Nutrient-drug interactions

The full range of drug-nutrient interactions is discussed, with emphasis on metabolic mechanisms. The effects of nutrition on drug oxidation and drug conjugations are discussed separately. Chemical interactions of drugs and nutrients in the stomach and intestine are evaluated.     

Tube feeding - who, how and when

Summary. The concept of enteral nutrition is well established for a long time. During the past twenty years different percutaneous tube feeding techniques have been established. The most popular method is the percutaneous endoscopic gastrostomy (PEG) which is applied as a pull-through technique in Germany. In some patients this approach is not successful and alternative techniques must be used (e. g. introducer method). In some patients nasal or percutaneous feeding tube have to be placed directly into the intestine. There are different systems available for this approach which have to be clearly indicated. As a second step after initiation of enteral nutrition therapy quality of life can be improved by implanting secondary systems (e. g. button gastrostomy).A standardized technique for inserting tubes is essential to have a successful long-term outcome in enteral nutrition and care after has to be integrated into the regimen. The aim of this article is to demonstrate different enteral nutrition tube techniques their indication, contraindication and long-term follow-up.     

Percutaneous endoscopic gastrostomy:Indications,technique,complications and management

Percutaneous endoscopic gastrostomy(PEG)is the preferred route of feeding and nutritional support in patients with a functional gastrointestinal system who require long-term enteral nutrition.Besides its wellknown advantages over parenteral nutrition,PEG offers superior access to the gastrointestinal system over surgical methods.Considering that nowadays PEG tube placement is one of the most common endoscopic procedures performed worldwide,knowing its indications and contraindications is of paramount importance in current medicine.PEG tubes are sometimes placed inappropriately in patients unable to tolerate adequate oral intake because of incorrect and unrealistic understanding of their indications and what they can accomplish.Broadly,the two main indications of PEG tube placement are enteral feeding and stomach decompression.On the other hand,distal enteral obstruction,severe uncorrectable coagulopathy and hemodynamic instability constitute the main absolute contraindications for PEG tube placement in hospitalized patients.Although generally considered to be a safe procedure,there is the potential for both minor and major complications.Awareness of these potential complications,as well as understanding routine aftercare of the catheter,can improve the quality of care for patients with a PEG tube.These complications can generally be classified into three major categories:endoscopic technical difficulties,PEG procedure-related complications and late complications associated with PEG tube use and wound care.In this review we describe a variety of minor and major tube-related complications as well as strategies for their management and avoidance.Different methods of percutaneous PEG tube placement into the stomach have been described in the literature with the"pull"technique being the most common method.In the last section of this review,the reader is presented with a brief discussion of these procedures,techniques and related issues.Despite the mentioned PEG tube placement complications,this procedure has gained worldwide popularity as a safe enteral access for nutrition in patients with a functional gastrointestinal system.     

Enteral nutrition and immune modulation of acute pancreatitis

Enteral nutrition has been strongly recommended by major scientific societies for the nutritional management of patients with acute pancreatitis.Providing severe acute pancreatitis patients with enteral nutrition within the first 24-48 h of hospital admission can help improve outcomes compared to parenteral nutrition and no feeding.New research is focusing in on when and what to feed to best improve outcomes for acute pancreatitis patients.Early enteral nutrition have the potential to modulate the immune responses.Despite this consistent evidence of early enteral nutrition in patients with acute pancreatitis,clinical practice continues to vary due to individual clinician preference.Achieving the immune modulating effects of enteral nutrition heavily depend on proper placement of the feeding tube and managing any tube feeding associated complications.The current article reviews the immune modulating effects of enteral nutrition and pro-and prebiotics and suggests some practical tools that help improve the patient adherence and tolerance to the tube feeding.Proper selection of the type of the tube,close monitoring of the tube for its placement,patency and securing its proper placement and routine checking the gastric residual volume could all help improve the outcome.Using peptide-based and high medium chaintriglycerides feeding formulas help improving feeding tolerance.     

