Large Intestine (II): Inflammatory Bowel Disease, Short Bowel Syndrome, and Malignant Tumors of the Digestive Tract

The small intestine is key in the digestion and absorption of macro and micronutrients. The large intestine is essential for the absorption of water, to allow adequate defecation, and to harbor intestinal microbiota, for which their nutritional role is as important as it is unknown. This article will describe the causes and consequences of malnutrition in patients with inflammatory bowel diseases, the importance of screening and replacement of micronutrient deficits, and the main indications for enteral and parenteral nutrition in these patients. We will also discuss the causes of short bowel syndrome, a complex entity due to anatomical or functional loss of part of the small bowel, which can cause insufficient absorption of liquid, electrolytes, and nutrients and lead to complex management. Finally, we will review the causes, consequences, and management of malnutrition in patients with malignant and benign digestive tumors, including neuroendocrine tumors (present not only in the intestine but also in the pancreas).

Chronic intestinal failure and short bowel syndrome in Crohn’s disease

Chronic intestinal failure (CIF) is a rare but feared complication of Crohn’s disease. Depending on the remaining length of the small intestine, the affected intestinal segment, and the residual bowel function, CIF can result in a wide spectrum of symptoms, from single micronutrient malabsorption to complete intestinal failure. Management of CIF has improved significantly in recent years. Advances in home-based parenteral nutrition, in particular, have translated into increased survival and improved quality of life. Nevertheless, 60% of patients are permanently reliant on parenteral nutrition. Encouraging results with new drugs such as teduglutide have added a new dimension to CIF therapy. The outcomes of patients with CIF could be greatly improved by more effective prevention, understanding, and treatment. In complex cases, the care of patients with CIF requires a multidisciplinary approach involving not only physicians but also dietitians and nurses to provide optimal intestinal rehabilitation, nutritional support, and an improved quality of life. Here, we summarize current literature on CIF and short bowel syndrome, encompassing epidemiology, pathophysiology, and advances in surgical and medical management, and elucidate advances in the understanding and therapy of CIF-related complications such as catheter-related bloodstream infections and intestinal failure-associated liver disease.

Alterations of gut microbiota and serum bile acids are associated with parenteral nutrition-associated liver disease

BACKGROUND

Parenteral nutrition-associated liver disease (PNALD) is a major complication of long-term parenteral nutrition (PN). The pathogenesis of PNALD remains unclear. We investigated the changes in taxonomic and functional composition of gut microbiota and serum bile acid levels in a rat model of PNALD.

METHODS

Male 4-week-old Sprague Dawley rats received either total parenteral nutrition or standard chow with 0.9% saline for 7 days. The taxonomic composition of cecal microbiota and its functional composition associated with bile acid metabolism were measured.

RESULTS

There were differences in taxonomic composition between the two groups. The abundance of the secondary bile acid biosynthesis pathway was higher in the TPN group (p < 0.05) with an increase in the percentage of bacteria expressing 7-alpha-hydroxysteroid dehydrogenase (p < 0.05). The abundance of enzymes associated with bile salt hydrolase was also higher (p < 0.05) in the TPN group. The TPN group showed a distinct bile acid profile characterized by a higher ratio of secondary bile acids to primary bile acids.

CONCLUSIONS

The alteration of bile acid-associated microbiota may lead to increased secondary bile acid production in a rat model of PNALD.

Short bowel syndrome: treatment options

Introduction Short bowel syndrome (SBS) refers to the malabsorptive state that occurs following extensive intestinal resection and is associated with several complications.

Methods The research for this review was conducted in the Pubmed database. Relevant scientific articles dated between 1991 and 2015 and written in Portuguese, Spanish or English were selected.

Results Several therapies, including nutritional support, pharmacological options and surgical procedures have been used in these patients.

Conclusions Over the last decades new surgical and pharmacological approaches emerged, increasing survival and quality of life (QoL) in patients with SBS. All SBS patients ought to have an individualized and multidisciplinary care that promotes intestinal rehabilitation.

Prolonged Parenteral Nutrition Is One of the Most Significant Risk Factors for Nosocomial Infections in Adult Patients With Intestinal Failure

BACKGROUND

Intestinal failure (IF) and its management are associated with an increased likelihood of infectious complications. This study aimed to evaluate the prevalence and potential risk factors for nosocomial infections (NIs) in hospitalized adult patients with IF.

METHODS

In total, 259 eligible patients with IF admitted to a single clinical nutrition center in a tertiary referral hospital from January 1, 2012, to January 1, 2019, were retrospectively identified. NIs were defined according to the 2008 Centers for Disease Control and Prevention criteria. Univariate and multivariate analyses were performed to identify independent risk factors for NIs.

RESULTS

The mean age of the study population was 47.0 ± 17.7 years, and 158 (61.0%) were men. The mean body mass index was 16.2 ± 2.9 kg/m² , and 219 (84.6%) were diagnosed with malnutrition. The prevalence of NIs was 25.5% (113 NIs in 66 patients). The most common NIs were pneumonia (14.3%), bacteremia of unknown origin (13.5%), catheter-related bloodstream infection (5.0%), lower respiratory tract infection (5.0%), surgical site infection (3.9%), and urinary tract infection (1.9%). Multivariate analysis revealed that decreased serum albumin level (odds ratio [OR], 0.884; 95% CI, 0.883-0.978, P < .05), presence of gallbladder stones or cholestasis (OR, 3.144; 95% CI, 1.044-9.464; P < .05), and prolonged parenteral nutrition (PN) use (OR, 1.072; 95% CI, 1.039-1.105; P < .001) were independent predictors for NIs.

