Decreased bile acid synthesis with total parenteral nutrition

BACKGROUND: Biliary changes occur in patients on total parenteral nutrition (TPN) predisposing them to gallstones and cholestasis. We hypothesized that patients on TPN, similar to animal models, would have reduced bile acid synthesis. METHODS: Serum from 13 controls and 17 patients on TPN were collected and tested with HPLC for 7alpha-hydroxy-4-cholesten-3-one, which has been shown to correlate with bile acid synthesis. Somatostatin and tumor necrosis factor alpha levels were determined with enzyme-linked immunosorbent assays. RESULTS: Bile acid synthesis was significantly reduced in patients on TPN. TPN patients on oral feeding (but not jejunostomy) had similar bile acid synthesis rates as controls. In patients on TPN and nothing by mouth, somatostatin had a significant negative correlation with bile acid synthesis (P < .01). CONCLUSION: TPN patients have a reduced bile acid synthesis, and this correlates with somatostatin if they are treated with nothing by mouth. Oral feeding is associated with a higher bile acid synthesis, and body mass index, age, albumin, and tumor necrosis factor alpha do not have an effect on bile acid synthesis.     

Essential fatty acid deficiency during total parenteral nutrition.

Essential fatty acid (EFA) deficiency has become a clinical problem since the advent of fat-free total parenteral nutrition (TPN). The following study was done to determine the minimum fat requirements for patients receiving continuous TPN solution. Seventy-seven patients who had 97 courses of TPN of at least 14 days duration were prospectively studied. The following fat supplementation was given: a) none, b) 10% soybean oil emulsion intravenously at fixed dosage, c) fat from an oral diet, or d) intravenous and oral fat. No patient was EFA deficient before the onset of TPN. EFA deficiency was prevented when at least 3.2% of total calories were given as intravenous fat or at least 15% as oral fat. Lesser amounts of fat decreased the rate of EFA deficiency development but did not prevent it from occurring. The 7.7 g/day of linoleic acid provided in 1000 ml per week of 10% soybean oil emulsion provides adequate fat to prevent EFA deficiency.     

Effects of glutamic acid and taurine on total parenteral nutrition

Background

The objective of the present study was to ascertain whether simultaneous administration of glutamic acid (Glu) and taurine (Tau) to patients on total parenteral nutrition (TPN) could improve intestinal mucosal atrophy and suppress bacterial translocation.

Methods

A 5-day TPN study was conducted in 5-week-old Sprague-Dawley rats. Commercially available Glu was used for TPN in group G and was enhanced with Tau (500 mg kg⁻¹ day⁻¹) in group GT. Oral nutrition was provided in group C controls. At 5 days, amino acid and cytokine levels in plasma and endotoxin levels in portal blood were measured. The histology of the small intestine, liver, and lung were analyzed.

Results

Mucosal thickness and villus height in the small intestine were lower for group G than for groups C and GT. Taurine level in group GT was higher than in group G. Arginine and citrulline levels in groups G and GT were lower than in group C. Taurine level in the small intestine was greater in group GT than in group G. Citrulline concentration was lower in group G than in groups GT and C. Endotoxin level in portal blood and cytokine (tumor necrosis factor α, interleukin-1β, and interleukin-6) levels in blood tended to be lower for group GT than for group G, but no significant differences were noted. Immunostaining showed strong positive reactions to vascular cell adhesion molecule-1 in the liver and lung for group G, and milder reactions for group GT.

Conclusions

Simultaneous administration of Glu and Tau improved small intestinal mucosal thickness and villus height during TPN. Levels of Tau in the small intestine and plasma increased, and the level of citrulline in the small intestine improved. Decreased expression of adhesion molecules in the liver and lung and improved microcirculation in the liver were also confirmed.     

Priapism in patients treated with total parenteral nutrition

Three patients who developed priapism associated with total parenteral nutrition are reported. To reduce the risk of priapism in such patients it is suggested that fat emulsions stronger than 10% should not be administered.     