Healthcare costs associated with percutaneous endoscopic gastrostomy among older adults in a defined community

OBJECTIVES: The effectiveness of percutaneous endoscopic gastrostomy (PEG) in older adults remains controversial. Although prior studies have examined the safety of PEG and its impact on nutrition, there are limited data on the economic costs. The purpose of this study is to describe the healthcare costs associated with PEG tube feeding over 1 year. DESIGN: Prospective cohort study. SETTING: Small community of approximately 60,000 residents served by two hospital systems. PARTICIPANTS: One hundred five (70%) of 150 patients age 60 and older receiving PEG over a 24-month period in the targeted community who permitted access to their medical records. MEASUREMENTS: Patients were interviewed at baseline and every 2 months for 1 year to obtain information on use of enteral formula, complication rates, and health services use. We obtained inpatient charge data for all hospitalizations and PEG procedures for 1 year. RESULTS: Censoring patients at death or 1 year post-PEG, the mean number of days of PEG tube feeding was 180 (range 5-365). The average cost for PEG tube feeding for this cohort of patients was $7,488 (median $3,691) in 1997 and 1998. The average daily cost of PEG tube feeding was $87.21 (median $33.50). The estimated cost of providing 1 year of feeding via PEG is $31,832 (median $12,227). The main components of this cost include the initial PEG procedure (29.4%), enteral formula (24.9%), and hospital charges for major complications (33.4%). CONCLUSIONS: Direct charges associated with PEG tube feeding over 1 year are conservatively estimated at $31,832; there was considerable variation in charges because of the cost of rare but costly major complications. Also, feeding patients via PEG resulted in cost shifts in terms of the primary payor. The economic cost of PEG tube feeding is another consideration in decision making for long-term enteral feeding among older adults.     

Differential therapy of parenteral and special feeding in intensive medicine

After having overcome the acute danger to life by a directed infusion therapy as well as by medicamentous, physical and operative measures question of the long-term nutrition frequently come fully into the foreground in intensive medicine. For this purpose as modern methods are at our disposal parenteral nutrition with mixtures of amino acids, carbohydrates and fat emulsions, the feeding by a stomach tube with easily decomposable mixtures of proteins, carbohydrates and fat and the feeding by a stomach tube with chemically defined diets. When the adequate form of nutrition is chosen, depends on the indications and contraindications for the use of these nutrient solutions and on the adequate stage of the present basic disease. The optimum nutrition of the intensive therapy patients is an essential prerequisite for the prevention and overcoming of the severe secondary diseases, which frequently develop after emergency situation and destroy the success of the initial therapy.     

ICU management of severe acute pancreatitis

In intensive care medicine, severe acute pancreatitis (SAP) remains a very challenging disease with multiple complications and high mortality. The main pathophysiological mechanisms determining outcome are an uncontrolled systemic hyperinflammatory response early on and infection of pancreatic necrosis later on in the disease process. Despite a better understanding in recent years of the mechanisms and the mediators involved in the hyperinflammatory response, there is, as yet, no generally recognized specific treatment for this disease. Since early identification and aggressive treatment of associated organ dysfunction can have a major impact on outcome, early assessment of prognosis and severity is important. The evidence available indicates that patients with severe acute pancreatitis do not benefit from therapy with available antisecretory drugs or protease inhibitors. Supportive therapy, such as vigorous hydration, analgesia, correction of electrolyte and glycemia disorders, and pharmacological or mechanical support targeted at specific organs, is still the mainstay of therapy. In spite of meager evidence, prophylactic antibiotics with good penetration in pancreatic tissue are recommended in severe acute pancreatitis. Enteral nutrition via a nasojejunal tube has become the preferred route of feeding. Most patients with sterile necrosis do not benefit from surgical intervention. In patients with proven infection of pancreatic tissue, surgery is necessary. Percutaneous, radiological drainage techniques may eventually become an alternative form of drainage in selected patients.     