CONCLUSIONS

NIs remain prevalent in hospitalized adult patients with IF. Prolonged PN use was one of the most significant predictors for NIs.

The Management of the Hospitalized Ulcerative Colitis Patient: the Medical-Surgical Conundrum

PURPOSE OF REVIEW

In this study, we present the evidence-based management for patients hospitalized for ulcerative colitis (UC) with a special focus on the synergic approach of the two key actors of the inflammatory bowel disease multidisciplinary team (IBD-MDT): gastroenterologist and surgeon.

RECENT FINDINGS

Focused treatment by a specialized IBD-MDT and early involvement of the colorectal surgeon in the management of hospitalized UC patients is advocated. The colectomy rate has not changed over the years. Moreover, delayed surgery after admission is burden by increase complication and mortality rates. Thus, it is pivotal to identify the patients who are likely to undergo surgery, by mean of predictors of outcome, and not to prolong ineffective medical treatment. The perfect timing based on clinical close monitoring is crucial. Up to 25% of patients with ulcerative colitis (UC) may require hospitalization. The aim of admission is to evaluate severity of the disease, exclude infections and establish proper treatment while monitoring the response. During admission, the patient has to be closely observed for the possible development of toxic megacolon or perforation, which should prompt emergency colectomy. Up to 30% of UC patients will fail to respond to initial intravenous corticosteroid. Non-responder or partial responder to medical therapy should be evaluated for timely surgery or could be considered for rescue medical therapy.

Clinical Nutrition of Critically Ill Patients in the Context of the Latest ESPEN Guidelines

The group of patients most frequently in need of nutritional support are intensive care patients. This year (i.e., 2019), new European Society for Clinical Nutrition and Metabolism (ESPEN) guidelines of clinical nutrition in intensive care were published, updating and gathering current knowledge on the subject of this group of patients. Planning the right nutritional intervention is often a challenging task involving the necessity of the choice of the enteral nutrition (EN) or parenteral nutrition (PN) route of administration, time of initiation, energy demand, amino acid content and demand as well as the use of immunomodulatory nutrition. The aim of this study was to specify and discuss the basic aspects of the clinical nutrition of critically ill patients recommended by ESPEN guidelines. Clinical nutrition in intensive care seems to be the best-studied type of nutritional intervention. However, meta-analyses and clinical studies comparing EN and PN and their impact on the prognosis of the intensive care patients showed ambiguous results. The nutritional interventions, starting with EN, should be initiated within 24-48 h whereas PN, if recommended, should be implemented within 3-7 days. The recommended method of calculation of the energy demand is indirect calorimetry, however, there are also validated equations used worldwide in everyday practice. The recommended protein intake in this group of patients and the results of insufficient or too high supply was addressed. In light of the concept of immunomodulatory nutrition, the use of appropriate amino acid solutions and lipid emulsion that can bring a positive effect on the modulation of the immune response was discussed.

Weaning from Parenteral Nutrition

The ultimate goal of treatment of short bowel syndrome/intestinal failure patients is to achieve enteral autonomy by eliminating parenteral nutrition (PN)/intravenous fluids (IV). After optimization of diet, oral hydration and anti-diarrheal medications, attempt should be made to eliminate PN/IV. Weaning from PN/IV should be individualized for each patient. Although teduglutide is the preferred agent for PN/IV volume reduction or successful weaning, optimal patient selection and long-term safety need further evaluation. Following PN/IV elimination, patients need long-term monitoring for nutritional deficiencies. This article will address clinical considerations before, during, and after PN/IV weaning to facilitate safe and successful PN/IV weaning process.

Enteral versus parenteral nutrition following pancreaticoduodenectomy: a systematic review and meta-analysis

BACKGROUND

The need for nutritional support following pancreaticoduodenectomy is well recognised due to the high prevalence of malnutrition, but the optimal delivery route is still debated. This meta-analysis evaluated postoperative outcomes in patients receiving enteral or parenteral nutrition.

METHODS

EMBASE, MEDLINE and Cochrane databases were searched to identify randomised controlled trials comparing enteral and parenteral nutrition in patients undergoing pancreaticoduodenectomy. The primary outcome measure was delayed gastric emptying (DGE). Secondary outcome measures included length of hospital stay (LOS); postoperative pancreatic fistula (POPF); post-pancreaticoduodenectomy haemorrhage (PPH); and infective complications (IC).

RESULTS

Five randomised controlled trials met inclusion criteria and reported on 690 patients (enteral nutrition n = 383; and parenteral nutrition n = 307). Median age was 61.5 years (interquartile range 60.1-63.6). The pooled relative risk (RR) of the primary outcome, DGE, was 0.97 (95% confidence interval (CI) 0.52-1.81, p = 0.93). There were no statistically significant difference in the secondary outcome measures of POPF (RR 1.07, 95% CI 0.42-2.76, p = 0.88); PPH (RR 0.67, 95% CI 0.31-1.48, p = 0.33) and infectious complications (RR 0.76, 95% CI 0.50-1.17, p = 0.22). However, LOS favoured enteral nutrition, weighted mean difference -1.63 days (95% CI -2.80, -0.46, p = 0.006).

