Diarrhoea during enteral nutrition is predicted by the poorly absorbed short-chain carbohydrate (FODMAP) content of the formula

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.

An Antioxidant Supplement Function Exploration: Rescue of Intestinal Structure Injury by Mannan Oligosaccharides after Aeromonas hydrophila Infection in Grass Carp (Ctenopharyngodon idella)

Mannan oligosaccharides (MOS) are a type of functional oligosaccharide which have received increased attention because of their beneficial effects on fish intestinal health. However, intestinal structural integrity is a necessary prerequisite for intestinal health. This study focused on exploring the protective effects of dietary MOS supplementation on the grass carp’s (Ctenopharyngodon idella) intestinal structural integrity (including tight junction (TJ) and adherent junction (AJ)) and its related signalling molecule mechanism. A total of 540 grass carp (215.85 ± 0.30 g) were fed six diets containing graded levels of dietary MOS supplementation (0, 200, 400, 600, 800 and 1000 mg/kg) for 60 days. Subsequently, a challenge test was conducted by injection of Aeromonas hydrophila for 14 days. We used ELISA, spectrophotometry, transmission electron microscope, immunohistochemistry, qRT-PCR and Western blotting to determine the effect of dietary MOS supplementation on intestinal structural integrity and antioxidant capacity. The results revealed that dietary MOS supplementation protected the microvillus of the intestine; reduced serum diamine oxidase and d-lactate levels (p < 0.05); enhanced intestinal total antioxidant capacity (p < 0.01); up-regulated most intestinal TJ and AJ mRNA levels; and decreased GTP-RhoA protein levels (p < 0.01). In addition, we also found several interesting results suggesting that MOS supplementation has no effects on ZO-2 and Claudin-15b. Overall, these findings suggested that dietary MOS supplementation could protect intestinal ultrastructure, reduce intestinal mucosal permeability and maintain intestinal structural integrity via inhibiting MLCK and RhoA/ROCK signalling pathways.

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

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.

The Brain-Gut Axis: Psychological Functioning and Inflammatory Bowel Diseases

The brain-gut axis represents a complex bi-directional system comprising multiple interconnections between the neuroendocrine pathways, the autonomous nervous system and the gastrointestinal tract. Inflammatory bowel disease (IBD), comprising Crohn's disease and ulcerative colitis, is a chronic, relapsing-remitting inflammatory disorder of the gastrointestinal tract with a multifactorial etiology. Depression and anxiety are prevalent among patients with chronic disorders characterized by a strong immune component, such as diabetes mellitus, cancer, multiple sclerosis, rheumatoid arthritis and IBD. Although psychological problems are an important aspect of morbidity and of impaired quality of life in patients with IBD, depression and anxiety continue to be under-diagnosed. There is lack of evidence regarding the exact mechanisms by which depression, anxiety and cognitive dysfunction may occur in these patients, and whether psychological disorders are the result of disease activity or determinants of the IBD occurrence. In this comprehensive review, we summarize the role of the brain-gut axis in the psychological functioning of patients with IBD, and discuss current preclinical and clinical data on the topic and therapeutic strategies potentially useful for the clinical management of these patients. Personalized pathways of psychological supports are needed to improve the quality of life in patients with IBD.

Risk Factors and Predictive Model of Diarrhea Among Patients with Severe Stroke

OBJECTIVE

To investigate the risk factors and predictive model of diarrhea among patients with severe stroke.

METHODS

The study analyzed the retrospective clinical data of patients with new-onset stroke who had been admitted to the intensive care unit at the Department of Neurology of X Hospital, between September 2017 and April 2018. All data were analyzed with a binary logistic regression, and a logistic regression equation was used to build a predictive model of diarrhea among patients with severe stroke.

