Influence of glutamine and branched chain amino acids on the jejunal atrophy associated with parenteral nutrition

Infusions of conventional parenteral nutrients (CPN) are associated with gut atrophy. This may be due to the absence of glutamine in such solutions. Although glutamine is a preferred gut nutrient, it is excluded from CPN because it is unstable at room temperature. This problem may be circumvented either directly by the infusion of fresh solutions of glutamine, or indirectly by the infusion of branched chain amino acids (BCAA). We evaluated the effect of infusing either glutamine, BCAA, or glutamine plus BCAA-enriched CPN on the rat jejunum. Sixty male Wistar rats were randomized to receive 6 days of either conventional parenteral nutrition (CPN), CPN plus 1.5% glutamine (GLN), CPN plus 2% BCAA (BCAA), CPN plus 0.8% BCAA and 1.0% glutamine (GLN/BCAA), or a normal oral diet (Chow). Standardized segments of jejunum were then removed for assessment. Compared with the CPN group, both the GLN/BCAA and the BCAA groups had greater mucosal weights (P less than 0.05) and mucosal protein concentrations (P less than 0.05), the GLN/BCAA group had greater jejunal weights (P less than 0.05), and the GLN group had an increased jejunal weight (P less than 0.05) and a higher crypt cell production rate (P less than 0.05). We conclude that the infusion of glutamine or BCAA-enriched parenteral nutrition improves jejunal morphology compared with conventional parenteral nutrition.     

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.     

Effect of bowel rehabilitative therapy on structural adaptation of remnant small intestine: animal experiment

AIM To investigate the individual and thecombined effects of glutamine, dietary fiber,and growth hormone on the structural adaptationof the remnant small bowel.METHODS Forty-two adult male Sprague-Dawley rats underwent 85% mid-small bowelresection and received total parenteral nutrition(TPN) support during the first threepostoperational days. From the 4thpostoperational day, animals were randomlyassigned to receive 7 different treatments for 8days: TPNcon group, receiving TPN and enteral20g·L~1 glycine perfusion; TPN Gin group,receiving TPN and enteral 20 g·L~1 glutamineperfusion; ENcon group, receiving enteralnutrition (EN) fortified with 20 g·L~1 glycine; EN Gin group, enteral nutrition fortified with20g·L~1 glutamine; EN Fib group, enteralnutrition and 2 g·d~1 oral soybean fiber; EN GHgroup, enteral nutrition and subcutaneousgrowth hormone (GH) (0. 3IU) injection twicedaily; and ENint group, glutamine-enriched EN,oral soybean fiber, and subcutaneous GHinjection.RESULTS Enteral glutamine perfusion duringTPN increased the small intestinal villus height(jejunal villus height 250μm 29μm in TPNcon vs 330μm±54μm in TPN Gln, ileal villus height260μm±28μm in TPNcon vs 330μm±22μm inTPN Gln, P<0.05) and mucosa thickness(jejunal mucosa thickness 360μm ± 32μm inTPNcon vs 460μm±65μm in TPN Gln, ilealmucosa thickness 400μm ± 25μm in TPNcon vs490μm ± 11μm in TPN Gin, P<0.05) incomparison with the TPNcon group. Either fibersupplementation or GH administration improvedbody mass gain (end body weight 270 g ± 3.6 g inEN Fib, 265.7 g ± 3.3 g in EN GH, vs 257g±3.3g in ENcon, P<0.05), elevated plasmainsulin-like growth factor (IGF-I) level(880μg·L~1±52μg.L~(-1) in EN Fib, 1200μg·L(-1) 96μg·L~(-1) in EN GH, vs 620μg·L~(-1) ±43μg·L~1 in ENcon, P<0.05), and increased thevillus height (jejunum 560μm ± 44μm in EN ± Fib,530μm ± 30μm in EN±GH, vs 450μm±44μm inENcon, ileum 400μm ± 30μm in EN Fib, 380μm±49μm in EN ± GH, vs 320μm ± 16μm in ENcon,P<0.05) and the mucosa thickness (jejunum740μm ± 66μm in EN ± Fib, 705μm ± 27 μm in EN ±GH, vs 608μm ± 58μm in ENcon, ileum 570μm ±27μm in EN ± Fib, 560μm ± 56μm in EN ± GH, vs480μm ± 40μm in ENcon, P<0.05) in remnantjejunum and ileum. Glutamine-enriched ENproduced little effect in body mass, plasma IGF-I level, and remnant small bowel mucosalstructure. The ENint group had greater bodymass (280g ± 2.2 g), plasma IGF-1 level(1450μg.L~1 ± 137μg.L~1), and villus height(jejunum 620μm ± 56μm, ileum 450μm ± 31μm)and mucosal thickness (jejunum 800μm ± 52μm,ileum 633μm ± 33μm) than those in ENcon, EN Gln (jejunum villus height and mucosa thickness450μm ± 47μm and 610μm ± 63μm, ileum villusheight and mucosa thickness 330μm ± 39μm and500μm±52μm), EN GH groups (P<0.05), andthan those in EN Fib group although nostatistical significance was attained.CONCLUSION Both dietary fiber and GH whenused separately can enhance the postresectionalsmall bowel structural adaptation. Simultaneoususe of these two gut-trophic factors can producesynergistic effects on small bowel structuraladaptation. Enteral glutamine perfusion isbeneficial in preserving small bowel mucosalstructure during TPN, but has little beneficialeffect during EN.     

