Dietary manipulation of methotrexate-induced enterocolitis

Administration of chemotherapy is limited by host toxicity, which is often manifested by severe enterocolitis. This study evaluated the effects of a liquid, elemental, chemically defined diet (ED) supplemented with 2% glutamine (Glu-ED) compared with a polypeptide diet (PPD) on the morbidity and mortality after methotrexate (MTX) administration. Fischer 344 rats (n = 80) were fed either a regular rat chow diet (RD), a 2% glycine supplemented elemental diet (Gly-ED), a 2% glutamine-supplemented elemental diet (GLU-ED), and a glycine-supplemented polypeptide diet(Gly-PPD) for 7 days prior to administration of MTX (20 mg/kg, ip). After 72 hours, eight rats per group were killed; portal vein and vena cava blood, mesenteric lymph nodes (MLN), liver, small intestine, and cecum were sampled for bacterial culture. Remaining animals were followed to calculate survival. One hundred percent of the Gly-PPD and 25% of the Glu-ED animals survived compared with 0% of the Gly-ED animals. Our data showed that ED resulted in an increased quantity of intestinal Gram-negative bacteria and diminished intestinal mucosal height and mucosal DNA/protein content. The polypeptide diet prevented intestinal mucosal atrophy, avoided MTX-induced enterocolitis and significantly improved animal survival compared with an elemental diet with or without glutamine supplementation.     

丙氨酰-谷氨酰胺双肽在术后病人的应用

目的 :观察丙氨酰 谷氨酰胺双肽 (Ala Gln)强化的全胃肠外营养 (TPN)对中、大手术病人的作用。　方法 :Ala Gln强化TPN与常规TPN各 15例比较。　结果 :①研究组外周血淋巴细胞总数 (TLC) (1.87± 0 .45× 10 9/L)明显上升 ,与对照组 (1.44± 0 .44× 10 9/L)比有显著差异 (P <0 .0 5 )。②两组间肝功能、血红蛋白 (Hb)、白蛋白(Alb)无明显差异。③两组间肠功能恢复无明显差异。④研究组对术后疲劳综合征 (POF)的缓解较对照组明显。　结论 :丙氨酰 谷氨酰胺强化的TPN能提高中、大手术病人的TLC ,加快病人POF的缓解。     

Inadvertent intravenous administration of enteral diet

Needle catheter jejunostomy feedings were instituted in a 64-yr-old man on postoperative day 1 following subtotal gastrectomy for carcinoma of the antrum. Several days later, the enteral tube catheter was inadvertently connected to the patient's peripheral intravenous cannula which resulted in the intravenous administration of the enteral formula solution. The administration was stopped immediately when recognized, but 4 hr later the patient became febrile, hypotensive, and tachycardic. Cultures from the enteral solution demonstrated Streptococcal viridans and yeast; the patient's blood cultures similarly demonstrated S. viridans. Broad spectrum antibiotics, hemodynamic monitoring, and intravascular support with crystalloid solutions resulted in a favorable outcome. Prevention of the complication could be assured by adopting luer connectors for enteral feeding sets which cannot be connected to intravenous cannulas. Until these are available, the addition of methylene blue to the tube feeding formula or utilization of color coded distal connecting tubing may prevent accidental intravenous administration of tube feeding formulas. The potential for this complication must be recognized by those dealing with enteral feeding.     

减量肠道喂养对早产儿输血相关性坏死性小肠结肠炎的保护作用

目的对输血相关性坏死性小肠结肠炎(TRNEC)的早产儿进行减量肠道喂养干预,以探讨减量肠道喂养对早产儿输血相关性坏死性小肠结肠炎的保护机制。方法选取2018年1月-2019年12月的在广东省韶关市第一人民医院进行治疗患有输血相关性坏死性小肠结肠炎的早产儿100例作为研究对象,随机数字表法分为对照组与试验组,每组各50例。对照组按照正常喂养,试验组实施减量喂养。比较两组早产儿输血前后的血浆TNF-α与IL-6浓度,以及输血48 h内的输血相关性坏死性小肠结肠炎发生情况。结果两组TNF-α与IL-6浓度比较差异无统计学意义(P>0.05)。输血后6、12 h,试验组TNF-α与IL-6浓度显著低于对照组(P<0.05);试验组输血后6、12 h TNF-α与IL-6浓度显著高于输血前(P<0.05);输血48 h内,试验组发生TRNEC的比例及出现呕吐、腹胀、血便等症状的比例均低于对照组组(P<0.05)。以上差异均具有统计学意义。结论减量肠道喂养可有效降低早产后输血后TNF-α与IL-6的浓度,减少TRNEC的病发,有助于早产儿输血相关性坏死性小肠结肠炎的预防。     

