Diarrhea in enterally fed patients: blame the diet?

Intragastric infusion of a liquid diet with low-methoxyl pectin alleviates fecal inconsistency and local proinflammatory cytokine expression in lipopolysaccharide-septic rats

OBJECTIVE

Diarrhea interrupts enteral nutrition management in hospitalized patients with severe illnesses, such as sepsis. Pectin, a water-soluble dietary fiber, has the potential to maintain intestinal function and may reduce inflammatory reactions. The aim of this study was to demonstrate that the addition of low-methoxyl (LM) pectin to a liquid diet suppresses softening of stool texture and reduces tissue inflammatory responses in enteral nutrition management during sepsis.

METHODS

A fat-enriched liquid diet with LM pectin (P-EN) or a liquid diet without dietary fiber (FF-EN) was given continuously to rats through a gastric catheter. Lipopolysaccharide (LPS; 10 mg/kg) was injected intraperitoneally 24 h (study 1) and 7 h (study 2) before sacrifice.

RESULTS

LPS injection significantly worsened fecal property scores in rats infused with FF-EN compared with the rats given P-EN in study 1. Whereas many myeloperoxidase-positive cells infiltrated the liver, and the hepatic expressions of chemokine genes were markedly elevated 24 h after LPS administration, these findings were clearly alleviated in the LM pectin-containing liquid diet group. In study 2, protein expressions of proinflammatory cytokines, such as small intestinal tumor necrosis factor-α and hepatic interleukin-1β, and interleukin-6, were significantly downregulated in the P-EN LPS group compared with the FF-EN LPS group.

CONCLUSIONS

A liquid diet containing LM pectin allows enteral nutrition management with a low risk for diarrhea and reduces local inflammation under septic conditions.

Effects of fibre-supplemented enteral feeds on bowel function of non-critically ill tube-fed adults: a meta-analysis of randomised controlled trials

Diarrhoea is common in enterally fed patients and can impact their nutritional and overall outcomes. This meta-analysis evaluates the potential benefits of fibre-supplemented (FS) feeds on incidence of diarrhoea and stool frequency in non-critically ill tube-fed adults. Databases including PubMed, Embase and CINAHL with full text were searched for randomised controlled trials (RCT) with adults on exclusive tube feeding, published until August 2022. The Cochrane Collaboration's tool was used for quality assessment. Studies with published results on incidence of diarrhoea and stool frequency were analysed using RevMan 5. Thirteen RCT with 847 non-critically ill patients between 20 and 90 years old without diarrhoea at the onset of enteral feeding were included. Study duration ranged from 3 to 35 d. Nine papers investigated the incidence of diarrhoea where intervention group was given FS and control was given non-fibre-supplemented (NFS) enteral feeds. Those receiving FS feeds were significantly less likely to experience diarrhoea as compared with those using NFS feeds (OR 0·44; 95 % CI 0·20, 0·95; P = 0·04; I2 = 71 %). Combined analysis showed no differences in stool frequency in those receiving NFS feeds (SMD 0·32; 95 % CI -0·53, 1·16; P = 0·47; I2 = 90 %). Results should be interpreted with caution due to considerable heterogeneity between study population, assessment tool for diarrhoea, potential conflict of interest and short duration of studies. This meta-analysis shows that FS feeds can reduce the incidence of diarrhoea in non-critically ill adults; however, the effects of stool frequency remain debatable.

Fluorescence imaging around the abdomen allows evaluation of gastrointestinal retention of various forms of diet in mice

OBJECTIVES

The aims of this study were to evaluate gastrointestinal (GI) retention of an ingested meal by fluorescence imaging and compare how retention is affected by differences in the physical characteristics of meals.

METHODS

Mice were given an oral fluorescent indocyanine green (ICG) probe enclosed in a liposome. We evaluated the correlation between abdominal and GI fluorescence signals. ICG was administered to mice treated with atropine, and abdominal fluorescence was observed repeatedly. Mice were continuously given a regular chow or a liquid diet containing a low or high methoxyl (LM or HM)-pectin through a catheter placed in the stomach for 2 d, after which the mice were given ICG. In all studies, the mice's abdominal and GI fluorescence signals were observed with in vivo imaging equipment.

RESULTS

The fluorescence intensities (FIs) of the abdomen and the excised GI tract correlated strongly. Attenuation of the abdominal FI was delayed in the atropine-treatment group compared with the non-treated group. The attenuation of abdominal FI 8 to 24 h after ICG administration was significantly weakened in the HM group compared with the regular chow and LM groups.

