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Chatzidaki V, Wood R, Alegakis A, Lawson M, Fagbemi A. Parenteral support and micronutrient deficiencies in children with short bowel syndrome: A comprehensive retrospective study. Clin Nutr ESPEN 2023; 58:270-276. [PMID: 38057017 DOI: 10.1016/j.clnesp.2023.10.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2023] [Revised: 10/08/2023] [Accepted: 10/10/2023] [Indexed: 12/08/2023]
Abstract
BACKGROUND & AIMS Short bowel syndrome (SBS) is the leading cause of chronic intestinal failure. The duration of parenteral support (PS) and the long-term micronutrient needs in children with SBS vary, based on their clinical and anatomical characteristics. Our study aimed to review the clinical course and identify high risk patient groups for prolonged PS and long-term micronutrient supplementation. METHODS A retrospective review was conducted on electronic medical records of children with SBS and chronic intestinal failure who were enrolled in the multidisciplinary intestinal rehabilitation program at Manchester Children's Hospital, UK. Children were included in the review if they required PN for more than 60 days out of 74 consecutive days and had at least 3 years of follow-up. Statistical analysis was performed using IBM SPSS Statistics 24.0. RESULTS 40 children with SBS achieved enteral autonomy (EA) and 14 remained dependent on PS after 36 months of follow up. Necrotizing enterocolitis was the most common cause for intestinal resection (38.9%) followed by gastroschisis (22.2%), malrotation with volvulus (20.4%), segmental volvulus (9.3%) and long segment Hirschsprung disease (1.9%). Those who achieved EA had significantly longer intestinal length 27.5% (15.0-39.3) than those who remained on PS 6.0% (1.5-12.5) (p < 0.001). Type I SBS was only found in the PS cohort. Median PN dependence was 10.82 months [IQR 5.73-20.78]. Congenital diagnosis was associated with longer PN dependence (21.0 ± 20.0) than acquired (8.7 ± 7.8 months), (p = 0.02). The need for micronutrient supplementation was assessed after the transition to EA; 87.5% children had at least one micronutrient depletion, most commonly Vitamin D (64.1%), followed by iron (48.7%), Vitamin B12 (34.2%), and vitamin E (28.6%). Iron deficiency and vitamin A depletion were correlated with longer PS after multivariate analysis (OR: 1.103, 1.006-1.210, p = 0.037 and OR: 1.048, 0.998-1.102, p = 0.062 respectively). CONCLUSION In our cohort, small bowel length was the main predictor for EA. Children on longer PS, had more often a congenital cause of resection and were at risk for micronutrient deficiencies in EA.
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Affiliation(s)
- V Chatzidaki
- Department of Pediatric Gastroenterology, Royal Manchester Children's Hospital, NHS Foundation Trust, UK.
| | - R Wood
- Department of Pediatric Gastroenterology, Royal Manchester Children's Hospital, NHS Foundation Trust, UK
| | - A Alegakis
- Laboratory of Toxicology, University of Crete, Greece
| | - M Lawson
- Department of Pediatric Gastroenterology, Royal Manchester Children's Hospital, NHS Foundation Trust, UK
| | - A Fagbemi
- Department of Pediatric Gastroenterology, Royal Manchester Children's Hospital, NHS Foundation Trust, UK
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Fourati S, de Dreuille B, Bettolo J, Hutinet C, Le Gall M, Bado A, Joly F, Le Beyec J. Hyperphagia is prominent in adult patients with short bowel syndrome: A role for the colon? Clin Nutr 2023; 42:2109-2115. [PMID: 37751660 DOI: 10.1016/j.clnu.2023.09.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2023] [Revised: 08/24/2023] [Accepted: 09/03/2023] [Indexed: 09/28/2023]
Abstract
RATIONALE Short Bowel Syndrome (SBS) is the major cause of chronic intestinal failure (IF) and requires parenteral nutrition (PN). After bowel resection, some patients develop spontaneous intestinal adaptations and hyperphagia. Since promoting oral energy intake contributes to PN weaning, this study aims to characterize hyperphagia in patients with SBS and identify its determinants. METHODS This observational retrospective study included adult patients with SBS who were followed at an expert PN center between 2006 and 2019, with at least 2 separate nutritional assessments. Exclusion criteria were: active neoplasia, alternative treatment for IF or appetite-affecting medication. Resting energy expenditure (REE) was calculated for each patient using the Harris-Benedict equation. Food Intake Ratio (FIR) was calculated by dividing the highest caloric oral intake by REE and hyperphagia was defined as FIR >1.5. RESULTS Among the 59 patients with SBS included in this study, 82.6% had a FIR >1.5, including 15.5% with a FIR >3. Protein supplied approximately 16% of total energy intake while fat and carbohydrates provided 36% and 48%, respectively. The FIR was independent of gender and whether patients received oral nutrition alone (n = 28) or combined with PN (n = 31). The FIR was also not associated with residual small bowel length, nor the proportion of preserved colon. However, it was negatively correlated with the body mass index (BMI) of these patients (r = -0.533, p < 0.001), whether they had PN support or not. Patients with either a jejuno-colonic (n = 31) or a jejuno-ileal anastomosis (n = 9), had a significantly higher FIR compared to those with an end-jejunostomy (n = 18) (p < 0.05). However, no difference was found in the proportion of calories provided by protein, fat and carbohydrate between the 3 patients groups divided according to the SBS anatomical type. CONCLUSION A large majority of patients with SBS exhibited a hyperphagia regardless of PN dependence or bowel length, which was inversely correlated with BMI. The presence of the colon in continuity, thus in contact with the nutritional flow, seems to favor a higher oral intake which is beneficial for the nutritional autonomy of patients. This raises the question of a role of colonic microbiota and hormones in this behavior. Finally, this study also revealed an unexpected discrepancy between recommended energy intakes from protein, fat and carbohydrate and the actual intake of patients with SBS.
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Affiliation(s)
- Salma Fourati
- UMR-S 1149 Centre de Recherche sur l'Inflammation Inserm, Université Paris Cité, 75018 Paris, France; Service de Biochimie Endocrinienne et Oncologique, Hôpital de la Pitié-Salpêtrière-Charles Foix, Sorbonne Université, 75013 Paris, France.
| | - Brune de Dreuille
- UMR-S 1149 Centre de Recherche sur l'Inflammation Inserm, Université Paris Cité, 75018 Paris, France
| | - Joanna Bettolo
- Department of Gastroenterology and Nutritional Support, Center for Intestinal Failure, Reference Centre of Rare Disease MarDI, AP-HP Beaujon Hospital, University of Paris Inserm UMR 1149, Paris, France
| | - Coralie Hutinet
- Department of Gastroenterology and Nutritional Support, Center for Intestinal Failure, Reference Centre of Rare Disease MarDI, AP-HP Beaujon Hospital, University of Paris Inserm UMR 1149, Paris, France
| | - Maude Le Gall
- UMR-S 1149 Centre de Recherche sur l'Inflammation Inserm, Université Paris Cité, 75018 Paris, France
| | - André Bado
- UMR-S 1149 Centre de Recherche sur l'Inflammation Inserm, Université Paris Cité, 75018 Paris, France
| | - Francisca Joly
- UMR-S 1149 Centre de Recherche sur l'Inflammation Inserm, Université Paris Cité, 75018 Paris, France; Department of Gastroenterology and Nutritional Support, Center for Intestinal Failure, Reference Centre of Rare Disease MarDI, AP-HP Beaujon Hospital, University of Paris Inserm UMR 1149, Paris, France
| | - Johanne Le Beyec
- UMR-S 1149 Centre de Recherche sur l'Inflammation Inserm, Université Paris Cité, 75018 Paris, France; Service de Biochimie Endocrinienne et Oncologique, Hôpital de la Pitié-Salpêtrière-Charles Foix, Sorbonne Université, 75013 Paris, France
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Fourati S, Hamon A, Daclat R, Salem JE, Peoc’h K, Le Beyec J, Joly F, Lacorte JM. Circulating Apolipoprotein B-48 as a Biomarker of Parenteral Nutrition Dependence in Adult Patients with Short Bowel Syndrome. Nutrients 2023; 15:3982. [PMID: 37764766 PMCID: PMC10536633 DOI: 10.3390/nu15183982] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2023] [Revised: 09/05/2023] [Accepted: 09/11/2023] [Indexed: 09/29/2023] Open
Abstract
Short bowel syndrome (SBS) is a rare but serious condition that may lead to chronic intestinal failure. Citrulline concentrations are currently used to reflect the residual intestinal mass in patients with SBS, although this method has several limitations. In a cohort of patients with SBS, we quantified apolipoprotein B-48 (ApoB-48), which is exclusively synthesized by enterocytes and secreted associated with dietary lipids and investigated the relationship between ApoB-48 and clinical and biological data as well as PN dependence. A total of 51 adult patients were included, 36 of whom were PN-dependent. We found a robust positive correlation between circulating ApoB-48 and residual small bowel length, which was also found in the subgroup of patients with jejunocolic anastomosis. Fasting ApoB-48 levels were significantly lower in PN-dependent patients than in PN-weaned patients and negatively correlated with parenteral nutrition dependence. Our results suggest that ApoB-48 could be proposed as a marker of intestinal absorptive function and could be an interesting follow-up marker in patients with SBS.