Effect of glutamine-supplemented total parenteral nutrition on the small bowel of septic rats

In order to study the effect of total parenteral nutrition (TPN) with or without glutamine supplementation in septic rats, septic Wistar albino rats were randomly assigned to receive 0.23 g of nitrogen and 113 kJ (100 g BW)(-1) per day in the form of amino acids with (group 2) or without (group 1) glutamine supplementation or 10% (w/v) glucose only (group 3). After 4 days of TPN treatments, rats receiving glutamine-supplemented TPN had a cumulative nitrogen balance of -24.4 +/- 3.3 mg N, which was significantly (P < 0.001) better compared to other TPN-treated groups. Septic rats of group 2 survived sepsis significantly (P < 0.001) better than those in groups 1 and 3. Glutamine-supplemented TPN treatment resulted in significant increases in jejunal weight (P < 0.001), DNA and protein contents (P < 0.001), villous height (P < 0.001) and crypt depth (P < 0.001) when compared with septic rats of group 1. Septic rats of group 2 extracted and metabolised glutamine by the small bowel at higher rates (P < 0.001) than that observed in septic rats of group 1. Increases in jejunal glutaminase (38.2%, P < 0.001) and decreases in glutamine synthetase (41.7%, P < 0.001) activities were observed in response to glutamine-supplemented TPN treatment. It is concluded that the administration of glutamine-supplemented TPN is beneficial to the small bowel of septic rats.     

早期肠内营养添加谷氨酰胺对重症急性胰腺炎炎症反应和免疫功能的影响

目的: 观察EEN中添加Gln对重症急性胰腺炎(SAP)炎症反应和免疫功能的影响. 方法: 将60例病人随机分为三组,常规EN组在入院第7～10天行EN;EEN组在第2～4天行EN;Gln强化组在EEN液中添加Gln 0.6 g/(kg·d).进行APACHEⅡ评分,并检测病人入院时、入院后第2、5、7、10、14和30天的CRP、IL-6、Gln浓度和单核细胞表面人白细胞抗原(HLA-DR);记录EN前后病人每天的膀胱压和肠鸣音.当膀胱压﹥25 cmH2O、肠鸣音消失时,停用EN. 结果: ①常规EN组、EEN组和Gln组病人各完成临床观察17例、16例和16例.常规EN组病人EN开始时间晚于EEN组和Gln组(P<0.05),但在耐受性、达全量时间、持续时间、EN支持途径和并发症等比较中,三组病人无显著性差异(P>0.05).②在病程早期,常规EN组病人APACHEⅡ评分、CRP、IL-6均高于EEN组和Gln组,HLA-DR和Gln浓度较低(P<0.05),Gln组IL-6较EEN组更低,而HLA-DR和Gln浓度更高(P<0.05);③未完成临床观察者EN前的APACHEⅡ评分、多器官功能障碍综合征(MODS)发生率、膀胱压均明显高于完成临床观察者(P<0.05). 结论:SAP病人早期在EN液中添加Gln,对升高血Gln浓度、降低早期炎症反应、改善免疫功能的作用更加明显.     

Diet-dependent effects of minimal enteral nutrition on intestinal function and necrotizing enterocolitis in preterm pigs

Background: A rapid advance in enteral feeding is associated with necrotizing enterocolitis (NEC) in preterm infants. Therefore, minimal enteral nutrition (MEN) combined with parenteral nutrition (PN) is common clinical practice, but the effects on NEC and intestinal function remain poorly characterized. It was hypothesized that a commonly used MEN feeding volume (16–24 mL/kg/d) prevents NEC and improves intestinal structure, function, and microbiology in preterm pigs. Methods: After preterm birth pigs were stratified into 4 nutrition intervention groups that received the following treatments: (1) PN followed by full enteral formula feeding (OF group, n = 12); (2) PN supplemented with formula MEN and followed by full formula feeding (FF, n = 12); (3) PN plus colostrum MEN followed by formula feeding (CF, n = 12); (4) PN plus colostrum MEN followed by colostrum feeding (CC, n = 10). Results: NEC was absent in the CC group but frequent in the other groups (50%–67%). Compared with other groups, CC pigs showed improved mucosal structures, brush border enzyme activities, and hexose absorption (all P < .05). Relative to formula MEN, colostrum MEN thus improved gut function but did not prevent later formula‐induced gut dysfunction and NEC. However, in CF pigs, intestinal lesions were restricted to the colon, compared with all regions in OF and FF pigs, which indicated proximal protection of colostrum MEN. Bacterial composition was not affected by MEN, diet, or NEC outcomes, but bacterial load and concentrations of short‐chain fatty acids were reduced in the MEN groups. Conclusion: Colostrum MEN improves intestinal structure, function, and NEC resistance in preterm pigs but does not protect against gut dysfunction and NEC associated with later full enteral formula feeding.     

