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PubMed2002

Localization and endothelin-3 dependence of stem cells of the enteric nervous system in the embryonic colon.

BACKGROUND/PURPOSE: The aganglionosis in a variable length of the distal gut found in Hirschsprung's disease results from the abnormal prenatal development of neural crest-derived stem cells of the enteric nervous system. The cytokine endothelin-3 is necessary for successful colonization of the distal gut, but the location of this interaction with neural crest-derived stem cells remains to be established. The hypothesis tested here is that the stem cells of the enteric nervous system (ENS) in the colon are located at the leading edge of the migrating wave of neural crest-derived stem cells and that these cells require colonic endothelin-3 for complete colonization of the gut. METHODS: Explants of 11.5-day-old embryonic intact mouse gut and isolated colon were cultured for 72 hours in the presence and absence of the endothelin-B receptor antagonist, BQ788. Specimens then were sectioned and stained by immunohistochemistry to assess enteric nervous system development. RESULTS: Isolated colon contained a very low number (mean, 73 cells; range, 37 to 106; n = 8) of neural crest-derived stem cells, which had just entered its proximal end at the leading edge of neural crest cell migration. After 72 hours of culture, progeny of these few neural crest-derived stem cells had colonized the colon at an equivalent ganglionic density to those in intact gut. Furthermore, neuronal differentiation, as shown by the appearance of nitric oxide synthase positive neurons, also was equivalent to intact gut. Blockade of the endothelin-B receptor produced terminal aganglionosis in both isolated colons and intact gut. CONCLUSIONS: The very small number of cells that first enter the proximal colon at the leading edge of neural crest cell migration have the ability to colonize the entire colon normally in an ET-3-dependent manner. These cells therefore have the functional characteristics expected of the stem cells of the colonic enteric nervous system. Furthermore, the normal development of these cells is dependent on the endothelin-3 expressed by the mesenchymal cells of the colon itself.

Animals↗
PubMed2001

Pharmacokinetics of menthol and carvone after administration of an enteric coated formulation containing peppermint oil and caraway oil.

Enteric coating of peppermint oil/caraway oil capsules avoids subjective discomfort to the patient caused by gastroesophageal reflux. In order to confirm bioequivalence of an enteric coated formulation containing peppermint oil and caraway oil (CAS 277309-55-4, Enteroplant) and an immediate release formulation of both oils, the pharmacokinetics of menthol and carvone after oral administration of the two formulations were studied in a randomized, two-period cross-over study in 16 healthy male volunteers. The subjects received 180 mg peppermint oil and 100 mg caraway oil, once as 2 enteric coated capsules of the fixed enteric coated combination preparation containing 90 mg peppermint oil (WS 1340) and 50 mg caraway oil (WS 1520) each (test) and once in the form of 5 capsules of an immediate release formulation (reference) containing 36 mg peppermint (WS 1340) oil and 20 mg caraway oil (WS 1520) each. The capsules were taken with 250 ml water after a 10 h fast. Both substances were determined in plasma by GC/MS after extraction. The limit of quantification was 10 ng/ml for menthol and 0.5 ng/ml for carvone. The mean maximum plasma levels for menthol were 1196 ng/ml after administration of the test medication and 1492 ng/ml after administration of the reference medication. The bioavailability with respect to the AUC was comparable after administration of test and reference preparation, the 90% confidence interval was 97 to 105%. As expected, there were considerable differences for Tmax. After application of the enteric coated form the maximum concentration was reached significantly later (3.0 h vs. 1.7 h) compared to the immediate release capsule. Corresponding data were also calculated for carvone. After application of the test medication the maxima of 14 ng/ml for both formulations were reached later (2.5 h vs. 1.3 h). The 90% confidence interval of the AUC for carvone was 79 to 119% and therefore slightly outside the acceptable range for bioequivalence of 80 to 125%. However, this fact should not be relevant, in particular since the dosage of the enteric coated capsule lies at the upper limit of the model text and positive clinical studies, also on the therapeutic equivalence of the two formulations, are available.

