Effect of a long acting somatostatin analogue SMS 201-995 on jejunostomy effluents in patients with severe short bowel syndrome

Current Status of Chronic Intestinal Failure Management in Adults

BACKGROUND

Chronic intestinal failure (CIF) is a heterogeneous disease that affects pediatric and adult populations worldwide and requires complex multidisciplinary management. In recent years, many advances in intravenous supplementation support, surgical techniques, pharmacological management, and intestinal transplants have been published. Based on these advances, international societies have published multiple recommendations and guidelines for the management of these patients. The purpose of this paper is to show the differences that currently exist between the recommendations (ideal life) and the experiences published by different programs around the world.

METHODS

A review of the literature in PubMed from 1980 to 2024 was carried out using the following terms: intestinal failure, CIF, home parenteral nutrition, short bowel syndrome, chronic intestinal pseudo-obstruction, intestinal transplant, enterohormones, and glucagon-like peptide-2.

CONCLUSIONS

There is a difference between what is recommended in the guidelines and consensus and what is applied in real life. Most of the world's countries are not able to offer all of the steps needed to treat this pathology. The development of cooperative networks between countries is necessary to ensure access to comprehensive treatment for most patients on all continents, but especially in low-income countries.

Metabolic and Nutritional Issues after Lower Digestive Tract Surgery: The Important Role of the Dietitian in a Multidisciplinary Setting

Many patients undergo small bowel and colon surgery for reasons related to malignancy, inflammatory bowel disease (IBD), mesenteric ischemia, and other benign conditions, including post-operative adhesions, hernias, trauma, volvulus, or diverticula. Some patients arrive in the operating theatre severely malnourished due to an underlying disease, while others develop complications (e.g., anastomotic leaks, abscesses, or strictures) that induce a systemic inflammatory response that can increase their energy and protein requirements. Finally, anatomical and functional changes resulting from surgery can affect either nutritional status due to malabsorption or nutritional support (NS) pathways. The dietitian providing NS to these patients needs to understand the pathophysiology underlying these sequelae and collaborate with other professionals, including surgeons, internists, nurses, and pharmacists. The aim of this review is to provide an overview of the nutritional and metabolic consequences of different types of lower gastrointestinal surgery and the role of the dietitian in providing comprehensive patient care. This article reviews the effects of small bowel resection on macronutrient and micronutrient absorption, the effects of colectomies (e.g., ileocolectomy, low anterior resection, abdominoperineal resection, and proctocolectomy) that require special dietary considerations, nutritional considerations specific to ostomized patients, and clinical practice guidelines for caregivers of patients who have undergone a surgery for local and systemic complications of IBD. Finally, we highlight the valuable contribution of the dietitian in the challenging management of short bowel syndrome and intestinal failure.

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.

ESPEN practical guideline: Clinical nutrition in chronic intestinal failure

BACKGROUND

This practical guideline is based on the ESPEN Guidelines on Chronic Intestinal Failure in Adults.

METHODOLOGY

ESPEN guidelines have been shortened and transformed into flow charts for easier use in clinical practice. The practical guideline is dedicated to all professionals including physicians, dieticians, nutritionists, and nurses working with patients with chronic intestinal failure.

RESULTS

This practical guideline consists of 112 recommendations with short commentaries for the management and treatment of benign chronic intestinal failure, including home parenteral nutrition and its complications, intestinal rehabilitation, and intestinal transplantation.

CONCLUSION

This practical guideline gives guidance to health care providers involved in the management of patients with chronic intestinal failure.

How to manage a high-output stoma

A high-output stoma (HOS) or fistula is when small bowel output causes water, sodium and often magnesium depletion. This tends to occur when the output is >1.5 -2.0 L/24 hours though varies according to the amount of food/drink taken orally. An HOS occurs in up to 31% of small bowel stomas. A high-output enterocutaneous fistula may, if from the proximal small bowel, behave in the same way and its fluid management will be the same as for an HOS. The clinical assessment consists of excluding causes other than a short bowel and treating them (especially partial or intermittent obstruction). A contrast follow through study gives an approximate measurement of residual small intestinal length (if not known from surgery) and may show the quality of the remaining small bowel. If HOS is due to a short bowel, the first step is to rehydrate the patient so stopping severe thirst. When thirst has resolved and renal function returned to normal, oral hypotonic fluid is restricted and a glucose-saline solution is sipped. Medication to slow transit (loperamide often in high dose) or to reduce secretions (omeprazole for gastric acid) may be helpful. Subcutaneous fluid (usually saline with added magnesium) may be given before intravenous fluids though can take 10-12 hours to infuse. Generally parenteral support is needed when less than 100 cm of functioning jejunum remains. If there is defunctioned bowel in situ, consideration should be given to bringing it back into continuity.

Is Lanreotide Really Useful in High Output Stoma? Comparison between Lanreotide to Conventional Antidiarrheal Treatment Alone

BACKGROUND

The incidence of high-output stoma (HOS) was reported to be approximately 3 to 16% in the literature, and HOS can cause dehydration. This complication is often severe enough to warrant hospital readmission and may result in renal failure. The aim of this study was to show a decrease of 50% in ileostomy output in the experimental arm using lanreotide treatment.

METHODS

Patients with an ileostomy output ≥ 1.5 l/24 hours were included in this prospective, open, multicentre randomized trial. Patients were randomly allocated between treatment arms with either lanreotide (LAN) and antidiarrhoeal treatments (TAD) (LAN-TAD group) or antidiarrhoeal treatments only (TADS group). The primary outcome was ileostomy output after 72 days. The secondary endpoints were ileostomy output during the first 6 days, blood urea and creatinine values, hospital length of stay and serious adverse events.