CONCLUSIONS

EN is associated with a significantly shorter LOS compared to PN in patients undergoing pancreaticoduodenectomy.

Dietary Support in Elderly Patients with Inflammatory Bowel Disease

Ageing of the human population has become a big challenge for health care systems worldwide. On the other hand, the number of elderly patients with inflammatory bowel disease (IBD) is also increasing. Considering the unique clinical characteristics of this subpopulation, including many comorbidities and polypharmacy, the current therapeutic guidelines for the management of IBD should be individualized and applied with caution. This is why the role of non-pharmacological treatments is of special significance. Since both IBD and older age are independent risk factors of nutritional deficiencies, appropriate dietary support should be an important part of the therapeutic approach. In this review paper we discuss the interrelations between IBD, older age, and malnutrition. We also present the current knowledge on the utility of different diets in the management of IBD. Considering the limited data on how to support IBD therapy by nutritional intervention, we focus on the Mediterranean and Dietary Approaches to Stop Hypertension diets, which seem to be the most beneficial in this patient group. We also discuss some new findings on their hypothetical anti-inflammatory influence on the course of IBD.

A Comprehensive Review of the Diagnosis and Pharmacological Management of Crohn's Disease in the Elderly Population

Crohn's disease (CD) in the elderly is rising in prevalence, which is related to an increase in its incidence and improving life expectancies. There are differences in the presentation, natural history, and treatment of CD between adult-onset patients who progress to older age and patients who are initially diagnosed at an older age. Presentation at an older age may also delay or make diagnosis challenging due to accumulating co-morbidities that mimic inflammatory bowel disease. Differences exist between adult- and older-onset disease, yet many guidelines do not specifically distinguish the management of these two distinct populations. Identifying patients at high risk for progression or aggressive disease is particularly important as elderly patients may respond differently to medical and surgical treatment, and may be at higher risk for adverse effects. Despite newer agents being approved for CD, the data regarding efficacy and safety in the elderly are currently limited. Balancing symptom management with risks of medical and surgical therapy is an ongoing challenge and requires special consideration in these two distinct populations.

Monitoring long-term parenteral nutrition

PURPOSE OF REVIEW

This review discusses the monitoring aimed at achieving good long-term outcomes in people dependent on home parenteral nutrition (HPN).

RECENT FINDINGS

There have been recent studies highlighting the importance of treating low bone mineral density in HPN-dependent patients, methods of screening for liver disease, assessment of quality of life (QoL) and the need for early assessment for intestinal transplantation and growth factor therapy.

SUMMARY

High-quality HPN services require expert multidisciplinary teams with a focus on strict aseptic catheter care protocols alongside regular monitoring and management of clinical, laboratory and patient-related factors. Areas that should be considered in the routine monitoring of HPN include regular laboratory measurements, QoL, assessment for intestinal failure-associated liver disease, treatment of metabolic bone disease and consideration of evolving treatments, alongside management of any underlying condition leading to intestinal failure.

Non-transplant Surgical Management of Short Bowel Syndrome in Children: An Overview

Management of severe Short Bowel Syndrome (SBS) is still one of the largest challenges of the medicine. Vast majority of the short bowel patients are children, the conditions that lead to this possible outcome most often are necrotizing enterocolitis (NEC), small intestinal volvulus as a result of intestinal malrotation, gastroschisis and the "apple peel" syndrome. Therefore, paediatricians and paediatric surgeons face this challenge most often. The nontransplant treatment appears to be effective using surgical procedure to increase absorptive surface and to reduce the transit time, but in some cases these procedures are enough to weaning of TPN. The aim of this review was to summarize the modern non-stransplant surgical management of short bowel syndrome.

Hair Mineral and Trace Element Contents as Reliable Markers of Nutritional Status Compared to Serum Levels of These Elements in Children Newly Diagnosed with Inflammatory Bowel Disease

Patients with inflammatory bowel disease (IBD) are at high risk for nutritional deficiencies because of long-term inflammation in the gut mucosa and decreased oral intake. Because inflammation responses affect serum micronutrient concentrations, serum levels are limited in reflecting body nutrient status in acute and chronic illness. We investigated the usefulness of measuring trace elements in hair as reliable markers of nutritional status compared to serum levels in children with IBD. We retrospectively analyzed pediatric patients newly diagnosed with Crohn's disease (n = 49) and ulcerative colitis (n = 16) and controls (n = 29) from 2012 to 2016. Serum micronutrient levels, inflammatory markers, and hair trace element content were evaluated and compared at the time of diagnosis and before initiating treatment. Serum calcium (p < 0.001), iron (p < 0.001), zinc (p = 0.013), selenium (p = 0.008), albumin (p < 0.001), prealbumin (p < 0.001), hemoglobin and hematocrit (p < 0.001), and WBC (p = 0.001) and lymphocytes (p < 0.001) differed significantly between the groups. After adjustment for the erythrocyte sedimentation rate, serum zinc and selenium levels were no longer significantly different between the groups (p < 0.062 and p < 0.057, respectively). Following hair analysis for mineral and trace elements, iron (p = 0.033), selenium (p = 0.017), and manganese (p = 0.009) differed significantly between the groups. Serum micronutrient levels need cautious interpretation in conjunction with inflammatory markers. Hair mineral and trace element measurement may support understanding micronutrient status in children with IBD.