Adult↗
PubMed2001

[Enteral nutrition in acute pancreatitis].

The metabolism of acute pancreatitis is characterized by hypermetabolism and catabolism. Evidence for glucose intolerance occurs in anywhere from 40 to 90% of cases and urine urea nitrogen may increase up to 40 g/day. The most important aspect when considering nutritional therapy is determining the severity of the pancreatitis. The APACHE-II-scoring-system and the time honored Ranson criteria are useful for differentiating severe from mild pancreatitis. Despite some limitations in sensitivity and specificity, studies have suggested that patients with 2 or less Ranson criteria and an APACHE-II-score of 9 or less have mild pancreatitis, while patients with 3 or more Ranson criteria and an APACHE-II-score of 10 or more have severe pancreatitis. Evidence of organ failure on clinical presentation and pancreatic necrosis on dynamic CT scan are also important factors in determining severity of pancreatitis and are probably the two major indicators of patient outcome. Only 3 prospective randomized controlled trials have compared enteral to parenteral nutrition for pancreatitis. All studies described successful use of enteral feeding without exacerbating the disease process although a mild stimulation of exocrine pancreatic secretion could not be prevented, even when the tube was placed below the ligament of Treitz. Kalfarentzos [11] and McClave [14] could show that hyperglycemia was worse in the parenteral feeding patients compared to the enteral feeding group and Windsor [24] concluded with respect to the results of his study, that enteral feeding modulates the inflammatory response in acute pancreatitis. Conclusions regarding the use of enteral or parenteral nutrition in acute pancreatitis are difficult to form, as there is a need of more prospective studies. As ileus may be a problem in patients with greater severity of pancreatitis, limiting the application of early enteral feeding, the route of nutritional support should be determined by the clinical course and the severity of the disease.

APACHE↗
PubMed2000

Effects of enteric-coated methylnaltrexone in preventing opioid-induced delay in oral-cecal transit time.

BACKGROUND: Methylnaltrexone is the first peripheral opioid receptor antagonist. It has the potential to prevent or reverse the peripherally mediated gastrointestinal effects of opioids. In previous human volunteer trials, we demonstrated that oral uncoated methylnaltrexone prevented morphine-induced delay in gastrointestinal transit time. METHODS: This trial consisted of two studies: a pilot study and a controlled study. The lactulose hydrogen breath test was used to measure the oral-cecal transit time. RESULTS: In the pilot study with three subjects, an oral dose of 6.4 mg/kg enteric-coated methylnaltrexone effectively reversed the effects of morphine, producing transit times shorter than baseline levels. Subsequently, in the controlled study with another nine subjects, the transit time increased after intravenous morphine administration in all nine subjects, and the lower dose (3.2 mg/kg) of enteric-coated methylnaltrexone completely prevented the morphine-induced change in oral-cecal transit time in all nine subjects. Morphine significantly increased oral-cecal transit time from baseline level of 96.7 +/- 54.1 minutes (mean +/- SD) to 155.0 +/- 53.6 minutes (P = .014). After enteric-coated methylnaltrexone and morphine, the transit time returned to the baseline level (93.3 +/- 56.0 minutes; P = .55 compared with placebo). Plasma concentrations after 6.4 mg/kg and 3.2 mg/kg enteric-coated methylnaltrexone were substantially lower compared with those after 6.4 mg/kg of the uncoated formulation. CONCLUSION: Our results suggest that there is a prevailing direct and local luminal effect of enteric-coated methylnaltrexone and that the enteric-coated formulation exerts its gut pharmacologic actions more efficiently than the uncoated formulation.

Administration, Oral↗
PubMed2001

Modification of enteral diets in inflammatory bowel disease.