The safe use of percutaneous gastrostomy for enteral nutrition in patients with Crohn's disease

OBJECTIVE: To determine the safety of percutaneous endoscopic gastrostomy (PEG) tube placement for nutritional support and/or defined therapeutic enteral nutrition (TEN) in adult patients with Crohn's disease. DESIGN: A prospective, observational study of patients with Crohn's disease in whom PEG tubes were placed for nutritional support or TEN. SETTING: A specialist nutrition clinic at a gastroenterology tertiary referral centre in Harrow, UK. PARTICIPANTS: Nine patients with Crohn's disease. Seven patients had nutritional failure and were unable to tolerate nasogastric feeding, and two patients were recruited in whom TEN therapy for active disease was indicated. The age range was 21-52 years (median, 30 years). Five patients were female; all had had previous ileo-colonic resections, one had a gastro-enterostomy and one had a non-healing Crohn's-related gastric ulcer. INTERVENTIONS: PEG insertion (Fresenius, Frecka 9 Fr) was performed at endoscopy with intravenous sedation. Follow-up with tubes in situ was for a median of 37 weeks (range, 4-276 weeks), and for a further median of 80 weeks (range, 52-120 weeks) in those whose tubes have been removed. MAIN OUTCOME MEASURES: The level of disease activity, nutritional status/body mass index and any complications associated with PEG tube placement were recorded. RESULTS: PEG was achieved in all patients; the only complication was a minor superficial entry site infection. Five patients continue to use PEG feeding to good effect, including healing of the Crohn's-associated ulcer. One patient now eats normally having regained target weight, and three require parenteral nutrition, having failed to achieve nutritional sufficiency despite an optimal enteral regimen via the PEG. An adverse body image in one of these patients (an opiate abuser with a long psychiatric history) was probably contributory to PEG failure. There was no peristomal or fistulous disease. CONCLUSIONS: Although nutrition via PEG is not always successful, failures are of enteral nutrition, and not of the means. PEG use in selected patients with Crohn's disease appears safe and can prove a useful addition to therapeutic options.     

空肠营养性造口与鼻肠管早期肠内营养在胃癌术后的应用比较

目的探讨空肠营养性造口与鼻肠管早期肠内营养在胃癌术后的临床应用效果比较。方法选取延安大学附属医院2011年6月-2013年6月收治的76例行肠内营养的胃癌患者,A组42例采用空肠营养性造口,B组34例采用鼻肠管。分析比较两组患者实施肠内营养后通气时间、术前术后营养状况变化、并发症(呼吸道症状、消化道症状及其他各类不适)、住院时间等。结果73例胃癌术后患者实施肠内营养效果较好,3例患者未完成肠内营养,两组患者在术前术后营养状况变化、住院时间、住院费用上比较差异无统计学意义(P0.05),A组患者在通气时间、并发症发生率上优于B组(P0.05)。结论与鼻肠管比较,空肠营养性造口能减少并发症的发生率,使患者胃肠功能恢复更快,但应根据具体情况合理选择肠内营养方式。     