Nutritional Composition Assessment of 3000 Individualized Parenteral Nutrition Bags in a Tertiary Referral Hospital: Current Prescribing Patterns

Individualized parenteral nutrition is the most specialized type of nutritional support in the hospital setting. The composition and prescribing patterns for parenteral nutrition have evolved due to new emerging scientific evidence. In the last few years, there has been a tendency to increase the nitrogen and lipid content and decrease the carbohydrate content. To assess the prescribing pattern in a tertiary referral hospital in Spain, the nutritional composition of individualized parenteral nutrition was evaluated retrospectively from January to December of 2016. A total of 3029 parenteral nutrition units were analysed, corresponding to 257 hospitalized adult patients. Medical specialists in General Surgery and Haematology were the most common petitioners. The three most frequently prescribed parenteral nutrition formulae contained 13.4 (28.8%), 15.7 (19.54%) and 17.9 (17.79%) g of nitrogen. The quantity of carbohydrates and lipids showed a mean non-protein calories-to-nitrogen ratio of approximately 78:1 and a carbohydrate-to-lipid ratio that was near 50:50 in most cases. These results suggest a trend towards the administration of parenteral nutrition with a high content of nitrogen and smaller proportion of the non-protein components.

Can Quantab titrator sticks reliably predict urinary sodium?

BACKGROUND & AIMS

Urinary sodium concentration is a commonly used marker for extracellular fluid depletion which is often associated with dehydration. A point of care test for urinary sodium may reduce delays in clinical decision making by offering more timely guidance leading to improved salt and fluid management. We compared laboratory assessed urinary sodium with a potential point of care measure of urinary chloride in a variety of in- and outpatient specialities, to explore its use as an indicator of low urine sodium.

METHODS

Urinary chloride concentrations were estimated using a Quantab titrator stick in samples from patients that had been sent for urinary sodium assays. We validated the results of this titrator stick with laboratory-assessed sodium concentrations by deriving correlation coefficients between these methods and using limits of agreement testing. We determined the optimal titrator stick cut-point for identifying low urinary sodium (urinary sodium <20 mmol/L) by maximising the product of the sensitivity and specificity. This level of urinary sodium was used to mirror the British Society of Gastroenterology guidance on short bowel patients Nightingale and Woodward, 2006.

RESULTS

We obtained laboratory urinary sodium concentration and Quantab stick chloride measures on 127 samples. Twenty three percent had a urinary sodium below 20 mmol/L so were regarded as biochemically dehydrated. A threshold of <4.3 on the Quantab scale had a positive predictive value for low sodium of 56% (95%CI 40%-71%) and a negative predictive value of 94% (95%CI 87%-98%).

CONCLUSIONS

These data suggest that the Quantab stick could be used as a point of care test to aid fluid and salt management decisions in an outpatient setting. Further work to explore the use of the titrator stick in specific patient populations at risk of salt and water depletion is justified.

Influence of Dietitians in Preventing Parenteral Nutrition Prescription Errors in Children

BACKGROUND

The purpose of this study is to determine whether direct involvement by dietitians in parenteral nutrition (PN) ordering resulted in a reduction in PN prescriptions errors.

METHODS

A prospective audit of PN prescriptions was undertaken at a pediatric hospital over 50 weeks. Prescriptions for PN that had dietitian involvement (dietitian group) were compared with prescriptions in which dietitians were not directly involved (nondietitian group). The number of total prescriptions, the number of prescriptions with errors, and the types of errors from both groups were recorded. Errors were classified into "dietitian-preventable errors" and "nondietitian-preventable errors." Comparisons were made between prescriptions with and without errors, between dietitian-preventable and nondietitian-preventable errors, and between the dietitian and nondietitian groups per error type.

RESULTS

The total number of PN prescriptions was 725 (from 45 patients) and 471 (from 66 patients) for the dietitian and nondietitian groups, respectively. The nondietitian group was more likely than the dietitian group to prescribe PN incorrectly-18.0% (85 of 471) vs 12.4% (90 of 725; P = .007)-with the nondietitian group having 1.5-times more PN prescriptions with errors (risk ratio = 1.5, 95% CI: 1.1-1.9). The total number of prescription errors was 126 and 146 for the dietitian and nondietitian groups, respectively. The dietitian group was less likely than the nondietitian group to be associated with dietitian-preventable errors: 65.9% (83 of 126) vs 87.0% (127 of 146; risk ratio = 1.3, 95% CI: 1.1-1.5; P < .0001).

CONCLUSION

Dietitian input into prescription of PN reduced the number of prescriptions with errors.

Partial enteral nutrition increases intestinal sIgA levels in mice undergoing parenteral nutrition in a dose-dependent manner

BACKGROUND AND AIMS

Partial enteral nutrition (PEN) protects parenteral nutrition (PN) induced gut mucosal immunity impairment. However, the gastrointestinal function of most patients with PN is too poor to tolerate full dosage of PEN and no guidelines recommend PEN dose. We aimed to identify an optimal PEN dose and to understand the protective mechanism.

