Intestinal transplantation

Intestinal transplantation has now emerged as a lifesaving therapeutic option and standard of care for patients with irreversible intestinal failure. Improvement in survival over the years has justified expansion of the indications for intestinal transplantation beyond the original indications approved by Center for Medicare and Medicaid services. Management of patients with intestinal failure is complex and requires a multidisciplinary approach to accurately select candidates who would benefit from rehabilitation versus transplantation. Significant strides have been made in patient and graft survival with several advancements in the perioperative management through timely referral, improved patient selection, refinement in the surgical techniques and better understanding of the immunopathology of intestinal transplantation. The therapeutic efficacy of the procedure is well evident from continuous improvements in functional status, quality of life and cost-effectiveness of the procedure. This current review summarizes various aspects including current practices and evidence based recommendations of intestinal transplantation.     

Intestinal failure

Abstract The recognition of intestinal failure (IF) as a distinct clinical entity over the past 20 years has primarily come about through the emergence of increasingly successful treatment based on use of intravenous nutrition delivered both in hospital and at home. Intestinal failure has many and varied causes, and may be complete or partial, acute and short lived, or chronic and permanent. If the latter, lifetime dependence on parenteral nutrition will usually be indicated and where possible patients are trained in the techniques of home parenteral nutrition (HPN). The success of HPN is itself primarily dependent on meticulous catheter care protocols. Sufficient numbers of such patients have now been entered into randomized controlled trials for there to be an evidence base for this aspect of IF treatment. The balanced delivery of nutrients, especially when an enteral component is included, can prevent many of the complications, such as liver and bone disease, recorded as being associated with prolonged total parenteral nutrition. However, nutritional balance is difficult to achieve in the presence of total gut resection, multiple intestinal fistulas or persisting sepsis. Surgical approaches involving bowel lengthening and reversed loops are indicated in selected patients. They have limited success and carry with them the risk of further loss of precious residual bowel. Greatest promise is held out by intestinal transplantation, but the problems associated with the powerful immunosuppression required reduce the value of this treatment. Specialized referral units for patients with severe and persistent IF can produce a high percentage of clinically effective and cost-effective outcomes.     

Intestinal Herpes Simplex Infection Presenting with Intestinal Perforation

A 77-yr-old man who had received systemic steroids for more than 6 yr presented with an acute abdomen. Laparotomy revealed an ulcerative jejunitis with purulent peritonitis. The patient underwent resection of involved bowel followed by a 10-day course of aciclovir, with excellent results. Pathologic examination showed a necrotizing enteritis with intranuclear inclusions typical of Herpesvirus that reacted immunocytochemically with antibodies to herpes simplex virus types I and II. A rising herpes simplex virus serum antibody titer confirmed the diagnosis. Intestinal herpes infection with perforation should be added to the list of complications from herpes simplex in the immunocompromised patient.     

Intestinal transplantation

Even though surgical techniques for isolated intestine, liver-intestine, and multivisceral transplantations were developed in the 1960's, very few patients were transplanted before 1990 because initial immunosuppression regimens were insufficient, making intestine transplantation impossible. Intestine transplantation resulted in death in most patients within days or months. The discouraging results of the first clinical trials were due to technical complications, sepsis, and the failure of conventional immunosuppression to control rejection. By 1990 the development of tacrolimus-based immunosuppression and improved surgical techniques, the increased array of potent immunosuppressive medications, infection prophylaxis, and suitable patient selection helped improve actuarial graft and patient survival rates for all types of intestine transplantation. The aims of this review are to describe the current status of intestine transplantation including the underlying diseases and conditions that may be indications for intestine transplantation, to identify patient populations for this indication, to provide key steps for patient evaluation, to summarize current recommendations for immunosuppression, to list the most common postoperative complications, and to discuss the international experience of small bowel transplantation compiled and analyzed by the International Intestine Transplant Registry since 1985.     

Intestinal cestodes

PURPOSE OF REVIEW: This review summarizes the biology, clinical aspects, diagnosis, treatment and epidemiology for the common and rarer (zoonotic) intestinal cestodes of humans. RECENT FINDINGS: Mass drug application to eliminate Taenia solium carriers may have only temporary effects on cysticercosis transmission. At least two major world genotypes of T. solium have been identified and greater genetic heterogeneity may occur at the regional level. A new human taeniid T. asiatica has been confirmed which occurs sympatrically with T. saginata and T. solium in Southeast Asia. Coproantigen and PCR tests for Taenia spp. have greatly improved diagnostic efficacy and epidemiological studies. There appears to be an increase in human diphyllobothriasis in Europe, Japan and the Americas. SUMMARY: Human intestinal cestode infections are globally primarily caused by species in three genera: Taenia, Hymenolepis or Diphyllobothrium. Sporadic zoonotic infections caused by nontaeniids are usually food-borne or due to accidental ingestion of invertebrate hosts. Intestinal cestode infections generally result in only mild symptoms characterized chiefly by abdominal discomfort and diarrhoea. Most human intestinal cestode infections can be treated with a single oral dose of praziquantel or niclosamide.     

Intestinal motility

Summary The motor activity of the small intestine and colon has been studied in 27 asymptomatic patients by means of manometry by endoradiosonde combined with synchronized fluorocinematography.In the small intestine, Type I waves were associated with ring-like, nonpropulsive contractions and Type III waves were seen to accompany propulsion of intraluminal contents.Ingestion of food caused an increase in rate and amplitude of intraluminal waves in both the small intestine and colon; an increase in propulsion of contents after eating was noted in the small intestine, but not in the colon.The authors are grateful to Dr. John T. Farrar for constant advice and help. The research described had its beginnings during the time that one of us was on the staff of the Gastroenterology Section of the Veterans Administration Hospital. New York, X. Y.