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Continuous high-energy low-flow-rate enteral support: a panoramic review of 1000 cases.

One thousand intensive care digestive surgical cases are reviewed concerning continuous low-flow-rate enteral support (CLFRES), using Nutripompe: 607 males and 393 females, average age 51 years. The average duration of CLFRES is 21.5 days +/- 13, range 4 to 180 days. CLFRES was used postoperatively in 76 per cent, preoperatively in 10 per cent, and pre- and postoperatively in 14 per cent of cases, respectively. The enteral support route was 63 per cent nasogastric, 20 per cent gastrostomy and 17 per cent jejunostomy. Five hundred and ten patients required extensive digestive surgery with temporary exclusions. More than 100 patients with either temporary enterostomies or enterocutaneous fistulas have had continuous reinstillation of digestive chyme (CRDC) associated with their intensive care unit treatment management. CRDC in the lower end of an enterostomy has shown a specific retrograde inhibitory effect on the upper digestive secretions, particularly on the intestinal secretions during pathologies associated with one or several interruptions of the continuity of the gastrointestinal tract. This technique and its physiological implications were discussed. The principal pathologies in this important study group are: severe digestive fistulas, 24 per cent; acute diffuse peritonitis, 18 per cent; acute enterocolitis, 14 per cent; digestive tumours, 35 per cent; and acute necrotizing haemorrhagic pancreatitis, 9 per cent. A comparative analysis of nutritional energy nitrogen requirement was presented in view of the cancer, the septic, and the non-cancer non-septic patient groups. Enteral support nutritional solutions were primarily mixed non-degraded food, 70 per cent, and semi-elemental diets, 30 per cent. Certain pathology groups required variations in protein and lipid percentage. An up-to-date evaluation of nutritive formulas based on small peptides in normal and small bowel postoperative patients was discussed. Four CLFRES administration programmes were discussed: normal gastrointestinal tract, 38 per cent; abnormal gastrointestinal tract, 44 per cent; pancreatitis, 11 per cent; short bowel, 7 per cent. Nutrition evolution parameters (clinical), were: weight gain curve (minimum 10 days), local regional healing, biological positive changes in protein metabolism, nitrogen balance, lipid metabolism and glucose regulation. Impact on complications such as thrombosis, embolism and haemorrhage were discussed. Clinical and biological results using CLFRES were most satisfactory in more than 90 per cent of patients.

Adolescent↗

Studies on fat digestion, absorption, and transport in the suckling rat. IV. In vivo rates of triacylglycerol secretion by intestine and liver.

The rate of triacylglycerol entry into plasma in 14- to 15-day-old suckling rats was measured using the Triton WR1339 method. When the pups were left with the mother and allowed to nurse continually, the rate was 31.8 +/- 2.3 mumol/hr per rat. If the pups were removed from the mother with full stomachs and kept in a warm box at 30-32 degrees C, the rate was 12.5 +/- 1.5 mumol/hr per rat. The rate of triacylglycerol output from the intestine measured in lymph duct-cannulated animals (kept in a warm box at 30-32 degrees C) was 14.9 +/- 2.7 mumol/hr per rat. Triton treatment of lymph duct-cannulated animals caused only a small increase in plasma triacylglycerol concentration (less than 2 mumol/hr per rat). These data suggest that nearly 100% of plasma triacylglycerol arises from intestinal input in the suckling rat.

Animal Population Groups↗

Secretory hormones of Entamoeba histolytica.

