Enteral versus Parenteral Nutrition as Adjunct Therapy in Acute Ulcerative Colitis

To ascertain the role of total enteral nutrition, compared with total parenteral nutrition, as adjunct therapy to steroids in patients with severe acute ulcerative colitis, a prospective randomized trial was conducted in 42 of such patients. Inclusion criteria were the persistence of a moderate or severe attack of the disease (Truelove's index) after 48 h on full steroid treatment (prednisone 1 mg/kg/day). Patients were randomized to receive polymeric total enteral nutrition or isocaloric, isonitrogenous total parenteral nutrition as the sole nutritional support. Remission rate and need for colectomy were similar in both groups. No significant changes in anthropometric parameters were observed in either nutritional group at the end of the study. Median increase in serum albumin was 16.7% (−0.5% to +30.4%) in the enteral feeding group, and only 4.6% (−12.0% to +13.7%) in the parenteral nutrition patients ( p = 0.019). Adverse effects related to artificial nutritional support were less frequent (9% vs. 35%, p = 0.046) and milder in enterally fed patients. Postoperative infections occurred more often with parenteral nutrition ( p = 0.028). These results suggest that total enteral nutrition is safe and nutritionally effective in severe attacks of ulcerative colitis. It is also cheaper and associated with fewer complications than parenteral nutrition. Total enteral nutrition should be regarded as the most suitable type of nutritional support in these patient     

Survival rate and prognostic factors in patients with intestinal failure

BACKGROUND: Intestinal failure impairs nutritional status and survival expectance. Though intestinal adaptation and enteral independence may be achieved, artificial nutrition is needed in about half of the patients. AIMS: This study is aimed at assessing the causes of death, survival rate, enteral independence in time, and factors affecting the clinical outcome in a group of patients with intestinal insufficiency. PATIENTS: Sixty-eight patients with intestinal insufficiency, due to major intestinal resection in 60 cases (short bowel syndrome) (remnant intestine length 101-150 cm in 31 cases, 50-100 cm in 23 cases, <50 cm in 6 cases), and due to chronic idiopathic pseudo-obstruction in 8 cases, were enrolled and followed-up for (median) 36 months (25th and 75th percentile in 12 and 60 months, respectively). In 60 short bowel syndrome patients, the main conditions that led to intestinal failure were ischemic bowel (28), major surgery complications or severe adhesions (17), radiation enteritis (10), Chron's disease, intestinal tuberculosis, small bowel lymphoma and trauma (others). METHODS: Seventeen variables age, underlying disorders, length of remnant bowel, type of surgery, hospital stay, type of nutrition (hospital and home) and its variations in time, causes of death, survival rate and time were considered. Statistical analysis was carried out by Mann-Whitney U-test, Pearson chi2, Spearman correlation test, Kaplan-Meyer method and Cox's proportion hazards regression model. RESULTS: At the time of admission to the hospital, none of the patients had nutritional independence, 54 (79.4%) were on parenteral nutrition and 14 (20.6%) were on enteral nutrition. At the time of discharge, 23 (33.8%) patients showed enteral independence, 39 were on home parenteral nutrition, 3 on enteral nutrition + i.v. feeding, 1 on enteral nutrition, and 2 needed oral supplementation with hydroelectrolyte solutions only. After a median value of 36 months, 30 and 2 patients were on home parenteral nutrition and enteral nutrition + i.v. feeding, respectively, 2 on enteral nutrition, 2 on oral supplementation with hydroelectrolyte solutions, and 26 cases reached enteral independence. A significant relationship was detected between the length of remnant bowel and types of nutrition at both admission (r = 0.38; P = 0.001) and discharge (r = 0.48; P = 0.001), parenteral nutrition being more frequent in patients with very short bowel. Twenty-two patients (32.4%) died (4 from newly occurring malignancies), 40 (58.8%) survived, and 6 (8.8%) were lost to the follow-up. Eleven of 22 patients died from conditions related to intestinal failure (8 cases) and/or home parenteral nutrition complications (3 cases). At 12, 24, 36, 48, 60 and 72 months, survival rates were 95.4, 93.3, 88.1, 78.6, 78.6 and 65.5%, respectively, but it was significantly lower for patients with <50 cm of remnant bowel than those with longer residual intestine (P < 0.05), and in patients who started home parenteral nutrition above the age of 45 years (P < 0.02). Survival rate was higher in patients with enteral independence than those with enteral dependence (P < 0.05). Better survival rates were registered in patients with chronic obstructive intestinal pseudo-obstruction and major surgery complications, whereas ischemic bowel and even more radiation enteritis were associated with a lower survival expectance. CONCLUSIONS: Actuarial survival rate of patients with intestinal failure quotes 88 and 78% at 3 and 5 years, respectively. It is influenced by the length of remnant intestine, age at the start of home parenteral nutrition, enteral independence and, to some extent at least, by the primary disorder. Enteral independence can be achieved in time by about 40% of the patients with intestinal insufficiency, but for home parenteral nutrition-dependent cases, intravenous feeding can be stopped in less than one out of five patients during a median 3-year period.     