CONCLUSIONS

Observing FI attenuation around the abdomen allows for the evaluation of GI tract retention of an ingested meal. Compared with a solid meal, a liquid meal stays longer in the digestive tract, whereas a liquid meal in which the viscosity increases in the stomach is retained like a solid meal.

A high-protein peptide-based enteral formula improves diarrhea in tube-fed patients: A prospective multicenter study

BACKGROUND

Diarrhea is a common problem in tube-fed patients. The relevant guidelines suggest using a peptide-based enteral formula in patients with diarrhea; however, sufficient evidence to support this recommendation is currently lacking.

AIM

This study aimed to evaluate the effects of a high-protein peptide-based formula on gastrointestinal intolerance, mainly focusing on diarrhea symptoms in patients who were intolerant to polymeric formula feeding.

METHODS

This prospective, single-arm, open-label, multicenter study was conducted from March 2021 to March 2022 at two tertiary-care hospitals. Patients who presented with diarrhea during tube feeding with polymeric formula were assigned to receive a high-protein peptide-based formula for ≤7 days. Stool weight and frequency were monitored at baseline, on day 3, and on day 7 (or end of the study) as the primary outcomes.

RESULTS

Twenty-eight tube-fed patients with diarrhea were recruited. After switching their feeding formula from polymeric to peptide based, significant improvements in stool frequency and stool weight were observed on day 3 and day 7 compared with the baseline (median [IQR] stool frequency: 5 (2), 2.5 (3.5), and 3 (3) times/day, respectively, p <0.001; median stool weight: 500 (370), 170 (285), and 275 (385) gram/day, respectively, p = 0.015). Stool consistency was assessed using the Bristol Stool Score and showed significant improvement with time. No serious adverse events were reported.

CONCLUSION

A high-protein peptide-based enteral formula was effective in reducing stool weight and frequency in patients who experienced diarrhea during tube feeding with a polymeric formula.Trial registration: TCTR20210302006.

The effect of fiber supplementation on the prevention of diarrhea in hospitalized patients receiving enteral nutrition: A meta-analysis of randomized controlled trials with the GRADE assessment

Introduction

Enteral nutrition (EN) in hospitalized patients has several advantages. However, post-feeding diarrhea occurs frequently and has been linked to negative outcomes. The EN formula itself may have an impact on how diarrhea develops, and fiber supplements may theoretically help patients experience less diarrhea. This study aimed to thoroughly evaluate whether adding fiber to EN decreases the likelihood of developing diarrhea and whether different types of fibers pose different effects on diarrhea (PROSPERO CRD 42021279971).

Methods

We conducted a meta-analysis on fiber supplementation in hospitalized adult patients receiving EN. We thoroughly searched PubMed, Medline, Embase, Scopus, Web of Science, CENTRAL, and ClinicalTrials.gov databases from inception to 1 September 2022. Only randomized controlled trials (RCTs) were included. Pooled results on the incidence of diarrhea were calculated using a random-effects model. The Grading of Recommendations, Assessment, Development, and Evaluations (GRADE) approach was applied. Only fiber types from soy polysaccharides (n = 4), psyllium (n = 3), mixed soluble/insoluble fiber (mixed fiber, n = 3), pectin (n = 2), and partially hydrolyzed guar gum (PHGG, n = 2) were examined in the sensitivity analysis.

Results

Among the 4,469 titles found, a total of 16 RCTs were included. Overall, compared to fiber-free formulas, fiber supplementation reduced the occurrence of diarrhea in patients receiving EN by 36% (pooled risk ratio [RR] of 0.64 [95% confidence interval (CI): 0.49-0.82, p = 0.005; I 2 = 45%]), with GRADE showing the evidence of moderate certainty. Only mixed fiber and PHGG significantly decreased the incidence of diarrhea according to the sensitivity analyses for fiber types (RR 0.54, 95%CI: 0.39-0.75, I 2 = 0% and RR 0.47, 95%CI: 0.27-0.83, I 2 = 0%, respectively). The results for the remaining fiber types were unclear.

Conclusion

According to a meta-analysis, fiber supplements help lessen post-feeding diarrhea in hospitalized patients receiving EN. However, not all fiber types produced successful outcomes. Diarrhea was significantly reduced by PHGG and mixed soluble/insoluble fiber.