Watery diarrhoea as distinct from dysentery is occasionally seen in intestinal amoebiasis, suggesting a component of intestinal secretion. To study the pathogenesis of this watery diarrhoea, we evaluated the effect of lysates of Entamoeba histolytica on active intestinal electrolyte transport using rabbit ileum and rat colon studied by the Ussing chamber-voltage clamp technique. Amoebic lysates added to the ileal and colonic mucosal surfaces did not alter electrolyte transport; in contrast, addition to the ideal and colonic serosal surfaces caused an increase in short-circuit current which was transient in the ileum but more prolonged in the colon. This increase in current corresponded to inhibition of active Na+ and Cl- absorption and apparent stimulation of Cl- secretion in rat colon. In rabbit ileum, the short-circuit current response was: (1) dependent on serosal Ca2+, (2) inhibited by serosally applied verapamil, (3) associated with reversible desensitization, and (4) only partially inhibited by heating. These characteristics were similar to those of a series of neurohumoral substances present in mammalian intestinal mucosa which affect active electrolyte transport by increasing the permeability of the basolateral membrane to Ca2+. Substances with these properties identified include serotonin, substance P and neurotensin. All three substances were shown to be present in amoebic lysates by radioimmunoassay. Serotonin was also present by high performance liquid chromatography (HPLC) and thin layer chromatography, and neurotensin by HPLC. Prostaglandins were not present by radioimmunoassay. Attempts were made to determine which of these neurohumoral substances contributed to the changes in intestinal transport caused by amoebic lysates. Serotonin was thought to be involved, from the inhibition of the transport effect of amoebic lysate on rat colon by anti-serotonin antibody and by bufotenine, which inhibits the effect of serotonin on ion transport. Prostaglandins also appeared to be involved, since pretreatment with PGE2 or indomethacin inhibited the effects of amoebic lysate on transport. We conclude that amoebae contain neurohumoral substances, including serotonin, neurotensin and substance P, which may be important in the intestinal secretion caused by amoebae. Serotonin appears partially responsible for the intestinal secretion. In addition, amoebae may induce prostaglandin synthesis by the intestinal mucosa which could also contribute to the secretory response. The relation between the neurohumoral substances which act by Ca2+ and the prostaglandins presumably caused to be synthesized in the intestinal mucosa is not known.

Animals↗

Distribution of monoclonal antibodies in intestinal and urogenital secretions of mice bearing hybridoma 'backpack' tumours.

Mice bearing IgA hybridoma 'backpack' tumours have been used to demonstrate that secretion of a single monoclonal IgA can protect against mucosal infection, but the relevance of this model to normal IgA protection is not clear. The authors analysed the distribution of specific monoclonal and total antibodies in bile, local intestinal secretions, cervical-vaginal secretions, urine and serum of mice bearing anti-cholera toxin (CT) IgA and IgG backpack tumours, with and without bile duct ligation. Backpack tumours resulted in high levels of both anti-CT and total IgA or IgG in serum, and IgA (but not IgG) in bile. Secretions recovered by absorbent filter 'wicks' from mucosal surfaces throughout the intestines of backpack tumour mice contained significant concentrations of monoclonal anti-CT IgA, but total IgA levels were as in normal mice. Neither monoclonal nor total IgA levels on mucosal surfaces were altered by bile duct ligation. Furthermore, anti-CT monoclonal IgA levels in local intestinal secretions of backpack tumour mice were comparable to specific polyclonal IgA levels previously elicited by mucosal immunization with CT. Thus, IgA-mediated protection against enteric challenge in the backpack tumour model may be a valid predictor of protection provided by natural mucosal immunization in vivo. High monoclonal IgA levels in bile, urine and the female genital tract, however, may not reflect the situation in normal immunized mice.

Animals↗

5'-adenosine monophosphate is the neutrophil-derived paracrine factor that elicits chloride secretion from T84 intestinal epithelial cell monolayers.