The provision of food is thought to promote the maintenance of gut integrity. Nutrients are able to elicit and affect both systemic and mucosal immune responses. Enteral diet therapy has long been known to be efficacious in inflammatory bowel disease (IBD), particularly in childhood Crohn's disease. However, the mechanisms of action of these diets are not clear. Nutritional repletion, direct effects on the gut mucosa or decreased intestinal permeability have all been postulated as being important in nutritional therapy. There is some evidence that the enteral diet has a direct effect on the gut mucosa by reducing cytokine production and the accompanying inflammation, thus leading to decreased intestinal permeability. Modifications of enteral diet composition have been evaluated in many studies. Such modifications include fat and/or protein content and the addition of bioactive peptides. The fatty acid composition of the enteral diet seems to have a much greater impact on its efficacy than modification of the N source. As specific fatty acids are precursors of inflammatory mediators derived from arachidonic acid, the reduction in these components may be beneficial in nutritional therapy for IBD. Addition of bioactive peptides to enteral diet formulas may also have a role; such peptides may have specific growth factor or anti-inflammatory actions. There is still much work to be done to define disease-specific enteral diet formulas that are effective as therapies for both Crohn's disease and ulcerative colitis.

Cell Membrane Permeability↗
PubMed2000

Randomised trial of safety and efficacy of postoperative enteral feeding in patients with severe pancreatitis: preliminary report.

OBJECTIVE: To find out whether postoperative enteral feeding is safe and effective in patients with severe pancreatitis. DESIGN: Prospective randomised trial. SETTING: Teaching hospital, Latvia. SUBJECTS: 29 patients who had been operated on for severe pancreatitis. INTERVENTIONS: They were randomised to have either enteral nutrition and conventional intravenous fluids postoperatively (n = 11), or conventional intravenous fluids only (n = 18). 17 additional patients who had had major abdominal operations for other conditions were also given enteral nutrition and intravenous fluids and comprised the control group. MAIN OUTCOME MEASURES: Nutritional intake, duration of stay in intensive care (ICU) and hospital morbidity, mortality, and outcome. RESULTS: 1 patient died of the 11 given enteral nutrition combined with conventional intravenous fluids, compared with 5/18 given fluids only. The pattern of bowel transit in the fed group did not differ from that in the control group. CONCLUSION: Postoperative enteral nutrition seems to be safe and effective in patients with severe pancreatitis and may improve survival. Our results suggest that enteral and parenteral nutrition may complement each other in seriously ill patients.

Acute Disease↗
PubMed2005

Glutamine-enriched enteral nutrition in very-low-birth-weight infants and effects on feeding tolerance and infectious morbidity: a randomized controlled trial.

BACKGROUND: Glutamine depletion has negative effects on the functional integrity of the gut and leads to immunosuppression. Very-low-birth-weight (VLBW) infants are susceptible to glutamine depletion because nutrition is limited in the first weeks of life. OBJECTIVE: The objective was to determine the effect of glutamine-enriched enteral nutrition on feeding tolerance, infectious morbidity, and short-term outcome in VLBW infants. DESIGN: In a double-blind randomized controlled trial, VLBW infants (gestational age <32 wk or birth weight <1500 g) were allocated to receive enteral glutamine supplementation (0.3 g . kg(-1) . d(-1)) or isonitrogenous control supplementation (alanine) between days 3 and 30 of life. The supplementations were added to breast milk or to preterm formula. The primary endpoint for the study was time to full enteral feeding. Secondary endpoints were other variables of feeding tolerance, infectious morbidity, and short-term outcome. RESULTS: Baseline patient and nutritional characteristics were not significantly different in the glutamine-supplemented (n = 52) and the control (n = 50) groups. The median time to full enteral feeding was 13 d (range: 7-31 d) in the glutamine-supplemented group and 13 d (range: 6-35 d) in the control group (hazard ratio: 1.19; 95% CI: 0.79, 1.79; P = 0.40). In the glutamine-supplemented group, 26 of 52 infants (50%) had >/=1 serious infection compared with 38 of 50 (76%) in the control group (odds ratio: 0.32; 95% CI: 0.14, 0.74; P = 0.008). Other variables of feeding tolerance and short-term outcome were not significantly different between groups. CONCLUSIONS: Glutamine-enriched enteral nutrition did not improve feeding tolerance or short-term outcome in VLBW infants. However, infectious morbidity was significantly lowered in infants who received glutamine-enriched enteral nutrition.