Systematic review registration

https://www.crd.york.ac.uk/PROSPERO/display_record.php?RecordID=279971, identifier: PROSPERO CRD 42021279971.

Gastrointestinal Dysmotility in Critically Ill Patients: Bridging the Gap Between Evidence and Common Misconceptions

Disruption of normal gastrointestinal (GI) function in critical illness is linked to increased morbidity and mortality, and GI dysmotility is frequently observed in patients who are critically ill. Despite its high prevalence, the diagnosis and management of GI motility problems in the intensive care unit remain very challenging, given that critically ill patients often cannot verbalize symptoms and the general lack of understanding of underlying pathophysiology. Common clinical presentations of GI dysmotility issues among critically ill patients include: (1) high gastric residual volumes, acid reflux, and vomiting, (2) abdominal distention, and (3) diarrhea. In this review, we discuss the differential diagnosis for intensive care unit patients with symptoms and signs concerning GI motility issues. There are many myths and longstanding misconceptions about the diagnosis and management of GI dysmotility in critical illness. Here, we uncover these myths and discuss relevant evidence in each subject area, with the goal of re-conceptualizing GI motility disorders in critical care and providing evidence-based recommendations for clinical care.

Effects of a low-FODMAP enteral formula on diarrhea on patients in the intensive care unit

BACKGROUND/OBJECTIVES

A dietary restriction on the intake of fermentable oligosaccharides, disaccharides, monosaccharides, and polyols (FODMAPs) has been reported to be effective in the treatment of gastrointestinal (GI) tract complications. Enteral nutrition (EN) is widely used for patients who cannot obtain their nutritional requirements orally, but many studies have reported EN complications, especially diarrhea, in up to 50% of patients.

SUBJECTS/METHODS

We performed a single-center, non-randomized, controlled trial to determine the effects of a low-FODMAP enteral formula on GI complications in patients in intensive care units (ICUs). Patients in the ICU who needed EN (n = 66) were alternately assigned to the low-FODMAP group (n = 33) or the high-FODMAP group (n = 33).

RESULTS

Anthropometric and biochemical parameters were measured, and stool assessment was performed using King's Stool Chart. We excluded patients who received laxatives, GI motility agents, proton pump inhibitors, antifungal agents, and antibiotics other than β-lactams. There were no differences in GI symptoms during 7 days of intervention, including bowel sound, abdominal distension, and vomiting between the 2 groups. However, diarrhea was more frequent in the high-FODMAP group (7/33 patients) than the low-FODMAP group (1/33 patients) (P = 0.044).

CONCLUSIONS

Our results suggest that a low-FODMAP enteral formula may be a practical therapeutic approach for patients who exhibit enteral formula complications. Our study warrants further randomized clinical trials and multicenter trials.

Trial Registration

Clinical Research Information Service Identifier: KCT0005660

Re-examining chemically defined liquid diets through the lens of the microbiome

Trends in nutritional science are rapidly shifting as information regarding the value of eating unprocessed foods and its salutary effect on the human microbiome emerge. Unravelling the evolution and ecology by which humans have harboured a microbiome that participates in every facet of health and disease is daunting. Most strikingly, the host habitat has sought out naturally occurring foodstuff that can fulfil its own metabolic needs and also the needs of its microbiota, each of which remain inexorably connected to one another. With the introduction of modern medicine and complexities of critical care, came the assumption that the best way to feed a critically ill patient is by delivering fibre-free chemically defined sterile liquid foods (that is, total enteral nutrition). In this Perspective, we uncover the potential flaws in this assumption and discuss how emerging technology in microbiome sciences might inform the best method of feeding malnourished and critically ill patients.

Diarrhea in tube-fed hospitalized patients: Feeding formula is not the most common cause

BACKGROUND AND AIM

Clostridium difficile-associated diarrhea (CDAD) and enteral nutrition (EN)-associated diarrhea are the most common recognized etiologies of nosocomial diarrhea. However, in clinical practice, the data regarding how each etiology contributes to the diarrheal episodes are limited. We identify the causes and factors associated with post-feeding diarrhea.

METHODS

Using the data of patients enrolled in "Effect of Psyllium Fiber Supplementation on Diarrhea Incidence in Enteral Tube-Fed Patients: A Prospective, Randomized, and Controlled Trial", the randomized controlled trial showed no difference in diarrheal incidences between fiber-added and fiber-free formulas. Hence, we analyzed the data of all enrolled patients. The causes of diarrhea were classified according to pre-specified definitions. The factors associated with diarrhea were analyzed using logistic regression.

