Chronic intestinal pseudo-obstruction in patients with extensive bowel resection for Crohn's disease

We report three cases of severe chronic intestinal pseudo-obstruction after extensive bowel resection for Crohn's disease. The patients retained less than or equal to 150 cm jejunum in continuity with the left half of the colon and had no evidence of inflammatory activity in the remaining bowel. Total parenteral nutrition was required, since even very small meals caused abdominal distention, pain, and vomiting. Two patients had a sigmoidostomy constructed, which alleviated the symptoms and enabled a normal oral intake, but only temporarily in one of the patients. Even with a sigmoidostomy the patients needed supplementary parenteral nutrition because of severe malabsorption with high stomal output.     

Treatment of Crohn's disease with home parenteral nutrition.

Home parenteral nutrition was used to treat 9 patients with severe Crohn's enterocolitis. Seven patients had a short bowel syndrome after multiple resections of bowel. In 2 patients home parenteral nutrition was used as primary therapy. The treatment was well tolerated and proved successful in 8 of 9 patients. Three patients have been able to discontinue parenteral infusions and currently are in remission. The main complications were associated with the access device which was replaced in 3 patients. Five patients currently have abnormal liver function tests without progressive liver disease. It is concluded that home parenteral nutrition is an important new therapeutic modality which can reduce or even eliminate the need for repeated or prolonged hospitalization of patients with short bowel syndrome complicating severe Crohn's disease. In addition, the technique of home parenteral nutrition, because it is relatively simple and safe, lends itself to early intervention in severe fulminant cases of Crohn's disease. This approach can result in healing of fistulae and abscesses and greatly shortening the period of hospitalization. The patient is more rapidly rehabilitated, and his fear of early relapse and recurrent malnutrition is minimized, thus facilitating a prolonged period of bowel rest which can lead to eventual remission. Home parenteral nutrition should be kept in mind as a possible alternative to early surgical intervention in selected cases of severe Crohn's disease.     

Favorable response to parenteral nutrition and medical therapy in Crohn's colitis. A report of 38 patients comparing severe Crohn's and ulcerative colitis

The courses of 38 patients with severe, uncomplicated acute colitis (16 with Crohn's colitis and 22 with ulcerative colitis) were analyzed retrospectively. The patients were placed on total parenteral nutrition and treated concomitantly with corticosteroids, antibiotics (often metronidazole), sulfasalazine, and/or azathioprine. Fifteen of the 16 Crohn's colitis patients were initially managed without surgery. Four patients subsequently relapsed, two responded to reinstituted medical therapy, and two underwent colon resection 2 and 4 years later. Of 22 ulcerative colitis patients, 16 required surgery during the initial hospitalization, one patient subsequently had surgery, and one died after refusing surgery. Three of the other four continue in remission on medical therapy. Thus, there were significant differences in this series between the clinical courses of severe ulcerative colitis and severe Crohn's colitis. While most of the ulcerative colitis patients with severe disease underwent colectomy, most of the patients with severe but uncomplicated Crohn's colitis responded to aggressive medical therapy, of which total parenteral nutrition and perhaps bowel rest seemed to be an important part. Afterwards, the majority remained in remission on long-term medical therapy.     

Outcomes after adult isolated small bowel transplantation: experience from a single European centre

BACKGROUND: Adult isolated small bowel transplantation is considered the standard treatment for patients with life-threatening parenteral nutrition-related complications. Here, we report a 3-year experience in a single European centre between December 2000 and December 2003. AIMS: To evaluate and discuss pre-transplant and post-transplant factors that influenced survival rates in our series. PATIENTS: Fourteen patients, with a mean parenteral nutrition course of 27 months, were transplanted. In eight cases they had not experienced any major complication from parenteral nutrition. METHODS: We described pre-transplant evaluation and inclusion criteria, surgical technique and clinical management after transplant. Immunosuppressive therapy was based on induction drugs and Tacrolimus. We reported survival rates, major complications and rejection events. RESULTS: One-year actuarial survival rate was of 92.3% with a mean 21-month follow-up (range 3-36 months). We had no intraoperative deaths. One patient (7.2%) died of sepsis following cytomegalovirus enteritis. One patient underwent graftectomy (7.2%) for intractable severe acute rejection. One-year actuarial graft survival rate of 85.1%. One patient (7.2%) affected by post-transplant lymphoproliferative disease is alive and disease-free after 8 months. CONCLUSION: We believe candidate selection, induction therapy, donor selection and short ischemia time play an important role in survival after small bowel transplantation.     