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Affiliation(s)
- Salma Fourati
- Service de Biochimie Endocrinienne et Oncologique, Pitié-Salpêtrière Hospital, Assistance Publique-Hôpitaux de Paris, UMR-S 1149 Centre de Recherche sur l’Inflammation Inserm, Paris Cité University, 75013 Paris, France
| | - Annick Hamon
- Department of Gastroenterology, IBD and Nutrition Support, CRMR MarDi, Beaujon Hospital, Assistance Publique-Hôpitaux de Paris, 92110 Clichy, France
| | - Rita Daclat
- UMR_S1166, Research Institute of Cardiovascular Disease, Metabolism and Nutrition Inserm, Pitié-Salpêtrière Hospital, Sorbonne University, 75013 Paris, France
| | - Joe-Elie Salem
- Department of Pharmacology and Clinical Investigation Centre (CIC-1901), Pitié-Salpêtrière Hospital, Assistance Publique-Hôpitaux de Paris, Sorbonne University, INSERM, 75013 Paris, France
| | - Katell Peoc’h
- Department of Biochemistry, CRI INSERM UMR1149, HUPNVS, Assistance Publique-Hôpitaux de Paris, Paris Cité University, 75018 Paris, France
| | - Johanne Le Beyec
- Service de Biochimie Endocrinienne et Oncologique, Pitié-Salpêtrière Hospital, Assistance Publique-Hôpitaux de Paris, UMR-S 1149 Centre de Recherche sur l’Inflammation Inserm, Sorbonne University, 75013 Paris, France;
| | - Francisca Joly
- Department of Gastroenterology, IBD and Nutrition Support, CRMR MarDi, Beaujon Hospital, Assistance Publique-Hôpitaux de Paris, 92110 Clichy, UMR-S 1149 Centre de Recherche sur l’Inflammation Inserm, Université Paris Cité, 75018 Paris, France;
| | - Jean-Marc Lacorte
- Service de Biochimie Endocrinienne et Oncologique, Pitié-Salpêtrière Hospital, Assistance Publique-Hôpitaux de Paris, Research Unit on Cardiovascular and Metabolic Disease, UMR ICAN, Sorbonne University, Inserm, 75013 Paris, France;
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de Dreuille B, Fourati S, Joly F, Le Beyec-Le Bihan J, le Gall M. [Short bowel syndrome: From intestinal insufficiency to intestinal adaptation]. Med Sci (Paris) 2021; 37:742-751. [PMID: 34491182 DOI: 10.1051/medsci/2021110] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
The short bowel syndrome results from an extensive intestinal resection. When intestinal function is below the minimum necessary for the absorption of macronutrients, water and electrolytes, short small bowel syndrome is responsible for chronic intestinal failure. The management is then parenteral nutrition. The evolution of the short bowel syndrome is schematically divided into three successive periods: (a) Immediate postoperative period lasting 3 to 6 weeks; (b) adaptive period lasting about 2 years and (c) stabilization period. However, the development of hyperphagia, spontaneous intestinal adaptation allowing an increase in the absorption surface area and in secretion of enterohormones and a modification of the microbiota occur spontaneously, improving intestinal absorption and decreasing dependence on parenteral nutrition. This review summarizes the main positive and negative pathophysiological consequences of extensive intestinal resection and the nutritional and drug management of short bowel syndrome in adults.
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Affiliation(s)
- Brune de Dreuille
- Centre de recherche sur l'inflammation, UMRS 1149, Université de Paris, Inserm, Hôpital Bichat 16 rue Henri Huchard, 75018 Paris, France - Département de gastroentérologie et assistance nutritive, Hôpital Beaujon, 100 boulevard du général Leclerc, 92110 Clichy, France
| | - Salma Fourati
- Centre de recherche sur l'inflammation, UMRS 1149, Université de Paris, Inserm, Hôpital Bichat 16 rue Henri Huchard, 75018 Paris, France - Département de biochimie endocrinienne et oncologique, Hôpital de la Pitié-Salpêtrière, 47-83 boulevard de l'hôpital, 75013 Paris, France
| | - Francisca Joly
- Centre de recherche sur l'inflammation, UMRS 1149, Université de Paris, Inserm, Hôpital Bichat 16 rue Henri Huchard, 75018 Paris, France - Département de gastroentérologie et assistance nutritive, Hôpital Beaujon, 100 boulevard du général Leclerc, 92110 Clichy, France
| | - Johanne Le Beyec-Le Bihan
- Centre de recherche sur l'inflammation, UMRS 1149, Université de Paris, Inserm, Hôpital Bichat 16 rue Henri Huchard, 75018 Paris, France - Département de biochimie endocrinienne et oncologique, Hôpital de la Pitié-Salpêtrière, 47-83 boulevard de l'hôpital, 75013 Paris, France
| | - Maude le Gall
- Centre de recherche sur l'inflammation, UMRS 1149, Université de Paris, Inserm, Hôpital Bichat 16 rue Henri Huchard, 75018 Paris, France
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Abstract
Abstract
Introduction Short bowel syndrome (SBS) refers to the malabsorptive state that occurs following extensive intestinal resection and is associated with several complications.
Methods The research for this review was conducted in the Pubmed database. Relevant scientific articles dated between 1991 and 2015 and written in Portuguese, Spanish or English were selected.
Results Several therapies, including nutritional support, pharmacological options and surgical procedures have been used in these patients.
Conclusions Over the last decades new surgical and pharmacological approaches emerged, increasing survival and quality of life (QoL) in patients with SBS. All SBS patients ought to have an individualized and multidisciplinary care that promotes intestinal rehabilitation.
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Affiliation(s)
- Rosário Eça
- Universidade do Porto, Faculdade de Medicina, Porto, Portugal
| | - Elisabete Barbosa
- Universidade do Porto, Faculdade de Medicina, Porto, Portugal
- Centro Hospitalar de São João, Serviço de Cirurgia Geral, Porto, Portugal
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Knop V, Neuberger SC, Marienfeld S, Bojunga J, Herrmann E, Poynard T, Zeuzem S, Blumenstein I, Friedrich-Rust M. Intestinal failure-associated liver disease in patients with short bowel syndrome: Evaluation by transient elastography. Nutrition 2019; 63-64:134-140. [DOI: 10.1016/j.nut.2019.02.001] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2018] [Revised: 12/27/2018] [Accepted: 02/11/2019] [Indexed: 12/13/2022]
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McFarlane IM, Bhamra MS, Kreps A, Iqbal S, Al-Ani F, Saladini-Aponte C, Grant C, Singh S, Awwal K, Koci K, Saperstein Y, Arroyo-Mercado FM, Laskar DB, Atluri P. Gastrointestinal Manifestations of Systemic Sclerosis. ACTA ACUST UNITED AC 2018; 8. [PMID: 30057856 PMCID: PMC6059963 DOI: 10.4172/2161-1149.1000235] [Citation(s) in RCA: 62] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Systemic sclerosis (SSc) is a rare autoimmune disease characterized by fibroproliferative alterations of the microvasculature leading to fibrosis and loss of function of the skin and internal organs. Gastrointestinal manifestations of SSc are the most commonly encountered complications of the disease affecting nearly 90% of the SSc population. Among these complications, the esophagus and the anorectum are the most commonly affected. However, this devastating disorder does not spare any part of the gastrointestinal tract (GIT), and includes the oral cavity, esophagus, stomach, small and large bowels as well as the liver and pancreas. In this review, we present the current understanding of the pathophysiologic mechanisms of SSc including vasculopathy, endothelial to mesenchymal transformation as well as the autoimmune pathogenetic pathways. We also discuss the clinical presentation and diagnosis of each part of the GIT affected by SSc. Finally, we highlight the latest developments in the management of this disease, addressing the severe malnutrition that affects this vulnerable patient population and ways to assess and improve the nutritional status of the patients.