RESULTS

Diarrhea was found in 37.3% (n = 31/83). The most common cause was medication associated (61.3%). CDAD and EN-associated diarrhea were found in only 9.7% and 6.5%, respectively. Patients with baseline albumin <3 g/dL and underlying cerebrovascular disease were more likely to develop diarrhea (adjusted odds ratio 5.70, 95% confidence interval 1.79-20.51, and adjusted odds ratio 10.83, 95% confidence interval 2.96-48.57, respectively). Compared with those without diarrhea, the length of hospital stay in CDAD patients was significantly longer (+23.1 days, P = 0.02), a trend of longer hospital stay in patients with diarrhea from other causes was observed (+3.2 days, P = 0.096).

CONCLUSIONS

Our study found that the most common cause of post-feeding diarrhea is medication associated. Review and cessation of possible drugs should be undertaken before EN modification. CDAD accounts for <10% of diarrhea causes, but it impacts the clinical outcome and should be identified and treated properly.

Healthcare associated diarrhea, not Clostridioides difficile

PURPOSE OF REVIEW

The aim of this article is to review the epidemiology, cause, diagnostic evaluation, and management of healthcare-associated diarrhea (HCAD) with particular attention to current epidemiology and recent developments in diagnostics.

RECENT FINDINGS

Multiplex polymerase chain reaction gastrointestinal panels allow rapid detection of a wide array of potential enteropathogens but the role, yield, and utility of these tests have not been systematically assessed in patients with HCAD. Recent epidemiologic studies reaffirm that HCAD is predominantly a noninfectious condition most often caused by medications or underlying medical conditions, sometimes Clostridioides difficile, and occasionally viruses. Other infections are rare.

SUMMARY

Clinical assessment remains fundamental to the evaluation of HCAD and targeted testing for C. difficile is sufficient in most patients. Multiplex gastrointestinal panels may have a role in immunocompromised patients but more study is needed. Medication-induced diarrhea is common and underappreciated and not limited to antibiotics, laxatives, and enemas.

Home-Prepared Enteral Tube Feeding: Evaluation of Microbiological Contamination, Hygiene, and the Profile of the Food Handler

BACKGROUND

Little is known about the risk to patients' health when using home-prepared enteral tube feeding. The objective of this study was to explore the differences in hygiene conditions and microbial load of different types of home-prepared enteral tube feeding and explore associations between those differences and food handlers' characteristics.

METHODS

We evaluated 96 enteral formulations, considering 3 types used by adult patients: homemade enteral preparations (HEPs), blended enteral preparations (BEPs), and commercial enteral formulas (CEFs). Enteral formulations were collected from homes and microbiologically analyzed. Hygiene criteria were assessed using a checklist, applied during the handling stages. The profile of the food handler was reviewed using a questionnaire.

RESULTS

82.3% (79/96) exceeded acceptable bacterial counts, which was 10³ colony-forming units per gram for aerobic mesophilic microorganisms and for total coliforms (35 °C), Escherichia coli, Staphylococcus sp, and Staphylococcus coagulase-positive, if present in the enteral formulations. The number of inadequate samples was higher in HEPs and BEPs than in CEFs. Considering the hygiene criteria, the home-prepared enteral tube feedings did not differ significantly. There was a significant difference among hygiene conditions considering the variables "monthly family income" and "food training."

CONCLUSION

Regardless of the type of enteral formulations used by patients, when handled at home, there was a risk of contamination. However, contaminants present in enteral formulations can be easily controlled with improvements in hygiene measures as well as with greater guidance and control during the handling stages.

Practices Involved in the Enteral Delivery of Drugs

PURPOSE OF REVIEW

While the delivery of medications through enteral tubes is common in critically ill patients, there are complications and a lack of unified practices between institutions. The purpose of this review is to evaluate current practices and literature evidence regarding this administration route. The effect of this administration on the medication's efficacy, safety, tolerability, and pharmacokinetics was examined, as well as other considerations to ensure that this route of delivery is both safe and effective for patients.

RECENT FINDINGS

Studies have found crushed oral tablets are the most frequent cause of obstructed feeding tubes. Complications such as this are primarily due to inadequate personnel training and failure to properly access medications before enteral administration. There are many factors that should be considered in order to effectively administer drugs via enteral tubes. Formal training and use of a multi-disciplinary approach that includes pharmacists and dieticians has been shown to reduce tube obstructions and administration errors.