Stimulation of disaccharidase activities in the jejunal brush border membrane of adult rat by total parenteral nutrition. Effects of thyroid hormones

This study examined the morphological and functional adaptations occurring in the jejunum of adult rats fed totally by parenteral nutrition during a 4-day period. Comparison was made with sham-operated animals receiving orally a similar isocaloric diet. The intravenously fed rats exhibited a 20% shortening of the villus height. The specific activity of aminopeptidase showed remarkable stability in all conditions. A major stimulation (2.5-fold) was measured for lactase-specific activity. Daily administration of thyroxine completely inhibited the rise of lactase activity. Thyroidectomy caused a significant increase of lactase activity in the orally fed controls, but did not exert any synergistic effect with parenteral nutrition on intestinal enzyme activities. In our experimental conditions intravenous feeding led to a 3-fold decrease in the concentration of thyroid hormones detected in the serum. The results show that total parenteral nutrition leads to a stimulation of the specific activity of brush border lactase in the intestine of adult rat which might be related to the level of thyroid hormones.     

The maximal activity of phosphate-dependent glutaminase and glutamine metabolism in the colon and the small intestine of streptozotocin-diabetic rats

Summary The effects of short- and long-term diabetes on the maximal activities of phosphate-dependent glutaminase and glutamine metabolism were studied in the colon and the small intestine of streptozotocin-diabetic rats. The maximal activity of colonic phosphate-dependent glutaminase was decreased [44% in mucosal scrapings (p<0.01); 29% in whole colon (p<0.001)] or unchanged in short- or long-term diabetes respectively. That of the small intestine was increased in both short- (110%) and long-term (200%–500%) diabetes; insulin treatment corrected this increase. Acute insulin-deficiency (using anti-insulin serum) resulted in the increase (18%, p<0.05) of the activity of only intestinal glutaminase. Chemically-induced acidosis and alkalosis decreased (46%, p<0.001) and increased (24%, p<0.001), respectively, the activity of intestinal glutaminase, but had no effect on the colonic enzyme. Changes in glutaminase of the enlarged colon and small intestine were only detectable when activities were measured in whole organ. Arteriovenous-difference measurements showed diminished metabolism of plasma glutamine by the gut which correlated with the duration of the state of diabetes, and was accompanied by enhanced release by skeletal muscle and increased uptake by both kidney and liver. It is concluded that insulin is directly or indirectly involved in the regulation of glutamine metabolism of the gut.     

Pharmaconutrition: a new emerging paradigm.