Cholecystokinin (CCK) Secretion in Patients with Severe Short Bowel Syndrome (SSBS)

This study examined the effects of a liquid meal on cholecystokinin (CCK) secretion in patients with severe short bowel syndrome (SSBS) receiving home total parenteral nutrition (TPN) support for 5–19 years after massive small bowel resection. Five patients with SSBS due to superior mesenteric artery or vein thrombosis were included. Five healthy volunteers served as controls. Blood was drawn before and 1 hr following consumption of 250 ml of a liquid diet containing 232 kcal with 8 g fat and 8 g protein. Plasma CCK activity was evaluated by amylase bioassay. All patients had stable weight with a normal BMI and serum albumin level, although there were mild abnormalities in their liver function tests. CCK secretion after stimulation was significantly decreased in patients. These results suggest that reduction in intestinal length influences CCK secretion in response to meal stimulation in SSBS patients.     

Effect of a long acting somatostatin analogue SMS 201-995 on jejunostomy effluents in patients with severe short bowel syndrome.

The effect of a long acting somatostatin analogue SMS 201-995 on stomal effluents in patients with severe short bowel syndrome was investigated in a double blind placebo controlled balance study. Six patients, five with Crohn's disease and one with radiation enteropathy were studied. Five patients had a jejunostomy and one an ileostomy. The patients had a normal food intake, but because of severe malabsorption had received home parenteral nutrition for several years. Faecal mass was reduced (p less than 0.005) and intestinal net sodium absorption was increased (p less than 0.005) by intravenous infusion of SMS 25 micrograms/h. Net absorption of potassium, calcium, magnesium phosphate, zinc, nitrogen and fat was not influenced. Subcutaneous injections of 50 micrograms SMS every 12 hours had a similar effect on net intestinal absorption of sodium and water. Four patients continued with a five to six months open follow up study when subcutaneous SMS in the same dose was administered by the patients at home. The effect on faecal sodium loss persisted, but in one patient faecal mass gradually increased and finally exceeded pretreatment values. SMS may decrease net absorption of water and sodium following reduced secretion of digestive juices rather than by increasing absorptive capacity. SMS may be useful as an antidiarrhoeal drug in patients with high output jejuno- or ileostomies, but in patients who need permanent parenteral nutrition the effect is too small to significantly alter management.     

Hypocaloric jejunal feeding is better than total parenteral nutrition in acute pancreatitis: results of a randomized comparative study

OBJECTIVES: The aims of this study were to define the indications for, and to evaluate the cost-effectiveness of, nutritional support in patients with acute pancreatitis. METHODS: All admissions during the 12-month period from January through December 2000, were entered into a common management protocol consisting of an initial 48-h fast with i.v. fluids and analgesics. After 48 h, those patients who were improving were restarted on oral feeding (group O). The remaining patients were randomized to receive nasojejunal (group EN) or parenteral feeding (group TPN). The randomization study was continued until 50 patients had been accrued. Outcomes in the three groups were compared with respect to length of hospital stay, duration of feeding, complications, and hospital costs. RESULTS: A total of 156 admissions were evaluated in the first 12 months. Of these, 87% patients had mild disease, 10% moderate, and 3% severe; 62% were related to alcohol abuse, 18% gallstones, and 8% idiosyncratic drug reactions. Of the patients, 75% improved on 48 h bowel rest and i.v. fluids, and were discharged within 4 days. The remainder were randomized to jejunal elemental (n = 26) or parenteral (n = 27) feeding. Duration of feeding was shorter with EN (6.7 vs 10.8 days, p < 0.05) and nutrition costs were lower, representing an average cost saving of $2362.00 per patient fed. EN was less effective in meeting estimated nutritional requirements (54 vs 88%, p < 0.0001), but metabolic (p < 0.003) and septic complications (p = 0.01) were lower. Subgroup analysis of patients with severe disease showed similar findings. CONCLUSION: Despite concerns that metabolic expenditure is increased and that food-stimulated pancreatic secretion might exacerbate the disease process, hypocaloric enteral feeding seems to be safer and less expensive than parenteral feeding and bowel rest in patients with acute pancreatitis.     

