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PubMed2004

Acceleration of blood-brain barrier formation after transplantation of enteric glia into spinal cords of rats.

Enteric glia share morphological, biochemical, and functional properties with astrocytes. Thus, like astrocytes, transplantation of enteric glia into the central nervous system (CNS) might facilitate the development of the characteristics of the blood brain barrier (BBB) in endothelial cells. This study explored this possibility by examining barrier formation after implantation into the spinal cord of rats. Phaseolus vulgaris leucoagglutin (PHAL)-treated enteric glia suspensions were injected into the spinal cord at the T11-T12 level of adult Wistar female rats. Control animals were injected with either 3T3 fibroblast, glioma C6 cells, or culture medium. Evan's blue, a dye excluded by the BBB, was injected intravenously from 1 week to 2 months after implantation. Leakage of dye was determined macroscopically and the ultrastructure of the capillaries was examined. During the first week leakage of dye correlated ultrastructurally with predominantly non-overlapping endothelial cell junctions, even with clefts between adjacent cells. Tight junctions were fully formed by 2 months and no dye leaked. Electron microscopic analysis showed that enteric glia had end-feet in close contact with endothelial cells. In contrast, the injection sites in all control animals leaked dye until 2 months, and most of the tight junctions that did form were incomplete. Furthermore, most 3T3 or C6 control cells had died at 2 months and those that survived, unlike enteric glia, had no anatomical relationship to blood vessels. These data demonstrate that implantation of enteric glia accelerates the formation of the characteristics of the BBB in spinal cord capillaries.

Animals↗

PubMed1999

Morphological classifications of enteric neurons--100 years after Dogiel.

The first differentiation of enteric neurons into three morphological types was done by the russian histologist A. S. Dogiel on the basis of the different shapes and lengths of their dendrites. Although a number of authors considered his results during the following decades, only a division into two types withstood time: type I neurons had one long and several short processes, whereas type II neurons were characterized by several long processes. Some further structural features were discussed but substantial progress was not made until the late 1970s. This stagnation was due to some inaccuracies in Dogiel's descriptions, to the fact that most histologists in this field followed the reticular concept of the nervous system, to the idea that enteric neurons represent no more than a vegetative, postganglionic relay station between the central nervous system and the periphery, and to methodological difficulties. With the application of modern neuroanatomical techniques it was realized that the enteric nervous system contains a considerable number of neuronal subpopulations. The search for morphological correlates of the chemical diversity of enteric neurons was done mainly in the pig and the guinea-pig. In the pig, additional structural features such as axonal projection, distribution of neurons within ganglia, within different plexuses and along the length of the gut, blood supply etc. were included as criteria for further refining neuronal classification. Most of our knowledge about functional features of enteric neurons, e.g. chemical coding, neuronal connectivity, electrophysiological behaviour, was derived from studies in the guinea-pig small intestine. In light of interspecies differences, comparison of findings from different species is mandatory. The search for morphological and functional peculiarities of human enteric neuronal circuitry has to consider all methodological and conceptual advances made within the past 100 years since the pioneering work of Dogiel.

Anatomy↗

PubMed1997

Spatial relationships of enteric nerve fibers to vagal motor terminals and the sarcolemma in motor endplates of the rat esophagus: a confocal laser scanning and electron-microscopic study.

Enteric co-innervation of motor endplates in the rat esophagus was studied with confocal laser scanning and electron microscopy. Enteric fibers were demonstrated with immunocytochemistry for nitric oxide synthase, vasoactive intestinal peptide or NADPH-diaphorase histochemistry. Vagal motor terminals were identified with calcitonin gene-related peptide (CGRP) immunocytochemistry. Teloglia was stained with immuno- cytochemistry for S100, and TRITC-tagged alpha-bungarotoxin was used to delineate endplate areas in immmunofluorescence preparations. Both confocal imaging and electron microscopy revealed intimate relationships between enteric and vagal terminals on the one hand, and enteric terminals and the sarcolemma on the other. In addition, electron microscopy could point out direct apposition of a significant proportion of enteric varicosities to vagal motor terminals without intervening teloglial processes. These morphological data are compatible with pre- and postsynaptic modulatory effects of enteric neurons on vagal neuromuscular transmission in striated esophageal muscle.