RESULTS

In the per-protocol analysis, there were nine patients in the control group (TADS) and six patients in the experimental group (TAD-LAN group). The stoma outputs at Day 3 (D3) in the experimental and control groups were 1,900 ± 855.7 mL and 1,728.6 ± 845.5 mL, respectively (p = 0.2). No differences were found concerning stoma output at D6, renal function, or hospital length of stay between the two groups.

CONCLUSION

The trial was prematurely stopped due to the low number of patients included. The question of the usefulness of somatostatin analogues in HOS persists, especially as the cost of this treatment is high, and there is a lack of evidence of its effectiveness.

The Long Road to the Development of Effective Therapies for the Short Gut Syndrome: A Personal Perspective

The ability to provide parenteral support represents a revolutionary change in medical therapy for patients with temporary and inadequate intestinal absorptive capacity or for patients with chronic intestinal failure due to digestive diseases. Nevertheless, due to the rarity of intestinal failure, a de facto policy of "discrimination by organ failure treatment" exists in many countries whereby this problem is under-recognized and under-treated. With the increasing recognition of the pathophysiological consequences of intestinal resection and the occurrence of new pro-adaptive treatments for patients suffering from short bowel syndrome, this review reflects on the history of developments in this area and discusses current practice and future directions of the field.

Lanreotide in the prevention and management of high-output ileostomy after colorectal cancer surgery

Objective: Patients with stage III and high-risk stage II colorectal cancer (CRC) are advised to initiate adjuvant treatment as soon as feasible and certainly before 8 to 12 weeks after resection of the tumor. A protective ileostomy is often constructed during surgery to protect a primary anastomosis “at risk”, especially in rectal cancer surgery. However, up to 17% of patients with a stoma suffer from high output, a major complication that can prevent adjuvant treatment implementation or completion. To avoid delay or cancellation of adjuvant therapy after CRC resection, effective strategies must be implemented to successfully treat and/or prevent high-output stoma (HOS).

Methods: We report two clinical case reports clearly demonstrating the impact and management of HOS in this setting. A review of the available literature and ongoing clinical studies is provided.

Results: The clinical cases describe patients with advanced stage CRC and focus on the different strategies for HOS management, presenting their outcome and how each strategy affects the implementation of adjuvant treatment. The patient population with the highest risk of developing HOS is described, along with the rationale for using somatostatin analogs, such as lanreotide, to treat and prevent high output.

Conclusion: In patients with CRC and protective ileostomies after primary resection, HOS could be treated with somatostatin analogs in combination with dietary recommendations and Saint Mark's solution. The role of this therapeutic approach as a preventive strategy in patients at high risk of developing HOS, deserves further exploration in a prospective randomized clinical trial.

Practical Guide to Intestinal Rehabilitation for Postresection Intestinal Failure: A Case Study

After massive small-intestinal resection or combined small-intestinal and colonic resection, diarrhea with resulting dehydration, electrolyte abnormalities, and malnutrition occur. Many patients become dependent on IV fluids and nutrition. An adaptation process manifested clinically by decreased diarrhea and improved nutrient absorption according to decreased parenteral nutrition and fluid requirements has been noted to occur over time. In some patients, adaptation is inadequate and may require special techniques to enhance and augment this process. This is a case of a 52-year-old woman who experienced increased stoma output 1 week after major intestinal resection, resulting in dehydration. She required IV fluids in order to maintain hydration. After the initiation of an intestinal rehabilitation program, which included modified diet, soluble fiber, oral rehydration solution (ORS), and medications, IV fluids were successfully weaned off in 3 months. She continues not to receive IV fluids and continues to follow the intestinal rehabilitation plan.

Lanreotide Autogel in the Treatment of Idiopathic Refractory Diarrhea: Results of an Exploratory, Controlled, Before and After, Open-label, Multicenter, Prospective Clinical Trial

PURPOSE

Chronic idiopathic diarrhea is the passage of loose stools >3 times daily, or a stool weight >200 g/d, persisting for >4 weeks without clear clinical cause. Patients refractory to standard anti-diarrhetics have limited treatment options. Somatostatin analogues have the ability to reduce gastrointestinal secretions and motility. This study evaluated the efficacy and safety of lanreotide Autogel(*) 120 mg in chronic idiopathic diarrhea.

METHODS

Other anti-diarrhetics were not allowed during the study and were stopped at screening. Patients received lanreotide Autogel 120 mg at baseline and day 28. Stool frequency and consistency (Bristol Stool Scale) were recorded; quality of life (QoL) was assessed using the 36-item Short Form Health Survey and irritable bowel syndrome QoL questionnaires; adverse events were monitored. The primary outcome was the proportion of patients with a reduction of ≥50% or normalization to a mean of ≤3 stools/d at day 28.

FINDINGS

Thirty-three patients with >3 stools/d at baseline were included; mean (SD) age was 55.2 (16.4) years. Fourteen patients (42.4%) had a response to lanreotide Autogel at day 28 and 17 (51.5%) at day 56. Mean (SD) number of stools decreased significantly from 5.7 (2.2) at baseline to 3.7 (2.2) at day 56 overall (n = 32; P < 0.001). Significant and clinically meaningful improvements in disease-specific QoL were found in the overall populations. No new safety signals emerged.

IMPLICATIONS

Lanreotide Autogel 120 mg decreased symptoms in these patients with chronic idiopathic refractory diarrhea, and meaningfully improved QoL. These finding have to be confirmed in further clinical trials. ClinicalTrials.gov

IDENTIFICATION

NCT00891371; Eudract CT 2009-009356-20.