PURPOSE OF REVIEW: This paper highlights recent studies of interest and provides rationale for why deficiencies with the current scientific paradigm of immunonutrition has produced studies with conflicting results, and why it should be replaced with a new paradigm termed 'pharmaconutrition'. RECENT FINDINGS: Considering the overall treatment effect of immune-modulating nutrients, parenteral glutamine is recommended in patients receiving parenteral nutrition, while enteral glutamine should be considered in burn and trauma patients. Antioxidants, particularly selenium, should be considered for critically ill patients, and enteral formulas enriched with fish oils are recommended in patients with acute respiratory distress syndrome. Arginine-supplemented diets are not recommended. There are currently insufficient data to enable useful recommendations on the optimal route, timing, duration and dosage of each nutrient. The pending results of a large, rigorously designed, randomized trial, however, in which nutrients are viewed and tested as pharmacological agents, promise to clarify some of the current ambiguities and inform future practice. SUMMARY: This review provides insights into why the current paradigm of immunonutrition has failed to consistently demonstrate a beneficial effect of key immunomodulating nutrients, and offers a timely solution through the new paradigm of pharmaconutrition.     

Nonspecific adaptation of jejunal amino acid uptake in the rat

Luminal nutrients are a major effector of intestinal adaptation. Amino acids are trophic to the intestine, but their role in regulating amino acid transport is not well documented. The presence of several distinct amino acid transport systems raises the question of whether adaptation is class-specific. Studies were carried out in parenterally nourished rats receiving a 7-day jejunal infusion of a 3% solution of either aminoisobutyric acid, aspartic acid, glutamine, histidine, lysine, or valine. While all amino acids were trophic to the intestine, their effects on the in vitro uptake of 0.1, 1.0 and 10.0 mM aspartic acid, lysine, and valine (representative acid, basic, and neutral amino acids) were variable and nonspecific. Compared to controls receiving either total parenteral nutrition alone or total parenteral nutrition plus luminal saline, prior lysine and aspartic acid infusion significantly increased in vitro uptake of all three amino acids tested, whereas valine had little effect on transport. No effect on transport was seen with glutamine (actively metabolized by the intestine as is aspartic acid), aminoisobutyric acid (a nonmetabolizable amino acid congener), or histidine (the most trophic amino acid). In conclusion, while individual amino acids cause an adaptation of amino acid uptake, the effects are nonspecific and independent of their metabolic or trophic potential.     

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.     

The effect of minimum luminal nutrition on bacterial translocation and atrophy of the jejunum during parenteral nutrition

In situations of catabolic stress, the gut becomes atrophic and may have diminished barrier function as evidenced by an increase in bacterial translocation. The aim of this study was to examine the effect of minimum luminal nutrition during parenteral nutrition on the extent of jejunal atrophy and rate of bacterial translocation. Central venous lines were inserted into 30 rats before they underwent randomization to receive nutritional support with: (a) conventional parenteral nutrition; (b) conventional parenteral nutrition with 3 g/day of rat food (i.e., minimum luminal nutrition); or (c) rat food ad libitum. The rats were assessed after 10 days for nutritional status, extent of jejunal atrophy, caecal flora, as well as the extent of bacterial translocation to the mesenteric lymph nodes, liver and spleen. Rats in the rat food ad libitum group lost the smallest amount of weight and had the least amount of jejunal atrophy, yet had a similar rate of bacterial translocation as the parenterally nourished groups. When compared with the conventional parenteral nutrition group, the minimum luminal nutrition group had better preservation of the weight of the small bowel and its isolated mucosa (P < 0.01), but had a similar rate of bacterial translocation. Minimum luminal nutrition reduced the extent of atrophy of the gut but did not affect the incidence of bacterial translocation. It is inferred that there is no direct relationship between the extent of mucosal atrophy and incidence of bacterial translocation.     