Animals↗

PubMed2002

Enteral nutrition in HPB surgery: past and future.

Perioperative nutrition has, during the past century, been transformed from a tool to provide calorie and nitrogen support to a tool to boost the immune system and increase resistance to complications. Despite all the progress in medicine and surgery, perioperative morbidity, the rate of infections, thrombosis, and the development of serosal adhesions has remained the same as long as can be judged, or at least during the past 80 years. Most prone to develop complications are persons above the age of 65 and persons with depressed immunity. About 80% of the immune system is localized in the gastrointestinal tract, which offers great opportunities for modulation through enteral nutrition. As the stomach has a tendency to develop postoperative paralysis, tube feeding is often necessary. In 1918, Andresen demonstrated the advantages of enteral nutrition, which already started on the operating table. Mulholland and colleagues and Rhoads and co-workers demonstrated, during the 1940s, certain advantages of enteral tube feeding. Also, the works by Alexander, Fischer, and Ryan, and their co-workers supported the value of early enteral feeding, and suggested enteral feeding as an effective tool to boost the immune system. It was, however, works published in the early 1990s, by Moore and colleagues and by Kudsk and colleagues, which made surgeons more aware of the advantages of early enteral nutrition. Surgery in the hepatobiliary pancreatic field is known to have a high rate of complications. Uninterrupted perioperative nutrition, i.e., nutrition during the night before, during surgery, and immediately after, offers a strong tool to prevent complications. It is essential that the nutrition also provides food for the colon, e.g., fiber and healthy bacteria (probiotics) to ferment the fiber and boost the immune system.

Acute Disease↗

PubMed1994

Reduced hepatic release of apoprotein B after enteral nutrition in rats.

To investigate the effects of enteral and parenteral alimentation on VLDL release from the liver, a lipid-free liquid nutriment was continuously administered to free-moving rats via the oral cavity (oral group), stomach (enteral group) or superior caval vein (parenteral group). After 1-week of nutrition, the plasma VLDL concentrations were significantly lowered in the enterally-fed group. By immunoblotting assay using a specific antiserum, plasma contents of both apoprotein B-100 and B-48, the major components of rat apoprotein B, were found to be decreased in the enteral group, whereas only that of apoprotein B-48 was reduced in the parenteral group as compared with the oral group. Sucrose gradient centrifugation of the lipid droplets in the liver from the enteral group showed an increase of the free-triacylglycerol fraction with a concomitant increase of the apoprotein B-48-rich triacylglycerol fraction. These results suggest that enteral nutrition causes triacylglycerol accumulation in the liver, at least in part by impairment of lipoprotein release from the liver.

Animals↗

PubMed1990

Effect of total enteral nutrition on the short-term outcome of severely malnourished cirrhotics. A randomized controlled trial.

Thirty-five severely malnourished cirrhotic patients were randomized to receive either enteral-tube feeding as the sole nutritional support (n = 16) or an isocaloric, isonitrogenous, low-sodium standard oral diet (n = 19). Both groups were homogeneous regarding age, sex distribution, etiology of liver cirrhosis, history of previous complications, clinical status, liver and renal function, modified Child's score, and nutritional status at admission. The enteral formula diet was energy dense, containing 40 mmol Na/day, whole protein plus branched-chain amino acids, medium- and long-chain triglycerides, and maltodextrin. It supplied 2115 kcal/day. The amount of vitamins and trace elements was at the upper limit of the recommended dietary allowances. The orally fed patients were encouraged to eat all meals served. Total enteral nutrition was well tolerated without major complications. Serum albumin and Child's score improved in the enterally fed patients but not in controls. Mortality rate while in the hospital was lower in patients on enteral feeding than in controls (12% vs 47%). These results show that total enteral nutrition is safe and effective in improving the short-term clinical outcome in severely malnourished cirrhotics.

Acute Disease↗

PubMed1987

Effects of enteral vs parenteral nutrition on reticuloendothelial function.