Meeting Calorie and Protein Needs in the Critical Care Unit: A Prospective Observational Pilot Study

Background:

Inadequate calorie and protein intake during critical illness is associated with poor clinical outcomes. Unfortunately, most critically ill patients do not consume adequate levels of these nutrients. An enteral formula with appropriate macronutrient composition may assist patients in meeting nutritional goals.

Design:

This study was a single center, prospective, observational study of 29 adults in the medical intensive care unit who required enteral nutrition for at least 3 days. Subjects received a calorically dense, enzymatically hydrolyzed 100% whey peptide-based enteral formula for up to 5 days to assess the ability to achieve 50% of caloric goals within the first 3 days (primary outcome), the daily percentage of protein goals attained and gastrointestinal tolerance (secondary outcomes).

Result:

A total of 29 subjects consented and began the study. Four subjects dropped out before first day and 25 subjects were included in analyses. Subjects were aged 55.5 ± 16.9 years with mean body mass index (BMI) of 27.9 ± 7.5 kg/m². Most (92%) subjects were on a mechanical ventilator and experienced organ failure. At least 50% of caloric and protein goals were achieved in 78.9% and 73.7% of the subjects, respectively, during the first 3 days. Overall, 75.0 ± 26.3% and 69.3 ± 26.7% of calorie and protein goals were achieved using the study formula.

Conclusions:

Subjects fed enterally with a calorically dense, enzymatically hydrolyzed 100% whey peptide-based enteral formula exceeded 50% of caloric and protein goals in most critically ill subjects included in this study. Use of study formula did not lead to severe gastrointestinal intolerance.

Loss of microbial diversity and pathogen domination of the gut microbiota in critically ill patients

Among long-stay critically ill patients in the adult intensive care unit (ICU), there are often marked changes in the complexity of the gut microbiota. However, it remains unclear whether such patients might benefit from enhanced surveillance or from interventions targeting the gut microbiota or the pathogens therein. We therefore undertook a prospective observational study of 24 ICU patients, in which serial faecal samples were subjected to shotgun metagenomic sequencing, phylogenetic profiling and microbial genome analyses. Two-thirds of the patients experienced a marked drop in gut microbial diversity (to an inverse Simpson’s index of <4) at some stage during their stay in the ICU, often accompanied by the absence or loss of potentially beneficial bacteria. Intravenous administration of the broad-spectrum antimicrobial agent meropenem was significantly associated with loss of gut microbial diversity, but the administration of other antibiotics, including piperacillin/tazobactam, failed to trigger statistically detectable changes in microbial diversity. In three-quarters of ICU patients, we documented episodes of gut domination by pathogenic strains, with evidence of cryptic nosocomial transmission of Enterococcus faecium. In some patients, we also saw an increase in the relative abundance of apparent commensal organisms in the gut microbiome, including the archaeal species Methanobrevibacter smithii. In conclusion, we have documented a dramatic absence of microbial diversity and pathogen domination of the gut microbiota in a high proportion of critically ill patients using shotgun metagenomics.

Tutorial on Diarrhea and Enteral Nutrition: A Comprehensive Step-By-Step Approach

This tutorial suggests a current strategy toward a multiprofessional therapy based upon a comprehensive step-by-step approach to the course of intensive care unit diarrhea episodes. Evidence published in the last 10 years, obtained through a database search (PubMed), shows that its prevalence is quite variable. Although multicausal, it is often erroneously associated with the supply of enteral nutrition. Several complications affect not only nutrition status but also the development of skin lesions, which can become the focus of infections, and the length of hospital stay. Here, we propose an early, objective, directed, and multimodal approach, aiming at optimizing care for these patients. In a dynamic walkthrough, the reader will find a guide for the general diagnosis and for colitis resulting from Clostridium difficile infections, as well as current instructions and recommendations for drug treatment and supportive therapy for these 2 modalities. We also bring together ways to prevent and treat associated skin lesions in this setting. Because it is neglected in the critical environment, diarrhea is still a poorly addressed disease, and its complications bring about a significant worsening in quality of life and hospital stay.

Association of prophylactic synbiotics with reduction in diarrhea and pneumonia in mechanically ventilated critically ill patients: A propensity score analysis

INTRODUCTION

The preventive association of synbiotics therapy has not been thoroughly clarified in mechanically ventilated patients. The purpose of this study was to evaluate whether synbiotics therapy has preventive association against septic complications in ventilated critically ill patients.