Role of enteral and parenteral nutrition in the patient with gastrointestinal and liver disease

This chapter discusses a number of key issues: the importance of nutritional support, both enteral (oral nutritional supplements, enteral tube feeding) and parenteral nutrition in the treatment of the nutritionally compromised patient with gastrointestinal and liver disease; prescribing and monitoring nutritional support; refeeding syndrome; practicalities, indications and contraindications and complications of using enteral and parenteral nutrition; choosing feeds with an optimal nutrient composition for nutritional support, including specific feeds for disease states; the evidence base for using nutritional support in the patient with gastrointestinal and liver disease.     

Intense nutritional support in inflammatory bowel disease

The value of intense nutritional support in inflammatory bowel disease is still debated. Claims have been made that total enteral nutrition is as effective as total parenteral nutrition. In this review, the use of parenteral and enteral nutritional support as primary therapy in patients with inflammatory bowel disease has been critically evaluated. Most studies have been uncontrolled and nonrandomized with short-term follow-up. The literature does suggest, however, that intense nutritional support may have an adjunctive role to drug therapy in achieving remission in Crohn's disease, especially in corticosteroid-refractory patients. Nutritional support has a lesser role in chronic ulcertive colitis, except for assistance in pre- and postoperative management. The data do not support one variety of nutritional support over another, although enteral support should be used if possible, as it is less costly and potentially less complicated.     

A review of the trends in the use of enteral and parenteral nutrition support

This is a review article that discusses the trends in the use of enteral and parenteral nutrition support. Although enteral nutrition has existed longer than parenteral nutrition, only recent data would suggest a clinical benefit of enteral nutrition compared with parenteral nutrition. In this article, indications for parenteral nutrition are listed. Also, data comparing bacterial translocation and complications associated with both forms of nutritional support are discussed. Clinical outcome in specific gastrointestinal diseases is also discussed.     

Survey of clinical nutrition practices of Canadian gastroenterologists.

OBJECTIVE: Nutrition education is a required part of gastrointestinal training programs. The involvement of gastroenterologists in clinical nutrition once their training has been completed is unknown. The aim of the present study was to determine the practice pattern of gastroenterologists in clinical nutrition and their perceived adequacy of nutrition training during their gastroenterology (GI) fellowship. METHODS: The Canadian Association of Gastroenterology mailed a survey to all of its 463 Canadian clinician members and 88 trainee members. Components of the survey included knowledge of nutritional assessment and total parenteral nutrition, involvement in a nutrition support service, physician involvement in nutritional assessment and nutrition support teams, obesity management, insertion of gastrostomy (G) tubes and management of tube-related complications, and adequacy of training in clinical nutrition. RESULTS: Sixty per cent (n=279) of the Canadian Association of Gastroenterology clinicians and 38% (n=33) of the fellows responded. Of the clinicians, 80% were practicing adult gastroenterologists with the following demographics: those practicing full time in academic centres (42%), community practice (45%), completed training in the last 10 years (32%) and those that completed training in the United States (14%). Although only 6% had a primary focus of nutrition in their GI practices, 65% were involved in nutrition support (including total parenteral nutrition), 74% placed G tubes and 68% managed at least one of the major complications of G tube insertion. Respondents felt a gastroenterologist should be the physician's consultant on nutrition support services (89%). Areas of potential inadequate training included nutritional assessment, indications for nutrition support, management of obesity and management of G tube-related complications. The majority of clinicians (67%) and trainees (73%) felt that nutrition training in their GI fellowship was underemphasized. CONCLUSIONS: The majority of Canadian gastroenterologists are involved in nutrition support. However, this survey demonstrated that nutritional training is underemphasized in most training programs. It is important for GI fellowship programs to develop standardized nutrition training that prepares trainees for their practice.     