Previous investigations have shown that animals maintained with enteral nutrition are better able to survive an intraperitoneal bacterial challenge than animals receiving parenteral nutrition. The aim of this study was to assess the effects of enteral and parenteral nutrition on reticuloendothelial function. Eighteen enteral-fed male Sprague-Dawley rats had access to a standard hyperalimentation solution via a sipper tube ad libitum. Seventeen parenteral-fed animals received the same solution at an infusion rate determined by the volume ingested by the pair-fed enteral animals. All animals had central venous catheters. After 12 days, reticuloendothelial function was assessed by measuring the clearance rate (K) and the organ distribution of intravenous 51Cr-labeled sheep red blood cells and by plasma fibronectin levels. Nutritional status was assessed by body weight and nitrogen balance. K values in enteral and parenteral animals were similar (0.110 +/- 0.011 and 0.140 +/- 0.012, respectively, mean +/- SEM) as were plasma fibronectin levels (196 +/- 22 and 228 +/- 15 micrograms, respectively). Organ distribution of the 51Cr-labeled sheep red blood cells was the same in both groups. Nitrogen balance and body weights were also similar in both groups. These data demonstrate that in this experimental model enteral nutrition and parenteral nutrition were equally effective at maintaining reticuloendothelial function and nutritional status.

Animals↗

PubMed1996

Nasogastric enteral feeding in the management of hyperemesis gravidarum.

OBJECTIVE: To report our experience in treating hyperemesis gravidarum with nasogastric enteral feeding. METHODS: Seven women (ages 17-36 years, mean 27 years) presented with intractable nausea, vomiting, dehydration, and weight loss (mean 13 lb) and were hospitalized for management of symptoms and nutritional support. An 8-Fr Dobbhoff nasogastric feeding tube was placed and nutritional supplement was administered as a continuous infusion, starting at a rate of 25 mL/hour. The rate of infusion was increased in an incremental fashion until daily caloric requirements were met. RESULTS: Nausea and vomiting improved within 24 hours after nasogastric tube placement. Enteral feedings were well tolerated, and all patients were discharged from the hospital within 8 days. Enteral feedings were continued, in an outpatient setting, for a mean of 43 days (range 5-174). Ultimately, all patients resumed oral feeding and discontinued enteral feeding. Subsequently, all patients gave birth to full-term, normal-weight babies. CONCLUSION: Enteral feeding via nasogastric tube seems to be effective in relieving intractable nausea and vomiting and in providing adequate nutritional support. Enteral nutrition should be considered as an alternative to total parenteral nutrition in the management of hyperemesis gravidarum.

Adult↗

PubMed1995

Bioavailability study of a new, sinking, enteric-coated ursodeoxycholic acid formulation.

A new enteric-coated ursodeoxycholic acid (UDCA) formulation which sinks in the stomach and releases the drug only at a pH > or = 6.5 was developed. In 12 healthy subjects we measured, using a specific enzyme immunoassay, the serum levels of UDCA after a single oral dose of 450 mg of UDCA in three different formulations; enteric coated sinking tablet, stomach-floating enteric coated hard gelatin capsule and conventional gelatin capsule. The drug was given after a meal. Results are expressed as mean +/- SD. The area under the curve [AUC, mumol l-1 (8 h)] following oral administration of enteric-coated, sinking UDCA (39.0 +/- 8.5) was significantly higher than that obtained after both conventional UDCA (30.5 +/- 4.9) and floating enteric coated UDCA (29.3 +/- 3.4). Moreover, the maximum UDCA serum concentration (Cmax) was significantly higher with the enteric coated sinking UDCA formulation when compared to the other two formulations, while the time of maximum UDCA serum concentration (tmax) occurred later. These results may be explained by the hypothesis that the sinking tablet is expelled in the latter phase of gastric emptying along with the solid content. It therefore reaches the intestine at the highest alkalization phase caused by sustained biliary and pancreatic secretions. When released, the protonated insoluble UDCA is promptly solubilized by the alkaline pH thus giving a higher UDCA concentration gradient which facilitates its passive absorption. On the other hand, the floating capsule reaches the intestine too early, still in presence of an acidic pH; and in this condition UDCA is almost insoluble and consequently may be malabsorbed.(ABSTRACT TRUNCATED AT 250 WORDS)

Administration, Oral↗

PubMed2004

Postinjury abdominal compartment syndrome does not preclude early enteral feeding after definitive closure.