RESULTS

A total of 153 patients with severe stroke were included in this study, including 45 patients (29.41%) with diarrhea. The binary logistic multivariate analysis showed that the National Institutes of Health Stroke Scale score at admission (odds ratio [OR], 1.123; 95% confidence interval [CI], 1.016-1.242), the Glasgow Coma Scale score at admission (OR, 1.563; 95% CI, 1.048-2.330), antibiotic use (OR, 2.168; 95% CI, 1.041-4.514), gavage feeding time (OR, 1.260; 95% CI, 1.098-1.445), and hospital stay before the occurrence of diarrhea (OR, 0.652; 95% CI, 0.552-0.770). The receiver operating characteristic curve was 0.862 (95% CI, 0.799-0.925), the specificity was 0.778, and the sensitivity was 0.843.

CONCLUSIONS

The National Institutes of Health Stroke Scale score at admission, the Glasgow Coma Scale score at admission, antibiotic use, gavage feeding time, and hospital stay before the occurrence of diarrhea independently predict diarrhea among patients with severe stroke. This model can be used to predict the risk of diarrhea among patients with severe stroke.

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.

Dietary Fermentable Oligosaccharides, Disaccharides, Monosaccharides, and Polyols (FODMAPs) and Gastrointestinal Disease

FODMAP is an acronym for fermentable oligosaccharides, disaccharides, monosaccharides, and polyols. Dietary modification of FODMAPs has been shown to have significant effects on the physiology of the gastrointestinal tract and improves symptoms of abdominal pain, distention, and bloating in patients with irritable bowel syndrome. Structured withdrawal and reintroduction of FODMAPs supervised by a dietitian is the optimal practice for dietary FODMAP modification in irritable bowel syndrome. FODMAPs are present in enteral feeding formulas and may have a role in diarrhea and bloating in tube-fed patients. Emerging areas of research include the effects of dietary modification of FODMAPs on the microbiome, micronutrient absorption, and caloric intake. FODMAP dietary modification is an emerging area in other gastrointestinal disorders and is of relevance to all practicing dietitians.

Low-FODMAP diet reduces irritable bowel symptoms in patients with inflammatory bowel disease

AIM

To investigate the effect of a low-FODMAP diet on irritable bowel syndrome (IBS)-like symptoms in patients with inflammatory bowel disease (IBD).

METHODS

This was a randomised controlled open-label trial of patients with IBD in remission or with mild-to-moderate disease and coexisting IBS-like symptoms (Rome III) randomly assigned to a Low-FODMAP diet (LFD) or a normal diet (ND) for 6 wk between June 2012 and December 2013. Patients completed the IBS symptom severity system (IBS-SSS) and short IBD quality of life questionnaire (SIBDQ) at weeks 0 and 6. The primary end-point was response rates (at least 50-point reduction) in IBS-SSS at week 6 between groups; secondary end-point was the impact on quality of life.

RESULTS

Eighty-nine patients, 67 (75%) women, median age 40, range 20-70 years were randomised: 44 to LFD group and 45 to ND, from which 78 patients completed the study period and were included in the final analysis (37 LFD and 41 ND). There was a significantly larger proportion of responders in the LFD group (n = 30, 81%) than in the ND group (n = 19, 46%); (OR = 5.30; 95%CI: 1.81-15.55, P < 0.01). At week 6, the LFD group showed a significantly lower median IBS-SSS (median 115; inter-quartile range [IQR] 33-169) than ND group (median 170, IQR 91-288), P = 0.02. Furthermore, the LFD group had a significantly greater increase in SIBDQ (median 60, IQR 51-65) than the ND group (median 50, IQR 39-60), P < 0.01.

CONCLUSION

In a prospective study, a low-FODMAP diet reduced IBS-like symptoms and increased quality of life in patients with IBD in remission.

Challenges of Quantifying FODMAPs in Enteral Nutrition Formulas: Evaluation of Artifacts and Solutions

BACKGROUND

Diarrhea associated with enteral nutrition has been attributed to excessive FODMAP (fermentable oligosaccharides, disaccharides, monosaccharides, and polyols) content of formulas. This study aimed to readdress their FODMAP content by measuring fermentation-specific effects after a formula load in healthy participants and by defining issues with analytical methods.