METHODS

Critically ill patients who were mechanically ventilated were included in this retrospective observational study. Patients who received synbiotics (Bifidobacterium breve, Lactobacillus casei, and galactooligosaccharides) within 3 days after admission (denoted as synbiotics group) were compared with patients who did not receive synbiotics. The incidences of enteritis, pneumonia, and bacteremia were evaluated as clinical outcome. Enteritis was defined as an acute onset of diarrhea consisting of continuous liquid watery stools for more than 12 h. The confounding factors include APACHE II on admission, gender, the cause of admission and antibiotics.

RESULTS

We included 179 patients in this study: 57 patients received synbiotics and 122 patients did not receive synbiotics. The incidences of enteritis were significantly lower in the synbiotics group compared with the control group (3.5% vs. 15.6%; p < 0.05). The odds ratios for diarrhea-free days during the first 28 days for the synbiotics group as compared with the controls were 4.354 (95% confidence interval (CI), 2.407 to 7.877; p < 0.001) in an ordinal logistic regression model with propensity scores. The odds ratios for pneumonia-free days during the first 28 days for the synbiotics group were 2.529 (95% CI, 1.715 to 3.731; p < 0.001). The incidences of bacteremia did not have significant differences.

CONCLUSION

Prophylactic synbiotics appeared to have preventive association on enteritis and pneumonia in mechanically ventilated critically ill patients.

Fecal imaging demonstrates that low-methoxyl pectin supplementation normalizes gastro-intestinal transit in mice given a liquid diet

This study has the following aims: (1) to confirm a methodology for a fecal indocyanine green (ICG) imaging test for measuring gastro-intestinal transit time (GITT); and (2) to compare GITT in mice given a liquid diet in which viscosity increases under acidic conditions to that in mice given stable liquid diets with comparable viscosity or regular chow. To address Aim 1, mice received ICG orally along with intraperitoneal injection of atropine in Study 1, and mice were given ICG orally with concurrent carmine red for Study 2. Fluorescence imaging of feces collected for 8 h thereafter was used to detect the first feces with fluorescence and thereby determine GITT. To address Aim 2, mice were fed ad libitum for 1 week with either liquid diet or regular chow for Study 3, or with liquid diet containing low-methoxyl (LM) pectin or high-methoxyl (HM) pectin, or regular chow for Study 4. GITT was then determined by fecal ICG imaging. Atropine delayed GITT in a dose-dependent manner. The GITT of ICG completely corresponded to that of carmine red (correlation coefficient, 1.00). The first ICG excretion in the loose/some diarrheal feces of mice given a liquid diet was seen at 170 min. Feces of mice given liquid diet were loose with LM pectin and loose/some diarrhea with HM pectin. GITT of mice given liquid diet with HM pectin was significantly delayed (280 min) compared to that of mice given liquid diet with LM pectin (111 min) or regular chow (130 min). Fecal imaging of ICG enables measurements of GITT. LM pectin supplementation in a liquid diet may normalize GITT in mice to that of a normal meal and may be associated with changes in fecal properties.

The effect of a natural food based tube feeding in minimizing diarrhea in critically ill neurological patients

BACKGROUND & AIMS

Diarrhea has negative consequences for patients, health care staff and health care costs when neurological patients are fed enterally over long periods. We examined the effect of tube feeding with natural foods in reducing the number of fluid stool evacuations and diarrhea in critically ill neurological patients.

METHODS

A multicenter, prospective, open-label and randomized controlled trial (RCT) was conducted at facilities in Germany specializing in early rehabilitation after neurological damage. Patients of the INTERVENTION group were fed by tube using a commercially available product based on real foods such as milk, meat, carrots, whereas CONTROL patients received a standard tube-feed made of powdered raw materials. All received enteral nutrition over a maximum of 30 days. The number of defecations and the consistency of each stool according to the Bristol Stool Chart (BSC) were monitored. In addition, daily calories, liquids and antibiotic-use were recorded.