METHODS

Mice were assigned to groups with total parenteral nutrition (TPN), total enteral nutrition (TEN), or various degrees of PEN with PN. Additionally, AS1517499 was used to inhibit STAT6. Five days after treatment, secretory immunoglobulin A (sIgA) levels of luminal washing fluid and JAK1-STAT6 signalling in ileum tissue of different groups were assessed.

RESULTS

We found that TPN lowered luminal sIgA and down-regulated pIgR, phosphorylated JAK1 and STAT6, IL-4 and IL-13 as well relative to TEN. Moreover, 40% EN were lowest dose that reversed these detrimental consequences of PN to an equivalent level as TEN. The rescue of pIgR and luminal sIgA expression was decreased when the JAK1-STAT6 pathway was inhibited.

CONCLUSION

We conclude that 40% EN is the optimal PEN dose that reverses PN-induced impairment of gut mucosal immunity. Additionally, we hypothesise that this benefit involves activation of the JAK1-STAT6 pathway.

Supplementary choline attenuates olive oil lipid emulsion-induced enterocyte apoptosis through suppression of CELF1/AIF pathway

Enterocyte apoptosis induced by lipid emulsions is a key cause of intestinal atrophy under total parenteral nutrition (TPN) support, and our previous work demonstrated that olive oil lipid emulsion (OOLE) could induce enterocyte apoptosis via CUGBP, Elav‐like family member 1 (CELF1)/ apoptosis‐inducing factor (AIF) pathway. As TPN‐associated complications are partially related to choline deficiency, we aimed to address whether choline supplementation could attenuate OOLE‐induced enterocyte apoptosis. Herein we present evidence that supplementary choline exhibits protective effect against OOLE‐induced enterocyte apoptosis both in vivo and in vitro. In a rat model of TPN, substantial reduction in apoptotic rate along with decreased expression of CELF1 was observed when supplementary choline was added to OOLE. In cultured Caco‐2 cells, supplementary choline attenuated OOLE‐induced apoptosis and mitochondria dysfunction by suppressing CELF1/AIF pathway. Compared to OOLE alone, the expression of CELF1 and AIF was significantly decreased by supplementary choline, whereas the expression of Bcl‐2 was evidently increased. No obvious alterations were observed in Bax expression and caspase‐3 activation. Mechanistically, supplementary choline repressed the expression of CELF1 by increasing the recruitment of CELF1 mRNA to processing bodies, thus resulting in suppression of its protein translation. Taken together, our data suggest that supplementary choline exhibits effective protection against OOLE‐induced enterocyte apoptosis, and thus, it has the potential to be used for the prevention and treatment of TPN‐induced intestinal atrophy.

Parenteral Nutrition and Intestinal Failure

Severe short bowel syndrome (SBS) is a major cause of chronic (Type 3) intestinal failure (IF) where structural and functional changes contribute to malabsorption and risk of micronutrient deficiencies. Chronic IF may be reversible, depending on anatomy and intestinal adaptation, but most patients require long-term nutritional support, generally in the form of parenteral nutrition (PN). SBS management begins with dietary changes and pharmacologic therapies taking into account individual anatomy and physiology, but these are rarely sufficient to avoid PN. New hormonal therapies targeting intestinal adaptation hold promise. Surgical options for SBS including intestinal transplant are available, but have significant limitations. Home PN (HPN) is therefore the mainstay of treatment for severe SBS. HPN involves chronic administration of macronutrients, micronutrients, fluid, and electrolytes via central venous access in the patient's home. HPN requires careful clinical and biochemical monitoring. Main complications of HPN are related to venous access (infection, thrombosis) and metabolic complications including intestinal failure associated liver disease (IFALD). Although HPN significantly impacts quality of life, outcomes are generally good and survival is mostly determined by the underlying disease. As chronic intestinal failure is a rare disease, registries are a promising strategy for studying HPN patients to improve outcomes.

Healthcare maintenance in elderly patients with inflammatory bowel disease

The increasing number of older patients (age ≥60 years) with inflammatory bowel disease (IBD) highlights the importance of healthcare maintenance in this vulnerable population. Older IBD patients are more susceptible and have higher rates of many disease- and treatment-related adverse effects. Compared to younger IBD patients, older patients are at increased risk for infection, malignancy, bone disease, eye disease, malnutrition and thrombotic complications. Preventive strategies in the elderly differ from those in younger adults and are imperative. Changes to the immune system with aging can decrease the efficacy of vaccinations. Cancer screening guidelines in older IBD patients have to account for unique considerations, such as life expectancy, functional performance status, multimorbidity, financial status, and patient desires. Additionally, providers need to be vigilant in screening for osteoporosis, ocular disease, depression, and adverse events arising from polypharmacy.