Somatostatin and Its Analogs in the Short Bowel Syndrome

The use of somatostatin to manage diarrhea associated with the short gut syndrome is impractical because of its need to be given by continuous infusion and a rebound effect on stool output with cessation of therapy. Octreotide has been used more successfully to control stool and electrolyte losses in patients with shortened gastrointestinal tracts. In published series and studies, all subjects appear to decrease stool losses, but clinical benefit for long-term use is not achieved for all patients. In the patients who do respond, the need for parenteral nutrition and intravenous hydration has been decreased or eliminated. The optimal dose is unclear, but many patients respond to 50-micrograms injections twice daily. Several investigations noted no additional beneficial effects with escalating dosages. Adverse effects include impairment of fat absorption, which may offset the therapeutic benefits of octreotide. The patients with the greatest response appear to have the least fat malabsorption. Other adverse effects noted when using octreotide for control of the short gut syndrome include pain associated with subcutaneous injection and abdominal complaints. Other potential concerns include the effect on gallstone formation in this high-risk population and intestinal adaptation.

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.

ESPEN guidelines on chronic intestinal failure in adults

BACKGROUND & AIMS

Chronic Intestinal Failure (CIF) is the long-lasting 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. CIF is the rarest organ failure. Home parenteral nutrition (HPN) is the primary treatment for CIF. No guidelines (GLs) have been developed that address the global management of CIF. These GLs have been devised to generate comprehensive recommendations for safe and effective management of adult patients with CIF.

METHODS

The GLs were developed by the Home Artificial Nutrition & Chronic Intestinal Failure Special Interest Group of ESPEN. The GRADE system was used for assigning strength of evidence. Recommendations were discussed, submitted to Delphi rounds, and accepted in an online survey of ESPEN members.

RESULTS

The following topics were addressed: management of HPN; parenteral nutrition formulation; intestinal rehabilitation, medical therapies, and non-transplant surgery, for short bowel syndrome, chronic intestinal pseudo-obstruction, and radiation enteritis; intestinal transplantation; prevention/treatment of CVC-related infection, CVC-related occlusion/thrombosis; intestinal failure-associated liver disease, gallbladder sludge and stones, renal failure and metabolic bone disease. Literature search provided 623 full papers. Only 12% were controlled studies or meta-analyses. A total of 112 recommendations are given: grade of evidence, very low for 51%, low for 39%, moderate for 8%, and high for 2%; strength of recommendation: strong for 63%, weak for 37%.

CONCLUSIONS

CIF management requires complex technologies, multidisciplinary and multiprofessional activity, and expertise to care for both the underlying gastrointestinal disease and to provide HPN support. The rarity of the condition impairs the development of RCTs. As a consequence, most of the recommendations have a low or very low grade of evidence. However, two-thirds of the recommendations are considered strong. Specialized management and organization underpin these recommendations.

The pharmacologic treatment of short bowel syndrome: new tricks and novel agents

Short bowel syndrome (SBS) is a manifestation of massive resection of the intestines resulting in severe fluid, electrolyte, and vitamin/mineral deficiencies. Diet and parenteral nutrition play a large role in the management of SBS; however, pharmacologic options are becoming more readily available. These pharmacologic agents focus on reducing secretions and stimulating intestinal adaptation. The choice of medication is highly dependent on the patient's symptoms, remaining anatomy, and risk versus benefit profile for each agent. This article focuses on common and novel pharmacologic medications used in SBS, including expert advice on their indications and use.

Novel therapies for the management of short bowel syndrome in children

Short bowel syndrome (SBS) is the most common cause of intestinal failure in children. It is defined as the inability to maintain adequate nutrition enterally as a result of a major loss of the small intestine. SBS is a life-threatening entity associated with potential significant morbidity and mortality. The etiology in the pediatric age group includes necrotizing enterocolitis (32%), atresia (20%), volvulus (18%), gastroschisis (17%), and aganglionosis (6%). It is characterized by substrate malabsorption, electrolyte imbalance, intestinal bacterial overgrowth, steatorrhea, and weight loss. Current medical management includes parenteral nutrition, progressive feeds as tolerated, various medications, and surgical manipulations. However, frequently this management is not successful in achieving the goal of attaining normal growth and development without parenteral nutrition. It has been known for decades that there is a normal physiologic response of the residual intestine to massive bowel resection referred to as intestinal adaptation. The mechanisms that control this process are unknown. Unfortunately, intestinal adaptation and the current management are not always successful. As a result of new knowledge regarding the pathophysiology of SBS over the past two decades, several novel strategies have been developed in experimental animal models as well as limited clinical trials in infants and children. They can be divided into several categories that potentially influence intestinal (1) absorption, (2) secretion, (3) motility, and (4) adaptation. More recently, newer modalities have been studied including small intestine transplantation, and the use of specific intestinal growth factors. Ultimately, tissue and organ engineering will become the treatment for infants and children with SBS.

Key issues in addressing the clinical and humanistic burden of short bowel syndrome in the US

BACKGROUND

The purpose of this analysis was to provide a concise report of the literature on the burden of intestinal failure associated with short bowel syndrome (SBS-IF) in adults, focused on clinical and humanistic issues important to clinicians and payers.

SCOPE

A literature search was performed using the National Library of Medicine PubMed database ( http://www.ncbi.nlm.nih.gov/pubmed ) with the search term 'short bowel syndrome' limited to adult populations and English-language reports published from January 1, 1965, to January 18, 2013. Citations were assessed for relevance and excluded articles focused on single case studies, colon fermentation, absorption of medications with PN/IV, surgical technique, mesenteric artery complications/surgery, and transplantation focus. Additional hand searches were performed using the terms 'short bowel syndrome' AND 'cost', and 'home parenteral nutrition' AND 'cost', along with the exclusion criteria described above.

FINDINGS

Despite advances in management in recent decades, SBS-IF continues to carry a high burden of morbidity and mortality. In the absence of sufficient intestinal adaptation following resection, many patients remain dependent on long-term parenteral nutrition and/or intravenous fluids (PN/IV). Although potentially life saving, PN/IV is costly, invasive, and associated with numerous complications and deleterious effects on health and quality of life. Surgical interventions, especially intestinal transplantation, are costly and are associated with substantial morbidity and high mortality. New therapies, which show promise in promoting intestinal rehabilitation and reducing dependence on PN/IV therapy, are the subject of active research.