Artificial nutrition after pancreaticoduodenectomy

Patients undergoing pancreaticoduodenectomy (PD) often require postoperative artificial nutrition. This trial was undertaken to evaluate whether the route of administration and the composition of the postoperative nutritional support could affect the immunometabolic response and outcome. A prospective, randomized trial was carried out in 212 subjects who underwent PD. Patients were randomized to receive a standard enteral formula (standard group, n = 73) or an enteral formula enriched with arginine, omega-3 fatty acids, and RNA (immunonutrition group, n = 71), or total parenteral nutrition (parenteral group, n = 68). Postoperative feeding started 6 hours after surgery. The three regimens were isocaloric and isonitrogenous. Assessed parameters were phagocytosis ability of polymorphonuclear cells, plasma interleukin-2 receptors, C-reactive protein, retinol binding protein, tolerance of enteral feeding, rate of postoperative complications, and length of hospital stay (LOS). Full nutritional goal (25 kcal/kg) was achieved in 87% of enterally fed patients versus 95% in the parenteral group. Subjects receiving immunonutrition had a significantly better recovery of the immunometabolic parameters on postoperative day 8 compared to the other two groups. The rate of postoperative complications was lower in the immunonutrition group (33.8%) than in either the standard (43.8%) or parenteral group (58.8%) (p = 0.005 immunonutrition vs. parenteral). Also, the mean LOS was shorter in the immunonutrition group than in the standard and parenteral groups (15.1 vs. 17.0 vs. 18.8 days, respectively; p < 0.05). Early postoperative enteral feeding may safely and effectively replace parenteral nutrition in patients undergoing PD. Immunonutrition ameliorates the immunometabolic response and improves outcome compared to parenteral feeding.     

Bidirectional supply of glutamine maintains enterocyte ATP content in the in vitro Ussing chamber model

Glutamine is the principal energy source for enterocytes, but it is not known whether parenteral or enteral supplementation is most beneficial to gut integrity. The aim of this study was to evaluate the effects of glutamine in uni- or bidirectional supply on the viability of intestinal mucosa of starved rats during incubation in Ussing chambers. Segments of jejunum from rats starved for 48 h were randomly mounted in Ussing chambers with three nutrient solutions: Krebs buffer without glutamine; 6 mM glutamine added to the mucosal side; 6 mM glutamine added to the mucosal side and 0.6 mM glutamine to the serosal side. ATP content of the mucosa, electrophysiology, and 51Cr-ethylenediaminetetraacetate (EDTA) permeability were studied during 180 min of incubation. The addition of glutamine to both sides of the stripped mucosa improved ATP levels compared to the Krebs solution (P < 0.05), and the addition of glutamine resulted in an increase in short circuit current (P < 0.05). No significant differences were seen in 51Cr-EDTA permeability or epithelial electrical resistance. Glutamine supplementation to both the luminal and serosal side in the Ussing chamber was more effective than luminal glutamine only in maintaining ATP levels of intestinal mucosa. Bidirectional supplementation of glutamine might improve intestinal energy metabolism and viability in in vitro studies.     

High-fat enteral nutrition reduces endotoxin, tumor necrosis factor-alpha and gut permeability in bile duct-ligated rats subjected to hemorrhagic shock

BACKGROUND/AIMS: Cholestatic patients are prone to septic complications after major surgery due to an increased susceptibility to endotoxin and hypotension. High-fat enteral nutrition reduces endotoxin after hemorrhagic shock. However, it is unknown whether this nutritional intervention is protective in biliary obstruction. We investigated the effect of high-fat enteral nutrition on endotoxin, tumor necrosis factor-alpha (TNF-alpha) and intestinal permeability in cholestatic rats subjected to hemorrhagic shock. METHODS: Bile duct-ligated (BDL) rats were fasted or fed with low-fat or high-fat enteral nutrition before hemorrhagic shock. Blood and tissue samples were taken after 90 min. RESULTS: Plasma endotoxin decreased after hemorrhagic shock in BDL-rats fed with high-fat nutrition compared to fasted (P<0.01) and low-fat treated rats (P<0.05). Additionally, circulating TNF-alpha was reduced in BDL-rats pretreated with high-fat nutrition compared to fasted rats (P<0.01). The increased intestinal permeability to macromolecules was reduced by high-fat enteral nutrition, whereas bacterial translocation did not significantly change. Simultaneously, tight junction distribution in ileum and colon was disrupted in non-treated BDL-rats but remained unchanged in high-fat pretreated BDL-rats. CONCLUSIONS: High-fat enteral nutrition protects against endotoxin-mediated complications independently of intraluminal bile. These results provide a potential new strategy to prevent endotoxin-mediated complications in cholestatic patients undergoing major surgery.     