RESULTS

118 Patients who had suffered ischemic stroke, intracerebral hemorrhage, traumatic brain injury or hypoxic brain damage and requiring enteral nutrition were enrolled; 59 were randomized to receive the intervention and 59 control feed. There were no significant differences in clinical screening data, age, sex, observation period or days under enteral nutrition between the groups. Patients in both groups received equivalent amount of calories and fluids. In both groups antibiotics were frequently prescribed (69.5% in the INTERVENTION group and 75.7% in the CONTROL group) for 10-11 days on average. In comparison to the CONTROL group, patients in the INTERVENTION group had a significant reduction of the number of watery stool evacuations (type 7 BSC) (minus 61%, IRR = 0.39, p < 0.001). Further statistical evaluations using the following corrections: major diarrhea-associated confounders (number and duration of antibiotics); shorter observation period of 15 days; excluding patients with Clostridium difficile associated diarrhea (CDAD) and the Per Protocol Population, confirmed the primary hypothesis. The number of days with diarrhea was significantly lower in the INTERVENTION group (0.8 ± 1.60 days versus 2.0 ± 3.46 days).

CONCLUSIONS

Tube feeding with natural based food was effective in reducing the number of watery defecations and diarrhea in long term tube-fed critically ill neurological patients, compared to those fed with standard tube feeding.

Sporulated Bacillus as alternative treatment for diarrhea of hospitalized adult patients under enteral nutrition: A pilot randomized controlled study

BACKGROUND & AIMS

Among hospitalized patients receiving enteral nutrition (EN), malnutrition and antibiotic use are some of the most common causes of diarrhea. Prebiotics and probiotics agents have been used for treatment of diarrhea in such patients. The aim of this study was to assess the efficacy of a sporulated Bacillus strain (Bacillus cereus A 05), compared to a control group using a prebiotic (soluble fiber), in reducing diarrhea in patients receiving EN and antibiotic therapy.

METHODS

Patients with diarrhea receiving EN were randomized to receive either B. cereus (study group) or soluble fiber (control group) for five days. The group treated with B. cereus received 4 vials with 5 mL × 10⁶ every 6 h. The control group treated with fiber received 10 g of soluble fiber every 8 h. Data assessed were serum albumin, nutrition status through Subjective Global Assessment (SGA), antibiotic use and osmolality (normal or hyperosmolar) of the tube feeding diets.

RESULTS

Twenty-nine patients were treated in each group. There was no significant difference between the groups regarding age, serum albumin, SGA score, dietary osmolality and antibiotic use. There was no significant difference between groups in ceasing diarrhea. However, the group treated with B. cereus took fewer days to cease diarrhea (2.5 ± 1.3 versus 3.7 ± 1.1 days, p = 0.011). Specifically, in the group treated with B. cereus A 05, malnourished patients did better than non-malnourished patients regarding diarrhea cessation (100% versus 25%, p < 0.001).

CONCLUSIONS

B. cereus A 05 was more effective than fiber in reducing diarrhea among patients under EN and antibiotic therapy and was more effective among malnourished patients.

ASPEN Safe Practices for Enteral Nutrition Therapy [Formula: see text]

Enteral nutrition (EN) is a valuable clinical intervention for patients of all ages in a variety of care settings. Along with its many outcome benefits come the potential for adverse effects. These safety issues are the result of clinical complications and of process-related errors. The latter can occur at any step from patient assessment, prescribing, and order review, to product selection, labeling, and administration. To maximize the benefits of EN while minimizing adverse events requires that a systematic approach of care be in place. This includes open communication, standardization, and incorporation of best practices into the EN process. This document provides recommendations based on the available evidence and expert consensus for safe practices, across each step of the process, for all those involved in caring for patients receiving EN.

Fiber, prebiotics, and diarrhea: what, why, when and how

PURPOSE OF REVIEW

Dietary fiber and prebiotics have been the focus of research and discussion for decades, but there are still pending concepts and definitions, in particular when addressing their use in the prevention and treatment of diarrhea. The purpose of this review is to present the latest advances in the understanding of dietary fiber and prebiotics, to review their proven role in the management of diarrhea, and to postulate the best timings and optimal doses.

RECENT FINDINGS

The use of prebiotics has encompassed not only prevention but also the treatment of distinct types of diarrhea, at different treatment moments, and with regard to various different markers of outcome. Furthermore, the description of soluble fibers claiming to be prebiotics, and vice versa, has too often been the tone in the literature, which has led to misconceptions in classification and, consequently, confusion over the interpretation of results. It remains difficult to establish a consensus about the real impact of fiber and prebiotics on the prevention and therapy of diarrhea.