METHODS

Breath hydrogen production expressed as mean area under the curve (AUC) for 12 hours after ingestion of 15 g lactulose or 500 mL of 1 of 2 formulas of seemingly different FODMAP content was evaluated in a double crossover design. Quantification of specified FODMAPs via enzymatic and liquid chromatographic assays was assessed with additional controls to investigate the influence of maltodextrin and sucrose present in the formulas, and alternative assays were applied.

RESULTS

In 15 hydrogen-producing participants, AUC following both formulas was minimal (≤21 ppm/12 h) compared with 15 g lactulose ( P < .001). Elevated breath hydrogen was detectable when >2.5 g fructo-oligosaccharide was consumed. Maltodextrin showed dose-dependent interference with enzymatic measurement of fructans and coeluted with raffinose with liquid chromatography. Application of an alternative fructan assay that includes additional enzymes to hydrolyze maltodextrins indicated that fructan content was <15% of that previous reported. Galacto-oligosaccharide (GOS) content could not be estimated by chromatography due to maltodextrins. An enzymatic assay, while overestimating GOS content, showed it to be very low.

CONCLUSION

FODMAPs were not detected in enteral formulas in human bioassays, and their content may be grossly overestimated mainly due to high formula concentrations of maltodextrin. Better estimates of FODMAP content in enteral formulas can be made by alternative assay approaches.

Low-FODMAP formula improves diarrhea and nutritional status in hospitalized patients receiving enteral nutrition: a randomized, multicenter, double-blind clinical trial

Background

Fermentable oligosaccharides, disaccharides, monosaccharides, and polyols (FODMAPs) are poorly absorbed, short-chain carbohydrates that play an important role in inducing functional gut symptoms. A low-FODMAP diet improves abdominal symptoms in patients with inflammatory bowel disease and irritable bowel syndrome. However, there were no study for the effect of FODMAP content on gastrointestinal intolerance and nutritional status in patients receiving enteral nutrition (EN).

Methods

In this randomized, multicenter, double-blind, 14-day clinical trial, eligible hospitalized patients receiving EN (n = 100) were randomly assigned to three groups; 84 patients completed the trial (low-FODMAP EN, n = 30; moderate-FODMAP EN, n = 28; high-FODMAP EN, n = 26). Anthropometric and biochemical parameters were measured; stool assessment was performed using the King’s Stool Chart and clinical definition.

Results

Baseline values were not significantly different among the three groups. After the 14-day intervention, diarrhea significantly improved in the low-FODMAP group than in the moderate- and high-FODMAP groups (P < 0.05). King’s Stool scores in diarrhea subjects were significantly and steadily reduced in the low-FODMAP group compared with the other two groups (P for time and EN type interaction <0.05). BMI increased significantly in the low- and high-FODMAP groups during the intervention (P < 0.05 for both), and showed a trend toward increasing in the moderate-FODMAP group (P < 0.10). Serum prealbumin increased significantly in all groups by 14-day; by 3-day, it had increased to the levels at 14-day in the low-FODMAP group. At 14-day, serum transferrin had increased significantly in the moderate-FODMAP group. In addition, subjects were classified by final condition (unimproved, normal maintenance, diarrhea only improved, constipation only improved, and recurrent diarrhea/constipation improved). Seventy-five percent of the diarrhea improved group consumed the low-FODMAP EN formula. 38.5 and 46.2 % of recurrent diarrhea/constipation improved group consumed the low- and moderate-FODMAP EN respectively. BMI significantly increased in all groups except the unimproved. Prealbumin levels significantly increased in the diarrhea-improved and recurrent diarrhea/constipation groups at 3-day and continued by 14-day, and in the constipation-improved group at 14-day. Transferrin levels significantly increased in the diarrhea-improved and recurrent diarrhea/constipation groups at 14-day.