Dose-Response Relationship, Drug↗
PubMed1995

Fluoroquinolones and bacterial enteritis, when and for whom?

During the last decade quinolones such as norfloxacin, ciprofloxacin, ofloxacin and fleroxacin have emerged as drugs of choice for treatment of various bacterial enteric infections. Controlled studies have shown that quinolones, administered in varying regimens ranging from a single dose to 5 days treatment, significantly reduce the intensity and severity of travellers' diarrhoea as well as shigellosis. They have also been found to be highly effective in the treatment of invasive non-typhoid salmonellosis as well as typhoid fever. Results from trials evaluating quinolone treatment of uncomplicated salmonella and campylobacter enteritis have generally been disappointing. We studied norfloxacin for the empirical treatment of suspected bacterial enteritis of less than 6 days duration in a large placebo controlled trial. Although statistical differences in clinical outcome favouring norfloxacin were found among 259 culture positive patients, the differences were not striking and of doubtful clinical importance. However, a clear beneficial effect of norfloxacin, resembling that observed in early treatment of travellers' diarrhoae was found among the severely ill patients who initiated treatment within 48 h of onset of symptoms to start of treatment seemed to be of major importance in relation to therapeutic efficacy. Quinolone treatment of bacterial enteritis is furthermore limited by the rapid development of resistance seen in Campylobacter spp. and the failure of these compounds to eradicate Salmonella spp. Presently quinolones can be recommended in treatment of travellers' diarrhoea and shigellosis as well as enteric fever. They have limited usefulness for the routine empirical treatment of bacterial enteritis caused by Salmonella spp and Campylobacter spp. Treatment should be restricted to early empirical treatment of the severely ill and vulnerable patients with an underlying health problem.

Anti-Infective Agents↗
PubMed1994

The protein quality of some enteral products is inferior to that of casein as assessed by rat growth methods and digestibility-corrected amino acid scores.

Protein digestibility and quality of six enteral nutrition products sold in Canada were studied by rat balance and growth methods. Casein+L-methionine, 0.2 g/100 g diet (control) and six enteral products (freeze-dried) were fed as the sole source of protein in diets containing 8.61-9.12 g/100 g protein (N x 6.25) to weanling and 18-mo-old rats for a period of 2 and 1 wk, respectively. A protein-free diet was also included in the feeding studies to permit calculations of true protein digestibility and net protein ratio values. Values for true digestibility of protein as determined in old rats for the control diet and the test products were 95 and 89-93%, respectively. Compared with old rats, protein digestibility values were 5-7 percentage units higher in young rats. The 2-wk relative protein efficiency ratio values (42-56%) or the relative net protein ratio values (61-74%) of the enteral products were considerably lower compared to those of the control (100). Supplementation of an enteral product with cysteine, cysteine + tryptophan, cysteine + threonine or cysteine + tryptophan + threonine caused significant improvement in protein quality; suggesting that the product was limiting in these three amino acids. The protein digestibility-corrected amino acid scores for the enteral products were 43-46, 69-75 and 86-93% by using whole egg, casein and the FAO-WHO (1991) pattern as reference proteins, respectively. The results indicate that these enteral products are inferior to casein in protein quality.

Amino Acids↗
PubMed2003

Health problems following Campylobacter jejuni enteritis in a Lancashire population.