SUMMARY

The review highlights the overlapping concepts of fiber and prebiotics, and supports the need for adequate individualization of their use, according to the goal - either prevention or treatment of diarrhea - as well as the optimal timing and dose to be used. Nonetheless, viscous soluble fibers seem to be the best option in treating diarrhea, whereas prebiotics are more important in preventing and avoiding recurrence.

Diarrhea in Critically Ill Patients: The Role of Enteral Feeding

This tutorial presents a systematic approach to the management of diarrhea in the critical care setting. Diarrhea is a common and prevalent problem in critically ill patients. Despite the high prevalence, its management is far from simple. Professionals are confronted with a myriad of definitions based on frequency, consistency, and volume. The causes are complex and multifactorial, yet enteral tube feeding formula is believed to be the perpetrator. Potential causes for diarrhea are discussed, and 3 case reports provide context to examine the treatment from a nutrition perspective. Each scenario is comprehensively addressed discussing potential causes and providing specific clinical strategies contributing to improved bowel function in this patient group. The approach used for diarrhea management is based on a complete understanding of enteral tube formula, their composition, and their impact in the presence of gut dysfunction. Choosing the right feeding formula may positively influence bowel function and contribute to improved nutrition.

ACG Clinical Guideline: Nutrition Therapy in the Adult Hospitalized Patient

The value of nutrition therapy for the adult hospitalized patient is derived from the outcome benefits achieved by the delivery of early enteral feeding. Nutritional assessment should identify those patients at high nutritional risk, determined by both disease severity and nutritional status. For such patients if they are unable to maintain volitional intake, enteral access should be attained and enteral nutrition (EN) initiated within 24-48 h of admission. Orogastric or nasogastric feeding is most appropriate when starting EN, switching to post-pyloric or deep jejunal feeding only in those patients who are intolerant of gastric feeds or at high risk for aspiration. Percutaneous access should be used for those patients anticipated to require EN for >4 weeks. Patients receiving EN should be monitored for risk of aspiration, tolerance, and adequacy of feeding (determined by percent of goal calories and protein delivered). Intentional permissive underfeeding (and even trophic feeding) is appropriate temporarily for certain subsets of hospitalized patients. Although a standard polymeric formula should be used routinely in most patients, an immune-modulating formula (with arginine and fish oil) should be reserved for patients who have had major surgery in a surgical ICU setting. Adequacy of nutrition therapy is enhanced by establishing nurse-driven enteral feeding protocols, increasing delivery by volume-based or top-down feeding strategies, minimizing interruptions, and eliminating the practice of gastric residual volumes. Parenteral nutrition should be used in patients at high nutritional risk when EN is not feasible or after the first week of hospitalization if EN is not sufficient. Because of their knowledge base and skill set, the gastroenterologist endoscopist is an asset to the Nutrition Support Team and should participate in providing optimal nutrition therapy to the hospitalized adult patient.

Enteral Nutrition for Adults in the Hospital Setting

In patients unable to tolerate oral intake, multiple options of nutrient delivery are available to the clinician. Administration of enteral nutrition (EN) has long been considered the standard of care for nutrition support among patients unable to meet energy and protein requirements orally. Healthcare practitioners must make careful decisions related to ordering, administering, and monitoring EN therapy. In the hospital setting, the registered dietitian is a key resource in enteral formula selection and method of administration, monitoring for and troubleshooting EN-related complications, and transitioning to oral feeding. The hospital setting also presents many unique challenges in providing optimal nutrition to the enterally fed patient.

Nutrition and metabolic support recommendations for the bariatric patient

Managing the metabolic needs of the patient with obesity is a challenge unto itself without the added demands of accounting for an altered gastrointestinal tract. Nevertheless, with about 200,000 bariatric procedures being performed annually in the United States, clinicians must be prepared to manage the critically ill bariatric surgery patient. This article reviews the recent literature relating to nutrient needs and metabolic support for the bariatric patient. Bariatric patients are at risk for several micronutrient deficiencies, including vitamins D and B₁₂, calcium, and iron; some bariatric procedures affect macronutrient needs as well. Literature on nutrition support guidelines for the bariatric population is limited. However, with an understanding of the anatomical and physiological effects of bariatric surgery, recent guidelines for critically ill patients with obesity can be applied to the bariatric surgery population. The unique needs of the bariatric population, such as susceptibility to micronutrient deficiencies and specialized access routes, must be considered to provide safe and efficacious nutrition support. Further research is necessary to develop specific nutrition support recommendations for the bariatric population.