Amino acid utilization during total parenteral nutrition in the surgical neonate

Amino acids, urea nitrogen, and creatinine in plasma and urine, and total urinary nitrogen were determined in five neonates during prolonged parenteral feeding. A fibrin hydrolysate-dextrose or a crystalline amino acid-dextrose solution was infused for periods as long as 33 days. These solutions supplied essential amino acids and total nitrogen (mostly as glycine) in excess of that available to infants on oral diets.Despite weight gain, positive nitrogen balance, and the absence of excessive amino aciduria, several biochemical abnormalities were detected. Plasma lysine, leucine, and glycine were consistently elevated and in one low birth weight infant, plasma phenylalanine and valine were also markedly raised. The excessive supply of glycine and nitrogen resulted in elevated urea levels in the blood and urine.The capacity to transform phenylalanine to tyrosine and methionine to cystine required by infants fed the tyrosine-cystine-free crystalline amino acid solution may be deficient in low birth weight premature infants and others with impaired liver function.These findings suggest that a more precise tailoring of the amino acid content of infusates for parenteral feeding is indicated. Such individually tailored solutions would decrease the metabolic and excretory load on the liver and kidneys.     

Value of total parenteral nutrition after total pancreatectomy

The authors report 5 cases of Total Pancreatectomy (T.P.) treated with Total Parenteral Nutrition (T.P.N.) in which the non-protein calorie supply consisted of lipids and carbohydrates ("dual energy system"). This form of nutrition, which provided a high energy supply with a reduced glucose intake, prevented the problems associated with hypertonic glucose solutions in the unstable diabetes which follows total pancreatectomy. The authors compared these cases with an earlier series of 11 cases of Total pancreatectomy who were not treated with Total Parenteral Nutrition and observed that the patients treated with TPN had a better recovery, a better glucose homeostasis, a reduction in the complications and mortality and a decreased length of stay in hospital.     

Communicating hydrocephalus following total parenteral nutrition

Communicating hydrocephalus secondary to cerebral venous outflow obstruction has been reported in a few patients several months following removal of a TPN catheter. We report the case of an infant who developed this sequal 4 mo after the catheter was removed. We illustrate the techniques used to delineate the type of hydrocephalus. A lumbo-peritoneal shunt was performed to alleviate the condition.     

Perioperative total parenteral nutrition in patients with gastrointestinal cancer

Forty-one male surgical patients with gastrointestinal cancer were randomized into three groups on the basis of preoperative weight loss: Group I (20 patients)—mean age 64.1 ± 11.0 years, less than 10-lb weight loss, no TPN; Group II (9 patients)—mean age 65.8 ± 12.0 greater than 10 pound weight loss, no TPN; Group III (12 patients)—mean age 63.7 ± 10.7 years, greater than 10-lb weight loss, TPN. Group III received greater than 2000 cc of D25/4.25% Travasol for at least 5 days preoperatively and 8 days postoperatively. Major postoperative complications included abscess, anastomotic leak, or wound infection. Results: Preoperative immunocompetence was no different between any group (P > 0.05). Postoperative weight loss was significantly greater in Group I than in Group III (P < 0.01) and Group II than in Group III (P < 0.01). Postoperative changes in serum albumin were not significant between any of the groups (P > 0.05). Rate of major complications was not significantly different between any of the groups (P > 0.05). Mortality was 10% in Group I, 0% in Group II, and 0% in Group III. Conclusion: An 18-day duration of perioperative TPN in comparable randomized patients based on preoperative weight loss does not alter the rate of major postoperative complications or mortality, but allows patients to maintain weight.     

Postoperative total parenteral nutrition in patients with liver disorders

Sixty-one patients with liver disorders receiving total parenteral nutrition (TPN) for about 14 postoperative days were divided into three groups based on the parenteral nutritional regimen. The influence of these TPN solutions on the liver function tests and the nutritional assessments, and the availability of the specially formulated amino acid solution were studied. Glucose alone as energy source was infused in Group Ia. The mixture of glucose and fructose was infused in Group Ib. In these patients (Group I), a commercially available amino acid solution was administered simultaneously. A specially formulated amino acid, rich in branched-chain amino acids but poor in aromatic amino acids was infused with the mixture of glucose and fructose in Group II. There was no remarkable elevation of blood glucose and lactate levels in all patients. Blood glucose levels in Group Ib were maintained lower than that in Group Ia. Except for serum alkaline phosphatase, no remarkable abnormality was observed in liver function tests. Body weight changes were less than 5% in each group. Average nitrogen balances were -44.5 mg/kg/day in Group Ia, -5.5 mg/kg/day in Group Ib, -51.5 mg/kg/day in Group II. While the abnormalities in serum amino acid pattern and molar ratio of leucine, isoleucine, and valine to phenylalanine and tyrosine tend to be more enhanced in Group I, these abnormalities returned to near normal in Group II during TPN. By multiple linear regression analyses, 45 kcal/kg/day of energy intake would be required to maintain nitrogen equilibrium and zero body weight change. And when nitrogen intakes were 159 mg/kg/day in Group Ia, 114 mg/kg/day in Group Ib, and 189 mg/kg/day in Group II at 45 kcal/kg/day in energy intake, nitrogen balances were expected to be equivalent. These results suggest that postoperative TPN is good for nutritional support in patients with liver disorders. And also, the combination of glucose and fructose has better effect on nitrogen balance. The postoperative TPN with a specially formulated amino acid solution may be a valuable way of maintaining the nutritional status as well as normal serum amino acid pattern in patients with liver disorders.     