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Affiliation(s)
- Isabel M McFarlane
- Division of Rheumatology and Gastroenterology, Department of Medicine and Pathology, Hospitals Kings County Hospital Brooklyn, State University of New York, USA
| | - Manjeet S Bhamra
- Division of Rheumatology and Gastroenterology, Department of Medicine and Pathology, Hospitals Kings County Hospital Brooklyn, State University of New York, USA
| | - Alexandra Kreps
- Division of Rheumatology and Gastroenterology, Department of Medicine and Pathology, Hospitals Kings County Hospital Brooklyn, State University of New York, USA
| | - Sadat Iqbal
- Division of Rheumatology and Gastroenterology, Department of Medicine and Pathology, Hospitals Kings County Hospital Brooklyn, State University of New York, USA
| | - Firas Al-Ani
- Division of Rheumatology and Gastroenterology, Department of Medicine and Pathology, Hospitals Kings County Hospital Brooklyn, State University of New York, USA
| | - Carla Saladini-Aponte
- Division of Rheumatology and Gastroenterology, Department of Medicine and Pathology, Hospitals Kings County Hospital Brooklyn, State University of New York, USA
| | - Christon Grant
- Division of Rheumatology and Gastroenterology, Department of Medicine and Pathology, Hospitals Kings County Hospital Brooklyn, State University of New York, USA
| | - Soberjot Singh
- Division of Rheumatology and Gastroenterology, Department of Medicine and Pathology, Hospitals Kings County Hospital Brooklyn, State University of New York, USA
| | - Khalid Awwal
- Division of Rheumatology and Gastroenterology, Department of Medicine and Pathology, Hospitals Kings County Hospital Brooklyn, State University of New York, USA
| | - Kristaq Koci
- Division of Rheumatology and Gastroenterology, Department of Medicine and Pathology, Hospitals Kings County Hospital Brooklyn, State University of New York, USA
| | - Yair Saperstein
- Division of Rheumatology and Gastroenterology, Department of Medicine and Pathology, Hospitals Kings County Hospital Brooklyn, State University of New York, USA
| | - Fray M Arroyo-Mercado
- Division of Rheumatology and Gastroenterology, Department of Medicine and Pathology, Hospitals Kings County Hospital Brooklyn, State University of New York, USA
| | - Derek B Laskar
- Division of Rheumatology and Gastroenterology, Department of Medicine and Pathology, Hospitals Kings County Hospital Brooklyn, State University of New York, USA
| | - Purna Atluri
- Division of Rheumatology and Gastroenterology, Department of Medicine and Pathology, Hospitals Kings County Hospital Brooklyn, State University of New York, USA
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Wong C, Lucas B, Wood D. Patients' experiences with home parenteral nutrition: A grounded theory study. Clin Nutr ESPEN 2018; 24:100-108. [PMID: 29576346 DOI: 10.1016/j.clnesp.2018.01.005] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2017] [Revised: 11/22/2017] [Accepted: 01/17/2018] [Indexed: 11/18/2022]
Abstract
BACKGROUND & AIMS Parenteral nutrition (PN) provides nourishment and hydration as an intravenous infusion to patients with intestinal failure (IF). The aim of the study is to generate theory that explains the experiences of adult patients living with home parenteral nutrition (HPN) and complex medication regimens. METHODS A grounded theory methodology was used to explore the experiences of twelve patients receiving HPN. A semi-structured interview was conducted and recorded in each participant's home setting. Each interview was transcribed verbatim. The simultaneous process of data collection and analysis was followed reflecting the principles of the constant comparative approach. RESULTS A total of 15 patients gave written consent, with 12 of them agreeing to be interviewed. All the participants had previously undergone surgery as a result of chronic ill health or sudden illness. Analysis revealed two core categories: stoma and HPN, and these were supported by the subcategories: maintaining stoma output, access to toilets, managing dietary changes, maintaining the HPN infusion routine, access to technical help to set up an HPN infusion, mobility with HPN equipment and general health changes. The strategy of living with loss was demonstrated by all the participants, and this was supported by the action strategies of maintaining daily activities and social interactions. CONCLUSIONS This study generates new understanding and insight into the views and experiences of patients receiving HPN in the UK. The findings from these participants have been shown to resonate with the Kubler-Ross Model [1] of the five stages of grief. The theory of living with loss was generated by the use of a grounded theory methodology. This small scale exploratory study reveals opportunities for improvements in practice to be considered by the nutrition support team (NST) and other healthcare professionals involved in the patient's hospital stay prior to discharge on HPN.
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Affiliation(s)
- Christina Wong
- Department of Pharmacy, Northern General Hospital, Sheffield Teaching Hospitals NHS Foundation Trust, Herries Road, Sheffield S5 7AU, UK.
| | - Beverley Lucas
- Faculty of Health Studies, University of Bradford, Richmond Building, Richmond Road, Bradford BD7 1DP, UK
| | - Diana Wood
- Bradford School of Pharmacy, University of Bradford, Richmond Building, Richmond Road, Bradford BD7 1DP, UK
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Chandra R, Kesavan A. Current treatment paradigms in pediatric short bowel syndrome. Clin J Gastroenterol 2017; 11:103-112. [PMID: 29280097 DOI: 10.1007/s12328-017-0811-7] [Citation(s) in RCA: 36] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/21/2017] [Accepted: 12/18/2017] [Indexed: 12/23/2022]
Abstract
Pediatric short bowel syndrome (SBS) is a serious condition which occurs in children with congenital or acquired reduction in length of the small intestine. SBS results in excessive fluid loss, nutrient malabsorption, electrolyte abnormalities, increased susceptibility to infections, parenteral nutrition associated complications and affects weight gain and growth. In children, SBS is debilitating and uniformly fatal without treatment. The primary goal of treatment is to restore enteral autonomy and reduce long-term dependence on parenteral support by increasing the absorptive potential of the remnant intestine. In this review, the medical and surgical management of SBS including pharmacologic agents, parenteral nutrition, dietary strategies, surgical lengthening procedures, and small bowel transplant will be discussed.
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Affiliation(s)
- Raghav Chandra
- Doctor of Medicine (MD) Program, Rush Medical College, 600 S. Paulina St, Chicago, IL, 60612, USA
| | - Anil Kesavan
- Section of Pediatric Gastroenterology, Rush University Medical Center, Professional Building, 1725 W. Harrison Street, Suite 710, Chicago, IL, 60612, USA.
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Joshi A, Siva C. Magnesium disorders can cause calcium pyrophosphate deposition disease: A case report and literature review. Eur J Rheumatol 2017; 5:53-57. [PMID: 29657876 DOI: 10.5152/eurjrheum.2017.16116] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2016] [Accepted: 03/16/2017] [Indexed: 01/15/2023] Open
Abstract
Calcium pyrophosphate deposition (CPPD) disease, also known as pseudogout, is one of the most common forms of inflammatory arthritis. A variety of comorbidities and metabolic conditions have been recognized to predispose to CPPD. We describe here a patient with chronic CPP arthritis due to hypomagnesemia, which is one of the metabolic etiologies associated with CPPD, especially in younger patients. We also performed a literature search and reviewed all reported cases of CPPD disease associated with hypomagnesemia. All cases of hypomagnesemia and its etiologies leading to CPP arthropathy identified in the literature by this systematic search are summarized in this paper.