Neutrophil transmigration across intestinal epithelia is thought to contribute to epithelial dysfunction and characterizes many inflammatory intestinal diseases. Neutrophils activated by factors, normally present in the lumen, release a neutrophil-derived secretagogue activity to which intestinal epithelia respond with an electrogenic chloride secretion, the transport event which underlies secretory diarrhea. Using sequential ultrafiltration, column chromatographic, and mass and Raman spectroscopic techniques, neutrophil-derived secretagogue was identified as 5'-AMP. Additional studies suggested that neutrophil-derived 5'-AMP is subsequently converted to adenosine at the epithelial cell surface by ecto-5'-nucleotidase and that adenosine subsequently activates intestinal secretion through adenosine receptors on the apical membrane of target intestinal epithelial cells. These findings suggest that this ATP metabolite may serve as a neutrophil-derived paracrine mediator that contributes to secretory diarrhea in states of intestinal inflammation.

Adenine Nucleotides↗

Clearance of furosemide by the gastrointestinal tract.

Approximately 45% of i.v. administered furosemide is eliminated by nonrenal clearance mechanisms. Indirect evidence suggests this might represent intestinal secretion. Therefore, we examined whether the intestinal tract serves as a drug-eliminating organ in man. Intestinal perfusion studies were performed in six healthy volunteers during i.v. furosemide administration (mean serum concentration, 3.74 +/- 0.64 microgram/ml). Subjects were intubated with a multilumen tube which allowed examination of transmucosal water, solute and furosemide movement at separate levels of the gastrointestinal tract. A poorly absorbable electrolyte-mannitol solution was infused in the jejunum (15 ml/min), with polyethylene glycol as a nonabsorbable marker. Furosemide elimination occurred at an equally low rate in all areas of the intestinal tract. Furosemide clearance for the total gastrointestinal tract was 2.1 +/- 0.4 ml/min (mean +/- S.E.M.) compared to a renal clearance of 93.1 +/- 4.6 ml/min. Thus, gastrointestinal elimination amounted to only 2% of renal elimination. The luminal concentration of furosemide in the intestinal tract did not exceed a mean of 0.5 microgram/ml. When the experiments were repeated after administration of probenecid, gut clearance was unchanged but renal clearance was reduced by 70%. In the ileum, furosemide enhanced bicarbonate secretion and induced chloride absorption. We conclude that the intestinal tract contributes only minimally to furosemide elimination in man. From concentration gradients between lumen and plasma and from the fact that probenecid had no effect on elimination rate, it appears likely that active secretion into the intestinal lumen does not occur and that all furosemide appearance in the gut results from passive diffusion.

Adolescent↗

Significance of calcium for the prostaglandin E2-mediated secretory response to 5-hydroxytryptamine in the small intestine of the rat in vivo.

5-Hydroxytryptamine (5-HT) has been claimed to mediate intestinal secretion in morphine withdrawal diarrhea through stimulation of local prostaglandin formation without involving cyclic adenosine monophosphate. Therefore, experiments were performed to study (a) the effects of exogenous 5-HT and the cyclic adenosine monophosphate-dependent secretagogue, vasoactive intestinal polypeptide, on intestinal prostaglandin E2 (PGE2) formation and (b) the involvement of calcium in the secretory response to close intraarterial infusion of 5-HT, PGE2, or vasoactive intestinal polypeptide in tied-off loops of rat jejunum in vivo. 5-Hydroxytryptamine and vasoactive intestinal polypeptide reversed fluid absorption to net secretion (p less than 0.01), but only 5-HT caused an increase in luminal PGE2 output (p less than 0.01). Indomethacin and d,l-verapamil prevented only the secretory effect of 5-HT. Exogenous PGE2 (1.6-160 ng/min) reversed absorption to secretion (p less than 0.01) in a dose-dependent manner, irrespective of whether the rats were pretreated with indomethacin or not. Racemic and l-verapamil, but not d-verapamil, markedly reduced (p less than 0.01) the secretory effect of physiologically low doses of PGE2 (1.6 and 16 ng/min), whereas high doses of PGE2 (160 ng/min), which caused a significant increase in mucosal cyclic adenosine monophosphate (p less than 0.005), were not inhibited by verapamil. These data suggest that PGE2 may be an important intermediate in the transduction mechanism leading to 5-HT-induced intestinal secretion, and that physiologic doses of PGE2 may act by facilitating calcium entry, rather than by increasing intracellular calcium through activation of the adenylate cyclase.