Increased risk of cholelithiasis with prolonged total parenteral nutrition

Patients who receive hyperalimentation undergo prolonged periods of fasting which may alter bile composition and lead to gallbladder stasis, both important factors in gallstone formation. Therefore, we tested the hypothesis that patients who receive long-term TPN are at increased risk for cholelithiasis by performing cholecystosonography on adult patients who had received a minimum of 3 months of intravenous hyperalimentation during 1981. Seventy-one patients whose mean age was 41.9 years, 41 percent of whom were men, met these criteria. Gallstones had been diagnosed in 11 of the 71 patients (15 percent) before the initiation of parenteral nutrition. Twenty-one of the remaining 60 at risk patients (35 percent) were discovered to have cholelithiasis after hyperalimentation was started. The 45 percent prevalence of gallstones in our 71 patients was significantly higher (p < 0.001) than predicted from autopsy data. In addition, the 49 percent prevalence of cholelithiasis in our 53 patients with ileal disorders was significantly greater (p < 0.02) than predicted from a study of patients with similarly defined ileal disorders. This analysis strongly suggests that patients who receive long-term TPN are at increased risk for the development of cholelithiasis.     

重症急性胰腺炎完全胃肠外营养与肠外联合肠内营养治疗对比研究

目的 观察重症急性胰腺炎(SAP)完全胃肠外营养(TPN)与肠外营养(PN)联合肠内营养(EN)治疗中各项指标的变化,分析二者疗效.方法 29例SAP随机分为TPN组(14例)和PN+EN组(15例),并均行非手术治疗14 d,观察疗效及化验指标的变化.结果 营养支持治疗14 d后,各组血清白蛋白(ALB)、总蛋白(TSP)、血钙(Ca2+)、谷丙转氨酶(ALT)、谷草转氨酶(AST) 较营养支持前均显著升高(P<0.05);各组血糖、血清淀粉酶、血WBC均较营养支持前显著下降(P<0.05);各组血总胆红素(TB)治疗前后差异无统计学意义(P>0.05);PN+EN组血WBC显著低于TPN组(P<0.05),其余化验指标组间比较差异无统计学意义(P>0.05);各组APACHEⅡ评分较治疗前显著降低(P<0.05),PN+EN组评分显著低于TPN组(P<0.05).PN+EN组住院天数、住院总费用、感染发生率及死亡率均显著低于TPN组(P<0.05).结论 PN联合EN治疗SAP优于TPN.     

重症急性胰腺炎完全胃肠外营养与肠外联合肠内营养治疗对比研究

目的 观察重症急性胰腺炎(SAP)完全胃肠外营养(TPN)与肠外营养(PN)联合肠内营养(EN)治疗中各项指标的变化,分析二者疗效.方法 29例SAP随机分为TPN组(14例)和PN+EN组(15例),并均行非手术治疗14 d,观察疗效及化验指标的变化.结果 营养支持治疗14 d后,各组血清白蛋白(ALB)、总蛋白(TSP)、血钙(Ca2+)、谷丙转氨酶(ALT)、谷草转氨酶(AST) 较营养支持前均显著升高(P<0.05);各组血糖、血清淀粉酶、血WBC均较营养支持前显著下降(P<0.05);各组血总胆红素(TB)治疗前后差异无统计学意义(P>0.05);PN+EN组血WBC显著低于TPN组(P<0.05),其余化验指标组间比较差异无统计学意义(P>0.05);各组APACHEⅡ评分较治疗前显著降低(P<0.05),PN+EN组评分显著低于TPN组(P<0.05).PN+EN组住院天数、住院总费用、感染发生率及死亡率均显著低于TPN组(P<0.05).结论 PN联合EN治疗SAP优于TPN.     

Zinc deficiency in total parenteral nutrition.

A patient with multiple enterocutaneous fistulae who developed the skin manifestations of acrodermatitis enteropathica while on total parenteral nutrition is described. The value of monitoring the serum alkaline phosphatase to demonstrate zinc deficiency is shown. The skin manifestations responded rapidly to the re-introduction of zinc to the diet.