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Affiliation(s)
- Akanksha Joshi
- Division of Rheumatology, Department of Internal Medicine, University of Missouri, Columbia, MO, USA
| | - Chokkalingam Siva
- Division of Rheumatology, Department of Internal Medicine, University of Missouri, Columbia, MO, USA
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12
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Gaifulina R, Maher AT, Kendall C, Nelson J, Rodriguez-Justo M, Lau K, Thomas GM. Label-free Raman spectroscopic imaging to extract morphological and chemical information from a formalin-fixed, paraffin-embedded rat colon tissue section. Int J Exp Pathol 2016; 97:337-350. [PMID: 27581376 PMCID: PMC5061758 DOI: 10.1111/iep.12194] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2016] [Accepted: 05/04/2016] [Indexed: 12/19/2022] Open
Abstract
Animal models and archived human biobank tissues are useful resources for research in disease development, diagnostics and therapeutics. For the preservation of microscopic anatomical features and to facilitate long-term storage, a majority of tissue samples are denatured by the chemical treatments required for fixation, paraffin embedding and subsequent deparaffinization. These aggressive chemical processes are thought to modify the biochemical composition of the sample and potentially compromise reliable spectroscopic examination useful for the diagnosis or biomarking. As a result, spectroscopy is often conducted on fresh/frozen samples. In this study, we provide an extensive characterization of the biochemical signals remaining in processed samples (formalin fixation and paraffin embedding, FFPE) and especially those originating from the anatomical layers of a healthy rat colon. The application of chemometric analytical methods (unsupervised and supervised) was shown to eliminate the need for tissue staining and easily revealed microscopic features consistent with goblet cells and the dense populations of cells within the mucosa, principally via strong nucleic acid signals. We were also able to identify the collagenous submucosa- and serosa- as well as the muscle-associated signals from the muscular regions and blood vessels. Applying linear regression analysis to the data, we were able to corroborate this initial assignment of cell and tissue types by confirming the biological origin of each layer by reference to a subset of authentic biomolecular standards. Our results demonstrate the potential of using label-free Raman microspectroscopy to obtain superior imaging contrast in FFPE sections when compared directly to conventional haematoxylin and eosin (H&E) staining.
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Affiliation(s)
- Riana Gaifulina
- Department of Cell and Developmental Biology, University College London, London, UK
| | - Andrew Thomas Maher
- Department of Cell and Developmental Biology, University College London, London, UK
- CoMPLEX, University College London, London, UK
| | - Catherine Kendall
- Biophotonics Research Unit, Gloucestershire Royal Hospital, Gloucester, UK
| | - James Nelson
- Department of Statistical Science, University College London, London, UK
| | | | - Katherine Lau
- Spectroscopy Products Division, Renishaw Plc, Wotton-under-Edge, UK
| | - Geraint Mark Thomas
- Department of Cell and Developmental Biology, University College London, London, UK.
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Carroll RE, Benedetti E, Schowalter JP, Buchman AL. Management and Complications of Short Bowel Syndrome: an Updated Review. Curr Gastroenterol Rep 2016; 18:40. [PMID: 27324885 DOI: 10.1007/s11894-016-0511-3] [Citation(s) in RCA: 47] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/06/2023]
Abstract
Short bowel syndrome (SBS) is defined as loss of bowel mass from surgical resection, congenital defects, or disease. Intestinal failure (IF) includes the subset of SBS unable to meet nutrition needs with enteral supplements and requires parenteral nutrition (PN). The parenteral treatment of SBS is now a half-century old. Recent pharmacologic treatment (GLP-2 analogues) has begun to make a significant impact in the care and ultimate management of these patients such that the possibility of reducing PN requirements in formerly PN-dependent patients is a now a real possibility. Finally, newer understanding and possible treatment for some of the complications related to IF have more recently evolved and will be an emphasis of this report. This review will focus on developments over the last 10 years with the goal of updating the reader to new advances in our understanding of the care and feeding of the SBS patient.
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Affiliation(s)
- Robert E Carroll
- Intestinal Rehabilitation and Transplant Center, Departments of Medicine and Surgery, University of Illinois at Chicago and Chicago Veterans Administration Medical Center (West Side Division), 840 South Wood Street (M/C 787), Chicago, IL, 60612, USA.
| | - Enrico Benedetti
- Intestinal Rehabilitation and Transplant Center, Departments of Medicine and Surgery, University of Illinois at Chicago and Chicago Veterans Administration Medical Center (West Side Division), 840 South Wood Street (M/C 787), Chicago, IL, 60612, USA
| | - Joseph P Schowalter
- Intestinal Rehabilitation and Transplant Center, Departments of Medicine and Surgery, University of Illinois at Chicago and Chicago Veterans Administration Medical Center (West Side Division), 840 South Wood Street (M/C 787), Chicago, IL, 60612, USA
| | - Alan L Buchman
- Intestinal Rehabilitation and Transplant Center, Departments of Medicine and Surgery, University of Illinois at Chicago and Chicago Veterans Administration Medical Center (West Side Division), 840 South Wood Street (M/C 787), Chicago, IL, 60612, USA
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Braga CBM, Ferreira IMDL, Marchini JS, Cunha SFDCD. Copper and magnesium deficiencies in patients with short bowel syndrome receiving parenteral nutrition or oral feeding. ARQUIVOS DE GASTROENTEROLOGIA 2016; 52:94-9. [PMID: 26039825 DOI: 10.1590/s0004-28032015000200004] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/18/2014] [Accepted: 11/28/2014] [Indexed: 11/22/2022]
Abstract
BACKGROUND Patients with short bowel syndrome have significant fluid and electrolytes loss. OBJECTIVE Evaluate the mineral and electrolyte status in short bowel syndrome patients receiving intermittent parenteral nutrition or oral feeding. METHODS Twenty two adults with short bowel syndrome, of whom 11 were parenteral nutrition dependent (PN group), and the 11 remaining had been weaned off parenteral nutrition for at least 1 year and received all nutrients by oral feeding (OF group). The study also included 14 healthy volunteers paired by age and gender (control group). Food ingestion, anthropometry, serum or plasma levels of sodium, potassium, phosphorus, magnesium, calcium, zinc, iron and copper were evaluated. PN group subjects were evaluated before starting a new parenteral nutrition cycle. RESULTS The levels of sodium, potassium, phosphorus, calcium and zinc were similar between the groups. The magnesium value was lower in the PN group (1.0 ± 0.4 mEq /L) than other groups. Furthermore, this electrolyte was lower in the OF group (1.4 ± 0.3 mEq /L) when compared to the Control group (1.8 ± 0.1 mEq/L). Lower values of copper (69±24 vs 73±26 vs 109±16 µg/dL) were documented, respectively, for the PN and OF groups when compared to the control group. CONCLUSION Hypomagnesemia and hypocupremia are electrolyte disturbances commonly observed in short bowel syndrome. Patients with massive intestinal resection require monitoring and supplementation in order to prevent magnesium and copper deficiencies.
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15
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Toresson L, Steiner JM, Suchodolski JS, Spillmann T. Oral Cobalamin Supplementation in Dogs with Chronic Enteropathies and Hypocobalaminemia. J Vet Intern Med 2015; 30:101-7. [PMID: 26648590 PMCID: PMC4913667 DOI: 10.1111/jvim.13797] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2015] [Revised: 09/12/2015] [Accepted: 10/22/2015] [Indexed: 01/06/2023] Open
Abstract
Background Cobalamin deficiency is commonly associated with chronic enteropathies (CE) in dogs and current treatment protocols recommend parenteral supplementation. In humans, several studies have reported equal efficacy of oral and parenteral cobalamin administration of cobalamin. Objectives To retrospectively evaluate whether oral cobalamin supplementation can restore normocobalaminemia in dogs with CE and hypocobalaminemia. Animals Fifty‐one client‐owned dogs with various signs of CE and hypocobalaminemia. Material and Methods Retrospective study based on a computerized database search for dogs treated at Evidensia Specialist Animal Hospital, Helsingborg, Sweden during January 2012–March 2014. Inclusion criteria were dogs with signs of CE, an initial serum cobalamin ≤270 ng/L (reference interval: 234–811 ng/L) and oral treatment with cobalamin tablets. Serum cobalamin for follow‐up was analyzed 20–202 days after continuous oral cobalamin supplementation started. Results All dogs became normocobalaminemic with oral cobalamin supplementation. The mean increase in serum cobalamin concentration after treatment was 794 ± 462 ng/L. Serum cobalamin concentrations were significantly higher after supplementation (mean 1017 ± 460 ng/L; P < .0001) than at baseline (mean 223 ± 33 ng/L). Conclusion and Clinical Importance Our results suggest that oral cobalamin supplementation is effective in normalizing serum cobalamin concentrations in dogs with CE. Prospective studies comparing cellular cobalamin status in dogs being treated with parenteral versus oral cobalamin supplementation are warranted before oral supplementation can be recommended for routine supplementation.