CONCLUSIONS

Overall, the available literature suggests that although SBS-IF affects a relatively small population, the clinical and humanistic burden is significant, and there is an unmet need for effective therapeutic options that target the underlying problem of inadequate absorptive capacity of the remaining intestine. Consequently, many patients with SBS-IF remain dependent on long-term PN/IV support, adding to the burden imposed by the underlying disorder.

A review of enteral strategies in infant short bowel syndrome: evidence-based or NICU culture?

INTRODUCTION

Short bowel syndrome (SBS) is an increasingly common condition encountered across neonatal intensive care units. Improvements in parenteral nutrition (PN), neonatal intensive care and surgical techniques, in addition to an improved understanding of SBS pathophysiology, have contributed in equal parts to the survival of this fragile subset of infants. Prevention of intestinal failure associated liver disease (IFALD) and promotion of intestinal adaptation are primary goals of all involved in the care of these patients. While enteral nutritional and pharmacological strategies are necessary to achieve these goals, there remains great variability in the application of therapeutic strategies in units that are not necessarily evidence-based.

MATERIALS AND METHODS

A search of major English language medical databases (SCOPUS, Index Medicus, Medline, and the Cochrane database) was conducted for the key words short bowel syndrome, medical management, nutritional management and intestinal adaptation. All pharmacological and nutritional agents encountered in the literature search were classified based on their effects on absorptive capacity, intestinal adaptation and bowel motility that are the three major strategies employed in the management of SBS. The Oxford Center for Evidence-Based Medicine (CEBM) classification for levels of evidence was used to develop grades of clinical recommendation for each variable studied.

RESULTS

We reviewed various medications used and nutritional strategies included soluble fiber, enteral fat, glutamine, probiotics and sodium supplementation. Most interventions have scientific rationale but little evidence to support their role in the management of infant SBS. While some of these agents symptomatically improve diarrhea, they can adversely influence pancreatico-biliary function or actually impair intestinal adaptation. Surgical anatomy and liver function are two important variables that should determine the selection of pharmacological and nutritional interventions.

DISCUSSION

There is a paucity of research investigating optimal clinical practice in infant SBS and the little evidence available is consistently of lower quality, resulting in a wide variation of clinical practices among NICUs. Prospective trials should be encouraged to bridge the evidence gap between research and clinical practice to promote further progress in the field.

Management and complications of stomas

Stomas are created for a wide range of indications such as temporary protection of a high-risk anastomosis, diversion of sepsis, or permanent relief of obstructed defecation or incontinence. Yet this seemingly benign procedure is associated with an overall complication rate of up to 70%. Therefore, surgeons caring for patients with gastrointestinal diseases must be proficient not only with stoma creation but also with managing postoperative stoma-related complications. This article reviews the common complications associated with ostomy creation and strategies for their management.

Randomised controlled trial of colostrum to improve intestinal function in patients with short bowel syndrome

BACKGROUND/OBJECTIVES

Colostrum is rich in immunoregulatory, antimicrobial and trophic components supporting intestinal development and function in newborns. We assessed whether bovine colostrum could enhance intestinal adaptation and function in adult short bowel syndrome (SBS) patients.

SUBJECTS/METHODS

Twelve SBS patients in this randomised cross-over study received 4 weeks oral supplement of bovine colostrum or an iso-energetic and iso-proteinaceous control (2.4 MJ/d, 500 ml/day) separated by a 4-week washout period. Patients were admitted four times for 72-h periods of fluid, electrolyte and nutrient balance studies. Meals, faeces and urine were weighed, and energy, macronutrient and electrolyte contents were analysed to calculate net nutrient uptake. Body composition was measured by dual-energy X-ray absorptiometry scans, and functional tests of handgrip strength and lung functions were performed. Eight patients completed the study and were included in the analysis.

RESULTS

Both supplements (colostrum and control) not only increased protein (0.96 ± 0.42 MJ/d, P=0.004 1.03 ± 0.44 MJ/d, P=0.003) and energy (1.46 ± 1.02 MJ/d, P=0.005, 1.76 ± 1.46 MJ/d, P=0.01) absorption but also absolute faecal wet weight excretions (231 ± 248 g/d, P=0.002, 319 ± 299 g/d, P=0.03), compared with baseline measurements. Both supplements improved handgrip strength (P=0.03) while only the control supplement increased lean body mass (1.12 ± 1.33 kg, P<0.049). Colostrum was not found to be superior to the control.

CONCLUSION

Intake of high-protein milk supplements increased net nutrient absorption for adult SBS patients, but at the expense of increased diarrhoea. Despite high contents of bioactive factors, colostrum did not significantly improve intestinal absorption, body composition or functional tests compared with the control.

Teduglutide, a novel glucagon-like peptide 2 analog, in the treatment of patients with short bowel syndrome