Postoperative Ern?hrung und medikament?se Substitutionstherapie

For patients undergoing gastrointestinal surgery, new concepts referred to as enhanced recovery after surgery (ERAS) or fast track surgery focus on enhanced recovery and the reduction of postoperative morbidity which include special metabolic and nutritional care. Whenever possible, artificial nutritional support should be withheld. Therefore, early detection and observation of patients with nutritional risks remain essential issues for perioperative management. In cases of inadequate oral intake, which has to be anticipated in risk patients, nutritional support should be started early via the enteral route, maybe in combination with parenteral nutrition. Long-term total parenteral nutrition should be restricted to special indications. This review includes the recent guideline recommendations for surgical patients of the German Society for Nutritional Medicine (DGEM; http://www.dgem.de, http://www.awmf@online.de) and the European Society for Clinical Nutrition and Metabolism (ESPEN; http://www.espen.org) from 2006 and 2009.     

Enteral nutrition in acute pancreatitis: A review of the current evidence

The use of enteral feeding as part of the management of acute pancreatitis dates back almost two decades.This review describes the indications for and limitations of enteral feeding for the treatment of acute pancreatitis using up-to-date evidence-based data.A systematic review was carried out to analyse current data on the use of enteral nutrition in the management of acute pancreatitis.Relevant literature was analysed from the viewpoints of enteral vs parenteral feeding,early vs delayed enteral nutrition,nasogastric vs nasojejunal feeding,and early oral diet and immunonutrition,particularly glutamine and probiotic supplementation.Finally,current applicable guidelines and the effects of these guidelines on clinical practice are discussed.The latest meta-analyses suggest that enteral nutrition significantly reduces the mortality rate of severe acute pancreatitis compared to parenteral feeding.To maintain gut barrier function and prevent early bacterial translocation,enteral feeding should be commenced within the first 24 h of hospital admission.Also,the safety of nasogastric feeding,which eases the administration of enteral nutrients in the clinical setting,is likely equal to nasojejunal feeding.Furthermore,an earlylow-fat oral diet is potentially beneficial in patients with mild pancreatitis.Despite the initial encouraging results,the current evidence does not support the use of immunoenhanced nutrients or probiotics in patients with acute pancreatitis.     

The effect of minimum luminal nutrition on mucosal cellularity and immunity of the gut

Many catabolic patients can only consume small volumes of enteral nutrients. The aim of this study was to evaluate markers of cellularity and immunity in the small intestine of rats randomized to receive 6 days of parenteral nutrition, 25% enteral and 75% parenteral nutrition (i.e. minimum luminal nutrition) or enteral nutrition. The same glutamine-enriched solution was used for both parenteral and enteral nutrition. Enteral nutrition was associated with the least amount of jejunal atrophy ( P < 0.01), with the results from the minimum luminal nutrition group approximating those of the parenteral nutrition group. Parenteral nutrition was associated with the greatest number of CD2+ cells ( P < 0.05) and the lowest CD4/CD8 cell ratio ( P < 0.01) in the jejunal mucosa. In essence, we failed to demonstrate that there are any appreciable benefits associated with the enteral consumption of 25% of a nutrient load.     