鼻空肠与鼻胃管管饲的急性重症卒中患者的肺炎

目的 探讨鼻空肠管与鼻胃管肠内营养支持对重症急性卒中患者卒中相关性肺炎(stroke associated pneumonia,SAP)以及其他并发症的影响.方法 共纳入60例需要管饲的重症急性卒中患者,随机分为鼻空肠管组和鼻胃管组进行肠内营养支持,观察2周内SAP、腹泻、呕吐、消化道出血和低钠血症的发生,记录置管前以及置管后7d和14 d时的营养指标(总蛋白、前白蛋白、血红蛋白)并进行比较.结果 鼻空肠管组和鼻胃管组各30例,2组人口统计学和基线临床资料均无显著差异.鼻空肠管组SAP(43.3％对70.0％;x2=4.340,P=0.037)、呕吐(13.3％对43.3％x2 =6.648,P=0.010)和低钠血症(16.7％对40.0％;x2 =4.022,P=0.045)发生率显著低于鼻胃管组,但腹泻和消化道出血发生率无显著差异.鼻空肠管组置管后14 d时的血浆总蛋白和前白蛋白浓度与置管前无显著差异,但血红蛋白浓度显著降低(P=0.001);相比之下,鼻胃管组置管后14 d时血浆总蛋白(P=0.001)、前白蛋白(P=0.036)和血红蛋白(P=0.001)浓度与置管前相比均显著降低.结论 重症急性卒中患者鼻空肠肠内营养能有效预防SAP以及呕吐和低钠血症的发生,并且有助于维持患者的营养状况.     

Enteral feeding in the critically ill: the role of the gastroenterologist

Expertise in enteral nutrition (EN) is an important aspect of the skill set of the clinical gastroenterologist. Delivery of adequate EN in critically ill patients is an active therapy that attenuates the metabolic response to stress and favorably modulates the immune system. EN is less expensive than parenteral nutrition and is favored in most cases because of improvement in patient outcomes, including infections and length of stay. Newer endoscopic techniques for placing nasoenteric feeding tubes have been developed, which improve placement success and efficiency. It appears that there is an ideal window period of 24-48 h when enteral feeding should be started in critically ill patients. Most patients can be fed into the stomach, but certain groups may benefit from small bowel feeding. Protocols on how to start and monitor enteral feeding have been developed. Immune-modulating feeding formulations also appear to be beneficial in specific patient populations. The gastroenterologist is a crucial member of the multidisciplinary team for nutritional support in the intensive care unit patient, with his knowledge of gastrointestinal pathophysiology, nutrition, and endoscopic feeding-tube placement.     

Clinical features and prognosis of terminally ill patients in a geriatric long-term care hospital with particular regard to the implications of artificial nutrition

AIM: To clarify the clinical features of terminally ill patients in our hospital and elucidate the implications of administering artificial nutrition. METHODS: Between April 2004 and March 2005, we assessed 155 patients who died in Nishimaruyama Hospital--a geriatric long-term care facility in Sapporo. We analyzed their clinical backgrounds on admission, the clinical course up to the terminal stage of the illness, and the outcome of patients who received artificial nutrition. RESULTS: In 95 patients, the main cause of the terminal illness was infection. The symptoms of these patients, such as cerebral infarction and cognitive dysfunction, deteriorated progressively, and eventually, eating became difficult. At this point, alternative methods for providing nutrition were discussed. For 60 patients (41 died of acute disease and 19, of advanced cancers), artificial nutrition was not considered. Artificial nutrition was administered to 63 patients; tube feeding was carried out in 30 patients. Because of repeated aspiration pneumonia, 14 of these 30 patients eventually underwent intravenous hyperalimentation (IVH). Thirty-three patients directly underwent IVH. Thirty-two patients did not undergo any feeding course. The mean survival times of the tube feeding and non-artificial nutrition groups were 827 and 60 days, respectively. The difference in the survival times was statistically significant. CONCLUSION: The outcome of patients who were placed on tube feeding was good. This may be because we selected those patients considered most suitable for tube feeding or IVH. The criteria that were used to select an appropriate method for providing nutrition varied, although the patients in our hospital requested palliative care.     

Supplemental enteral tube feeding nutrition after hospital discharge of esophageal cancer patients who have undergone esophagectomy

Background

After undergoing esophagectomy to treat esophageal cancer, there are changes in the normal intake patterns in most patients, with more than half found to have an inadequate oral intake at the time of their hospital discharge. However, the use of home supplemental enteral tube feeding nutrition after hospital discharge in esophagectomy patients has yet to be established. The aim of this study was to evaluate the feasibility of 90-day home supplemental enteral tube feeding nutrition in esophagectomy patients.