Conclusion

Low-FODMAP EN may improve diarrhea, leading to improved nutritional status and facilitating prompt recovery from illness.

Electronic supplementary material

The online version of this article (doi:10.1186/s12937-015-0106-0) contains supplementary material, which is available to authorized users.

Enteral tube feeding of patients with acute stroke: when does the risk of diarrhoea increase?

BACKGROUND/AIM

We aimed to evaluate the relationship between the length of time acute stroke patients underwent enteral tube feeding (ETF) and episodes of diarrhoea, and to investigate the temporal cut-off point at which diarrhoea risk increases.

METHODS

An observational, retrospective study was conducted on patients with acute stroke admitted to a Stroke Centre. Patients undergoing ETF (ETF group) and those not undergoing ETF (control group) were analysed and matched by age and stroke severity. Data regarding demographic and clinical variables were recorded. The analysis was conducted using a receiver operating characteristic (ROC) curve and multivariate analyses.

RESULTS

A total of 130 inpatients was included (age 75.08 ± 11.53 years, 56.2% men). The ETF group had higher diarrhoea frequency (27.7% vs 6.2%, P = 0.001). The length of time on ETF was associated with diarrhoea development (odds ratio (OR), 1.12 increment per day; 95% confidence interval (CI) 1.05-1.18; P < 0.001), after adjusting for confounders. The ROC curve showed 7 days on ETF as a cut-off point for diarrhoea risk. Seven days or more on ETF was independently associated with diarrhoea (OR, 6.26; 95% CI 1.66-23.62; P = 0.007), whereas less than 7 days was not when compared with the control group (OR, 0.38; 95% CI 0.04-3.91; P = 0.413).

CONCLUSIONS

The length of time on ETF is associated with diarrhoea development in patients with acute stroke, demonstrating a temporal cut-off point. Seven days or longer on ETF is related to the occurrence of diarrhoea, whereas less than 7 days on ETF does not show this effect.

Preventing diarrhoea in enteral nutrition: the impact of the delivery set hang time

BACKGROUND

To meet the current recommendations for enteral tube feeding (ETF), we updated our previous practice in 2011 and began to use a 24-h delivery set hang time (DSHT). We evaluated the impact of this update on the risk of diarrhoea and in diarrhoea-free survival.

METHODS

Observational, retrospective study with historical controls on ischaemic and haemorrhagic stroke patients undergoing ETF. Diarrhoea occurrence (≥ 3 liquid stools in 24 h) was compared between patients with a 24 h DSHT (2011-2014) and a 72/96 h DSHT (2010-2011). The analysis was conducted using Kaplan-Meier curves and a Cox regression model.

RESULTS

A total of 175 patients were included [median age 81 years (IQR = 12), 46.9% males], 103 in the group with a 24 h DSHT and 72 in the group with a 72/96 h DSHT. The group with a 24 h DSHT had a lower diarrhoea frequency (13.6% vs. 34.7%, risk ratio: 0.39, 95% CI: 0.22-0.70, p = 0.001) and a lower diarrhoea incidence rate (0.87 vs. 2.32 cases of diarrhoea/100 patient*day, rate ratio: 0.37, 95% CI: 0.19-0.72, p = 0.004). The Kaplan-Meier curves showed a longer diarrhoea-free survival for this group (p = 0.003, log-rank test). A 24 h DSHT was associated with a lower risk of diarrhoea (HR = 0.27, 95% CI: 0.12-0.61, p = 0.002), adjusted by albumin, stroke severity, intravenous thrombolysis, the administration of clindamycin and cefotaxime, and the administration of an enteral formula for diabetic patients.

CONCLUSIONS

The 24 h DSHT was independently associated with a lower risk of diarrhoea and longer diarrhoea-free survival in hospitalised patients with acute stroke under ETF, compared with a 72/96 h DSHT.