OBJECTIVES: Campylobacter jejuni enteritis can lead to musculoskeletal, neuropathic or other health sequelae. We investigated the coexistence, seasonal occurrence, strain-type associations and impact on work capacity of different health problems following C. jejuni enteritis in a Lancashire population during 1999 and 2001. METHODS: A semistructured questionnaire was used to characterize health problems that occurred in the community after laboratory-confirmed episodes of C. jejuni enteritis. The questionnaire was posted to all adults in the Preston and Chorley area who developed C. jejuni enteritis in 1999 or 2001. All Campylobacter isolates from this population were serotyped. RESULTS: Several types of sequelae occurred consistently in both years, including the coexistence of musculoskeletal and neuropathic problems. There was no evidence of C. jejuni strain-type associations or seasonal preponderance for any type of sequela. The overall health impact of C. jejuni enteritis, as measured by workdays lost, was high in this population. CONCLUSIONS: A variety of health problems occur consistently following C. jejuni enteritis and substantially increase morbidity due to campylobacteriosis in the community.

Acute Disease↗
PubMed1992

Enteral versus parenteral feeding. Effects on septic morbidity after blunt and penetrating abdominal trauma.

To investigate the importance of route of nutrient administration on septic complications after blunt and penetrating trauma, 98 patients with an abdominal trauma index of at least 15 were randomized to either enteral or parenteral feeding within 24 hours of injury. Septic morbidity was defined as pneumonia, intra-abdominal abscess, empyema, line sepsis, or fasciitis with wound dehiscence. Patients were fed formulas with almost identical amounts of fat, carbohydrate, and protein. Two patients died early in the study. The enteral group sustained significantly fewer pneumonias (11.8% versus total parenteral nutrition 31.%, p less than 0.02), intra-abdominal abscess (1.9% versus total parenteral nutrition 13.3%, p less than 0.04), and line sepsis (1.9% versus total parenteral nutrition 13.3%, p less than 0.04), and sustained significantly fewer infections per patient (p less than 0.03), as well as significantly fewer infections per infected patient (p less than 0.05). Although there were no differences in infection rates in patients with injury severity score less than 20 or abdominal trauma index less than or equal to 24, there were significantly fewer infections in patients with an injury severity score greater than 20 (p less than 0.002) and abdominal trauma index greater than 24 (p less than 0.005). Enteral feeding produced significantly fewer infections in the penetrating group (p less than 0.05) and barely missed the statistical significance in the blunt-injured patients (p = 0.08). In the subpopulation of patients requiring more than 20 units of blood, sustaining an abdominal trauma index greater than 40 or requiring reoperation within 72 hours, there were significantly fewer infections per patient (p = 0.03) and significantly fewer infections per infected patient (p less than 0.01). There is a significantly lower incidence of septic morbidity in patients fed enterally after blunt and penetrating trauma, with most of the significant changes occurring in the more severely injured patients. The authors recommend that the surgeon obtain enteral access at the time of initial celiotomy to assure an opportunity for enteral delivery of nutrients, particularly in the most severely injured patients.

Abdominal Injuries↗
PubMed1995

Enteral nutrition during multimodality therapy in upper gastrointestinal cancer patients.