Animals↗

Acute denervation alters the epithelial response to adrenoceptor activation through an increase in alpha1-adrenoceptor expression on villus enterocytes.

Loss of sympathetic input due to intestinal denervation results in hypersensitivity and increased intestinal secretion. It is unknown whether denervation-induced alterations in intestinal epithelial physiology are the result of changes in adrenoceptors on enterocytes (ENTs). The purpose of this study was to examine adrenoceptor distribution and pharmacology on small intestinal ENTs following acute intestinal denervation. Lewis rats underwent small bowel transplantation (SBT) or sham operation and proximal small intestinal segments were harvested 1, 2 and 4 weeks postoperatively. Intestinal electrolyte movement was assessed using short-circuit current (Isc) measurements of stripped epithelial sheets following stimulation with phenylephrine (PE), an alpha(1)-adrenoceptor agonist. The presence of adrenoceptor subtypes on separated villus and crypt ENTs was assessed using flow cytometry. Alpha(1)-adrenoceptors were found on approximately 27% of jejunal villus ENTs, but not crypt ENTs, following acute extrinsic denervation. ENTs from the Lewis rat have few beta-adrenoceptors. Alpha(1)-adrenoceptor stimulation of acutely denervated intestinal epithelial sheets decreased Isc by -13.45%. This effect was mediated by a reduction in chloride (Cl(-)) secretion; the absence of Cl(-) reversed the Isc to +13.79%. In conclusion, loss of sympathetic innervation to the gastrointestinal epithelium causes acute upregulation of alpha(1)-adrenoceptors on villus ENTs, leading to inhibition of Cl(-) secretion at the villus tip. The increase in adrenoceptors may reflect a compensatory mechanism to combat the increased secretory state of the bowel due to the loss of the sympathetic innervation and tonic control over intestinal secretion.

Animals↗

Comparative study of Clostridium difficile toxin A and cholera toxin in rabbit ileum.

The purpose of this study was to compare the effects of Clostridium difficile toxin A and cholera toxin on fluid secretion, intestinal permeability, and arachidonate metabolites in rabbit ileum. Injection of 25 micrograms of either purified toxin into 10-cm ileal loops caused significant increases in fluid secretion and intestinal permeability to mannitol as well as release of prostaglandin E2 into the lumen. Toxin A, but not cholera toxin, caused a severe inflammatory reaction of the lamina propria and necrosis of enterocytes as well as increased release of leukotriene B4. The toxin A-mediated increases in prostaglandin E2 and leukotriene B4 could be blocked by prior instillation of 10 mg of 5-aminosalicylic acid into ileal loops. 5-Aminosalicylic acid also significantly diminished the expected increase in mannitol permeability after both toxins, but had no significant inhibitory effect on fluid secretion or, in the case of toxin A, intestinal inflammation. Our results indicate that C. difficile and cholera enterotoxins differ substantially in their effects on the rabbit intestine. Clostridium difficile toxin A, an inflammatory toxin, produces a striking infiltration of the lamina propria with neutrophils that is associated with increased release of leukotriene B4. In contrast, cholera toxin does not cause inflammation or leukotriene B4 release. Increased release of prostaglandin E2 occurs after exposure to both toxins and appears to be correlated with increased intestinal permeability.