Gastroenteric tube feeding: Techniques, problems and solutions

Gastroenteric tube feeding plays a major role in the management of patients with poor voluntary intake, chronic neurological or mechanical dysphagia or gut dysfunction, and patients who are critically ill. However, despite the benefits and widespread use of enteral tube feeding, some patients experience complications. This review aims to discuss and compare current knowledge regarding the clinical application of enteral tube feeding, together with associated complications and special aspects. We conducted an extensive literature search on PubMed, Embase and Medline using index terms relating to enteral access, enteral feeding/nutrition, tube feeding, percutaneous endoscopic gastrostomy/jejunostomy, endoscopic nasoenteric tube, nasogastric tube, and refeeding syndrome. The literature showed common routes of enteral access to include nasoenteral tube, gastrostomy and jejunostomy, while complications fall into four major categories: mechanical, e.g., tube blockage or removal; gastrointestinal, e.g., diarrhea; infectious e.g., aspiration pneumonia, tube site infection; and metabolic, e.g., refeeding syndrome, hyperglycemia. Although the type and frequency of complications arising from tube feeding vary considerably according to the chosen access route, gastrointestinal complications are without doubt the most common. Complications associated with enteral tube feeding can be reduced by careful observance of guidelines, including those related to food composition, administration rate, portion size, food temperature and patient supervision.

Mechanisms and efficacy of dietary FODMAP restriction in IBS

IBS is a debilitating condition that markedly affects quality of life. The chronic nature, high prevalence and associated comorbidities contribute to the considerable economic burden of IBS. The pathophysiology of IBS is not completely understood and evidence to guide management is variable. Interest in dietary intervention continues to grow rapidly. Ileostomy and MRI studies have demonstrated that some fermentable carbohydrates increase ileal luminal water content and breath hydrogen testing studies have demonstrated that some carbohydrates also increase colonic hydrogen production. The effects of fermentable carbohydrates on gastrointestinal symptoms have also been well described in blinded, controlled trials. Dietary restriction of fermentable carbohydrates (popularly termed the 'low FODMAP diet') has received considerable attention. An emerging body of research now demonstrates the efficacy of fermentable carbohydrate restriction in IBS; however, limitations still exist with this approach owing to a limited number of randomized trials, in part due to the fundamental difficulty of placebo control in dietary trials. Evidence also indicates that the diet can influence the gut microbiota and nutrient intake. Fermentable carbohydrate restriction in people with IBS is promising, but the effects on gastrointestinal health require further investigation.

Dietary fructose intolerance, fructan intolerance and FODMAPs

Dietary intolerances to fructose, fructans and FODMAPs (fermentable oligosaccharides, disaccharides, monosaccharides, and polyols) are common, yet poorly recognized and managed. Over the last decade, they have come to the forefront because of new knowledge on the mechanisms and treatment of these conditions. Patients with these problems often present with unexplained bloating, belching, distension, gas, abdominal pain, or diarrhea. Here, we have examined the most up-to-date research on these food-related intolerances, discussed controversies, and have provided some guidelines for the dietary management of these conditions. Breath testing for carbohydrate intolerance appears to be standardized and essential for the diagnosis and management of these conditions, especially in the Western population. While current research shows that the FODMAP diet may be effective in treating some patients with irritable bowel syndrome, additional research is needed to identify more foods items that are high in FODMAPs, and to assess the long-term efficacy and safety of dietary interventions.