Short bowel syndrome results from surgical resection, congenital defect or disease-associated loss of absorption. Parenteral support (PS) is lifesaving in patients with short bowel syndrome and intestinal failure who are unable to compensate for their malabsorption by metabolic or pharmacologic adaptation. Together, the symptoms of short bowel syndrome and the inconvenience and complications in relation to PS (e.g. catheter-related blood steam infections, central thrombosis and intestinal failure associated liver disease) may impair the quality of life of patients. The aim of treatment is to maximize intestinal absorption, minimize the inconvenience of diarrhea, and avoid, reduce or eliminate the need for PS to achieve the best possible quality of life for the patient. Conventional treatments include dietary manipulations, oral rehydration solutions, and antidiarrheal and antisecretory treatments. However, the evidence base for these interventions is limited and treatments that improve the structural and functional integrity of the remaining intestine are needed. Teduglutide, an analog of glucagon-like peptide 2, improves intestinal rehabilitation by promoting mucosal growth and possibly by restoring gastric emptying and secretion, thereby reducing intestinal losses and promoting intestinal absorption. In a 3-week, phase II balance study, teduglutide reduced diarrhea by around 700 g/day and fecal energy losses by around 0.8 MJ/day. In two randomized, placebo-controlled, 24-week, phase III studies, similar findings were obtained when evaluating the fluid composite effect, which is the sum of the beneficial effects of teduglutide - reduction in the need for PS, increase in urine production and reduction in oral fluid intake. The fluid composite effect reflects the increase in intestinal fluid absorption (and the concomitant reduction in diarrhea) and may be used in studies in which metabolic balance assessments are not performed. In studies of up to 24 weeks' duration, teduglutide appears to be safe and well tolerated. Treatment with teduglutide was associated with enhancement or restoration of the structural and functional integrity of the remaining intestine with significant intestinotrophic and proabsorptive effects, facilitating a reduction in diarrhea and an equivalent reduction in the need for PS in patients with short bowel syndrome and intestinal failure.

Octreotide for the treatment of diarrhoea in patients with ileal pouch anal anastomosis: a placebo-controlled crossover study

AIM

Diarrhoea with urgency is a debilitating long-term complication of ileal pouch anal anastomosis (IPAA) after a proctocolectomy. Somatostatin analogues are used to control diarrhoea and high-output ostomies. Hence, we designed a prospective, double-blind, crossover trial to explore the efficacy and tolerability of octreotide to reduce diarrhoea in adult patients with IPAA.

METHOD

Patients were randomized to octreotide subcutaneously (SC), 500 μg three times daily (t.i.d.), or matching placebo SC for 7 days. Responders (a reduction in stool frequency of three or more stools per 24-h period and with a reduction in stool frequency of at least 30% after 7 days of treatment compared with baseline; the primary end-point) remained in the same group and nonresponders could cross over to the alternative treatment for 7 days. Open-label octeotide LAR 30 mg was offered to all responders on day 14. Flexible pouchoscopy with biopsies was performed at baseline in all patients and was repeated on days 7 and 14 in patients with pouchitis.

RESULTS

Fifteen patients (11 men, median age 52 years), all with ulcerative colitis, were randomized. Three patients were withdrawn for side effects during the blinded phase. Response was achieved by two of 12 and two of 11 patients treated with octreotide or placebo, respectively (including crossover, P = 0.9). The median stool frequency remained stable in both groups [Δoctreotide: 0 (IQR, -4 to 0), Δplacebo: -1 (IQR, -1 to 1), P = 0.45]. Octreotide had no effect on the modified pouch disease activity index (mPDAI), and pouchitis persisted in five of six subjects with pouchitis at onset. One subject received open-label octreotide LAR.

CONCLUSION

Octreotide has no clear beneficial effect on the stool pattern or on pouchitis severity in patients with high stool frequency after IPAA.

Treatment of adult short bowel syndrome patients with teduglutide

INTRODUCTION

Parenteral support is lifesaving in short bowel syndrome patients with intestinal failure (SBS-IF), who are unable to compensate for their malabsorption by metabolic or pharmacologic adaptation. Mutually, the symptoms of SBS-IF and the inconveniences and complications in relation to parenteral support may cause impairment of the quality of life of SBS-IF patients. Conventional treatments include dietary manipulations, oral rehydration solutions, antidiarrheal and antisecretory treatments. However, the evidence base for these interventions is limited, and treatments improving structural and functional integrity of the remaining intestine are desired. Teduglutide , an analog of glucagon-like peptide 2, improves intestinal rehabilitation by promoting mucosal growth and possibly by inhibiting gastric emptying and secretion, which in turn reduces intestinal losses and promotes intestinal absorption.

AREAS COVERED

This paper reviews the following findings: in a 3-week, Phase II balance study, teduglutide reduced diarrhea by ∼ 700 g/day and fecal energy losses by ∼ 0.8 MJ/day, and in a randomized, placebo-controlled, 24-week, Phase III study, corresponding reductions in the need for parenteral support were obtained.

EXPERT OPINION

Teduglutide seems to be safe and well-tolerated and demonstrates restoration of structural and functional integrity of the remaining intestine with significant intestinotrophic and proabsorptive effects, facilitating a reduction in diarrhea and an equivalent reduction in the need for parenteral support in SBS-IF patients.

Pharmacological management of diarrhea

According to the World Health Organization, there are approximately 2 billion annual cases of diarrhea worldwide. Diarrhea is the leading cause of death in children younger than 5 years and kills 1.5 million children each year. It is especially prevalent in the developing world, where mortality is related to dehydration, electrolyte disturbance, and the resultant acidosis, and in 2001, it accounted for 1.78 million deaths (3.7% of total deaths) in low- and middle-income countries. However, diarrhea is also a common problem in the developed world, with 211 million to 375 million episodes of infectious diarrheal illnesses in the United States annually, resulting in 73 million physician consultations, 1.8 million hospitalizations, and 3100 deaths. Furthermore, 4% to 5% of the Western population suffers from chronic diarrhea. Given the high prevalence of diarrhea, research has been directed at learning more about the cellular mechanisms underlying diarrheal illnesses in order to develop new medications directed at novel cellular targets. These cellular mechanisms and targets are discussed in this article.

Ileostomy diarrhea

Ileostomy diarrhea is not an uncommon problem and can lead to considerable loss of quality of life. Unfortunately, well-designed therapeutic trials are lacking, and thus, treatment of patients with ileostomy diarrhea remains largely empiric. The majority of individuals will have "idiopathic" ileostomy diarrhea, or increased output due to proctocolectomy with limited ileal resection alone. Once other, less common causes are excluded, empiric treatment should be initiated with the safest, least costly option. In general, this consists of a dietary evaluation and symptomatic treatment with loperamide and advancing as needed to other, more expensive options, frequently with an increase in side effect profile. Other more recently evaluated treatment options include budesonide and oleic acid; however, efficacy has only been demonstrated in preliminary studies; further evaluation is needed. Limited data exist regarding success of surgical therapy such as reversed peristaltic ileal segments. It remains to be seen if surgery, other than ileostomy revision, has a role in the treatment of ileostomy diarrhea.