Rubber band ligation for piles can be disastrous in HIV-positive patients

We report a patient with haemorrhoids treated with rubber band ligation who developed a huge supralevator abscess. A diverting sigmoidostomy had to be established as surgical drainage via the rectum was not adequate. Eventually the patient accepted the HIV-testing which proved positive. Six months later the sigmoidostomy was still needed as the abscess cavity remained large. We conclude that rubber band ligation in HIV-positive patients should be abandoned.     

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.     

Evaluation of the use of parenteral nutrition in chronic and severe radiation enterocolitis

The effects of parenteral nutrition in the treatment of patients with severe chronic radiation enterocolitis is not known. We retrospectively studied 19 adult patients who received parenteral nutrition during 8.6 +/- 2.4 months (mean +/- SEM), including 6 cases in our home-parenteral nutrition-program. Parenteral nutrition was started 49 +/- 12 months after radiation therapy; follow-up after parenteral nutrition was 22 +/- 7 months. Indication for parenteral nutrition was malnutrition (weight = 73 +/- 2 p. 100 of ideal body weight, serum albumin level = 27 +/- 1 g/l) due to multifocal gastrointestinal radiation injuries with stenoses (n = 12), fistulae (n = 3) and short bowel syndrome (n = 4). Parenteral nutrition was given during the peri-operative period in 15 patients. Neither fistulae nor stenoses resolved with parenteral nutrition alone (n = 7) or in association with steroids (n = 5). There was a 57 p. 100 mortality rate (11 patients): 10 p. 100 were postoperative (2 of the 3 patients with fistulae), 21 p. 100, due to radiation complications and 26 p. 100, due to progression of cancer. In those patients with severe and multifocal chronic radiation enteropathy, parenteral nutrition did not influence the lesions in the digestive tract. Nutritional support could, however, be considered as an useful adjunct with a low perioperative mortality rate. In the 14 patients without superimposed unresponsive cancer, parenteral nutrition followed by curative abdominal surgery seemed to be associated with the best prognosis and in 7 of the 8 survivors, parenteral nutrition has been discontinued without reappearance of clinical malnutrition.     

The novel use of an intravenous proton pump inhibitor in a patient with short bowel syndrome.

Recent evidence suggests that parenteral proton pump inhibitors (PPIs) can effectively control gastric acid hypersecretion. Intravenous PPI (omeprazole) can substantially reduce the risk of recurrent bleeding in patients with peptic ulcer disease. We describe a patient with short bowel syndrome who had recurrent life-threatening upper gastrointestinal bleeding from severe gastric and esophageal ulcerations. The patient had failed long-term, maximal-dose intravenous ranitidine therapy but was successfully treated and maintained on long-term therapy with an intravenous PPI (pantoprazole). To our knowledge, this is the first case report in the literature describing the use of an intravenous PPI to treat upper gastrointestinal bleeding in a patient with complete intestinal resection. Intravenous PPIs should be considered as the first line of treatment of erosive esophagitis and peptic ulcer disease in patients with short bowel syndrome and in patients who are nil per os and who fail intravenous H 2 -receptor antagonist treatment. Parenteral PPI may also be the drug of choice in intensive care patients who have erosive esophagitis. Furthermore, this is the first case report describing the novel use of intravenous pantoprazole to treat erosive esophagitis in a patient with short bowel syndrome, suggesting that intravenous PPI may also be useful for the treatment of ulcer prophylaxis in patients undergoing intestinal transplantation.     

Liver and small bowel transplantation: therapeutic alternatives for the treatment of liver disease and intestinal failure

Intestinal transplantation is an established life-saving therapy for parenteral nutrition dependent patients suffering from severe complications of parenteral nutrition. Improvements in outcomes over the last decade have occurred with refinements in surgical technique, better immunosuppressive regimens, and clinical experience. The long-term results of intestinal transplantation are not well known and morbidity remains an important obstacle to wider application of this procedure to patients with short bowel syndrome (SBS). This article reviews the indications for intestinal transplantation, the evaluation of potential candidates, therapeutic considerations, postoperative management and common complications experienced by the recipients.     