Advances in nutritional therapy in inflammatory bowel diseases: Review

Inflammatory bowel diseases(IBD), including ulcerative colitis and Crohn's disease are chronic, life-long, and relapsing diseases of the gastrointestinal tract. Currently, there are no complete cure possibilities, but combined pharmacological and nutritional therapy may induce remission of the disease. Malnutrition and specific nutritional deficiencies are frequent among IBD patients, so the majority of them need nutritional treatment, which not only improves the state of nutrition of the patients but has strong anti-inflammatory activity as well. Moreover, some nutrients, from early stages of life are suspected as triggering factors in the etiopathogenesis of IBD. Both parenteral and enteral nutrition is used in IBD therapy, but their practical utility in different populations and in different countries is not clearly established, and there are sometimes conflicting theories concerning the role of nutrition in IBD. This review presents the actual data from research studies on the influence of nutrition on the etiopathogenesis of IBD and the latest findings regarding its mechanisms of action. The use of both parenteral and enteral nutrition as therapeutic methods in induction and maintenance therapy in IBD treatment is also extensively discussed. Comparison of the latest research data, scientific theories concerning the role of nutrition in IBD, and different opinions about them are also presented and discussed. Additionally, some potential future perspectives for nutritional therapy are highlighted.     

肠内和肠外营养支持在老年重症肺炎病人中的应用

目的研究老年重症肺炎病人肠内和肠外营养支持效果。方法对呼吸重症监护病房38例老年重症肺炎病人的营养支持情况进行分析，其中肠内营养支持组20例，完全肠外营养支持组18例，摄入同等热量和同等氮量，营养支持时间〉10d。结果经肠内营养支持后，血红蛋白、白蛋白和血清前白蛋白明显升高（P〈0．05），免疫球蛋白显著升高（P〈0．01）；而完全肠外营养支持后，各指标差异无显著性。结论老年重症肺炎病人救治中，根据病人的不同情况，选择合适的营养支持方式，肠内营养有更好的代谢效应及营养效果，并能改善病人的免疫功能。     

营养支持对机械通气患者营养状况和免疫功能的影响

目的探讨不同营养支持途径对机械通气患者的营养状况和免疫功能的影响。方法选择2008年7月至2010年12月入住我院重症监护病房（ICU）机械通气危重症患者48例,随机分为全肠外营养（TPN）组和肠内营养（EN）组,并对两组患者营养支持前和10 d后各项营养指标及免疫球蛋白变化、机械通气时间及并发症等进行比较分析。结果 10 d后,EN组患者与治疗前比较血清总蛋白（PT）、ALB、PA和HB水平明显上升（P〈0.05）,TPN组病人也较治疗前有所上升（P〉0.05）;与TPN组比较上述指标上升更明显（P〈0.05）;EN组免疫指标：IgA、IgM较营养支持前明显升高,与TPN组比较P〈0.05;EN组与TPN组比较,机械通气时间缩短,腹泻、肺部感染、导管相关感染、上消化道出血、肝功能损害、高血糖等并发症明显降低,均P〈0.05。结论肠内营养支持可以改善机械通气危重症患者的营养状况和免疫功能,促进患者康复。     

Post-feeding hyperammonaemia in patients with transjugular intrahepatic portosystemic shunt and liver cirrhosis: role of small intestinal ammonia release and route of nutrient administration

BACKGROUND: Hyperammonaemia is a pathogenetic factor for hepatic encephalopathy that may be augmented after a transjugular intrahepatic portosystemic shunt (TIPS). Experimental data suggest that hyperammonaemia may be caused to a large extent by metabolism of small intestinal enterocytes rather than colonic bacteria. AIMS: To evaluate if ammonia release and glutamine metabolism by small intestinal mucosa contribute to hyperammonaemia in vivo in patients with liver cirrhosis. METHODS: Using TIPS to examine mesenteric venous blood, we measured mesenteric venous-arterial concentration differences in ammonia and glutamine in patients with liver cirrhosis before, during, and after enteral (n = 8) or parenteral (n = 8) isonitrogenous infusion of a glutamine containing amino acid solution. RESULTS: During enteral nutrient infusion, ammonia release increased rapidly compared with the post-absorptive state (65 (58-73) v. 107 (95-119) micromol/l after 15 min; mean (95% confidence interval)) in contrast with parenteral infusion (50 (41-59) v. 62 (47-77) micromol/l). This resulted in a higher portal ammonia load (29 (21-36) v. 14 (8-21) mmol/l/240 minutes) and a higher degree of systemic hyperammonaemia (14 (11-17) v. 9 (6-12) mmol/l/240 minutes) during enteral than parenteral infusion. The mesenteric venous-arterial concentration difference in glutamine changed from net uptake to release at the end of the enteral infusion period (-100 (-58 to -141) v. 31 (-47-110) micromol/l) with no change during parenteral nutrition. CONCLUSIONS: These data suggest that small intestinal metabolism contributes to post-feeding hyperammonaemia in patients with cirrhosis. When artificial nutrition is required, parenteral nutrition may be superior to enteral nutrition in patients with portosystemic shunting because of the lower degree of systemic hyperammonaemia.     