Olive Oil-Supplemented Lipid Emulsion Induces CELF1 Expression and Promotes Apoptosis in Caco-2 Cells

Background and Aims: Parenterally-administered lipid emulsion (LE) is a key cause of enterocyte apoptosis under total parenteral nutrition, yet the pathogenesis has not been fully understood. CUGBP, Elav-like family member 1 (CELF1) has been recently identified as a crucial modulator of apoptosis, and thus this study sought to investigate its role in the LE-induced apoptosis in vitro. Methods: Caco-2 cells were used as an in vitro model. The cells were treated with varying LEs derived from soybean oil, olive oil or fish oil, and changes in the apoptosis and CELF1 expression were assessed. Rescue study was performed using transient knockdown of CELF1 with specific siRNA prior to LE treatment. Regulation of CELF1 by LE treatment was studied using quantitative real-time PCR and Western blotting. Results: All the LEs up-regulated CELF1expression and induced apoptosis, but only olive oil-supplemented lipid emulsion (OOLE)-induced apoptosis was attenuated by depletion of CELF1. Up-regulation of apoptosis-inducing factor (AIF) was involved in OOLE-induced CELF1 dependent apoptosis. The protein expression of CELF1 was up-regulated by OOLE in a dose- and time-dependent manner, but the mRNA expression of CELF1 was unchanged. Analysis by polysomal profiling and nascent protein synthesis revealed that the regulation of CELF1 by OOLE treatment was mediated by directly accelerating its protein translation. Conclusion: OOLE-induces apoptosis in Caco-2 cells partially through up-regulation of CELF1.

When Is Parenteral Nutrition Appropriate?

Parenteral nutrition (PN) represents one of the most notable achievements of modern medicine, serving as a therapeutic modality for all age groups across the healthcare continuum. PN offers a life-sustaining option when intestinal failure prevents adequate oral or enteral nutrition. However, providing nutrients by vein is an expensive form of nutrition support, and serious adverse events can occur. In an effort to provide clinical guidance regarding PN therapy, the Board of Directors of the American Society for Parenteral and Enteral Nutrition (ASPEN) convened a task force to develop consensus recommendations regarding appropriate PN use. The recommendations contained in this document aim to delineate appropriate PN use and promote clinical benefits while minimizing the risks associated with the therapy. These consensus recommendations build on previous ASPEN clinical guidelines and consensus recommendations for PN safety. They are intended to guide evidence-based decisions regarding appropriate PN use for organizations and individual professionals, including physicians, nurses, dietitians, pharmacists, and other clinicians involved in providing PN. They not only support decisions related to initiating and managing PN but also serve as a guide for developing quality monitoring tools for PN and for identifying areas for further research. Finally, the recommendations contained within the document are also designed to inform decisions made by additional stakeholders, such as policy makers and third-party payers, by providing current perspectives regarding the use of PN in a variety of healthcare settings.

Stress resilience and the risk of inflammatory bowel disease: a cohort study of men living in Sweden

OBJECTIVE

To determine if low psychosocial stress resilience in adolescence (increasing chronic stress arousal throughout life) is associated with an increased inflammatory bowel disease (IBD) risk in adulthood. Subclinical Crohn's disease (CD) and ulcerative colitis (UC) can exist over many years and we hypothesise that psychosocial stress may result in conversion to symptomatic disease through its proinflammatory or barrier function effects.

DESIGN

National register-based cohort study of men followed from late adolescence to middle age.

SETTING

A general population cohort of men in Sweden.

PARTICIPANTS

Swedish population-based registers provided information on all men born between 1952 and 1956 who underwent mandatory Swedish military conscription assessment (n=239 591). Men with any gastrointestinal diagnoses (except appendicitis) prior to follow-up were excluded.

PRIMARY OUTCOME MEASURES

An inpatient or outpatient diagnosis of CD or UC recorded in the Swedish Patient Register (1970-2009).

RESULTS

A total of 938 men received a diagnosis of CD and 1799 UC. Lower stress resilience in adolescence was associated with increased IBD risk, with unadjusted HRs (95% CIs) of 1.54 (1.26 to 1.88) and 1.24 (1.08 to 1.42), for CD and UC, respectively. After adjustment for potential confounding factors, including markers of subclinical disease activity in adolescence, they are 1.39 (1.13 to 1.71) and 1.19 (1.03 to 1.37).

CONCLUSIONS

Lower stress resilience may increase the risk of diagnosis of IBD in adulthood, possibly through an influence on inflammation or barrier function.

Adult parenteral nutrition in the North of England: a region-wide audit

OBJECTIVES

Parenteral nutrition (PN) is widely used to provide nutritional support to patients with inaccessible or inadequate length of gut or non-functioning gut. The objective was to compare practice in PN administration to results of the National Confidential Enquiry into Patient Outcome and Death (NCEPOD) report, 'A Mixed Bag', and to establish whether good practice was being followed within this part of the UK.

SETTING

Using the Northern Nutrition Network (NNN), we examined the care of adult patients receiving PN in all 10 secondary care hospitals in our region.

PARTICIPANTS

All patients receiving PN were included with no exclusions. Data were collected on 192 patients (51% females, median age 65 years (range 18-96)).

OUTCOME MEASURES

A data collection tool was designed based on the recommendations of the NCEPOD report.

RESULTS

PN was used for a median of 7 days with a 30-day mortality rate of 8%. Metabolic complications occurred in 34%, of which only 13% were avoidable. The catheter sepsis rate was 1.5 per 1000 PN days. The audit suggests that nutrition team input improves patient assessment prior to starting PN and review once PN is established. Risk of refeeding syndrome was identified in 75%. Areas for improvement are documentation of treatment goal (39%), review of PN constitution (38%), ensuring patients are weighed regularly (56%) and documentation of line-tip position (52%).

CONCLUSIONS

This region-wide prospective audit suggests improved practice within the UK compared to the NCEPOD audit with lower mortality and line sepsis rates. However, documentation remains suboptimal. This work strengthens the case for introducing nutrition teams in hospitals without this service. These findings are likely to be reproduced across the UK and in other healthcare settings. We provide a template for similar audits of clinical practice.