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Affiliation(s)
- L Toresson
- Department of Equine and Small Animal Medicine, Faculty of Veterinary Medicine, Helsinki University, Helsinki, Finland.,Evidensia Specialist Animal Hospital, Helsingborg, Sweden
| | - J M Steiner
- Gastrointestinal Laboratory, Texas A&M University, College Station, TX
| | - J S Suchodolski
- Gastrointestinal Laboratory, Texas A&M University, College Station, TX
| | - T Spillmann
- Department of Equine and Small Animal Medicine, Faculty of Veterinary Medicine, Helsinki University, Helsinki, Finland
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Clarebrough E, Guest G, Stupart D. Eating marshmallows reduces ileostomy output: a randomized crossover trial. Colorectal Dis 2015; 17:1100-3. [PMID: 25951410 DOI: 10.1111/codi.12992] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/05/2015] [Accepted: 04/13/2015] [Indexed: 02/08/2023]
Abstract
AIM Anecdotally, many ostomates believe that eating marshmallows can reduce ileostomy effluent. There is a plausible mechanism for this, as the gelatine contained in marshmallows may thicken small bowel fluid, but there is currently no evidence that this is effective. METHOD This was a randomized crossover trial. Adult patients with well-established ileostomies were included. Ileostomy output was measured for 1 week during which three marshmallows were consumed three times daily, and for one control week where marshmallows were not eaten. There was a 2-day washout period. Patients were randomly allocated to whether the control or intervention week occurred first. In addition, a questionnaire was administered regarding patient's subjective experience of their ileostomy function. RESULTS Thirty-one participants were recruited; 28 completed the study. There was a median reduction in ileostomy output volume of 75 ml per day during the study period (P = 0.0054, 95% confidence interval 23.4-678.3) compared with the control week. Twenty of 28 subjects (71%) experienced a reduction in their ileostomy output, two had no change and six reported an increase. During the study period, participants reported fewer ileostomy bag changes (median five per day vs six in the control period, P = 0.0255). Twenty of 28 (71%) reported that the ileostomy effluent was thicker during the study week (P = 0.023). Overall 19 (68%) participants stated they would use marshmallows in the future if they wanted to reduce or thicken their ileostomy output. CONCLUSION Eating marshmallows leads to a small but statistically significant reduction in ileostomy output.
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Affiliation(s)
- E Clarebrough
- Department of Surgery, Deakin University, Geelong, Victoria, Australia
| | - G Guest
- Department of Surgery, Deakin University, Geelong, Victoria, Australia
| | - D Stupart
- Department of Surgery, Deakin University, Geelong, Victoria, Australia
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Jandhyala SN, Madireddi J, Belle J, Rau NR, Shetty R. Hypokalaemic Periodic Paralysis- A Prospective Study of the Underlying Etiologies. J Clin Diagn Res 2015; 9:OC17-9. [PMID: 26500936 DOI: 10.7860/jcdr/2015/13237.6529] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2015] [Accepted: 07/08/2015] [Indexed: 11/24/2022]
Abstract
BACKGROUND Hypokalaemic periodic paralysis (HPP) is a rare muscular disorder characterised by episodic weakness associated with hypokalaemia. The disease can either be inherited or acquired and misdiagnosis of the disease is quite common. Most of the data available on the disease is from the western world. Studies reporting aetiological, clinical and metabolic profiles of Indian population are sparse. Hence we tried to provide insights of the disease among the Indian population. AIM To study the aetiological, clinical and metabolic profile of patients diagnosed with Hypokalaemic Periodic Paralysis (HPP). MATERIALS AND METHODS This is an observational and analytical study on HPP diagnosed patients, during September 2011 to September 2014 in Kasturba Hospital, Manipal. A total of 23 patients were studied. Detailed history, clinical evaluation and metabolic workup for secondary causes of HPP were analysed. RESULTS Of the 23 patients, 57% had primary HPP while 43% had secondary HPP. The group of patients with primary HPP comprised of 92% males and 8% females with mean age of 28 years and the mean duration of symptoms of 18 hours. The group with secondary HPP comprised of 70% males and 30% females with mean age of 38.7 years and the mean duration of symptoms of 60 hours. The secondary causes of HPP were thyrotoxicosis (50%), infective diarrhea (20%), Crohn's disease (10%), renal tubular acidosis (RTA) Type I (10%) and Conn's syndrome (10%). CONCLUSION In our study primary HPP was found to be more common than secondary HPP. Males were predominantly affected in both groups. HPP should be ruled out before starting therapy for Guillain-Barré Syndrome (GBS).
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Affiliation(s)
| | - Jagadesh Madireddi
- Post Graduate, Department of Medicine, Kasturba Medical College , Manipal University, India
| | - Jayaprakash Belle
- Associate Professor, Department of Medicine, Kasturba Medical College, Manipal University , India
| | - N R Rau
- Professor and Head of Unit, Department of Medicine, Kasturba Medical College, Manipal University , India
| | - Ranjan Shetty
- Professor and Head of Unit, Department of Cardiology, Kasturba Medical College, Manipal University , India
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Gastrointestinal Manifestations, Malnutrition, and Role of Enteral and Parenteral Nutrition in Patients With Scleroderma. J Clin Gastroenterol 2015; 49:559-64. [PMID: 25992813 DOI: 10.1097/mcg.0000000000000334] [Citation(s) in RCA: 37] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Abstract
Scleroderma (systemic sclerosis) is an autoimmune disease that can affect multiple organ systems. Gastrointestinal (GI) involvement is the most common organ system involved in scleroderma. Complications of GI involvement including gastroesophageal reflux disease, small intestinal bacterial overgrowth, and chronic intestinal pseudoobstruction secondary to extensive fibrosis may lead to nutritional deficiencies in these patients. Here, we discuss pathophysiology, progression of GI manifestations, and malnutrition secondary to scleroderma, and the use of enteral and parenteral nutrition to reverse severe nutritional deficiencies. Increased mortality in patients with concurrent malnutrition in systemic sclerosis, as well as the refractory nature of this malnutrition to pharmacologic therapies compels clinicians to provide novel and more invasive interventions in reversing these nutritional deficiencies. Enteral and parenteral nutrition have important implications for patients who are severely malnourished or have compromised GI function as they are relatively safe and have substantial retrospective evidence of success. Increased awareness of these therapeutic options is important when treating scleroderma-associated malnutrition.
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Lim DW, Turner JM, Wales PW. Emerging Piglet Models of Neonatal Short Bowel Syndrome. JPEN J Parenter Enteral Nutr 2014; 39:636-43. [PMID: 25293943 DOI: 10.1177/0148607114554621] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2014] [Accepted: 09/15/2014] [Indexed: 12/19/2022]
Abstract
Short bowel syndrome (SBS) is a growing problem in the human neonatal population. In infants, SBS is the leading cause of intestinal failure, the state of being unable to absorb sufficient nutrients for growth and development. Neonates with SBS are dependent on long-term parenteral nutrition therapy, but many succumb to the complications of sepsis and liver disease. Research in neonatal SBS is challenged by the ethical limits of studying sick human neonates and the heterogeneous nature of the disease process. Outcomes in SBS vary depending on residual intestinal anatomy, intestinal length, patient age, and exposure to nutrition therapies. The neonatal piglet serves as an appropriate translational model of the human neonate because of similarities in gastrointestinal ontogeny, physiological maturity, and adaptive processes. Re-creating the disease process in a piglet model presents a unique opportunity for researchers to discover novel insights and therapies in SBS. Emerging piglet models of neonatal SBS now represent the entire spectrum of disease seen in human infants. This review aims to contextualize these emerging piglet models within the context of SBS as a heterogeneous disease. We first explore the factors that account for SBS heterogeneity and then explore the suitability of the neonatal piglet as an appropriate translational animal model. We then examine differences between the emerging piglet models of neonatal SBS and how these differences affect their translational potential to human neonates with SBS.