BACKGROUND: Critically injured patients are susceptible to the abdominal compartment syndrome (ACS), which requires decompressive laparotomy with delayed abdominal closure. Previous work by the University of Texas Houston group showed impaired gut function after resuscitation-associated gut edema. The purpose of this study was to determine if enteral nutrition was precluded by the intra-abdominal hypertension and bowel edema of the ACS. METHODS: Patients developing postinjury ACS from January 1996 to August 2003 at our level-I trauma center were reviewed. Patient demographics, time to definitive abdominal closure, and institution and tolerance of enteral nutrition were evaluated. RESULTS: Thirty-seven patients developed postinjury ACS during the study period; 26 men and 11 women with a mean age of 36 +/- 4 and injury severity score of 33 +/- 4. Mean intra-abdominal pressure before decompression was 32 +/- 3 mm Hg, and concurrent mean peak airway pressure was 50 +/- 4 cm oxygen. Enteral feeding was never started in 12 patients; 4 died within 48 hours of admission, 7 required vasoactive agents until their death, and 1 developed an enterocutaneous fistula requiring parenteral nutrition. Enteral feeding was initiated in the remaining 25 patients: 13 had feeds started within 24 hours of abdominal closure; 5 were fed with open abdomens; and 7 had a delay because of vasopressors (n = 2), multiple trips to the operating room (n = 2), paralytics (n = 2), and increased intra-abdominal pressures (n = 1). Once advanced, enteral feeding was tolerated in 23 (92%) of the 25 patients with attainment of goal feeds in a mean of 3.1 +/- 1 days. CONCLUSIONS: Despite the bowel edema and intra-abdominal hypertension related to the ACS, early enteral feeding is feasible after definitive abdominal closure.

Abdomen↗

PubMed2005

Enteral nutrition delivery and energy expenditure in medical intensive care patients.

BACKGROUND AND AIMS: Delivery of enteral nutrition (EN) in critical illness is often inadequate. This prospective observational study addresses the implementation of enteral feeding in critically ill medical patients and its relation to energy expenditure. METHODS: All admissions to a university medical ICU over a period of one year were screened. Patients receiving EN for at least 7 days were followed up. The caloric target was a minimum of 20 kcal/kg/day. The feeding volume was increased daily by 500 ml and a maximum of 2000 ml/day was targeted to be achieved by day 4 of admission. Energy expenditure was measured with indirect calorimetry on day 3 or 5. RESULTS: Two hundred and thirtyone patients required artificial nutrition, of which 61 patients were enterally fed for 7 days. This group was followed for a total of 750 feeding days. The gastric route was used at the start, with a post-pyloric feeding required during follow-up in 36.1% of patients due to high gastric residual. EN was interrupted in 32.1% of the feeding days. The daily administered volume was 86.2 +/- 30.4% of the prescribed. The mean enteral caloric supply in relation to energy expenditure was between 39.2 +/- 34.6% on day 1 and 83.1 +/- 31.1% on day 6. The targeted maximum feed volume was achieved on day 4 in 75.4% of the patients. Patients with a delayed target time had a higher mortality rate than those with a target time of <4 days (73.3% vs. 26.1%), CONCLUSIONS: A high delivery-to-prescription rate could be achieved with a standardized enteral feeding protocol in critically ill medical patients. However, caloric delivery is much less than measured energy expenditure. Enteral feeding intolerance is associated with a high mortality rate.

Adolescent↗

PubMed2005

Production of enteric capsules by means of hot-melt extrusion.

The aim of this study was to develop an alternative technique for enteric coating consisting of the hot-melt extrusion of coating polymers. An enteric coating polymer (PVAP or HPMC AS), premixed with a plasticizer, was extruded into hollow cylinders. The hollow pipes were filled with a model drug and both open ends of the cylinders were closed, yielding hot-melt extruded enteric capsules. Main advantages of this new technology are the continuity of the process and its application for the formulation of moisture sensitive active ingredients. The enteric capsules showed excellent gastro-resistance, since no drug release was observed after 2 h 0.1N HCl. The influence of wall thickness (0.15, 0.3, 0.5, 0.8, and 1.0 mm) of the capsules on drug release was investigated. Enteric capsules with a wall thickness of 1.0 mm were subjected to a pH gradient dissolution method, simulating passage through the gastro-intestinal tract, in order to evaluate their suitability for ileal or colonic drug targeting. Storing the capsules for 1 month at high relative humidity (RH) (60 and 75% RH) revealed that the HPMC AS capsules were superior to the PVAP capsules. It can be concluded that hot-melt extruded capsules seem suitable as an alternative for enteric coating.