Role of FODMAP content in enteral nutrition-associated diarrhea

Gastrointestinal symptoms including diarrhea are common complications of enteral nutrition (EN); however, the cause is unclear. Mode of EN delivery that alters digestion and possibly absorption is suggested to contribute to the high incidence of diarrhea; however, enteral formula is frequently blamed. Most research has focused on fiber-supplemented EN, with a meta-analysis showing that fiber reduces the incidence of diarrhea in non-intensive care unit studies. Other hypotheses include formula osmolality and FODMAP (fermentable oligosaccharides, disaccharides, monosaccharides, and polyols) content. FODMAPs are poorly absorbed short-chain carbohydrates that exert an osmotic effect. Dietary FODMAPs have been shown to reduce gastrointestinal symptoms, including diarrhea, in those with irritable bowel syndrome and, given a high-enough dose, will induce a laxative effect in most people. As FODMAPs are commonly added to enteral formula and EN is frequently used as the main source of nutrition, it is reasonable to hypothesize that EN provides more FODMAPs than usual dietary intake and increases risk for developing diarrhea. This hypothesis was assessed through a retrospective study showing that the standard-use enteral formula Isosource 1.5 had a protective effect of developing diarrhea. The only characteristic unique to Isosource 1.5 was the lower FODMAP content as determined through methodologies previously validated for food analysis. Methodologies for application to enteral formulas are currently undergoing formal validation. Once confirmed for application in enteral formula, future directions include FODMAP analysis of specific ingredients to increase understanding of potential problems associated with enteral formula and a randomized, controlled trial investigating the role of formula FODMAP content.

Diarrhea in enterally fed patients: blame the diet?

PURPOSE OF REVIEW

Diarrhea has great impact on enteral nutrition. The purpose of this review is to identify the factors leading to diarrhea during enteral nutrition and to provide the published updates on diarrhea prevention through nutritional intervention.

RECENT FINDINGS

Diarrhea in enteral fed patients is attributed to multiple factors, including medications (major contributor), infections, bacterial contamination, underlying disease, and enteral feeding. Diet management can alleviate diarrhea in enteral feeding. High content of fermentable oligosaccharides, disaccharides, and monosaccharides and polyols (FODMAPs) in enteral formula is postulated to induce diarrhea and lower FODMAPs formula may reduce the likelihood of diarrhea in enterally fed patients. Fiber-enriched formula can reduce the incidence of diarrhea and produce short-chain fatty acids for colonocytes. Ingesting prebiotics, nonviable probiotics or probiotic derivatives, and human lactoferrin may provide alternatives for reducing/preventing diarrhea.

SUMMARY

Enteral feeding is not generally considered the primary cause of diarrhea, which is frequently linked to prescribed medications. When diarrhea is apparent, healthcare members should evaluate the possible risk factors and systematically attempt to eliminate the underlying causes of diarrhea before reducing or suspending enteral feeding. Lower FODMAPs formula, prebiotics, probiotic derivatives, and lactoferrin may be used to manage enteral feeding-related diarrhea.

Extending our knowledge of fermentable, short-chain carbohydrates for managing gastrointestinal symptoms

The Monash University low FODMAP (fermentable oligosaccharides, disaccharides, monosaccharides, and polyols) diet is now accepted as an effective strategy for managing symptoms of irritable bowel syndrome (IBS) in Australia, with interest expanding across the world. These poorly absorbed, short-chain carbohydrates have been shown to induce IBS symptoms of diarrhea, bloating, abdominal pain, and flatus due to their poor absorption, osmotic activity, and rapid fermentation. Four clinical trials have been published to date, all with significant symptomatic response to the low FODMAP diet. Up to 86% of patients with IBS have achieved relief of overall gastrointestinal symptoms and, more specifically, bloating, flatus, abdominal pain, and altered bowel habit from the approach. This review provides an overview of the low FODMAP diet and summarizes the research to date, emerging concepts, and limitations. FODMAPs are known to be beneficial to bowel health; the importance of this and how this should be considered in the clinical management of IBS is also discussed. A clinical management flowchart is provided to assist nutrition professionals in the use of this approach.