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Affiliation(s)
- David W Lim
- Department of Surgery, University of Alberta, Edmonton, Alberta, Canada
| | - Justine M Turner
- Department of Pediatrics, University of Alberta, Edmonton, Alberta, Canada Department of Agricultural, Food & Nutritional Science, University of Alberta, Edmonton, Alberta, Canada
| | - Paul W Wales
- Department of Surgery, University of Alberta, Edmonton, Alberta, Canada Department of Pediatrics, University of Alberta, Edmonton, Alberta, Canada Department of Surgery, Hospital for Sick Children, and University of Toronto, Toronto, Ontario, Canada
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Wong C, Lucas B, Wood D. Patients’ experiences with home parenteral nutrition: a literature review: Table 1. Eur J Hosp Pharm 2014. [DOI: 10.1136/ejhpharm-2014-000481] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
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[After-care in general practice after lower intestinal resection]. MMW Fortschr Med 2014; 156:47-51; quiz 52. [PMID: 24930310 DOI: 10.1007/s15006-014-0001-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
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Vecino López R, Andrés Moreno AM, Ramos Boluda E, Martinez-Ojinaga Nodal E, Hernanz Macías A, Prieto Bozano G, Lopez Santamaria M, Tovar Larrucea JA. [Plasma citrulline concentration as a biomarker of intestinal function in short bowel syndrome and in intestinal transplant]. An Pediatr (Barc) 2013; 79:218-23. [PMID: 23528708 DOI: 10.1016/j.anpedi.2013.02.007] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2012] [Revised: 01/28/2013] [Accepted: 02/08/2013] [Indexed: 11/15/2022] Open
Abstract
INTRODUCTION Citrulline is a non-essential amino acid produced solely in the enterocyte. The aim of this study was to analyse the role of serum citrulline as a biomarker of enterocyte load in children with intestinal failure due to short bowel syndrome (SBS) and its relationship to enteral adaptation. MATERIAL AND METHODS Plasma citrulline concentration was determined by chromatography (normal value>15 μmol/L) in 57 patients (age 0.5-18 years) admitted to our Intestinal Rehabilitation Unit with intestinal failure. Those who were dehydrated, with renal insufficiency, or other conditions able to modify the results were excluded. Patients were divided into 4 groups: group i: SBS totally dependent on parenteral nutrition (PN); group ii: SBS under mixed enteral-parenteral nutrition; group iii: IF weaned from PN after a rehabilitation period; group iv: small bowel transplanted patients weaned from PN and taking a normal diet. RESULTS The mean ± SD plasma citrulline values were: group i (n=15): 7.1 ± 4.1; group ii (n=11): 15.8 ± 8.9; group iii (n=13): 20.6 ± 7.5; group iv (n=25): 28.8 ± 10.1. Values were significantly lower in group i in comparison with groups ii-iii-iv (P<.001), and in group ii in comparison with groups iii-iv (P<.001). A low citrulline was associated with remnant small bowel length (P<.001, r=0.85). In group iv citrulline levels decreased >50% in 3 patients who developed moderate-severe rejection, and in one patient who developed viral enteritis. CONCLUSIONS 1. Plasma citrulline could be a sensitive and specific biomarker of the residual functional enterocyte load. 2. It is related to enteral feeding tolerance. 3. Its prognostic value in the process of intestinal adaptation and as a rejection marker in small bowel transplanted patients needs to be confirmed.
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Affiliation(s)
- R Vecino López
- Servicio de Gastroenterología Infantil, Hospital Infantil La Paz, Madrid, España.
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Hahn M, Raithel M, Hagel A, Biermann T, Manger B. Chronic calcium pyrophosphate crystal inflammatory arthritis induced by extreme hypomagnesemia in short bowel syndrome. BMC Gastroenterol 2012; 12:129. [PMID: 22998213 PMCID: PMC3527343 DOI: 10.1186/1471-230x-12-129] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/02/2012] [Accepted: 09/19/2012] [Indexed: 12/28/2022] Open
Abstract
BACKGROUND Short bowel syndrome (SBS) may induce a plethora of clinical symptoms ranging from underweight to nutrient-, vitamin- and electrolyte deficiencies. The objective of this case report is to illustrate how demanding the management of a 60 year old patient with SBS and recurrent joint attacks was for different medical disciplines. CASE PRESENTATION The patient with SBS presented with a body mass index of 16.5 kg/m2 after partial jejunoileal resection of the small intestine with a six year long history of recurrent pain attacks in multiple peripheral joints, chronic diarrhoea and food intolerances. Pain attacks occurred 4-5 times a week with a median consumption of 15 mg prednisone per day. The interdisciplinary workup after several gastroenterologic, rheumatologic, radiologic, psychiatric and orthopedic consultations is shown including successful treatment steps.Clinical diagnosis revealed no systemic inflammatory disease, but confirmed extreme hypomagnesemia (0.2 mmol/l) after reproducible pathological magnesium resorption tests as causative for chronic calcium pyrophosphate crystal inflammatory arthritis (pseudogout, chondrocalcinosis).Multidisciplinary treatment included application of colchicines, parenteral nutrition and magnesium substitution, antiperistaltic agents and avoidance of intolerant foods. Normalization of magnesium levels and a marked remission of joint attacks were achieved after six months with significant reduction of prednisone to 1.5 mg/day. CONCLUSION Despite the rarity of this condition, it is important to know that hypomagnesaemia may be associated with calcium pyrophosphate crystal inflammatory arthritis (chondrocalcinosis) and that SBS patients may be prone to develop extreme hypomagnesaemia causing recurrent joint attacks without systemic inflammation.
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Affiliation(s)
- Markus Hahn
- Department of Medicine I, Gastroenterology, University Erlangen-Nürnberg, Ulmenweg 18, Erlangen 91054, Germany
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Abstract
Based on the current available evidence, this article explores the nutritional management of those with a high-output stoma. The main alterations required to the intake of patients with a high-output stoma include the use of an oral rehydration solution to ensure optimum absorption of fluid and sodium, and a high-calorie, high-protein diet, with the aim of optimizing nutritional status. Diet advice should be delivered by a dietitian with experience in managing these complex patients. Monitoring of electrolytes and micronutrients is essential, and long-term follow up from a multidisciplinary nutrition support team is invaluable in coordinating this. Patients with high-output stomas can enjoy good quality of life and long-term health if their condition is managed effectively by a well-organized multidisciplinary team.
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Affiliation(s)
- V S R Rao
- Department of General Surgery, Diana, Princess of Wales Hospital, Grimsby, UK.
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Solutions entérales semi-élémentaires : pour quels patients de réanimation ? MEDECINE INTENSIVE REANIMATION 2011. [DOI: 10.1007/s13546-011-0284-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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Muddu AK, Stroud MA. The value of multidisciplinary nutritional gastroenterology clinics for intestinal failure and other gastrointestinal patients. Frontline Gastroenterol 2010; 1:178-181. [PMID: 28839572 PMCID: PMC5517187 DOI: 10.1136/fg.2010.002071] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/18/2010] [Indexed: 02/04/2023] Open
Abstract
An increasing number of patients have chronic intestinal failure (IF) or other problems needing nutritional support. These patients need regular input from gastroenterologists, nutrition nurse specialists and dietitians, but traditionally these healthcare professionals see them separately. Here the authors describe their experience of a combined regional nutritional gastroenterology clinic and outline strategies that can avoid the need for home parenteral nutrition (HPN) or intravenous fluids in most cases. Over a 1-year period, 73 patients attended their clinic, with the majority (74%) coming from their own catchment area of 500 000. Of the 63 patients with IF, 49 had short bowel syndrome. 38 of the patients with IF (60%) could be managed with dietary and pharmacological modifications alone, while eight (13%) needed enteral tube feeding and 17 (27%) HPN or intravenous fluids. However, only nine (53%) of the 17 patients referred from other centres specifically for HPN instigation actually needed HPN or intravenous fluids. Patient satisfaction with the combined multidisciplinary clinic was high, with 85% of patients preferring to be seen within this model of outpatient care, although questionnaire response rates were low. The authors have therefore shown that a multidisciplinary nutritional gastroenterology clinic can provide effective patient-centred care and can minimise the need for invasive and costly intravenous nutritional support. Clinics of this type should be an integral part of the current plans to implement regional IF services.