Capsules↗

PubMed2004

A review of the nursing care of enteral feeding tubes in critically ill adults: part I.

Enteral tubes are frequently used in critically ill patients for feeding and gastric decompression. Many of the nursing guidelines to facilitate the care of patients with enteral tubes have not been based on current research, but on ritual and opinion. Using a computerised literature search and an evidence-based classification system as described by the Joanna Briggs Institute for Evidence Based Nursing and Midwifery (JBI), a comprehensive review was undertaken of enteral tube management. Several nursing practices related to enteral tube management are described. Evidence to support alternate methods of tube placement assessment other than abdominal X-ray was inconclusive. Enteral feeding should continue if gastric residual volumes are not considered excessive, as feeding is often withheld unnecessarily. Frequency of checking gastric residual volumes is largely opinion based and varies considerably, but prokinetics that aid gastric emptying should be used if absorption of feeds is problematic. Other recommendations include continuous rather than intermittent feeding, semi-recumbent positioning to reduce the risk of airway aspiration and diligent artificial airway cuff management. Contamination of feeds can be minimised by minimal, meticulous handling and the use of closed rather than open systems. Generally, there was little high quality evidence to support practice recommendations leaving significant scope for further research by nurses in the management of patients with enteral tubes.

Adult↗

PubMed2005

A review of the nursing care of enteral feeding tubes in critically ill adults: part II.

Adult↗

PubMed2005

Enteral feeding in the critically ill: are nursing practices contributing to hypocaloric feeding?

INTRODUCTION: Enteral feeding is the preferred method of nutritional support for the critically ill; however, a significant number of these patients are under-fed. It is possible that common nursing practices associated with the delivery of enteral feeding may contribute to under-feeding although there is little data available describing nursing practice in this area. METHOD: A descriptive survey-based design was used to explore the enteral feeding practices of 376 critical care nurses (response rate 50.5%). Participants completed a 57-item survey that focused on general enteral feeding practice and the management of feeding intolerance and complications. RESULTS: The enteral feeding practice of critical care nurses varied widely and included some practices that could contribute to under-feeding in the critically ill. Practices associated with the measurement of gastric residual volumes (GRV) were identified as the most significant potential contributor to under-feeding. GRV measurements were commonly used to assess feeding tolerance (n = 338; 89.9%) and identified as a reason to delay feeding (n = 246; 65.4%). Delayed gastric emptying was frequently managed by prokinetic agents (n = 237; 63%) and decreasing the rate of feeding (n = 247; 65.7%) while nursing measures, such as changing patient position (n = 81; 21.5%) or checking tube placement (n = 94; 25%) were less frequently reported. CONCLUSION: The findings of this survey support the contention that nursing practices associated with the delivery of enteral feeds may contribute to under-feeding in the critically ill patient population.

Adult↗

PubMed2004

Family caregivers of older adults on home enteral nutrition have multiple unmet task-related training needs and low overall preparedness for caregiving.