OBJECTIVE: The objective of this study was to evaluate long-term enteral nutrition support in postoperative cancer patients. BACKGROUND: Multimodality therapy for surgical patients with upper gastrointestinal malignancies may improve survival, but often results in substantial malnutrition, immunosuppression, and morbidity. The benefits of combined inpatient and outpatient enteral feeding with standard diets or diets supplemented with arginine, RNA + omega-3 fatty acids are unclear. METHODS: Sixty adult patients with esophageal (22), gastric (16), and pancreatic (22) lesions were stratified by disease site and percent usual weight and randomized to receive supplemental or standard diet via jejunostomy beginning on the first postoperative day (goal = 25 kcal/kg/day) until hospital discharge. Patients also were randomized to receive (n = 37) or not receive (n = 23) enteral jejunostomy feedings (1000 kcal/day overnight) for the 12- to 16-week recovery and radiation/chemotherapy periods. Plasma and peripheral white blood cells were obtained for fatty acid levels and PGE2 production measurements. RESULTS: Mean plasma and cellular omega 3/omega 6 fatty acid levels (percent composition) increased significantly (p < 0.05) in the arginine + omega-3 fatty acid group by postoperative day 7 (0.30 vs. 0.13) and (0.29 vs. 0.14) and continued to increase over time. Mean PGE2 production decreased significantly (p < 0.05) from 2760 to 1600 ng/10(6) cells/mL at day 7 in the arginine + omega-3 fatty acid group, whereas no significant change over time was noted in the standard group. Infectious/wound complications occurred in 10% of the supplemented group compared with 43% of the standard group (p < 0.05); mean length of hospital stay was 16 vs. 22 (p < 0.05) days, respectively. Of the patients who received postoperative chemoradiation therapy, only 1 (6%) of the 18 patients randomized to receive tube feeding did not continue, whereas 8 (61%) of the 13 patients not randomized to tube feedings required crossover to jejunostomy nutritional support. CONCLUSIONS: Supplemental enteral feeding significantly increased plasma and peripheral white blood cell omega 3/omega 6 ratios and significantly decreased PGE2 production and postoperative infectious/wound complications compared with standard enteral feeding. For outpatients receiving adjuvant therapy, those initially randomized to oral feedings alone required rehospitalization more frequently, and 61% crossed over to supplemental enteral feedings.

Aged↗
PubMed1996

A randomized trial of isonitrogenous enteral diets after severe trauma. An immune-enhancing diet reduces septic complications.

OBJECTIVE: The authors randomized patients to an enteral diet containing glutamine, arginine, omega-3 fatty acids, and nucleotides or to an isonitrogenous, isocaloric diet to investigate the effect of septic outcome. A third group of patients, without enteral access but eligible by severity of injury, served as unfed controls and were studied prospectively to determine the risk of infection. SUMMARY BACKGROUND DATA: Laboratory and clinical studies suggest that diets containing specialty nutrients, such as arginine, glutamine, nucleotides, and omega-3 fatty acids, reduce septic complications. Unfortunately, most clinical trials have not compared these diets versus isonitrogenous, isocaloric controls. This prospective, blinded study randomized 35 severely injured patients with an Abdominal Trauma Index > or = 25 or a Injury Severity Score > or = 21 who had early enteral access to an immune-enhancing diet ([IED] Immun-Aid, McGaw, Inc., Irvine, CA; n = 17) or an isonitrogenous, isocaloric diet (Promote [Ross Laboratories, Columbus, OH] and Casec [Mead-Johnson Nutritionals, Evansville, IN]; n = 18) diet. Patients without early enteral access but eligible by severity of injury served as contemporaneous controls (n = 19). Patients were evaluated for septic complications, antibiotic usage, hospital and intensive care unit (ICU) stay, and hospital costs. RESULTS: Two patients died in the treatment group and were dropped from the study. Significantly fewer major infectious complications (6%) developed in patients randomized to the IED than patients in the isonitrogenous group (41%, p = 0.02) or the control group (58%, p = 0.002). Hospital stay, therapeutic antibiotics, and the development of intra-abdominal abscess was significantly lower in patients receiving the IED than the other two groups. This improved clinical outcome was reflected in reduced hospital costs. CONCLUSIONS: An IED significantly reduces major infectious complications in severely injured patients compared with those receiving isonitrogenous diet or no early enteral nutrition. An IED is the preferred diet for early enteral feeding after severe blunt and penetrating trauma in patients at risk of subsequent septic complications. Unfed patients have the highest complication rate.

Adult↗
PubMed1992

Effect of acidified enteral feedings on gastric colonization in the critically ill patient.