A prospective within-patient comparison clinical trial on the effect of parenteral cimetidine for improvement of fluid secretion and electrolyte balance in patients with short bowel syndrome

BACKGROUND/AIMS: Survival of patients with gastrointestinal cancer has improved recently with various multidisciplinary treatments. However, complications associated with the latter also increased, leading to impairment of quality of life and functional disability in patients. Short bowel syndrome, characterized by severe watery diarrhea and electrolyte losses, is one of the major problems caused by gastrointestinal cancer and subsequent treatments. We investigated whether cimetidine, a gastric antisecretory agent, would ameliorate short bowel syndrome in patients after massive small bowel resection. METHODOLOGY: The study design was such that the evaluation of cimetidine effects was an intra-patient comparison. The randomized block method was used for statistical analyses of frequency and amount of daily watery fluid excretion and urine output, electrolyte levels in fluid secretions, as well as blood biochemistry, body weight and performance status. RESULTS: Cimetidine administered at an early stage after bowel surgery, especially while patients are receiving parenteral nutrition, significantly decreased stool fluid excretion (p=0.0001), urine output (p=0.0010) and electrolyte loss, which was no longer apparent a week after initiation of oral intake. CONCLUSIONS: Cimetidine appears to be beneficial for cancer patients who have had extensive small bowel resection.     

Reversible acute gastrointestinal syndrome associated with active systemic lupus erythematosus in patients admitted to hospital

Patients with systemic lupus erythematosus (SLE) frequently have gastrointestinal (GI) symptoms. These are usually self-limiting and related to treatment side-effects or concurrent illness. However, abdominal pain may be due to bowel ischaemia which can lead to infarction and perforation. The likelihood of these serious events is increased in individuals with pain severe enough to require assessment in hospital or a SLEDAI score > 5. This paper describes a group of patients with active SLE and GI symptoms severe enough to require admission to hospital using a retrospective review of 52 SLE patients admitted to hospital with acute abdominal symptoms. The results showed that abdominal pain (87%), vomiting (82%) and diarrhoea (67%) had been present for a mean of 4.4 +/- 6.5 days and SLEDAI score was > or = 4 in 83% of patients. CT scanning showed evidence of serositis and bowel involvement in 63% of patients who underwent this investigation. Intravenous (iv) fluids were used in 87%, parenteral steroids in 90% and iv cyclophosphamide in 31%. Most (n = 51) were discharged well. Recurrence of GI symptoms occurred in 12 patients. The conclusions are that active SLE may manifest as an acute gastrointestinal syndrome. Early diagnosis, bowel rest, supportive medical therapy and treatment with corticosteroids and/or immunosupressives can result in a good outcome.     

Fluid and electrolyte absorption and renin-angiotensin-aldosterone axis in patients with severe short-bowel syndrome.

In eight patients who had received long-term parenteral nutrition because of short-bowel syndrome the need for parenteral supply of fluid, sodium, and potassium was estimated by balance studies. Six patients had jejunostomies. In two, most of the colon was preserved. Jejunostomy patients had a huge stool mass (1710--5270 g, median 2530 g/day) with fixed concentrations of sodium (92 +/- 10 mmol/l) and potassium (15 +/- 4 mmol/l). In contrast, two patients with massive small-bowel resection but with more than half of the colon intact showed almost normal sodium absorption and considerably smaller stool mass (170--510 g/day). Despite apparently good health and normal plasma electrolytes, urea, and haematocrit, four of six jejunostomy patients were sodium-depleted with low plasma volume, low sodium excretion in the urine, and increased plasma renin activity and, in the three most severe cases, increased aldosterone. Even in case of sodium depletion the sodium loss from jejunostomy effluents remained high and presumably unaffected by salt-retaining hormones. The study confirms the importance of preservation of part of the colon for maintenance of fluid and electrolyte balance in patients with extensive bowel resection. Jejunostomy patients who are eating normally may need large parenteral saline supply. Assessment of water and electrolyte homeostasis in these patients requires determination of the urinary sodium excretion and is supported by measurements of plasma renin activity and plasma aldosterone concentration.     