Food choice as a key management strategy for functional gastrointestinal symptoms

Recognition of food components that induce functional gut symptoms in patient's functional bowel disorders (FBD) has been challenging. Food directly or indirectly provides considerable afferent input into the enteric nervous system. There is an altered relationship between the afferent input and perception/efferent response in FBD. Defining the nature of food-related stimuli may provide a means of minimizing such an input and gut symptoms. Using this premise, reducing the intake of FODMAPs (fermentable oligo-, di-, and mono-saccharides and polyols)--poorly absorbed short-chain carbohydrates that, by virtue of their small molecular size and rapid fermentability, will distend the intestinal lumen with liquid and gas--improves symptoms in the majority of patients. Well-developed methodologies to deliver the diet via dietician-led education are available. Another abundant source of afferent input is natural and added food chemicals (such as salicylates, amines, and glutamates). Studies are needed to assess the efficacy of the low food chemical dietary approach. A recent placebo-controlled trial of FODMAP-poor gluten provided the first valid evidence that non-celiac gluten intolerance might actually exist, but its prevalence and underlying mechanisms require elucidation. Food choice via the low FODMAP and potentially other dietary strategies is now a realistic and efficacious therapeutic approach for functional gut symptoms.

Alternatives to prokinetics to move the pylorus and colon

PURPOSE OF REVIEW

Gastrointestinal motility disorders (GMDs) are common in the ICU. When encountering these problems, one typically thinks of prokinetics. This review summarizes current evidence of treatments.

RECENT FINDINGS

Prokinetics are not the first-line therapy for GMDs. In fact, the clinical implications of using prokinetic agents are rather controversial. Current evidence on alternative treatment modalities such as fluid and electrolyte management, laxatives, opioid antagonists, purgative enemas, acupuncture, physical therapies and probiotics is growing.

SUMMARY

Current state of the art to treat GMDs is primarily focused at the elimination of underlying trigger factors. Fluid and electrolyte management as well as laxatives and peripherally acting μ-opioid receptor antagonists are the recommended first-line therapies that can be complemented with prokinetics. Acupuncture as well as physical modalities, such as massage or warming of the abdomen, is promising with few side-effects and should be considered as well.

Definitions, attitudes, and management practices in relation to diarrhea during enteral nutrition: a survey of patients, nurses, and dietitians

BACKGROUND

Diarrhea is a common complication in patients receiving enteral nutrition (EN), and understanding this problem among patients and healthcare professionals is required. The aim of the study was to investigate patients', nurses', and dietitians' definitions of diarrhea during EN, the attitudes of nurses and patients toward it, and the management practices of nurses and dietitians in response to diarrhea during EN.

METHODS

Twenty-two patients receiving EN, 57 nurses, and 33 dietitians were recruited and interviewed in a cross-sectional study, using a questionnaire that had been developed following an extensive literature review and pretested for clarity.

RESULTS

The ratings assigned by the 3 groups differed significantly for all the characteristics used to define diarrhea: frequency (P = .006), quantity (P < .001), consistency (P = .003), color (P < .001), odor (P < .001), and incontinence (P < .001). Patients gave incontinence the highest rank when defining diarrhea, whereas the healthcare professionals gave fecal consistency and frequency the highest ranks. Patients and nurses rated the unpleasantness of each characteristic of diarrhea during EN differently, with patients rating incontinence and fecal frequency and nurses rating odor and changing the patients' underwear as the most unpleasant characteristics. Nurses and dietitians differed in the frequency with which they adopted various strategies to manage patients who developed diarrhea during EN.

CONCLUSIONS

Patients have different definitions and attitudes toward diarrhea during EN from those of nurses and dietitians. Patients' perceptions need to be understood and respected by healthcare professionals to improve patient-centered care.

Association of lactose sensitivity with inflammatory bowel disease--demonstrated by analysis of genetic polymorphism, breath gases and symptoms

BACKGROUND

Sensitivity to lactose has been reported in Crohn's disease, but its true role in inflammatory bowel disease (IBD) is unclear. The genetic marker CC₁₃₉₁₀, on chromosome2, with measurement of breath hydrogen and methane, and gut and systemic symptoms, are now the most comprehensive tests for evaluating sensitivity to lactose.

