Hydroxystearic acid and diarrhoea following ileal resection

The faecal outputs of 10 patients who complained of diarrhoea after ileal resection were measured whilst they consumed identical diets in which most of the fat was present as olive oil. No relationship was found between faecal weight and hydroxystearic acid production. In three patients the output of hydroxystearic acid was reduced by changing the dietary fat. There was no reduction in faecal weight. It is concluded that hydroxystearic acid does not contribute to diarrhoea in these cases.     

Gallstones after ileostomy and ileal resection.

One hundred and eight patients with ileostomies were investigated for cholelithiasis at routine annual review in a large Ileostomy Clinic. Gallstones were demonstrated in 24-5%, which is three times the incidence that might have been expected in a population of this age and sex distribution. The frequency of cholelithiasis was significantly increased in those patients who had lost more than 10 cm of ileum at operation, regardless of whether the primary condition had been ulcerative colitis or Crohn's disease. It was significantly increased in those patients who had had a resection of less than 10 cm of ileum if the original condition had been Crohn's disease, but not if it had been colitis.     

Bilirubin cycles enterohepatically after ileal resection in the rat

BACKGROUND & AIMS: Patients with ileal disease, resection, or bypass are at increased risk of developing pigment gallstones, but the pathophysiological mechanisms are unknown. The aim of this study was to test the hypothesis that ileectomy induces enterohepatic cycling of bilirubin. METHODS: Ileectomy or sham operation was performed in adult male Sprague-Dawley rats with the following control procedures: no operation, ileal transection, proximal or distal jejunectomy, ileocolonic transposition, and ileocecectomy. Bilirubin and bile salt secretion rates were measured after bile duct cannulation performed 3- 11 days after intestinal surgery. Also measured were bilirubin and bile salt concentrations in the colon as well as indices of hemolysis in blood. RESULTS: Compared with controls, bilirubin secretion rates were increased significantly 3-5 days after ileectomy, distal jejunectomy, ileocolonic transposition, and ileocecectomy, with no hemolysis occurring. Bile salt secretion rates also increased significantly after ileectomy but decreased markedly with prevention of coprophagy, whereas bilirubin secretion rates remained elevated. By 8-11 days after surgery, intestinal adaptation normalized bile salt reabsorption, and hypersecretion of bilirubin was abolished. Colonic levels of unconjugated bilirubin and bile salts were increased fivefold and eightfold respectively in ileectomized animals, but unconjugated bilirubin levels remained normal in bile. CONCLUSIONS: These results are consistent with the hypothesis that enterohepatic cycling of bilirubin occurs with bile salt malabsorption. (Gastroenterology 1996 Jun;110(6):1945-57)     

Intestinal absorption of phosphatidylcholine and triglyceride after ileal resection

The intestinal absorption of (14C)oleoyl moieties in triglyceride and phospholipid was investigated by means of (14C)phosphatidylcholine and (14C)triolein breath tests. In patients who had undergone ileal resection the absorption of both phosphatidylcholine and triglyceride was subnormal, as reflected by a lower production of 14CO2. In healthy subjects the production of expiratory 14CO2 after oral administration of (14C)phosphatidylcholine was slightly higher than after administration of (14C)triolein. This was also observed in the patient group, indicating that the absorption of both triglyceride and phospholipid was decreased to similar extents, although triglyceride absorption tended to be more affected after major ileal resection. In patients with lipid malabsorption the proportion of linoleic acid in serum phosphatidylcholine was subnormal, and the decrease was correlated to the decrease in lipid absorption. The concentration in serum of selenium, alpha-tocopherol, and carotene but not of ascorbic acid and retinol was subnormal after ileal resection.     

Impairment of `ileostomy adaptation' in patients after ileal resection

Ileostomists claim that in the months following the establishment of an ileostomy, the faecal output decreases in volume and becomes less fluid. It is claimed that this ;ileostomy adaptation' does not occur in those patients who have had an ileal resection.To determine whether ileostomy adaptation does occur and to examine its physiological mechanisms, 10 ileostomy patients were studied. Five had had ileal resection and five had not. The output of fluid, sodium, and potassium from the ileostomy was studied in each patient for the first 11 days after ileostomy and again at six months.Those patients in whom the terminal ileum was preserved had small faecal outputs of fluid and sodium from the outset, and the water content of the effluent was significantly less at six months. After rapid expansion of the extracellular fluid by intravenous saline, there was a marked increase in faecal volume and sodium output.In those patients with an ileal resection, the faecal volume and sodium output were more than two and a half times greater than those for the non-resected group. At six months there was no change in either the volume or chemistry of the effluent. After intravenous saline, no faecal response was observed.It is therefore concluded that ileostomy adaptation does occur and it is a response of the intestine to conserve body salt. This response is lacking in ileostomists who have had an ileal resection.     