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Affiliation(s)
- Ajay Kiran Muddu
- Department of Gastroenterology, Southampton General Hospital, Southampton, UK
| | - Michael A Stroud
- Southampton University Hospitals NHS Trust, University of Southampton School of Medicine and Southampton NIHR Biomedical Research Unit in Nutrition, Diet and Lifestyle, Southampton, UK
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Abstract
Antisecretory factor (AF) is a protein secreted in plasma and other tissue fluids in mammals with proven antisecretory and anti-inflammatory activity; its immunohistological distribution suggests a role in the immune system. The expression level and the distribution of AF protein are altered during an immunological response. Exposure to bacterial toxins induces secretion of AF in plasma, probably reflecting a natural defence mechanism to agents causing diarrhoea, thereby contributing to a favourable clinical outcome and disease termination. An increase of AF levels in plasma by dietary means, such as specially processed cereals (SPC), has been demonstrated in human subjects and animals. Administration of SPC to patients affected by inflammatory bowel disease, gastroenteritis and Ménière's disease relieved symptoms and improved quality of life. A recent study showed the positive effect of SPC diet supplementation on prevention of the effects of exposure to low levels of blast overpressure in rats, reducing the extent of intracranial pressure increase and cognitive function impairment. AF-rich egg yolk powder improved health status in children suffering acute and chronic diarrhoea, reducing the frequency and increasing the consistency of stools. This kind of functional food could be used for prophylaxis in populations exposed to a high risk of morbidity and mortality caused by diarrhoea and as a complementary therapy in patients affected by chronic intestinal inflammatory disease to improve well-being. In pig husbandry AF-inducing diets, owing to their antisecretory activity and anti-inflammatory action, are a suitable option as an alternative to antibiotic growth promoters to counteract post-weaning diarrhoea.
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Abstract
Intestinal failure (IF) is the ultimate malabsorption state, with multiple causes, requiring long-term therapy with enteral or intravenous fluids and nutrient supplements. The primary goal during management of children with potentially reversible IF is to promote intestinal autonomy while supporting normal growth, nutrient status, and preventing complications from parenteral nutrition therapy. This article presents how an improved understanding of digestive pathophysiology is essential for diagnosis, successful management, and prevention of nutrient deficiencies in children with IF.
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Van Gossum A, Cabre E, Hébuterne X, Jeppesen P, Krznaric Z, Messing B, Powell-Tuck J, Staun M, Nightingale J. ESPEN Guidelines on Parenteral Nutrition: gastroenterology. Clin Nutr 2009; 28:415-27. [PMID: 19515465 DOI: 10.1016/j.clnu.2009.04.022] [Citation(s) in RCA: 77] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2009] [Accepted: 04/29/2009] [Indexed: 12/14/2022]
Abstract
Undernutrition as well as specific nutrient deficiencies has been described in patients with Crohn's disease (CD), ulcerative colitis (UC) and short bowel syndrome. In the latter, water and electrolytes disturbances may be a major problem. The present guidelines provide evidence-based recommendations for the indications, application and type of parenteral formula to be used in acute and chronic phases of illness. Parenteral nutrition is not recommended as a primary treatment in CD and UC. The use of parenteral nutrition is however reliable when oral/enteral feeding is not possible. There is a lack of data supporting specific nutrients in these conditions. Parenteral nutrition is mandatory in case of intestinal failure, at least in the acute period. In patients with short bowel, specific attention should be paid to water and electrolyte supplementation. Currently, the use of growth hormone, glutamine and GLP-2 cannot be recommended in patients with short bowel.
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Affiliation(s)
- André Van Gossum
- Hôpital Erasme, Clinic of Intestinal Diseases and Nutrition Support, Brussels, Belgium
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ESPEN Guidelines on Parenteral Nutrition: home parenteral nutrition (HPN) in adult patients. Clin Nutr 2009; 28:467-79. [PMID: 19464089 DOI: 10.1016/j.clnu.2009.04.001] [Citation(s) in RCA: 255] [Impact Index Per Article: 17.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2009] [Accepted: 04/01/2009] [Indexed: 12/28/2022]
Abstract
Home parenteral nutrition (HPN) was introduced as a treatment modality in the early 1970s primarily for the treatment of chronic intestinal failure in patients with benign disease. The relatively low morbidity and mortality associated with HPN has encouraged its widespread use in western countries. Thus there is huge clinical experience, but there are still few controlled clinical studies of treatment effects and management of complications. The purpose of these guidelines is to highlight areas of good practice and promote the use of standardized treatment protocols between centers. The guidelines may serve as a framework for development of policies and procedures.
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Effects of a supplementary diet with specially processed cereals in patients with short bowel syndrome. Eur J Gastroenterol Hepatol 2008; 20:1085-93. [PMID: 19047840 DOI: 10.1097/meg.0b013e328303c00a] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/10/2022]
Abstract
OBJECTIVE Short bowel syndrome patients frequently experience impaired health-related quality of life. This syndrome is also associated with increased costs for the individuals concerned and the community. Intake of specially processed cereals has been demonstrated to decrease intestinal secretion. This study evaluates the effect of a supplementary diet with specially processed cereals compared with nonprocessed cereals. METHODS This investigation is a randomized double-blind, cross-over multicentre prospective study of 26 intestinal resected out patients, considered as short bowel syndrome patients. The patients were divided into groups A or B, in accordance with the first allocated treatment. Subgroup analyses of the underlying diagnoses and type of surgical procedure were performed. The studied parameters were faecal volume, nocturnal stools, abdominal pain/discomfort, health-related quality of life, peripheral blood tests and anthropometric data. RESULTS In both groups, intake of nonprocessed cereals significantly decreased the faecal volume. The subgroup analyses of patients with a history of ulcerative colitis (compared with Crohn's disease) and nonileostomy-operated procedure (compared with ileostomi-operated procedure) showed significantly decreased faecal volume during nonprocessed cereals intake. Peripheral blood tests, quality of life and anthropometry were not affected. CONCLUSION In this study, nonprocessed cereals seemed to be as effective as specially processed cereals in decreasing faecal volume in general and especially in ulcerative colitis patients (mainly operated with nonileostomy techniques). Our results indicate that use of supplementary cereals is safe for this group of patients, but should optimally include evaluation of the underlying diagnosis and the surgical method used.
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Enteral nutrition regimen for neonates with short bowel syndrome. Nutrition 2008; 24:1045-7. [DOI: 10.1016/j.nut.2008.04.010] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2008] [Revised: 04/23/2008] [Accepted: 04/25/2008] [Indexed: 11/23/2022]
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Dahhak S, Uhlen S, Mention K, Romond MB, Fontaine M, Gottrand F, Turck D, Michaud L. Acidose d-lactique chez un enfant présentant un syndrome de grêle court. Arch Pediatr 2008; 15:145-8. [DOI: 10.1016/j.arcped.2007.11.009] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2007] [Revised: 08/14/2007] [Accepted: 11/23/2007] [Indexed: 11/28/2022]
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Richette P, Ayoub G, Lahalle S, Vicaut E, Badran AM, Joly F, Messing B, Bardin T. Hypomagnesemia associated with chondrocalcinosis: A cross-sectional study. ACTA ACUST UNITED AC 2007; 57:1496-501. [DOI: 10.1002/art.23106] [Citation(s) in RCA: 39] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
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Abstract
Short bowel syndrome is a chronic malabsorptive state usually resulting from extensive small bowel resections. A combination of diarrhea, nutrient malabsorption, dysmotility, and bowel dilatation may constitute the clinical symptomatology of this syndrome. The remaining bowel undergoes a process called adaptation, which may replace lost intestinal function. Chronic complications include nutrient, electrolyte, and vitamin deficiencies. Therapy depends largely on the administration of various factors stimulating intestinal adaptation of the remaining bowel. If the patient despite medical therapy fails to return to oral diet alone, then long-term parenteral nutrition is required. However, long-term parenteral nutrition may gradually induce cholestatic liver disease. Surgical methods may be required for treatment including intestinal transplantation, as a last resort for the treatment of end-stage intestinal failure. The goal of this review is to analyze the clinical spectrum and pathophysiologic aspects of the syndrome, the process of intestinal adaptation, and to outline the medical and surgical methods currently used to treat this complicated group of patients.
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Affiliation(s)
- Evangelos P Misiakos
- 3rd Department of Surgery, University of Athens School of Medicine, Attikon University Hospital, Athens, Greece.