How we Provide Nutritional Treatment in Hospitalized Patients?

Background: In this study, we aimed to evaluate enteral nutrition (EN), parenteral nutrition (PN) and supplemental parenteral nutrition (SPN) in terms of achieving nutritional goals. Methods: Patients receiving either EN, PN, or SPN treatment followed up by the clinical nutrition team between January and December 2017 at the university research and training hospital were included in the study. Daily nutritional requirements were calculated according to the recommendations. Total energy intake during nutritional treatment (NT) and all metabolic, mechanical, technical complications of NT were recorded. Results: A total of 603 inpatients were included in the study. The nutritional goal was achieved in the majority of the SPN group patients (87.5%) statistically significant relation was found between the achievement of the target (or not) and PN access route (peripheral or central) (P < .001). However, none of the complications found statistically related to achieving the target, including gastrointestinal complications of EN (P = .46), metabolic complications of EN (P = .07), mechanical complications of EN (P = .79), metabolic complications of PN (P = .89), gastrointestinal complications in SPN group (P = .45), and metabolic complications in SPN group (P = .68).Conclusion: Nutritional goals could be achieved with SPN without increasing complications in the majority of patients. Commencement of SPN should be considered for positive outcomes in patients who failed to achieve desired nutritional outcomes.     

机械通气患者早期肠内营养支持的应用研究

目的:探讨早期肠内营养对机械通气患者营养状态和预后的影响.方法:机械通气患者30例,随机分为2组:早期肠内营养(EEN)组15例和早期完全胃肠外营养(TPN)组15例,在摄入相当热量和氮量的情况下,比较2组治疗前后营养状态、1周内撤机成功率、呼吸机相关性肺炎(VAP)发生率、平均营养费用、机械通气时间及平均住院天数.结果:治疗2周后,EEN组血清总蛋白、清蛋白、血红蛋白水平和氮平衡较治疗前明显升高(均P＜0.05),且均高于TPN组治疗后水平(均P＜0.05).上臂肌围、肱三头肌皮褶厚度2组无差异(P＞0.05).EEN组1周内撤机成功率明显高于TPN组(P＜0.05),机械通气时间、平均住院天数则明显低于TPN组(均P＜0.05).2组1周内VAP发生率差异无统计学意义(P＞0.05).结论:EEN能改善机械通气患者的营养状况和预后.只要患者胃肠道功能正常,应尽早实施肠内营养支持.     

肠内外营养在胃肠术后患者中的应用比较

目的:探讨胃肠手术后肠内营养(EN)与肠外营养(PN)对患者营养状况的改善及并发症发生率的影响。方法:将48例接受择期胃肠手术的患者随机分为PN组和EN组,两组患者于手术后第1天开始分别给予肠外或肠内营养支持。于术前1d、术后第8天检测体重、血生化、营养状态指标及肠道黏膜通透性,并观察并发症的发生率和平均住院费用。结果:EN组体重、白蛋白、转铁蛋白下降幅度少于PN组,但差异无统计学意义;EN组前白蛋白、纤维连接蛋白下降幅度明显少于PN组(P<0.05)。EN组C-反应蛋白升高幅度少于PN组(P<0.05)。EN组患者肠道通透性、平均住院费用及术后并发症发生率显著低于PN组(P均<0.01)。结论:胃肠术后早期肠内营养能改善患者的营养状况,降低并发症发生率,减少住院费用。     