口服益生菌及早期微量喂养对早产儿NEC的影响

目的探讨益生菌联合早期微量喂养对早产儿NEC的影响。方法将90例早产儿随机分为治疗组(45例)和对照组(45例),两组均给予常规保暖、治疗原发病、早期微量喂养等对症支持治疗与护理,治疗组在此基础上口服益生菌(双歧杆菌三联活菌胶囊105mg/次,每天两次)14天,而后观察两组坏死性小肠结肠炎的发病率及肠道菌群的数量。结果治疗组NEC的发病率为4.4%,对照组的发病率为13.3℅,差异具有统计学意义(P0.05);治疗前两组患儿大便益生菌和肠道菌群的数量无差别(P0.05),治疗后治疗组大便益生菌和肠道菌群的数量明显高于对照组,差异具有统计学意义(P0.05);两组治疗后均未出现不良反应及肝肾功能损害。结论口服益生菌可以促进早产儿肠道正常菌群的定植和优势化,能降低早产儿NEC的发生。     

Effect of an enteral diet supplemented with a specific blend of amino acid on plasma and muscle protein synthesis in ICU patients

BACKGROUND & AIM: Polytrauma patients are characterized by a negative nitrogen balance and muscle wasting. Standard nutrition is relatively inefficient to improve muscle protein turnover. The aim of this study was to investigate the effect of enteral nutrition (EN) supplemented with specific amino acids on protein metabolism in polytrauma patients. METHODS: In a double blind study, 12 polytrauma patients were randomized to receive EN supplemented with either a mixture of cysteine, threonine, serine and aspartate (AA patients) or alanine at isonitrogenous levels (Ala patients). An intravenous infusion of l-[1-(13)C]-leucine was performed in the fed state between day 9 and 12 post-injury (Df) in patients and in a group of healthy volunteers (n=8) (EN+Ala) to measure whole body leucine kinetics, plasma and muscle protein synthesis rates. Nitrogen balance, 3-methyl histidine excretion were measured from day 3 to Df. RESULTS: The contribution of total plasma proteins to whole body protein synthesis was greatly increased, from 11% in healthy volunteers to about 25% in polytrauma patients. AA supplementation had no effect on nitrogen balance, leucine kinetics or plasma protein synthesis in patients. In contrast, the urinary excretion of 3-methyl histidine tended to decrease along the study in the AA supplemented group compared to an increase in the Ala group. Muscle protein synthesis tended to be higher in the AA group than in the Ala group (46%, P=0.065). CONCLUSION: During injury, an increased supply of cysteine, threonine, serine and aspartate could be able to better cover the specific amino requirements, thus resulting in improved muscle protein synthesis without impairment of acute phase protein synthesis.     

肿瘤患者术后用特殊配方与标准配方肠内营养二周的效果比较

目的 观察五官科肿瘤病人作喉切术使用肿瘤特异性免疫营养配方肠内营养对患营养、免疫的调理作用。方法 本研究是一个随机、前瞻、控制、双盲的临床研究。40例手术的五官科肿瘤病人随机分为两组：（1）免疫营养组（Supportan n=20)，（2）标准营养组（n=20)，两组使用等热量的肠内营养管饲，均为连续性鼻胃途径泵辅助喂养。手术当天、术后第1天及喂饲结束当天进行体格检查、询问营养史、人体测量、抽取静脉血作实验室分析检测包括TNFα、IgA及血糖等指标。统计学方法：方差分析，对数转化或mann-Whitney U-检验。结果 手术导致大部分的指标参数发生显变化，且两组的变化接近。本研究中Suportan显示了良好的胃肠道耐受性，并显示出营养和免疫的调理作用。     

Clinical evaluation of two-liter prepacked enteral diet delivery system: a controlled trial

Following a recent study in our Unit which showed that significantly more of prescribed enteral diet was administered from 2-liter bags than 0.51 bottles, a controlled clinical trial was undertaken to investigate further the effectiveness of the 2-liter prepackaged enteral delivery system. Forty patients with normal gastrointestinal function requiring enteral nutrition were randomized to receive nasogastrically 2-liter/day of polymeric diet (2000 kcal, 12 g N) either from a presterilized 2-liter PVC bag (Express EFI Ltd, UK) or from two 1-liter rigid plastic containers filled with cans of Clinifeed 400 (Roussel Laboratories Ltd, UK). The actual volumes of feed infused were monitored in patients fed for 5 days or more. Both nursing and dietetic staff preferred the 2-liter bags which were more convenient to prepare and use. Significantly larger quantities of prescribed diet were delivered from the 2-liter bags than from the 1-liter containers (p less than 0.001). It was concluded that the 2-liter bag system was potentially more convenient and nutritionally efficacious than 1-liter containers. Although the incidence of microbial contamination associated with the 2-liter bags was low, measures to maintain the sterility of this system may need to be more stringent.     