OBJECTIVE: To evaluate the effect of acidified enteral nutritional formulas (feedings) on gastric colonization and pH in critically ill patients. DESIGN: Randomized, double-blind trial of three groups: a) regular feedings into the stomach; b) regular feedings into the duodenum; and c) acidified feedings into the stomach. Nasogastric aspirates for gastric pH and microbiological determinations were obtained daily for a mean of 5 days after feeding began. SETTING: ICU at a tertiary care hospital. PATIENTS: Thirty-one patients indicated to receive enteral feedings before day 4 in the ICU were randomized. Seven patients had their feedings discontinued because of intolerance, accidental extubation, or tolerance of oral supplementation. One patient received the wrong feedings and was dropped from the study. A total of 23 patients finished the study. They were mostly trauma (n = 15) or neurosurgical (n = 6) patients. The average age was 40 yrs (range 15 to 71). INTERVENTIONS: An enteral formula with a pH of 6.5 was used as the control feeding. Hydrochloric acid was added to the control feeding to titrate the pH to 3.5 and this acidified enteral formula was given to the experimental group. All patients received continuous enteral feedings via an 8-Fr feeding tube. MAIN RESULTS: Seven of eight patients receiving the acidified feedings were sterile (no microbial growth) on receiving feedings compared with five of 15 of those patients receiving regular feedings (p = .027). For those patients initially colonized, four of four patients receiving acidified feedings immediately became sterile and remained so. Only two of ten patients receiving regular feedings remained sterile (p = .021). The mean gastric pH of the acidified group was 3.2 compared with the group receiving regular feedings into the stomach (pH = 4.7) and the group receiving regular feedings into the duodenum (pH = 3.8) (p < .01). There was no evidence of gastrointestinal bleeding in any patient. CONCLUSIONS: Acidified enteral feedings are effective in eliminating and preventing gastric colonization in critically ill patients. Further investigation is needed to assess its effect on nosocomial infection rates.

Acidosis, Lactic↗
PubMed1993

Enteral nutrition with simultaneous gastric decompression in critically ill patients.

OBJECTIVE: Early enteral nutrition is an important adjunct in the care of critically ill patients. A double-lumen gastrostomy tube with a duodenal extension has been reported to enable early enteral feeding with simultaneous gastroduodenal decompression. We tested the ability of this device to achieve these goals in critically ill patients. DESIGN: Noncomparative, descriptive case series. SETTING: Surgical intensive care unit in a university hospital. PATIENTS: Fifteen consecutive critically ill patients, who, at the time of laparotomy, were assessed likely to need long-term nutritional support and gastric decompression, underwent tube placement. Mean age was 47 +/- 21 yrs. Mean Acute Physiology and Chronic Health Evaluation (APACHE II) and Therapeutic Intervention Scores were 15 +/- 7.3 (SD) and 29 +/- 10.2, respectively, and the mean Injury Severity Score of 11 trauma patients in the group was 27 +/- 7.4. INTERVENTIONS: Correct tube positioning was verified by radiograph or endoscopy. METHODS: Caloric and protein requirements, nutritional parameters, and problems encountered with the device were recorded. The correlation between the volume of feeding port input and suction port output was noted, and this correlation was considered significant if r2 was > or = .5. RESULTS: Only three (20%) of 15 patients reached full enteral nutritional support via the enteral route. None of these patients achieved this level of nutritional support within the first postoperative week. In 67% of the patients, large quantities of enteral feeding solution appeared in the gastroduodenal suction port effluent. When feeding port input was plotted against effluent volume, a correlation coefficient of > .71 (r2 = > or = .5) was found in 40% of the patients. Other complications included: a) excessive gastroduodenal drainage requiring fluid/electrolyte replacement in eight (53.3%) patients; and b) skin ulceration at the tube entrance site in seven (46.7%) patients. CONCLUSIONS: These data do not support the use of this device for early enteral feeding and simultaneous gastric decompression in critically ill patients.