Preoperative oral polymeric diet enriched with transforming growth factor-beta 2 (Modulen) could decrease postoperative morbidity after surgery for complicated ileocolonic Crohn's disease

OBJECTIVE

Exclusive polymeric diet enriched with transforming growth factor-beta 2 (ANS-TGF-β2) has been used for remission induction and maintenance in pediatric Crohn's disease (CD). Its use in the preoperative setting has never been evaluated. The aim of this study was to evaluate preoperative ANS-TGF-β2 to decrease postoperative complications after surgery for complicated ileocolonic CD.

METHODS

From 2011 to 2015, data of all consecutive patients who underwent elective surgery for ileocolonic CD were collected prospectively. Preoperative, exclusive ANS-TGF-β2 was administered in high-risk patients with complicated CD. Complicated CD was defined by the presence of obstructive symptoms, and/or steroid treatment, and/or preoperative weight loss >10% and/or perforating CD. Outcomes of high-risk patients receiving preoperative ANS-TGF-β2 were compared to those of low-risk patients with no complicated CD who underwent upfront surgery.

RESULTS

Fifty-six patients underwent surgery for ileocolonic CD. Among them, 35 high-risk patients received preoperative ANS-TGF-β2 and 21 low-risk patients underwent upfront surgery. Preoperative full-dose ANS-TGF-β2 was feasible in 34/35 high-risk patients. Discontinuation of steroids during preoperative ANS-TGF-β2 could be achieved in 10/16 patients (62.5%). Postoperative complications rates were 8/35 (23.8%) and 5/21 (22.9%) in high-risk and low-risk patients, respectively (p = 1). Temporary ileocolostomy rates in high-risk patients and in low-risk patients were 4/35 (11%) and 0/21, respectively (p = 0.286) Conclusion: Preoperative ANS-TGF-β2 is feasible in most high-risk patients with complicated ileocolonic CD and could limit the deleterious effects of risk factors of postoperative morbidity. These results need to be confirmed in a large randomized controlled trial.

ESPEN guideline: Clinical nutrition in inflammatory bowel disease

INTRODUCTION

The ESPEN guideline presents a multidisciplinary focus on clinical nutrition in inflammatory bowel disease (IBD).

METHODOLOGY

The guideline is based on extensive systematic review of the literature, but relies on expert opinion when objective data were lacking or inconclusive. The conclusions and 64 recommendations have been subject to full peer review and a Delphi process in which uniformly positive responses (agree or strongly agree) were required.

RESULTS

IBD is increasingly common and potential dietary factors in its aetiology are briefly reviewed. Malnutrition is highly prevalent in IBD - especially in Crohn's disease. Increased energy and protein requirements are observed in some patients. The management of malnutrition in IBD is considered within the general context of support for malnourished patients. Treatment of iron deficiency (parenterally if necessary) is strongly recommended. Routine provision of a special diet in IBD is not however supported. Parenteral nutrition is indicated only when enteral nutrition has failed or is impossible. The recommended perioperative management of patients with IBD undergoing surgery accords with general ESPEN guidance for patients having abdominal surgery. Probiotics may be helpful in UC but not Crohn's disease. Primary therapy using nutrition to treat IBD is not supported in ulcerative colitis, but is moderately well supported in Crohn's disease, especially in children where the adverse consequences of steroid therapy are proportionally greater. However, exclusion diets are generally not recommended and there is little evidence to support any particular formula feed when nutritional regimens are constructed.

CONCLUSIONS

Available objective data to guide nutritional support and primary nutritional therapy in IBD are presented as 64 recommendations, of which 9 are very strong recommendations (grade A), 22 are strong recommendations (grade B) and 12 are based only on sparse evidence (grade 0); 21 recommendations are good practice points (GPP).

Sodium butyrate attenuates soybean oil-based lipid emulsion-induced increase in intestinal permeability of lipopolysaccharide by modulation of P-glycoprotein in Caco-2 cells

Down-regulation of intestinal P-glycoprotein (P-gp) by soybean oil-based lipid emulsion (SOLE) may cause elevated intestinal permeability of lipopolysaccharide (LPS) in patients with total parenteral nutrition, but the appropriate preventative treatment is currently limited. Recently, sodium butyrate (NaBut) has been demonstrated to regulate the expression of P-gp. Therefore, this study aimed to address whether treatment with NaBut could attenuate SOLE-induced increase in intestinal permeability of LPS by modulation of P-gp in vitro. Caco-2 cells were exposed to SOLE with or without NaBut. SOLE-induced down-regulation of P-gp was significantly attenuated by co-incubation with NaBut. Nuclear recruitment of FOXO 3a in response to NaBut was involved in P-gp regulation. Transport studies revealed that SOLE-induced increase in permeability of LPS was significantly attenuated by co-incubation with NaBut. Collectively, our results suggested that NaBut may be a potentially useful medication to prevent SOLE-induced increase in intestinal permeability of LPS.