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Lloyd DAJ, Vega R, Bassett P, Forbes A, Gabe SM. Survival and dependence on home parenteral nutrition: experience over a 25-year period in a UK referral centre. Aliment Pharmacol Ther 2006; 24:1231-40. [PMID: 17014582 DOI: 10.1111/j.1365-2036.2006.03106.x] [Citation(s) in RCA: 103] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
BACKGROUND Home parenteral nutrition (HPN) is the standard treatment for severe intestinal failure in the United Kingdom. AIM To review long-term survival and ongoing HPN dependence of patients receiving HPN treated at a specialist UK referral centre. METHODS Medical records of patients commenced on HPN between 1979 and 2003 were reviewed retrospectively. Regression analysis was employed to identify factors associated with poor prognosis. RESULTS Case notes of 188 patients were reviewed. Overall probability of survival was 86%, 77%, 73% and 71% at 1, 3, 5 and 10 years after starting treatment. In multivariate analysis, association was seen between mechanism of intestinal failure and survival: short bowel syndrome associated with a favourable prognosis, and intestinal dysfunction, dysmotility and obstruction with poorer prognoses. There was an association between increasing age and poor prognosis, but increased mortality was also seen in the youngest age groups. Only 9% of deaths were due to complications of HPN. Continued HPN dependence was 89%, 87%, 84% and 84% at 1, 3, 5 and 10 years in survivors. CONCLUSIONS Long-term survival of patients receiving HPN remains better than that reported after intestinal transplantation. Mortality predominantly relates to underlying disease rather than complications of HPN.
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Affiliation(s)
- D A J Lloyd
- Lennard-Jones Intestinal Failure Unit, St Mark's Hospital and Academic Institute, Watford Road, Harrow, UK.
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Abstract
Resection of the small bowel can lead to malabsorption of fluid, electrolytes, minerals, and other essential nutrients, resulting in malnutrition and dehydration. Individualized and tailored nutritional management for patients with short bowel syndrome (SBS) helps to optimize intestinal absorption, leading to nutritional independence such that a patient can resume as normal a lifestyle as possible. Parenteral nutrition (PN), used to supply the required nutrients following resection, is associated with a number of complications affecting patient morbidity and mortality. Attempts should be made to wean patients from PN to an oral diet as soon as possible. Dietary management is complex and needs to be individualized for each patient on the basis of his or her specific gastrointestinal anatomy, underlying disease, and lifestyle. In addition to nutrient intake, management of SBS also requires appropriate oral rehydration, vitamin and mineral supplementation, and pharmacotherapy. Several medications provide a useful adjunctive function to dietary intervention, including antidiarrheal agents, H2 antagonists and proton pump inhibitors, pancreatic enzymes, somatostatin analogs, antimicrobials, and trophic factors.
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Affiliation(s)
- Laura E Matarese
- Intestinal Rehabilitation and Transplant Center, Thomas E. Starzl Transplantation Institute, University of Pittsburgh Medical Center, Pittsburgh, PA 15213, USA.
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Lardy H, Thomas M, Noordine ML, Bruneau A, Cherbuy C, Vaugelade P, Philippe C, Colomb V, Duee PH. Changes induced in colonocytes by extensive intestinal resection in rats. Dig Dis Sci 2006; 51:326-32. [PMID: 16534676 DOI: 10.1007/s10620-006-3133-z] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/15/2005] [Accepted: 06/15/2005] [Indexed: 12/23/2022]
Abstract
After massive intestinal resection, physiological compensatory events occur in the remnant small bowel and in the colon. The aim of our work was to study the propensity of the colon to evolve after a massive small bowel resection in rats. The resected group, where 80% of the small bowel length was removed, was compared with sham-operated rats (transected). During the 7 postoperative days, rats were fed orally or they received an elemental nutrition through a gastric catheter. PepT1 and NHE3 mRNAs encoding apical membrane transporters were not modified in the present experiment. However, two unexpected genes (I-FABP and UroR) were up-regulated in the colon following intestinal resection. These modifications occurred without an imbalance of cell cycle protein content and in a context of low short-chain fatty acid production.
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Affiliation(s)
- Hubert Lardy
- Laboratoire de Nutrition et de sécurité alimentaire, INRA, Doaine de Vilvert, 78350, Jouy en Josas, France
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Abstract
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.
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Affiliation(s)
- Andrew W DuPont
- Division of Gastroenterology, University of Texas Medical Branch, 301 University Boulevard, Galveston, TX 77555-0764, USA
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Martínez-Riquelme A, Rawlings J, Morley S, Kendall J, Hosking D, Allison S. Self-administered subcutaneous fluid infusion at home in the management of fluid depletion and hypomagnesaemia in gastro-intestinal disease. Clin Nutr 2005; 24:158-63. [PMID: 15681114 DOI: 10.1016/j.clnu.2004.09.016] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2003] [Accepted: 09/27/2004] [Indexed: 10/25/2022]
Abstract
BACKGROUND AND AIMS In short bowel fistula and some other gastrointestinal (GI) diseases, salt, water and magnesium (Mg) balance may continue negative despite oral treatment, even in patients with adequate nutritional status. This study describes the use of self-administered subcutaneous fluid infusions (HSCF) to treat this problem. PATIENTS & METHODS HSCF was administered to patients with GI failure and adequate macro-nutrient status (BMI) when GI salt, water and magnesium balance continued negative despite optimal diet, drug and supplemental treatment. Mg depletion was confirmed using the Mg load test. Patients were taught to self-administer 0.5-1.0 l 0.9% saline +/-0.5 l 5% dextrose +/-2-4 mmol MgSO4 subcutaneously by gravity drip during 6-12 h overnight, 3-7 days/week. Water and Na balance were assessed (weight, serum creatinine, urea, Na) at baseline and at 1 and 3 months of treatment, but also monitored carefully during the first few days of treatment. Serum Mg was measured at baseline and at 2 and 4 weeks. RESULTS In 10 patients (mean age 65.3+/-13.5 years) Na and water balance was rapidly restored. At baseline, 1 and 3 months, serum biochemical results were: Eight patients received 8-28 mmol MgSO4/week in the infused fluid. Serum Mg [0.7-1.0 mmol] at baseline, 2 and 4 weeks was 0.49+/-0.06, 0.79+/-0.18, 0.83+/-0.10 mmol/l (P=0.002). Tolerance was good; transient oedema developed in 2 patients, resolved by reducing infusion dose. No patient developed hypokalaemia. CONCLUSIONS Subcutaneous self-administered fluid infusion at home (HSCF) is an easily managed, safe and effective method of restoring and maintaining water, salt and Mg balance in patients with large GI fluid losses but adequate macronutrient status, particularly in the frail or elderly in whom home parenteral nutrition may be difficult.
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Affiliation(s)
- Amparo Martínez-Riquelme
- Clinical Nutrition and Investigation Unit, Queen's Medical Centre, Derby Road, Nottingham, NG7 2UH, UK.
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Dabney A, Thompson J, DiBaise J, Sudan D, McBride C. Short bowel syndrome after trauma. Am J Surg 2004; 188:792-5. [PMID: 15619501 DOI: 10.1016/j.amjsurg.2004.08.032] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2004] [Revised: 08/07/2004] [Accepted: 08/07/2004] [Indexed: 10/26/2022]
Abstract
PURPOSE Traumatic injury to the intestine and its vasculature is a potential cause of short bowel syndrome (SBS). Our aim was to determine the incidence and mechanisms of traumatic injury to the bowel resulting in massive resection. METHODS We reviewed the records of 196 adult patients evaluated with SBS over a 23-year period. RESULTS Sixteen (8%) patients had SBS secondary to traumatic injury. Injury to the intestinal blood supply accounted for 81% (n = 13), and direct injury to the bowel wall accounted for the remaining 19% (n = 3). Nineteen associated injuries were present in 11 (67%) patients. CONCLUSION Traumatic injury to the abdomen accounts for a small proportion of patients with SBS. These patients often have other associated injuries which might influence their outcome. Early diagnosis of vascular injury, use of second look procedures, appropriate resuscitation, and avoidance of all unnecessary resections may aid in prevention of this serious complication.
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Affiliation(s)
- Anne Dabney
- Departments of Surgery and Medicine, University of Nebraska Medical Center, 983280 Nebraska Medical Center, Omaha, NE 68198-3280, USA.
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