配方膳在内外科病人肠内营养中的应用

接受营养支持的内外科病人33例，年龄33～77岁，随机分为实验组（行配方膳肠内喂养）和对照组（行周围静脉营养），持续15天，使用2～3天后，实验组剂量维持在每天1000～1750ml，能量1．3BEE，对照组每天约2000～3000ml和1．3BEE。应用前后营养测量指标表明，配方膳用于肠内喂养可使机体维持营养状态稳定，对肝、肾功能无不良影响，消化道副反应轻，单位容积内营养素可在一定范围内调整，是一种较好的管饲膳。     

消化道肿瘤手术后早期应用免疫增强型肠内营养的作用

目的：评价免疫增强型肠内营养制剂对肿瘤病人手术创伤后代谢，炎症反应，免疫功能及预后的影响。方法：88例消化道恶性肿瘤手术病人随机分为常规肠内营养组（对照组）和免疫增强型肠内营养组（研究组）。手术后第1天开始等热量，等氮肠内营养支持1周。于术前，术后第1，4天和研究结束时分别检测免疫，炎症反应及营养指标。结果 ：研究结束时，研究组多数免疫指标均明显高于对照组（P＜0．01）；而血IL－6，TNF－α）浓度及CRP水平则明显低于对照组（P＜0．05）。研究期间两组白蛋白，每天及氮平衡无显著差异，术后第8天，研究组血浆前白蛋白，转铁蛋白浓度明显高于对照组。研究组术后4天以后的感染性并发症发生率明显低于对照组，平均住院时间也明显低于对照组。结论：免疫增强型肠内营养制剂可减轻肿瘤病人手术创伤后的应激和炎症反应程度，增强机体免疫功能，改善预后。     

The effect of a fibre free and fibre supplemented polymeric enteral diet on normal human bowel function

Although the effects of dietary fibre in a normal diet on intestinal function are well known, the effects of supplementing enteral diet with fibre on intestinal function are not so clear. The aims of the present study were two fold: firstly to compare intestinal function during ingestion of a self selected diet and fibre free polymeric enteral diet and secondly to investigate the effect of adding the fibre source, soy polysaccharide to the same polymeric diet, on bowel function. Six healthy subjects were randomly assigned to 3 treatment periods (7 days) of a self selected diet (SSD), 2 l polymeric enteral diet (ED), or 2 l of the same polymeric enteral diet supplemented with 20 g/l of soy polysaccharide fibre (SPED). Parameters measured were bowel frequency/day, mean daily wet stool weights and whole gut transit time. Highest stool wet weights (g/24 h +/- SEM) were obtained from subjects consuming a SSD (180.3 +/- 30.6). This was significantly higher (p < 0.02) than those consuming an ED (81.9 +/- 14.5) but not a SPED (123 +/- 22.3). Whole gut transit (h +/- SEM) on a SSD (47 +/- 5.9) was significantly (p < 0.05) quicker than on an ED (73 +/- 4.9), but not significantly different from those ingesting a SPED (54 +/- 5.5). Bowel frequency/day (+/- SEM) in subjects consuming a SPED (1.0 +/- 0.1) was significantly (p < 0.02) higher than in subjects ingesting an ED (0.8 +/- 0.1) but was not significantly different when compared to a SSD (1.0 +/- 0.2). We conclude that ingestion of an ED results in significantly longer whole gut transit time, significantly decreased daily stool wet weights and decreased bowel frequency when compared to a SSD. The ingestion of 30 g of soy polysaccharide in a polymeric enteral diet not only tends to normalise whole gut transit time and daily stool wet weights, but also significantly increases bowel frequency when compared with values seen during the consumption of a fibre free polymeric enteral diet.     