Long-term treatment of high intestinal output syndrome with budesonide in patients with Crohn's disease and ileostomy

PURPOSE

In a previous, controlled study, it was shown that orally administered budesonide increases the absorptive capacity of the intestinal mucosa in patients with ileostomies caused by Crohn's disease. This open, nonrandomized study was designed to analyze this functional, not inflammation-dependent steroid-effect in the long-term course comparing exposure, withdrawal, and reexposure.

METHODS

Phase 1: 23 patients without inflammatory activity of the disease received oral budesonide (3 mg t.i.d.) for at least four weeks (36.7 weeks; standard deviation, 45.3 weeks) because of high intestinal output syndrome. Phase 2: Medication was stopped for four weeks. Phase 3: Medication as in Phase 1. In each phase the weight of the ileostomy bags was measured with a spring balance before emptying and documented in a diary. Mean values per day and per week were calculated and the differences statistically evaluated by the Wilcoxon-(Pratt)-test.

RESULTS

Comparing the last week of Phase 1 to first week of Phase 2, a significant (P < 0.0001) increase of the intestinal output (295 g; standard deviation, 313 g) was observed after omitting budesonide. In contrast, comparing the last week of Phase 2 to Phase 3, a significant (P < 0.0001) decrease of the intestinal output by 323.7 g (standard deviation, 322.2 g) was noticed reaching the same level as in Phase 1.

CONCLUSIONS

These data show that the functional, inflammation-independent effect of budesonide on the intestinal mucosa is strongly correlated to the administration of the drug and may be maintained long-term. These results should be confirmed by a larger number of patients.

Intestinal rehabilitation and the short bowel syndrome: part 2

The management of patients with intestinal failure due to short bowel syndrome is complex, requiring a comprehensive approach that frequently necessitates long-term, if not life-long, use of parenteral nutrition. Despite tremendous advances in the provision of parenteral nutrition over the past three decades, which have allowed significant improvements in the survival and quality of life of these patients, this mode of nutritional support carries with it significant risks to the patient, is very costly, and ultimately, does not attempt to improve the function of the remaining bowel. Intestinal rehabilitation refers to the process of restoring enteral autonomy, and thus, allowing freedom from parenteral nutrition, usually by means of dietary, medical, and occasionally, surgical strategies. While recent investigations have focused on the use of trophic substances to increase the absorptive function of the remaining gut, whether intestinal rehabilitation occurs as a consequence of enhanced bowel adaptation or is simply a result of an optimized, comprehensive approach to the care of these patients remains unclear. In Part 1 of this review, we provided an overview of short bowel syndrome and pathophysiological considerations related to the remaining bowel anatomy in these patients. We also reviewed intestinal adaptation and factors that may enhance the adaptive process, focusing on evidence derived from animal studies. In Part 2, relevant data on the development of intestinal adaptation in humans are reviewed as is the general management of short bowel syndrome. Lastly, the potential benefits of a multidisciplinary intestinal rehabilitation program in the care of these patients are also discussed.

The medical management of intestinal failure: methods to reduce the severity

A new definition of intestinal failure is of reduced intestinal absorption so that macronutrient and/or water and electrolyte supplements are needed to maintain health or growth. Severe intestinal failure is when parenteral nutrition and/or fluid are needed and mild intestinal failure is when oral supplements or dietary modification suffice. Treatment aims to reduce the severity of intestinal failure. In the peri-operative period avoiding the administration of excessive amounts of intravenous saline (9 g NaCl/l) may prevent a prolonged ileus. Patients with intermittent bowel obstruction may be managed with a liquid or low-residue diet. Patients with a distal bowel enterocutaneous fistula may be managed with an enteral feed absorbed by the proximal small bowel while no oral intake may be needed for a proximal bowel enterocutaneous fistula. Patients undergoing high-dose chemotherapy can usually tolerate jejunal feeding. Rotating antibiotic courses may reduce small bowel bacterial overgrowth in patients with chronic intestinal pseudoobstruction. Restricting oral hypotonic fluids, sipping a glucose-saline solution (Na concentration of 90-120 mmol/l) and taking anti-diarrhoeal or anti-secretory drugs, reduces the high output from a jejunostomy. This treatment allows most patients with a jejunostomy and > 1 m functioning jejunum remaining to manage without parenteral support. Patients with a short bowel and a colon should consume a diet high in polysaccharides, as these compounds are fermented in the colon, and low in oxalate, as 25% of the oxalate will develop as calcium oxalate renal stones. Growth factors normally produced by the colon (e.g. glucagon-like peptide-2) to induce structural jejunal adaptation have been given in high doses to patients with a jejunostomy and do marginally increase the daily energy absorption.

Sandostatin impairs postresection intestinal adaptation in a rat model of short bowel syndrome

Because of its antisecretory properties, sandostatin has been advocated for the treatment of patients with short bowel syndrome (SBS). This study was conducted to determine the effect of sandostatin on structural intestinal adaptation, cell proliferation and apoptosis in a rat model of SBS. Sprague-Dawley rats were divided into three experimental groups: Sham rats underwent bowel transection, SBS rats underwent 75% small bowel resection, and SBS-sandostatin rats underwent bowel resection and were treated with sandostatin (SBS-SND). Parameters of intestinal adaptation, enterocyte proliferation, and enterocyte apoptosis were determined on day 14 following operation. We have demonstrated that SBS-SND animals demonstrated lower (vs SBS rats) duodenal and jejunal bowel weights, jejunal and ileal mucosal weight, jejunal and ileal mucosal DNA and protein, jejunal and ileal villus height, cell proliferation index in the ileum, and enterocyte apoptosis in jejunum and ileum. We conclude that in a rat model of SBS sandostatin decreases cell proliferation and inhibits structural intestinal adaptation.