Ursodeoxycholic acid and superoxide anion

AIM: To investigate the ability of ursodeoxycholic acid (UDCA) to scavenge superoxide anion (Of). METHODS: We assessed the ability of UDCA to scavenge (O2-) generated by xanthine-xanthine oxidase (X-XO) in a cell-free system and its effect on the rate of O2--induced ascorbic acid (AA) oxidation in hepatic post-mitochondrial supernatants. RESULTS: UDCA at a concentration as high as 1 mmol/L did not impair the ability of the X-XO system to generate O2-, but could scavenge O2- at concentrations of 0.5 and 1 mmol/L, and decrease the rate of AA oxidation at a concentration of 100 lmol/L CONCLUSION: UDCA can scavenge O2-, an action that may be beneficial to patients with primary biliary cirrhosis.     

Anal sphincter function after intersphincteric resection and stapled ileal pouch-anal anastomosis

This study was done to determine the effect of the direct ileal pouch-anal anastomosis upon pressure and sensory components of the anal canal and ileal pouch. These findings were related to postoperative continence. Thirty-three patients with ileal pouch-anal anastomosis (25 continent, eight with episodic minor incontinence) were studied 3±0.3 and 25±5 months after ileostomy takedown. The maximum resting pressure in the anal canal was significantly lower in patients with an imperfect result (35±5 mm Hg) than in continent patients (44±5 mm Hg) (P<0.05). Postoperatively the maximum squeeze anal pressure was slightly greater in continent than in incontinent patients (99±8 mm Hg vs.87±7 mm Hg) (P>0.05). The postoperative recto-(ileo-)anal inhibitory reflex was present in 27 percent. The linear correlation between strength of rectal (ileal) distension and depth resp. duration of internal sphincter relaxation as preoperatively observed disappeared postoperatively in every group of patients. Simultaneous measurements of pouch and anal pressure in patients with imperfect results revealed a reduced positive pouch anal pressure gradient compared to the continent group. This low pouch-anal pressure gradient is thought to be responsible for the increased incidence of soiling in some of our patients.     

Neoterminal ileal blood flow after ileocolonic resection for Crohn's disease.

Endoscopic laser Doppler flowmetry was used to measure neoterminal ileal blood flow in 16 patients who had undergone ileocolonic resection for Crohn's disease and had since remained clinically and biochemically free of disease, and eight control patients who had undergone similar surgery for colonic carcinoma. Four patients with clinically active Crohn's disease of the terminal ileum were also studied. Neoterminal ileal recurrence in those with inactive Crohn's disease was graded endoscopically. The median and minimum of five local blood flow measurements performed in each patient were inversely correlated with the endoscopic recurrence grade (r = -0.52, p = 0.04 and r = -0.63, p = 0.01 respectively). Relative to the control group, median blood flow was non-significantly lower in the inactive Crohn's disease group as a whole (p > 0.05) but was significantly reduced in patients with active disease (p = 0.02). A progressive reduction in tissue perfusion may accompany recurrence of Crohn's disease while at a subclinical stage.     

Ursodeoxycholic acid treatment of gallstones

Although data must be gleaned from international studies representing a broad range of dosage, duration of therapy, and details reported, sufficient evidence exists to state that UDCA is approximately as effective as CDCA in dissolving gallstones. Complete stone dissolution can be expected in a majority of well-selected patients treated with 10 to 15 mg/kg/day. Additional data on potential toxicity are needed, but current evidence suggests that this is very low. Treatment will be required for 1 to 2 years in most patients. Recurrence is emerging as an important aspect which needs a solution. Clearly, stone dissolution therapy is the treatment of choice in patients with a high operative risk and stones with radiologic characteristics suggesting a high probability of success. The proper place of this management modality in the therapy of the remaining majority of patients with gallstones will require careful assessment of potential benefit in each individual patient, the known risks, and the potential of as yet unrecognized long-term toxicity.     