AIM

To investigate, for the first time, the prevalence of lactose sensitivity in IBD, using the most comprehensive tests for diagnosing this condition.

METHODS

Prevalence of CC₁₃₉₁₀ genotype was investigated using RT-PCR in 165 patients (Crohn's disease = 70, ulcerative colitis = 95), and 30 healthy volunteers. Genotype was correlated with breath hydrogen and methane up to 6 h after 50 g of oral lactose, all symptoms being recorded for up to 48 h. Critically, Crohn's disease and ulcerative colitis patients were selected with no record of lactose sensitivity, in remission at the time of the test.

RESULTS

Lactose sensitivity occurred in a much higher proportion of patients, (approximately 70%), with IBD than previously thought. Seventeen per cent had raised methane, without raised breath hydrogen; those with ulcerative colitis exhibiting most symptoms. All CC patients were lactose sensitive. There was no correlation between genetic phenotype and IBD. As substantial numbers of IBD patients were CT or TT, and were lactose sensitive, this polymorphism cannot explain full down-regulation of the lactase gene.

CONCLUSIONS

Our results have implications for the clinical management of IBD. The high breath methane raised the possibility of a pathogenic role for methanogenic archaebacteria (Archaea) in IBD. This needs to be investigated.

Food intolerance in functional bowel disorders

BACKGROUND AND AIM

Food-related symptoms are commonly described by patients with functional bowel disorders, but dietary change as an evidence-based therapy has not been part of routine management strategies. This reviews aims to discuss strategies commonly applied.

METHOD

Published literature was reviewed.

RESULTS

Traditional approaches involve elimination diets followed by placebo-controlled reintroduction of specific foods, which is tedious at best and not applied in routine practice. Pathogenically-based approaches include determining what food components are inducing food hypersensitivity responses using specific biomarkers, but this is probably applicable to a small proportion of patients only and has met with only limited success. Food bioactive chemicals, such as salicylates, have been targeted, but there is a paucity of quality evidence for or against this approach. In contrast, targeting poorly absorbed dietary components that might induce luminal distension via osmotic effects and rapid fermentation (FODMAPs) has been successful and the efficacy of the dietitian-delivered low FODMAP diet is now supported by high quality evidence. Improvement of all symptoms of FBD in three out of four patients has been achieved. The diet may potentially improve stool frequency in patients with an ileal pouch or a high output ileostomy, or functional symptoms in patients with inflammatory bowel disease. FODMAPs in enteral formulas may also be responsible for diarrhoea induced by enteral nutrition.

CONCLUSION

Dietary restriction of FODMAPs is an effective therapy in the majority of patients with functional bowel symptoms and, provided dietitians are trained in the technique, should be first line therapy.

Mechanisms, prevention, and management of diarrhea in enteral nutrition

PURPOSE OF REVIEW

Diarrhea is a common and problematic complication of enteral nutrition, about which there has been considerable recent research. This article briefly reviews the mechanisms of diarrhea during enteral nutrition and then critically appraises the recent and emerging evidence for the prevention and management of this distressing complication.

RECENT FINDINGS

For many years, fiber was extensively investigated for its role in preventing diarrhea; however, a more recent focus has been the investigation of specific fiber blends, including soluble fibers and prebiotics, for which there is now considerable quality evidence. Enteral nutrition may result in deleterious effects on the gastrointestinal microbiota, including reductions in bifidobacteria and key butyrate producers. Their modulation by prebiotics has been confirmed in studies on healthy individuals, but convincing evidence in acutely ill patients is required. Probiotics have undergone extensive recent research and their effect on preventing diarrhea in enteral nutrition would seemingly be strain dependent. Further research is required on systematic approaches to treating diarrhea during enteral nutrition.

SUMMARY

A number of factors contribute to the pathogenesis of diarrhea in enteral nutrition, meaning that approaches to its prevention and management are necessarily multifaceted. Approaches to prevent diarrhea during enteral nutrition, and a clinical algorithm to manage it, are now presented.