Methods

This single-center, prospective, and single-arm study evaluated the feasibility of using supplemental tube feeding nutrition intervention for 90 days in esophageal cancer patients who have undergone esophagectomy.

Results

This study enrolled 24 post-esophagectomy patients between February 2015 and September 2016. Twenty patients were administered 70% or more of the planned nutrient, with 83% of the patients completing the nutritional intervention procedure. There were no grade 3/4 adverse events observed, with a mean body weight change of ? 7.6?±?6.0%.

Conclusions

Our results showed that routine use of 90-day home supplemental enteral tube feeding nutrition after hospital discharge for esophagectomy patients was both feasible and acceptable.

Trial registration

UMIN000016286.

     

Gastric and postpyloric total enteral nutrition

Opinion statement The provision and maintenance of good nutrition in patients with acute and chronic illness is a fundamental part of standard medical and surgical care. Recently, there is great interest in using enteral nutritional support to reverse the morbidity and mortality associated with malnutrition. Enteral nutrition is preferred over parenteral nutrition because it is more physiologic, maintains intestinal structure and function, limits bacterial translocation, has less morbidity, has fewer complications, and is less expensive. However, the decision to feed into the stomach or into the small bowel (postpyloric) continues to be a matter of some debate and continued clinical investigation. Although the gastric route of enteral feeding is easier and less expensive, some physicians worry that gastric feeding may predispose to aspiration and pneumonia, especially in critically ill patients who frequently have delayed gastric transit. In these critically ill patients, small bowel function usually remains relatively intact and placement of a postpyloric feeding tube may permit more effective delivery of nutrients. However, it should be noted that placement of postpyloric feeding tubes can be challenging, and this may lead to a delay in initiation of nutritional support.     

Nutrition in acute pancreatitis

Nutritional concepts in acute pancreatitis are undergoing a rapid change. An early start of nutrition via nasojejunal tubes is about to replace parenteral nutrition. Yesterday it was believed that the pancreas had to be put at rest. Thus, stimulation of pancreatic secretion by enteral nutrition was believed to be detrimental. However, on comparing the results of enteral with those of parenteral nutrition, the pancreatic infection rates, rate of surgical interventions, days of hospital stay, and costs are found to be significantly reduced. Whether or not enteral nutrition decreases mortality has not been clearly proven. Pancreatitis is associated with the risk of paralytic ileus. Thus, data suggesting that one does not have to feed via a nasojejunal tube but rather via an easier to place nasogastric tube, are provocative. Numerous questions still have to be answered such as composition of tube diet, nutrition in mild to moderate pancreatitis, ways to reduce pain and composition of diet when oral refeeding is started. The nutrition of tomorrow may implicate immunonutrition. There are only a few small studies suggesting beneficial effects by supplementation of tube feeding with MCT/LCT triglycerides, glutamine, arginin, omega-3-fatty acids, nucleotides. So far, these supplements have failed to show efficacy for clinically relevant endpoints. In an recently published study, prebiotics were associated with a high complication rate. In this review, we summarise the current knowledge on nutrition in acute pancreatitis and discuss future developments.     

Optimal timing and route of nutritional support after esophagectomy: A review of the literature

Some controversy surrounds the postoperative feeding regimen utilized in patients who undergo esophagectomy.Variation in practices during the perioperative period exists including the type of nutrition started,the delivery route,and its timing.Adequate nutrition is essential for this patient population as these patients often present with weight loss and have altered eating patterns after surgery,which can affect their ability to regain or maintain weight.Methods of feeding after an esophagectomy include total parenteral nutrition,nasoduodenal/nasojejunal tube feeding,jejunostomy tube feeding,and oral feeding.Recent evidence suggests that early oral feeding is associated with shorter LOS,faster return of bowel function,and improved quality of life.Enhanced recovery pathways after surgery pathways after esophagectomy with a component of early oral feeding also seem to be safe,feasible,and cost-effective,albeit with limited data.However,data on anastomotic leaks is mixed,and some studies suggest that the incidence of leaks may be higher with early oral feeding.This risk of anastomotic leak with early feeding may be heavily modulated by surgical approach.No definitive data is currently available to definitively answer this question,and further studies should look at how these early feeding regimens vary by surgical technique.This review aims to discuss the existing literature on the optimal route and timing of feeding after esophagectomy.     