Effects of bowel rehabilitation and combined trophic therapy on intestinal adaptation in short bowel patients

AIM: To evaluate the effects of bowel rehabilitation and combined trophic therapy on intestinal adaptation in short bowel patients. METHODS: Thirty-eight patients with severe short-bowel syndrome (SBS) were employed in the present study, whose average length of jeJunum-ileum was 35.8&#177;21.2cm. The TPN treatment was initiated early to attain positive nitrogen balance and prevent severe weight loss. The TPN composition was designated to be individualized and altered when necessary. Enteral feeding was given as soon as possible after resection and increased gradually. Meals were distributed throughout the day. Eight patients received treatment of growth hormone (0.14mg/kg.day) and glutamine (0.3g/kg.day) for 3 weeks. D-xylose test, 15SN-Gly trace test and 13C-palmitic acid breath test were done todetermine the patients‘‘ absorption capability. RESULTS: Thirty-three patients maintained well bodyweight and serum albumin concentration. The average time of follow-up for 33 survival patients was 5.9&#177;4.3 years. Twenty-two patients weaned from TPN with an average TPN time of 9.5_+6.6 months. Two patients, whose whole small bowel, ascending and transverse colon were resectedreceived home TPN. An other 9 patients received parenteralor enteral nutritional support partly as well as oral diet. Threeweek rhGH+GLN therapy increased nutrients absorption but the effects were transient. CONCLUSION: By rehabilitation therapy, most short bowel patients could wean from parenteral nutrition. Dietary manipulation is an integral part of the treatment of SBS. Treatment with growth hormone and glutamine may increase nutrients absorption but the effects are not sustained beyond the treatment period.     

Controlled trial of bowel rest in the treatment of severe acute colitis.

In a prospective, randomised clinical trial, 47 patients with severe, acute, non-infective colitis treated with 60 mg intravenous prednisolone daily, received either bowel rest with parenteral nutrition or oral diet. Although those who received 'bowel rest' experienced a reduction in daily stool weight, there were no differences in the operation or mortality rates between the groups. Fourteen of the 27 patients with ulcerative colitis, but none of the 16 patients with Crohn's disease required urgent surgery. Bowel rest did not affect the outcome in severe ulcerative colitis treated with intravenous prednisolone. Ulcerative colitis and Crohn's colitis behaved differently in the acute attack.     

Short bowel syndrome

Short bowel syndrome is an uncommon disease that results from extensive intestinal resection. Short bowel patients develop severe malabsorption of macronutrients, micronutrients, electrolytes and water, and pose difficult management problems. This report describes a typical patient with the short bowel syndrome and how each component of the malabsorption syndrome is managed to maintain nutritional, electrolyte, and water balance. In practice, some short bowel patients become dependent on parenteral nutrition for life, while others become independent with time due to intestinal adaptation and can be managed on oral intake and supplementations. Short bowel patients are at risk of developing gallstones, oxalate kidney stones and, rarely, d-lactic acidosis, and the pathophysiology of these disease processes is outlined. A minority of short bowel patients may ultimately require intestinal transplantation due to irreversible complications, and the current status of this intervention is reviewed. Finally, growth factors that stimulate intestinal growth and, thus, enhance absorptive capacity, are currently being identified and may eventually be introduced in the treatment of these patients.     

Total parenteral nutrition needs in different types of short bowel syndrome

Thirty-nine patients with short bowel syndrome after extensive small bowel resection, with or without associated partial or total colectomy, received continuous total parenteral nutrition followed by discontinuous parenteral nutrition. Home parenteral nutrition was introduced in 16 of these patients; in eight it was permanent. The assessment of nutritional status included body weight; standard urinary and blood studies; albumin, prealbumin, and transferrin serum levels; and both urinary and fecal nitrogen. A statistically significant correlation (P<0.001) was observed between the length of the remaining small bowel and the necessary duration of nutritional support. Multivariate analysis allowed us to classify patients into three groups as a function of remaining gut length and the duration of required nutritional support. This study should help to define the best nutritional support protocol for patients with various short bowel syndromes in order to ensure the best possible intestinal adaptation and to improve their quality of life.