Update on management and treatment of short gut

Management of patients with short-bowel syndrome represents a formidable challenge. Aggressive treatment including nutritional care and anticipation of potential complications and rapid treatment of complications enhance outcome. New therapies offer the promise of significantly improving morbidity and mortality. Intestinal transplant is appropriate for infants who would otherwise die from liver disease, recurrent sepsis, or lack of venous access.

Management of patients with a short bowel

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

Systematic review: the use of somatostatin or octreotide in refractory diarrhoea

BACKGROUND

Somatostatin and octreotide have multiple effects which make them ideal for treating diarrhoea of different aetiologies. Their use in a variety of conditions with refractory diarrhoea, however, is based on a limited number of studies.

AIM

We undertook a systematic review of the available English literature to maximize an evidence-based approach to the treatment of refractory diarrhoea. We tested the hypothesis that efficacy is independent of aetiology.

METHODS AND RESULTS

A Medline and individual article search from 1965 to 2000 was undertaken on the use of somatostatin and octreotide in diarrhoea. All reports containing at least five subjects were included. The percentage response in case series and randomized controlled trials was compared, and a meta-analysis of randomized controlled trials where patient level data were provided was carried out. There were 30 publications found (18 case series, 12 randomized controlled trials). The response percentage was 73% overall in case series and 64% in randomized controlled trials (not significant). A meta-analysis of nine randomized controlled trials revealed significant heterogeneity despite an overall relative risk of 0.5 (95% confidence interval, 0.27-0.91). Subgroup analysis of the largest aetiological groups showed that acquired immunodeficiency syndrome studies were homogeneous, but somatostatin and octreotide were less effective. Post-chemotherapy studies remained heterogeneous and somatostatin and octreotide were highly effective.

CONCLUSIONS

While this review strengthens the consensus guidelines on the use of somatostatin and octreotide for refractory diarrhoea, evidence-based support requires additional studies.

Pharmacotherapy and growth factors in the treatment of short bowel syndrome

A review of the pharmacologic substances and growth factors that have been studied experimentally and administered clinically for the management of short bowel syndrome is presented. The medical management of short bowel syndrome is multifaceted. In the acute phase, efforts focus on fluid and electrolyte management and the reduction of gastric acid output. As enteral feeding is initiated, antimotility and antisecretory agents may be effective in reducing gastrointestinal losses. Additional modalities of management, including nutrients and growth factors, may be directed at maximizing absorptive function beyond that which occurs with intestinal adaptation. Continued research aimed at further elucidating the process of intestinal adaptation may allow us to use the various peptides and hormones that act as growth factors for the bowel mucosa. Knowledge gained from these studies combined with gene therapy techniques will result in the permanent enhancement of intestinal function beyond the normal adaptation process, eliminate the dependence on total parenteral nutrition, and avoid the need for intestine transplantation.

An open trial of octreotide long-acting release in the management of short bowel syndrome

OBJECTIVES

The aim of this study was to assess the effects of the long-acting release (LAR) depot octreotide preparation Sandostatin LAR Depot on stool water and electrolyte losses, fecal fat excretion, and GI transit in patients with short bowel syndrome.

METHODS

We performed a 15-wk, prospective, open-label study of intramuscular (i.m.) Sandostatin LAR Depot, 20 mg, at 0, 3, 7, and 11 wk. Balance studies were performed before and at the end of the 15-wk study. Baseline and posttreatment measurements of body weight, stool fat, sodium and potassium, and gastric and small bowel transit of a radiolabeled egg meal were compared by paired analysis.

RESULTS

We studied eight patients with short bowel syndrome (five women and three men; mean age 52 yr, range 37-72 yr) who had been TPN dependent for a mean of 11.8 yr (range 1.5-22 yr). The underlying diagnoses were Crohn's disease (n = 6), intestinal ischemia (n = 1), and resection for carcinoid tumor (n = 1). Treatment with Sandostatin LAR Depot significantly increased small bowel transit time (p = 0.03). Changes in body weight, urine volume, stool weight, fecal fat excretion, stool sodium and potassium excretion, or gastric emptying rate were highly variable, and no overall significance was observed.

CONCLUSIONS

Sandostatin LAR Depot for 15 wk significantly prolonged small bowel transit time. Body weight and stool parameters in response to Sandostatin LAR Depot treatment needs to be assessed further in multicenter studies assessing dose, frequency of administration, and a larger sample size.

Management of patients with a short bowel

Short bowel syndrome most commonly results after bowel resections for Crohn's disease. The normal human small intestinal length ranges from about 3 to 8 m, thus if the initial small intestinal length is short, a relatively small resection of the intestine may result in the problems of a short bowel. Two types of patient with a short bowel are encountered in clinical practice: those with their jejunum anastomosed to a functioning colon, and those with a jejunostomy. Both types of patient have problems absorbing adequate macronutrients, and both need long-term vitamin B12 therapy. Patients with a jejunostomy also have major problems with large stomal losses of water, sodium, and magnesium. This high-volume jejunostomy output is treated by restricting oral fluids, giving a glucose-saline solution to drink, and using drugs that either reduce gastrointestinal motility (loperamide or codeine phosphate) or secretions (H2 antagonists, proton pump inhibitors, or octreotide). Patients whose jejunal length is less than 100 cm, and whose stomal output is greater than their oral intake, benefit most from antisecretory drugs. In patients with a retained colon, bacterial fermentation of unabsorbed carbohydrate in the colon results in energy being salvaged. However, they have increased oxalate absorption and a 25% chance of developing calcium oxalate renal stones. Thus patients with a colon are advised to eat a high-energy diet rich in carbohydrate but low in oxalate. Patients with a jejunostomy need a high-energy iso-osmolar diet with added salt. Both patient types have a 45% prevalence of gallstones. With current therapy most patients with a short bowel have a normal body mass index and a good quality of life.