Adolescent↗
PubMed2002

Enteral access for nutritional support: rationale for utilization.

Acquisition of enteral access and provision of a sufficient volume of enteral nutrients early in the hospital course of a critically ill patient afford an opportunity to improve the outcome of that patient through the progression of his or her disease process. Failure to use the enteral route of feeding not only squanders this opportunity, but may, in addition, promote a pro-inflammatory state, which exacerbates disease severity and worsens morbidity. Enteral feeding provides a conduit for the delivery of immune stimulants and serves as effective prophylaxis against stress-induced gastropathy and gastrointestinal hemorrhage. Tube placement beyond the stomach into the small bowel in hypermetabolic, severely ill patients prone to ileus and disordered gut motility aids delivery of enteral nutrients while reducing risk of aspiration. Endoscopic skills and expertise in gastrointestinal physiology are vital to the success of a nutrition support service and the provision of enteral tube feeding.

Burns↗
PubMed2003

Enteral nutritional support of the patient with cancer: route and role.

Malnutrition is a common and significant problem in patients with cancer. Enteral nutrition support is an important therapy and is preferred over parenteral nutrition in the setting of a functional gastrointestinal tract. Familiarity with the indications for enteral support, the choice of an enteral access device, and the selection of an enteral formula are critical for the care of patients with cancer and malnutrition. Enteral nutrition has proven efficacy in patients receiving radiation to the head and neck, those with persistent dysphagia, and critically ill patients with impaired gastric emptying. Placement of feeding tubes through the nose or percutaneously provides a mechanism to deliver nutrients when proximal obstructions or oropharyngeal dysphagia prevent adequate oral intake. Direct access to the jejunum can be safely obtained endoscopically and is very useful in patients who require enteral nutrition support following a gastrectomy or esophagectomy or have impaired gastric emptying. Standard polymeric formulas are appropriate for most patients. Specialized formulas designed to enhance immune function may decrease infectious complications but do not improve survival.

Enteral Nutrition↗
PubMed2003

Low fecal elastase: potentially related to transient small bowel damage resulting from enteric pathogens.

UNLABELLED: Fecal elastase is considered to be a highly sensitive and specific non-invasive exocrine pancreatic function test. However, enteropathy may theoretically cause decreased exocrine pancreatic enzyme secretion through alteration of enteric hormone release. OBJECTIVE: The aim of this study was to evaluate the possible influence of transient small bowel damage on pancreatic elastase secretion. METHODS: We studied 166 children (aged 4 months to 14 years, mean 2 years); 114 of these children had acute enteritis and 52 children were control subjects (with gastro-intestinal symptoms or extra-intestinal diseases). Feces were collected from each patient 3 days after the onset of diarrhea and then tested for fecal elastase, bacterial pathogens, Rotavirus, and Adenovirus. Liquid fecal samples were not considered eligible for elastase measurement. Pancreatic elastase was measured using an ELISA method (Sche.Bo.Tech, Germany). We classified the results, expressed in microg/g stool, as: severe pancreatic insufficiency (<100 microg/g), moderate pancreatic insufficiency (100 to 200 microg/g), and normal (>200 microg/g). RESULTS: In the acute enteritis group we found severe levels in 14 (12%) children, moderate levels in 18 children (16%), and normal levels in 82 children (72%). In contrast, 52 of 52 (100%) control subjects demonstrated normal results. Statistical analysis (Wilcoxon rank test) demonstrated a significant difference between the enteritis and control groups (P < 0.01). Serial measurement of fecal elastase performed in 10 patients with enteritis showed a progressive increase of levels in 6 patients and an early decline with subsequent increases in the other 4 patients. CONCLUSIONS: Transient exocrine pancreatic insufficiency may be present in transient small bowel disease, caused by both bacterial and viral infections, possibly related to reduced enteric CCK secretion.

Acute Disease↗