European Society of Coloproctology consensus on the surgical management of intestinal failure in adults

Intestinal failure (IF) is a debilitating condition of inadequate nutrition due to an anatomical and/or physiological deficit of the intestine. Surgical management of patients with acute and chronic IF requires expertise to deal with technical challenges and make correct decisions. Dedicated IF units have expertise in patient selection, operative risk assessment and multidisciplinary support such as nutritional input and interventional radiology, which dramatically improve the morbidity and mortality of this complex condition and can beneficially affect the continuing dependence on parenteral nutritional support. Currently there is little guidance to bridge the gap between general surgeons and specialist IF surgeons. Fifteen European experts took part in a consensus process to develop guidance to support surgeons in the management of patients with IF. Based on a systematic literature review, statements were prepared for a modified Delphi process. The evidence for each statement was graded using Oxford Centre for Evidence-Based Medicine Levels of Evidence. The current paper contains the statements reflecting the position and practice of leading European experts in IF encompassing the general definition of IF surgery and organization of an IF unit, strategies to prevent IF, management of acute IF, management of wound, fistula and stoma, rehabilitation, intestinal and abdominal reconstruction, criteria for referral to a specialist unit and intestinal transplantation.

Quality of Life and Nutrition Condition of Patients Improve Under Home Parenteral Nutrition: An Exploratory Study

BACKGROUND

Patients with end-stage cancer and advanced chronic bowel disease are often malnourished, which has a negative effect on patients' outcome, well-being, and activity. It is inconclusive whether these patients benefit from home parenteral nutrition. This prospective exploratory study investigates its influence on nutrition state, muscle strength, mobility, and quality of life.

MATERIALS AND METHODS

Patients ≥18 years old with an indication for home parenteral nutrition were included and followed for 2-24 months. Nutrition parameters, activity, and quality of life were assessed.

RESULTS

Forty-eight patients participated (mean age 11.5 years), and 85% were severely malnourished (subjective global assessment score, class C). Four weeks after parenteral nutrition, patients with tumors demonstrated a deterioration in phase angle (from 3.9 to 3.4) and extracellular mass:body cell mass ratio (from 1.6 to 2.1), while patients with bowel disease improved (from 3.4 to 4.0 and 2.1 to 1.6, respectively); grip strength remained constant in both groups (difference: 1.11 and -2.11, respectively). Activity improved in patients with bowel disease but stayed the same in the tumor group (P = .02 and P = .33, respectively). When the groups were pooled, emotional and social functioning domain scores (P < .03), dyspnea and sleeping (P < .04), and median quality of life improved (P = .02) 4 weeks after home parenteral nutrition.

CONCLUSION

Both groups seem to benefit from home parenteral nutrition without harmful side effects. If the indication is determined early, the patients' disease course could perhaps be improved.

Short Bowel Syndrome and Intestinal Failure in Crohn's Disease

Crohn's disease is a chronic and progressive inflammatory disorder of the gastrointestinal tract. Despite the availability of powerful immunosuppressants, many patients with Crohn's disease still require one or more intestinal resections throughout the course of their disease. Multiple resections and a progressive reduction in bowel length can lead to the development of short bowel syndrome, a form of intestinal failure that compromises fluid, electrolyte, and nutrient absorption. The pathophysiology of short bowel syndrome involves a reduction in intestinal surface area, alteration in the enteric hormonal feedback, dysmotility, and related comorbidities. Most patients will initially require parenteral nutrition as a primary or supplemental source of nutrition, although several patients may eventually wean off nutrition support depending on the residual gut anatomy and adherence to medical and nutritional interventions. Available surgical treatments focus on reducing motility, lengthening the native small bowel, or small bowel transplantation. Care of these complex patients with short bowel syndrome requires a multidisciplinary approach of physicians, dietitians, and nurses to provide optimal intestinal rehabilitation, nutritional support, and improvement in quality of life.

Definitions of intestinal failure and the short bowel syndrome

The European Society for Clinical Nutrition and Metabolism defined intestinal failure (IF) as "the reduction of gut function below the minimum necessary for the absorption of macronutrients and/or water and electrolytes, such that intravenous supplementation is required to maintain health and/or growth". IF is classified as type 1-acute, type 2-prolonged acute and type 3-chronic IF. A short bowel syndrome (SBS) due to the intestinal malabsorption associated with a functional small intestine length of less than 200 cm is the most frequent mechanism of IF. SBS is a difficult and multifaced disease. Complications due to SBS itself and to treatments, such as long term home parenteral nutrition, can adversely affect the patient outcome. The care of SBS requires complex technologies and multidisciplinary and multiprofessional activity and expertise. Patient outcome is strongly dependent on care and support from an expert specialist team. This paper focuses on the aspects of the pathophysiology and on the complications of SBS, which are most relevant in the clinical practice, such as intestinal failure associated liver disease, renal failure, biliary and renal stones, dehydration and electrolyte depletion, magnesium deficiency and D-lactic acidosis.

Promoting intestinal adaptation by nutrition and medication

The ultimate goal in the treatment of short bowel syndrome is to wean patients off parenteral nutrition, by promoting intestinal adaptation. Intestinal adaptation is the natural compensatory process that occurs after small bowel resection. Stimulating the remaining bowel with enteral nutrition can enhance this process. Additionally, medication can be used to either reduce factors that complicate the adaptation process or to stimulate intestinal adaptation, such as antisecretory drugs and several growth factors. The aim of this review was to provide an overview of the best nutritional strategies and medication that best promote intestinal adaptation.