Effect of octreotide (Sandostatin 201-995) on bile flow and bile components

Octreotide (Sandostatin 201-995) has an inhibitory effect on gastric, intestinal, and pancreatic secretions and hepatic and splachnic blood flow. We examined the effects of octreotide on bile flow and bile components in 10 patients with T-tube choledochostomy. A Fogarty balloon catheter was inserted distal to the T-tube of these patients for measurement of bile flow and bile components. Bile samples were obtained to analyze bile acid, phospholipid, lipoprotein, and cholesterol, and bile flow measurements were performed every 15 min for a period of 90 min before study and after normal saline and octreotide administrations. While octreotide had an inhibitory effect on bile flow, the concentrations of bile acid, phospholipid, and lipoprotein in bile were increased with octreotide.

Lack of inhibitory effect of octreotide on intestinal adaptation in short bowel syndrome in the rat

BACKGROUND

Octreotide is a long-acting analogue of somatostatin, which is effective in the treatment of secretory diarrhea in a number of disorders including short bowel syndrome. Its use in this syndrome has been limited because of concerns about potential adverse effect on intestinal adaptation, because it inhibits a number of trophic hormones. This study was conducted to determine whether octreotide inhibits intestinal adaptation in a rat model of short bowel syndrome.

METHODS

Thirty male Sprague-Dawley rats were divided into four treatment groups, eight receiving 80% small-bowel resection and treated with 2.25 microg/kg(-1) per day(-1) of octreotide, eight receiving 80% small-bowel resection and treated with 25 microg/kg(-1) per day(-1) of octreotide, eight receiving 80% small-bowel resection with saline control, and six receiving sham operation with saline control. Mucosal weight, protein, and sucrase levels were subsequently analyzed after 2 weeks of therapy.

RESULTS

Massive adaptation occurred in all three groups relative to sham-operated controls. However, neither the pharmacologic nor the much higher dose of octreotide demonstrated any adverse effects on intestinal adaptation.

CONCLUSION

In our animal model, octreotide does not inhibit intestinal adaptation after massive small-bowel resection.

Effects of somatostatin on luminal transit and absorption of nutrients in the proximal gut of minipigs

A discrepancy exists on the effects of somatostatin on the absorption of nutrients: in humans, absorption was found to be reduced, whereas in rats no effects were observed. However, intestinal absorption might be influenced by the transit rate of contents. This was not considered in previous studies. Therefore, we investigated simultaneously the effects of somatostatin on the absorption of nutrients and on luminal transit. In five minipigs (44-62 kg), a 150-cm segment of the proximal jejunum was temporarily isolated by two cannulas and perfused with an oligomer diet (60% carbohydrate, 18% protein, and 22% fat). The perfusion rate was 2 kcal/min. Flow rate and mean transit time were determined by markers (Cr-EDTA and Cu-EDTA). Somatostatin was infused intravenously at rates of 0.5, 1.25, 2.5, and 5 micrograms/kg/hr. In control experiments saline was administered intravenously. Somatostatin dose-dependently diminished flow rate of luminal contents and increased the transit time. At the largest dose of somatostatin (5 micrograms/kg/hr) flow rate was reduced by 50% compared with control infusion of saline (1.0 +/- 0.4 vs 2.0 +/- 0.05 ml/min, P < 0.05), and transit time was increased 3.6-fold (39.8 +/- 4.7 vs 11.2 +/- 4.9 min; P < 0.05). Somatostatin also dose-dependently enhanced the absorption of nutrients and energy. However, the increase in absorption was small compared with the effects on flow rate and transit time. At the largest dose (5 micrograms/kg/hr) absorption of energy, carbohydrate, protein, and fat was enhanced only by 9.7%, 7.0%, 5.2%, and 15.3%, respectively (49.9 vs 40.2%, 50.9 vs 43.9%, 67.3 vs 62.1%, and 30.1 vs 14.8% during saline infusion; P < 0.05). Results indicate that the major effects of somatostatin consist in a marked reduction of flow rate and a delay of luminal transit. The small increase in absorption was caused by the delay in transit and the prolonged contact of the nutrients with the mucosa. Therefore, in absorption studies, effects on transit need to be considered.

Short bowel syndrome in children and small intestinal transplantation

This article discusses the management of short bowel syndrome from the time of intestinal resection until the patient either recovers free of supplemental parenteral and enteral nutrition or progresses to the point of needing intestinal transplantation. The importance of aggressive use of enteral feedings is emphasized, especially in relation to the process of intestinal adaptation. An approach to the various complications of short bowel syndrome, especially small bowel bacterial overgrowth, is discussed. Surgical options short of transplantation also are described. Intestinal transplantation and its present and future roles in the management of patients with short bowel syndrome are discussed.

The randomized controlled clinical trial in gastroenterology: the Danish contributions from 1970 to 1994

More than 200 Danish randomized controlled clinical trials in gastroenterology published from 1970 to 1994 were retrieved by electronic media, by hand-searching relevant journals, and by direct requests to Danish gastroenterologists. With the historical perspective through a quarter of a century, these papers are outlined to provide a survey of the pieces of information that Danish gastroenterologists have contributed to the present knowledge of therapeutics. The presented randomized controlled clinical trials constitute an impressive sum of knowledge within a diversity of topics. A cautious analysis of the time pattern for the publications in addition to the contents of the reports discloses that the discipline of planning and executing relevant controlled clinical trials is now in blossom in Danish gastroenterology.