Animals↗

E. coli heat-stable enterotoxin and guanylyl cyclase C: new functions and unsuspected actions.

Some E. coli cause diarrhea by elaborating heat-labile and heat-stable (ST) enterotoxins which stimulate intestinal secretion. E. coli ST's are small peptides which bind to intestinal luminal epithelial cell receptors. The ST receptor, one of a family of receptor-cyclases called guanylyl cyclase C (GC-C), is a membrane spanning protein containing an extracellular binding domain and intracellular protein kinase and catalytic domains. The intestine synthesizes and secretes homologous peptides, guanylin and uroguanylin. The kidney also synthesizes uroguanylin. ST, guanylin or uroguanylin binding to GC-C results in increased cGMP, phosphorylation of the CFTR Cl- channel and secretion. Proguanylin and prouroguanylin circulate in blood and bind to receptors in intestine, kidney, liver, brain etc. In the kidney, they stimulate the excretion of Na+ and K+. Study of GC-C "knock-out" mice reveal that GC-C is important to intestinal salt and water secretion, duodenal bicarbonate secretion, recovery from CCl4-induced liver injury, and to intestinal polyp formation in Min mice lacking GC-C.

Amino Acid Sequence↗

Evidence for a non-MDR1 component in digoxin secretion by human intestinal Caco-2 epithelial layers.

Caco-2 epithelial layers were used as a model to re-evaluate the mechanism(s) by which intestinal digoxin absorption is limited by its active secretion back into the lumen. It is widely recognised that intestinal secretion of digoxin is mediated by the ATP-binding cassette (ABC) transporter Multidrug Resistance 1, MDR1. In MDR1-transfected Madin-Darby canine kidney, MDCKII, cell monolayers, digoxin secretion was reduced by the MDR1 inhibitor cyclosporin A, whereas no inhibition was seen in the presence of MK-571, 3-([(3-(2-[7-chloro-2-quinolinyl]ethyl)phenyl]-[(3-dimethylamino-3-oxoprphyl)-thio)-methyl]-thio) propanoic acid, a Multidrug Related Protein (MRP) inhibitor. In contrast, digoxin secretion by Caco-2 epithelia was significantly inhibited by both cyclosporin A and MK-571, suggesting that an additional non-MDR1 component may contribute to this transport. Since digoxin secretion by MRP2-transfected MDCKII monolayers was increased by only 1.2-fold relative to controls, it is likely that the contribution of MRP2 to digoxin secretion by Caco-2 cells is negligible. An additional MK-571-sensitive secretory pathway for digoxin, together with MDR1, is likely to mediate digoxin secretion in Caco-2 epithelia.

ATP Binding Cassette Transporter, Subfamily B, Mem↗

Pathogen-induced chemokine secretion from model intestinal epithelium is inhibited by lipoxin A4 analogs.

Enteric pathogens induce intestinal epithelium to secrete chemokines that direct movement of polymorphonuclear leukocytes. Mechanisms that might downregulate secretion of these proinflammatory chemokines and thus contain intestinal inflammation have not yet been elucidated. The antiinflammatory activities exhibited by the arachidonate metabolite lipoxin A4 (LXA4) suggests that this eicosanoid, which is biosynthesized in vivo at sites of inflammation, might play such a role. We investigated whether chemokine secretion could be regulated by stable analogs of LXA4. Monolayers of T84 intestinal epithelial cells were infected with Salmonella typhimurium, which elicits secretion of distinct apical (pathogen-elicited epithelial chemoattractant) and basolateral (IL-8) chemokines. Stable analogs of LXA4 inhibited S. typhimurium-induced (but not phorbol ester-induced) secretion of both IL-8 and pathogen-elicited epithelial chemoattractant. LXA4 stable analogs did not alter bacterial adherence to nor internalization by epithelia, indicating that LXA4 stable analogs did not block all signals that Salmonella typhimurium activates in intestinal epithelia, but likely led to attenuation of signals that mediate chemokine secretion. Inhibition of S. typhimurium-induced IL-8 secretion by LXA4 analogs was concentration- (IC50 approximately 1 nM) and time-dependent (maximal inhibition approximately 1 h). As a result of these effects, LXA4 stable analogs inhibited the ability of bacteria-infected epithelia to direct polymorphonuclear leukocyte movement. These data suggest that LXA4 and its stable analogs may be useful in downregulating active inflammation at mucosal surfaces.

Cells, Cultured↗