Case report of tracheobronchial injuries after acid ingestion: CT findings with serial follow-up: Airway complication after acid ingestion

Rationale:Tracheobronchial injury from acid ingestion is a less reported clinical presentation than injury of the gastrointestinal tract, but it can occur due to direct exposure from acid aspiration and cause fatal complications.Patient concerns:A 43-year-old man presented to the emergency department after ingesting nitric acid complaining of chest pain and dyspnea.Diagnoses:The initial chest computed tomography (CT) images revealed an acute lung injury related to acid aspiration. The follow-up chest CT showed acute and late tracheobronchial injures.Interventions:Bronchoscopy showed deep caustic airway injuries consisting of hemorrhage, sloughing of the mucosa, and ulceration of the trachea and left-side bronchial tree.Outcomes:Progressive narrowing of the left main bronchus with total collapse of the left lung occurred as a late complication of acid ingestion.Lessons:Tracheobronchial injury should be considered in cases of aspiration pneumonia after acid ingestion; chest CT can be used to detect and assess acute and late complications of tracheobronchial injuries.     

The colon influences ileal resection diarrhea

Fecal mass and electrolyte concentrations from 25 ileectomy and/or colectomy patients on known diets were used to assess those factors most responsible for their diarrhea. In 18 ileectomy patients the severity of diarrhea, expressed as a fecal weight, was a function of both percent of colon and centimeters of ileum removed. Linear regression analysis, however, showed that the extent of missing colon had three times the effect of missing ileum on fecal weight. Patients who lost the ileocecal valve and part of the right colon had more diarrhea than those who lost comparable lengths of ileum but had this area preserved. Fecal ion concentrations seemed independent of diet but were related to fecal weight and the amount of colon and ileum removed. Potassium concentration was strongly dependent on the amount of colon lost, while sodium concentration was more influenced by the length of resected ileum. Chloride was most dependent on fecal weight. As expected, fecal fat correlated strongly with the extent of ileum removed. Regression equations were constructed from the electrolyte data which described and predicted the extent of lost ileum or colon. Our data were also used to separate patients with less than 100 cm of ileum removed from those with more extensive resections. The severity of diarrhea following ileal resection depends primarily on the amount of contiguous colon removed. Varying loss of ileum and colon produced predictable effects on fecal weight and electrolyte composition. Surgeons should preserve the maximum amount of colon possible to reduce the severity of diarrhea in these patients.This work was supported by Grant No. 3666 from the endowment of Thomas T. Dee and George F. Moody through Evanston Hospital.This paper was presented in part at the Annual Meeting of the American Gastroenterology Association in Toronto, Canada, May, 1977 and published in abstract form in Gastroenterology 72:1103, 1977.     

Ursodeoxycholic acid for primary sclerosing cholangitis

The effects of ursodeoxycholic acid (UDCA, 750-1250 mg/day) were evaluated prospectively in 15 patients with primary sclerosing cholangitis (PSC). Five patients had associated inflammatory bowel disease. After 6 months of treatment, the proportion of patients suffering from fatigue or pruritus decreased from 60% to 20% and from 33% to 20%, respectively. No exacerbation of associated disorders was observed. Serum alkaline phosphatase levels (normal less than 100 IU/l) decreased from 401 +/- 53 to 222 +/- 42 (mean +/- S.E.; p less than 0.001), those of gamma-glutamyl transpeptidase, (normal less than 40 IU/l) from 520 +/- 89 to 185 +/- 32 (p less than 0.001) and those of alanine aminotransferases, (normal less than 30 IU/l) from 79 +/- 12 to 42 +/- 6 (p less than 0.02). In three patients, the discontinuation of UDCA was associated with an aggravation of the liver test results. In conclusion, this study shows that 6 months of treatment with UDCA leads to clinical and biochemical improvements in patients with PSC. These results suggest that UDCA could be an effective treatment for PSC, and may justify a controlled therapeutic trial.     

Ursodeoxycholic acid therapy in hepatobiliary disease

Ursodeoxycholic acid is a hydrophilic bile acid that under normal circumstances represents a small fraction of the bile acid pool in humans. It is effective in dissolving cholesterol gallstones in appropriately selected patients. Ursodeoxycholic acid improves serum alkaline phosphatase and aminotransferase levels in primary biliary cirrhosis, but its effects on rates of liver transplantation and death are less certain. Ursodeoxycholic acid has had promising [corrected] effects in several other cholestatic liver diseases, such as cystic fibrosis and intrahepatic cholestasis of pregnancy, but data are too preliminary to make recommendations about its routine use in these conditions. Its effects are mediated by amelioration of damage to cell membranes caused by retained toxic bile acids. Ursodeoxycholic acid improves biliary secretion of bile acids, may improve bile flow, and it has immunomodulatory properties that may reduce immune-mediated liver damage. However, its use in the treatment of cholestatic liver disease remains uncertain pending additional randomized trials.