Glutamine supplementation in acute pancreatitis: A meta-analysis of randomized controlled trials

BackgroundThere is emerging evidence that glutamine supplementation should be considered in patients with acute and critical illness associated with a catabolic response. There are reports of glutamine supplementation in acute pancreatitis but the results of these studies are conflicting. The aim of this study was to systematically review the randomised controlled trials (RCT) of glutamine in patients with acute pancreatitis.MethodsThe Cochrane Central Register of Controlled Trials, MEDLINE, EMBASE, SCOPUS and 3 major Chinese databases were searched. The outcomes studied were mortality, total infectious complications, and length of hospital stay. A random effects model was used for meta-analysis of the outcomes in the included trials. A number of pre-specified subgroup analyses were also conducted. The summary estimates were reported as risk ratio (RR) for categorical variables and mean difference (MD) for continuous variables together with the corresponding 95% confidence interval.ResultsTwelve RCT that enrolled 505 patients with acute pancreatitis were included in the final analysis. Overall, glutamine supplementation resulted in a significantly reduced risk of mortality (RR 0.30; 95% CI, 0.15 to 0.60; P < 0.001) and total infectious complications (RR 0.58; 95% CI, 0.39 to 0.87; P = 0.009) but not length of hospital stay (MD ?1.35; 95% CI, ?3.25 to 0.56, P = 0.17). In the subgroup analyses, only patients who received parenteral nutrition and those who received glutamine in combination with other immunonutrients demonstrated a statistically significant benefit in terms of all the studied outcomes.ConclusionsThis meta-analysis demonstrates a clear advantage for glutamine supplementation in patients with acute pancreatitis who receive total parenteral nutrition. Patients with acute pancreatitis who receive enteral nutrition do not require glutamine supplementation. Further studies are warranted to determine whether patients who receive combined enteral and parenteral nutrition need glutamine supplementation.     

The effects of the formula of amino acids enriched BCAA on nutritional support in traumatic patients

AIM: To investigate the formula of amino acid enriched BCAA on nutritional support in traumatic patients after operation. METHODS: 40 adult patients after moderate or large abdominal operations were enrolled in a prospective, randomly and single-blind-controlled study, and received total parenteral nutrition (TPN) with either formula of amino acid (AA group, 20 cases) or formula of amino acid enriched BCAA (BCAA group, 20 cases). From the second day after operation, total parenteral nutrition was infused to the patients in both groups with equal calorie and equal nitrogen by central or peripheral vein during more than 12 hours per day for 6 days. Meanwhile, nitrogen balance was assayed by collecting 24 hours urine for 6 days. The markers of protein metabolism were investigated such as amino acid patterns, levels of total protein, albumin, prealbumin, transferrin and fibronectin in serum. RESULTS: The positive nitrogen balance in BCAA group occurred two days earlier than that in AA group. The serum levels of total protein and albumin in BCAA group were increased more obviously than that in AA group. The concentration of valine was notably increased and the concentration of arginine was markedly decreased in BCAA group after the formula of amino acids enriched BCAA transfusion. CONCLUSION: The formula of amino acid enriched BCAA may normalize the levels of serum amino acids, reduce the proteolysis, increase the synthesis of protein, improve the nutritional status of traumatic patients after operation.     

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.     

Is postoperative early enteral nutrition with regular or disease-specific enteral formula really beneficial in patients undergoing esophagectomy?