OBJECTIVES: We used stress process theory to identify family caregiving variables that are salient to the experience of managing older adults' home enteral nutrition. In this article, we describe the specific tasks family caregivers performed and their unique training needs in the context of caregiver preparedness, competence, effectiveness, and health care use. DESIGN: Hospital billing lists from two university-affiliated institutions in Miami, FL, were used to identify older adults who had enteral tubes placed over a 6-month period. Consent was obtained from those older adults discharged for the first time on home enteral nutrition and their family caregivers at the first scheduled outpatient visit. SUBJECTS/SETTING: In-home interviews were conducted with a diverse sample of 30 family caregivers (14 white, 8 Hispanic, 7 African-American, 1 Asian) during their first 3 months (mean=1.83+/-0.69 months) of home enteral nutrition caregiving. STATISTICAL ANALYSES PERFORMED: Descriptive statistics were used to summarize data for all variables; chi(2) analysis was conducted to analyze differences in categorical variables. One-way analysis of variance was used to analyze mean differences among caregivers grouped by ethnicity for total number of hours and tasks performed. Post hoc comparisons were conducted using the Tukey HSD test. The Spearman rho correlations were calculated to assess bivariate associations between quantitative variables. RESULTS: Caregivers reported providing from 6 to 168 hours of care weekly (mean=61.87+/-49.67 hours), in which they performed an average of 19.73+/-8.09 caregiving tasks daily. Training needs identified were greatest for technical and nutrition-related tasks. Preparedness for caregiving scores were low (mean=1.72, maximum=4.0) and positively correlated with caregiver competence (P<.001) and self-rated caregiver effectiveness (P=.004). Preparedness negatively correlated with health care use (P=.03). CONCLUSIONS: Caregivers of older adults on home enteral nutrition need training for multiple nutrition-related and caregiving tasks. Multidisciplinary interventions, involving dietitian expertise, are needed to better prepare caregivers to improve both caregiver effectiveness and enteral nutrition outcomes.

Adult↗

PubMed2006

Distinction between porcine circovirus type 2 enteritis and porcine proliferative enteropathy caused by Lawsonia intracellularis.

The presence of porcine circovirus type 2 (PCV2) was studied immunohistochemically in formalin-fixed, paraffin wax-embedded samples of intestinal tissue from 80 pigs with a clinical history suggestive of Lawsonia intracellularis-associated diarrhoea. Histopathologically, enteritis of varying intensity was diagnosed in 64 of the pigs. Of these 64 animals, 34 (18%) were infected with both PCV2 and L. intracellularis. Of the remaining 30 cases of enteritis, 23 (77%) were attributed to PCV2 infection alone. The PCV2-associated enteritis cases showed necrotizing ileitis and colitis, indistinguishable macroscopically from proliferative enteritis (PE) due to L. intracellularis. Histopathologically, L. intracellularis-positive intestines showed adenomatous proliferation of crypt enterocytes, whereas PCV2 enteritis was characterized by histiocytosis of varying intensity, with PCV2-positive cells in the submucosa, lamina propria and crypt epithelium, as well as in the lymphoid tissue of the ileum and colon. Multinucleated giant cells, however, were seen in both infections. PCV2 was about three times more likely to be detected in L. intracellularis-negative than in L. intracellularis-positive samples (P<0.001). There was no association between PCV2 and other intestinal bacterial pathogens. The study demonstrated that PCV2 enteritis should be borne in mind in the differential diagnosis of L. intracellularis infection in pigs aged 2-4 months with a clinical history of diarrhoea.

Animals↗

PubMed2005

Effects of total parenteral nutrition on rat enteric nervous system, intestinal morphology, and motility.

Total parenteral nutrition (TPN) is often crucial for patients not being able to feed enterally or having intestinal absorptive deficits. Enteral nutrition is, however, frequently regarded vital for maintaining functional and structural intestinal integrity. The aim of this study was to investigate possible effects of TPN on rat distal small intestine compared to enterally fed identically housed controls, regarding the enteric nervous system (ENS), motility in vitro, and morphology. This study shows that motor responses evoked by electrical stimulation or exposure to vasoactive intestinal peptide (VIP), pituitary adenylate cyclase activating peptide-27 (PACAP-27), and nitric oxide (NO) donor were unchanged. By using immunohistochemistry, the numbers of submucous (P < 0.05) and myenteric (P < 0.05) nerve cells were found to increase, expressed as numbers per unit length. The percentage of neurons expressing VIP, PACAP-27, NO-synthase, and galanin remained unchanged, however. By in situ hybridization the number of submucous neurons expressing neuropeptide Y-mRNA was found to decrease (P < 0.05); the other populations were unaltered. Morphometry revealed an increased submucosal thickness (P < 0.05), while intestinal circumference markedly decreased (P < 0.0001) in TPN-treated rats. In conclusion, TPN treatment resulted in reduced intestinal circumference leading to condensation of enteric neurons. No marked changes in neurotransmitter expression of the enteric neurons or in motor activity were noted.

Animals↗