Evaluation of the microbial safety of a new 1.5 l enteral feeding diet reservoir system

BACKGROUND & AIMS: Microbial safety is essential during enteral nutrition (EN) as it can be the origin of gastrointestinal symptoms, but can also lead to systemic infections. The use of large-volume diet reservoirs could limit the risk of contamination and reduce nursing time, due to fewer repeated manipulations. The aim of the study was to evaluate in vivo the microbial safety of a new 1.5l enteral feeding diet reservoir system. METHODS: After validation of the study settings under standard laboratory conditions, 86 EN lines with sealed fittings were connected to 1.5l diet reservoirs under hospital/patient conditions. Microbial identification and quantification at different sampling times and points were performed. RESULTS AND CONCLUSIONS: No microbial contamination was observed in the diet reservoirs and in the nutrition lines above the drip chamber, demonstrating the microbial safety of this system. Retrograde contamination of the distal nutrition line end at completion of EN was observed and may be affected by the cumulative time of use of the tube. The contaminating microbial species were essentially bacteria of normal oral and digestive flora.     

Energy and mineral utilization from a peptide-based elemental diet and a polymeric enteral diet given to ileostomists in the early postoperative course

Small intestinal absorption was studied in 12 patients receiving enteral nutrition in the immediate postoperative period after colorectal surgery including construction of an ileostomy. Seven patients were given a peptide-based, low osmolality elementary diet and five patients were given a polymeric diet. Comparisons between the intake and ileal excretion showed on both diets a high utilization of energy, fat, and nitrogen as well as of calcium, phosphorus, magnesium, zinc, and iron. From a nutritional point of view a polymeric diet could thus replace an elementary diet in the immediate postoperative course.     

Response of glutamine metabolism to glutamine-supplemented parenteral nutrition

BACKGROUND: Increasing evidence suggests that glutamine is important for the function of many organ systems and supports the use of glutamine-enriched total parenteral nutrition (TPN) during severe illness. However, the effect of prolonged glutamine supplementation on glutamine kinetics has not been studied. OBJECTIVE: We investigated the effect of 8-10 d of TPN enriched with glutamine dipeptides on glutamine kinetics. DESIGN: Twenty-three preoperative patients were randomly allocated to receive either TPN enriched with glutamine dipeptides (60 micromol glutamine*kg body wt(-1)*h(-1)) or isonitrogenous, isoenergetic, glutamine-free TPN. A primed, continuous, 6-h intravenous infusion of L-[5-(15)N]glutamine and L-[1-(13)C]leucine was given before (baseline) and 8-10 d after the TPN solutions were administered. Baseline measurements were performed after a 40-h administration of a standard solution of glucose and amino acids (no glutamine). RESULTS: Glutamine-enriched TPN increased the total appearance rate of glutamine (P: < 0.05) but did not inhibit or increase the endogenous appearance rate. The standard TPN solution also increased the glutamine appearance rate (P: < 0.05), but the change was much smaller than in the glutamine-supplemented group (P: < 0.01). The plasma glutamine concentration did not rise significantly during either treatment, suggesting increased tissue glutamine utilization, especially in the glutamine-supplemented group. CONCLUSION: In view of the enhanced glutamine requirements in response to trauma and disease by tissues such as those of the gut, the immune system, and the liver, increased glutamine availability during glutamine-enriched TPN may be beneficial preoperatively in patients with gastrointestinal disease.     

Control of diarrhea by fiber-enriched diet in ICU patients on enteral nutrition: a prospective randomized controlled trial

BACKGROUND AND AIMS: Enteral fiber-free diets alter intestinal transit and produce diarrhea or constipation. This prospective double blind, controlled study evaluates the use of guar gum, a soluble fiber and a candidate prebiotic in enteral feeds, to prevent diarrhea and potential health benefits in intensive care unit patients. METHODS: Twenty patients on enteral nutrition with persistent diarrhea were randomized to receive a new enteral feed either enriched with 2% soluble guar gum (study group, n = 10) or fiber-free (control group, n = 10) for 4 successive days. RESULTS: The number of liquid stools in response to a soluble fiber-enriched diet was 2.0+/-0.9 (first day) vs. 1.0+/-0.7 (fourth day) (P < 0.01), and in the control group 1.2+/-0.7 (first day) vs. 2.1+/-0.8 (fourth day) (P < 0.05). In the fiber-enriched feed group, plasma glucose and cholesterol levels at termination of the study, respectively, reached 126+/-81 and 164+/-71 mg dl(-1), as compared to 333+/-108 and 378+/-26 mg dl(-1) on Day first (P < 0.01). In the control group, these values on the fourth day were, respectively, 267+/-94 and 263+/-79 vs. 247+/-115 and 315+/-78 on Day first (P > 0.05). CONCLUSIONS: Guar gum-enriched enteral nutrition was related to a decrease of diarrheal episodes in ICU patients with preexisting diarrhea; and to a trend for lower plasma glucose and cholesterol levels.