The provision of a percutaneously placed enteral tube feeding service

There is overwhelming evidence that the maintenance of enteral feeding is beneficial in patients in whom oral access has been diminished or lost. Short-term enteral access is usually achieved via naso-enteral tube placement. For longer term tube feeding there are recognised advantages for enteral feeding tubes placed percutaneously. The provision of a percutaneous enteral tube feeding service should be within the remit of the hospital nutrition support team (NST). This designated team should provide a framework for patient selection, pre-assessment and post-procedural care. Close working relations with community-based services should be established. An accredited therapeutic endoscopist should be a member of the NST and direct the technical aspects of the service. Every endoscopy unit in an acute hospital setting should provide a basic percutaneous endoscopic gastrostomy (PEG) service. This should include provision for fitting a PEG jejunal extension (PEGJ) if required. Specialist units should be identified where a more comprehensive service is provided, including direct jejunal placement (DPEJ), as well as radiological and laparoscopically placed tubes. Good understanding of the indications for percutaneous enteral tube feeding will prevent inappropriate procedures and ensure that the correct feeding route is selected at the appropriate time. Each unit should adopt and become familiar with a limited range of PEG tube equipment. Careful adherence to the important technical details of tube insertion will reduce peri-procedural complications. Post-procedural complications remain relatively common, however, and an awareness of the correct approach to managing them is essential for all clinicians involved in providing a percutaneous enteral tube feeding service. Finally, ethical considerations should always be taken into account when considering long-term enteral feeding, especially for patients with a poor quality of life.     

经胃镜置放鼻空肠营养管治疗重症急性胰腺炎的疗效观察

目的:观察重症急性胰腺炎(SAP)患者经胃镜置放鼻空肠营养管行肠内营养的疗效观察.方法:将50例患者随机分为2组:①全肠外营养(TPN)组26例,行常规治疗:禁食、胃肠减压、抑酸、抗炎、生长抑素、全肠外营养及对症治疗等;②肠内营养(EN)组24例,在常规治疗的基础上,入院后3d左右经胃镜置放鼻空肠营养管,逐渐停止肠外营...     

Naso-jejunal feeding in allogeneic bone marrow transplant recipients: results of a pilot study.

Patients undergoing allogeneic bone marrow transplants (BMT) are often malnourished prior to commencing the procedure. They face intensive treatment with often marked nutritional consequences. There is no consensus on the optimal nutritional management of these patients. Elective parenteral nutrition (PN), beginning pre-transplant irrespective of the patients nutritional status, or the use of "salvage" PN, beginning during the post-transplant period if the patient fails to maintain nutritional status with oral diet, have been used. Enteral nutrition may benefit the patient by maintaining nutritional support throughout the transplant period, avoiding the complications and expense of PN and possibly, by using specific diets, protecting the gastrointestinal tract from the effects of chemoradiation. However, naso-gastric feeding during a transplant is not without risks, including the safe insertion of a tube in patients with mucositis and pan-cytopenias, tube displacement by vomiting and aspiration from gastro-oesophageal reflux. An alternative approach is to use naso-jejunal (NJ) feeding tubes which are associated with less risk of loss due to vomiting and less risk of aspiration. We report a pilot study of 15 allogeneic BMT patients who had elective NJ feeding initiated before conditioning therapy irrespective of perceived nutritional compromise. This was well tolerated and feasible with a motivated nutritional team.