营养支持对45例早期机械通气患者的治疗作用观察

目的 探讨营养支持对接受机械通气患者的早期治疗作用.方法 将接受机械通气治疗的45例危重病患者随机分为全肠外营养(PN)组、全营养食物均浆肠内营养(EN)组和肠内肠外营养相结合(PN EN)组,各组患者均接受等氮等热量营养支持.结果 各组脱机时间比较无显著性差异,营养效果相似,肠外组和混合组较快达氮平衡.肠外组和混合组的胃肠道并发症较肠内组少,两者比较有显著性差异.肠内组费用最便宜,混合组免疫学指标最高.结论 机械通气患者普遍存在营养不良,可采用肠内营养或肠外营养或二者结合方式进行营养,肠内营养经济方便,有利于肠道能力恢复,而全肠外营养效果准确迅速,两者结合能互相取长补短.     

肠内免疫微生态营养对重症急性胰腺炎肝损害的影响

目的:探讨不同营养支持对重症急性胰腺炎肝损害的影响.方法:86例重症急性胰腺炎肝损害患者在入院48 h内随机分为3组,即肠外营养(PN)组28例,肠内营养(EN)组29例和免疫微生态肠内营养(EIN)组29例,分别行PN,EN和EIN支持14 d.检测其内毒素、细胞因子及肝功能的改变.结果:入院时EIN组内毒素、TNF-α、IL-6及肝功能与PN组、EN组比较无显著差异.营养支持14 d后,EIN组内毒素、TNF-α和IL-6分别为1.28 ng/L±0.17 ng/L,30.13 ng/L±8.12ng/L.36.43 ng/L±8.24 ng/L,上述指标均较PN组及EN组明显下降(P＜0.01或0.05).EIN组14 d后肝功能各项指标均恢复正常,与PN组、EN组比较有统计学意义(P＜0.01或0.05).结论:肠内免疫微生态营养,可以补充肠道正常菌群,减少细菌易位,减少内毒素血症及炎症因子的发生,从而减轻重症急性胰腺炎肝损害.     

重型颅脑损伤行鼻肠管早期肠内营养辅以肠外营养的应用

目的观察鼻肠管早期肠内营养辅以肠外营养对重型颅脑损伤患者的疗效。方法将84例重型颅脑损伤患者随机分为观察组与对照组各42例,观察组留置鼻肠管,对照组留置鼻胃管,均给予早期肠内营养辅以肠外营养的营养支持方式,观察两组生活指标、胃肠道耐受及并发症情况。结果营养支持后7d血清总蛋白、清蛋白两组间差异无统计学意义（P〉0.05）;两组患者营养支持后7d血糖水平间差异有统计学意义（P〈0.01）。1周内并发症发生情况：观察组42例中发生消化道出血5例,反流2例,腹泻4例,腹胀2例。对照组42例中发生消化道出血9例,反流19例,腹泻9例,腹胀17例。结论重型颅脑损伤病患者鼻肠管早期肠内营养辅以肠外营养支持方式,可以明显改善营养状况,减少并发症的发生。     

阶段性营养支持在重症急性胰腺炎治疗中的应用

目的观察肠内和肠外联合阶段性营养对重症急性胰腺炎治疗效果的影响。方法重症急性胰腺炎患者50例分为完全胃肠外营养组（TPN组,n=25）和肠内营养加肠外阶段性营养组（PN＋EN组,n=25）,比较两组治疗效果及临床指标的变化。结果两组患者治疗后血淀粉酶均有下降,但两组间比较无显著性差异（P〉0．05）。营养支持后PN＋EN组在APACHE1I评分和CT评分较TPN组明显降低（P〈0．01）,两组血清白蛋白及血钙水平较治疗前升高（P〈0．01）,血糖明显降低（P〈0．01）,但两组间比较无显著性差异（P〉0．05）。与TPN组相比,PN＋EN组患者住院天数、腹胀缓解时间、体温恢复正常时间均明显缩短,感染发生率显著降低（P〈0．01）。结论肠内和肠外联合阶段性营养对重症急性胰腺炎治疗效果优于完全胃肠外营养。