Although recent studies have shown that early enteral nutrition (EEN) has certain advantages over parenteral nutrition for preventing postoperative complications, few previous studies have examined the effects of enteral nutrition in patients undergoing esophagectomy. Here we review the effects of EEN with regular polymeric or other disease-specific enteral formulas in patients undergoing esophagectomy. Previously reported data suggest that nutritional management with early enteral feeding may be beneficial and that an appropriate selection of specific enteral formula enriched with disease-specific nutrients is important to prevent postoperative complications in patients undergoing radical esophagectomy. The use of immune-enhancing enteral formula (IEF) showed a certain benefit to enhance postoperative immunological function after esophagectomy. The use of IEF in the critically ill condition is still controversial, however, and thus the indication for using IEF in patients with septic complications after surgery should be considered carefully. IEF without the enrichment of arginine may be another option for patients with septic complications. EEN with a specific enteral formula may be important for patients with esophageal cancer after neoadjuvant chemotherapy or radiation therapy and salvage surgery to prevent postoperative complications and to improve nutritional status. Appropriate perioperative enteral formula enriched with disease-specific nutrients may be an important target of future clinical research for patients undergoing esophagectomy.     

Ern?hrung und metabolische Kontrolle bei Sepsis

Nutrition in septic patients should be more than just caloric support. Septic patients may benefit from early enteral nutrition. The concept of metabolic control has been evaluated in large multicenter studies in septic patients. However, a tight glycemic control with a blood sugar level target of 80–110 mg/dl was not successful in septic patients. An enteral immunonutrition that resulted in a reduced length of stay in post-operative patients may be associated with increased mortality in patients suffering from severe sepsis. Newly developed lipid emulsions for parenteral nutrition have become available and these emulsions may prove to be beneficial in septic patients. An intravenous supplementation with glutamine of long-term exclusively parenterally fed intensive care patients may reduce mortality. A nutrition individually optimized and adapted to the severity of the disease is an adjunct therapy in the treatment of septic patients.     

Effect of enteral nutrition on dextran sulfate sodium-induced colitis in rats

OBJECTIVE: To study the effect of enteral nutrition (EN) on dextran sulfate sodium (DSS)‐induced colitis in rats. METHODS: Eighty‐four Sprague–Dawley rats were divided into 7 groups (12 rats in each group). The blank control group was given ordinary laboratory feed and drinking water. The experimental groups received 5% DSS as drinking water for 7 days. Of the experimental groups, the model control group received ordinary laboratory feed, protein based enteral nutrition (PEN) was fed in the PEN group, while other groups received ordinary laboratory feed plus 5‐aminosalicylic acid (5‐ASA), methyl‐prednisolone, Lactobacillus or glutamine, respectively. On the 8th day, all the rats were sacrificed. Inflammatory scores were assessed from colonic mucosa. Blood culture from inferior vena cava, fecal culture and secretary immunoglobulin‐A (S‐IgA) levels from colonic contents were determined. RESULTS: Colon inflammatory scores of Lactobacillus, PEN, glutamine and drug‐treated groups were lower than that of the model control group (P < 0.01). The ratios of bacteria translocation in the EN (PEN, Lactobacillus and glutamine) groups were lower than that in the model control group (P < 0.0083). Fecal Lactobacilli in the Lactobacillus and glutamine groups were higher than that in the model control group (P < 0.05). S‐IgA levels in colonic contents of the PEN and 5‐ASA group were lower than that in the model control group (P < 0.05). CONCLUSIONS: EN is an effective therapy for treating DDS‐induced colitis. EN could alleviate damage, promote the repair of colonic epithelial cells and inhibit bacterial translocation. Lactobacillus and glutamine could also increase the Lactobacilli in colon.     

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     

Nutritional management of acute pancreatitis

Most patients with acute pancreatitis have mild to moderate disease and require no specialized nutritional support. Twenty percent to 30% have severe cases, resulting in a catabolic hypermetabolic state, and these patients may require early aggressive nutritional support. Traditionally, this support has been in the form of total parenteral nutrition. However, recent data suggest that enteral nutrition infused into the jejunum is feasible, well tolerated, associated with fewer complications, and significantly less expensive than parenteral nutrition. The pathophysiology of gut function in acute pancreatitis and the rationale and evidence for parenteral and enteral nutritional support are reviewed herein. An algorithm on the nutritional management of acute pancreatitis is suggested.