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T1473 Acyl Ghrelin Improves Selective Serotonin Reuptake Inhibitor-Induced Gastrointestinal Motility in Rats
used, and p<0.05 was considered significant. Results: There were 139 patients who met the inclusion criteria. Forty-three(31%) of the patients had MOT. The remainder were on TPN for other reasons. Patient demographics and outcomes can be seen in Table 1. Gender was similar, but the MOT group was significantly younger. CRBSI, HOSP and HOSPD were all significantly higher in the MOT group. Thus, the MOT group had a significantly greater chance for a CRBSI (OR: 3.0; 95%CI: 1.5-5.9) and HOSP (OR: 2.9; 95%CI: 1.5-5.8). Discussion: Complications HPN patients include CRBSI and HOSP. We reviewed a large population of HPN patients to determine if underlying disease (MOT or OTH) was associated with a different CRBSI or HOSP. The gender in the two groups were similar, but the MOT group was significantly younger. Incidence of CRBSI, HOSP and HOSPD were all significantly higher in the MOT group. While these data are not a randomized trial, the differences are significant. Thus, it might be rational to attempt to address efforts to prevent these complications in HPN patients with MOT. While more work is needed in this area Demographics and outcomes
that SSRIs decrease plasma acyl ghrelin and induce GI motility similar to anorexigenic peptides. Acyl ghrelin may be effective in relieving SSRI-induced GI symptoms.
Percutaneous Endoscopic Gastrostomy (PEG) Insertion Rate Is Falling But Early Mortality Remains High Reshma C. Rakshit, Jeremy M. Nightingale INTRODUCTION Percutaneous endoscopic gastrostomies have been inserted in Leicester Royal Infirmary (LRI), a large teaching hospital in United Kingdom since 1990, where the numbers had been increasing each year till 2000. AIMS A retrospective study between January 2001 and December 2006 of the number, indications and mortality after PEG insertion. METHODS Data collection was from endoscopy reports and a hospital patient information database. The indications included cerebrovascular disease (CVD), trauma and head injury (THI), ear, nose and throat and maxillofacial disease (EAM), general and vascular surgery (GVS), motor neuron disease (MND), multiple sclerosis (MS), retroviral disease (HIV) and others (OTH). Data was analysed using the Statistical Package for Social Sciences version 14.0. RESULTS 522 patients were identified (57.5% males) with a mean age of 66 years (+/- 18). The most common reason was CVD. The annual number of procedures reduced from 93 in 2001 to 59 in 2006. The number of PEGs inserted for CVD, THI, MS and MND decreased partly due to a more rigourous selection process and partly due to a relocation of the stroke and neurology units in 2004 (Table 1). The procedure completion rate was 97.7 % (511 of 522)with no procedural complications in 98.4% (514 of 520). Total mortality rate was 68.7% (359 of 517) while 30-day mortality was 17.4 % (91 of 515) of which the GVS group was the highest (27.8%). Mortality at one year fell from 64.5% (60 of 93) in 2001 to 50.8% (30 of 59) in 2006. Median survival time post PEG insertion was 105 days. See Table 2 for details. SUMMARY AND CONCLUSIONS There is a fall in the annual number of PEGs inserted especially for CVAs. The 30-day all cause mortality post-PEG was 17.4% which has not changed over time though the 1-year mortality has fallen from 64.5% to 50.8%. Total deaths have reduced from 86%(80 of 93 in 2001) to 54% (32 of 59)in 2006. TABLE 2: DETAILS OF MORTALITY IN EACH CATEGORY
T1472 Feeding Tube Preferences and Knowledge of Published Literature of Intensive Care Unit Physicians a Single Center Experience At the Johns Hopkins Hospital Ghazaleh Aram, Kerry B. Dunbar, Francis M. Giardiello, John H. Kwon Background: Multiple modalities for enteric feeding exist in the intensive care unit (ICU), including nasogastric (NG), nasoduodenal (ND), percutaneous endoscopic gastrostomy (PEG), and percutaneous endoscopic jejunostomy (PEJ) tubes. There are no established guidelines for the mode of enteric feeding in critically ill patients. Aim: To determine the preference for enteric feeding modality and interpretation of published literature between medical (MICU) and surgical (SICU) physicians. Methods: A 26 question multiple choice survey, including 3 case vignettes, opinion, and knowledge questions was designed. MICU (pulmonologists) and SICU (surgeons and anesthesiologists) faculty and ICU fellows from Johns Hopkins Hospital were surveyed. Data were analyzed using the Fisher's exact test and the Wilcoxon rank sum test. Results: 27 MICU & 11 SICU surveys were obtained. Overall, 64% of SICU physicians rated starting enteral nutrition within the first 3 days of admission as very to extremely important while 30% of MICU physicians (p=.08). Accordingly, 93% of MICU physicians agreed that intra-gastric feeding was safe as compared to 36.4% of SICU physicians (p=0.003). For short (< 3 days) ICU stays, 59% of MICU physicians preferred to initiate NG feeding as compared to 9% of SICU physicians (p=0.005). In this setting, 27% of SICU physicians chose post-pyloric feeding as compared to 4% of MICU physicians (p=0.005). For ICU stays between 3 days and 2 weeks, 89% of MICU physicians preferred using NG tubes while 82% of SICU physicians preferred ND tubes (p<0.0001). For prolonged ICU stays (> 2 weeks), 52% of MICU physicians preferred PEG tube placement while 64% of SICU physicians preferred either ND or PEJ tubes (27% and 36%, respectively) (p=0.06). Regardless of the patient characteristics presented in vignettes, MICU physicians preferred intra-gastric feeding while SICU physicians preferred post-pyloric feeding. Although published studies suggest that post-pyloric feeding does not reduce pneumonia, 30% of MICU physicians and 73 % of SICU physicians believe it does, and half believe that post-pyloric feeding reduces ICU length of stay. Both MICU (97%) and SICU (81%) physicians agreed that treatment guidelines for enteric feeding of critically ill patients would be helpful. Conclusion: There are significant differences in opinion and implementation of enteric feeding modalities between medical and surgical ICUs. Studies of ICU patient outcomes for the different enteral feeding methods followed by the development of treatment guidelines may help standardize the approach to initiating and maintaining the nutritional status of ICU patients.
TABLE 1: Number of procedures each year based on indications
T1475 Early Enteral Nutrition Improves Functional Parameters in Liver Cirrhosis Kristina Norman, Christine Smoliner, Nicole Stobaeus, Tatjana Schuetz, Herbert Lochs, Johann Ockenga, Matthias Pirlich
T1473
Introduction: Malnutrition is a frequent problem in liver cirrhosis affecting morbidity and mortality. Both physical and metabolic functions are severely compromised. Aim: We investigated whether short term enteral nutrition is useful in improving physical and metabolic parameters in patients with advanced liver cirrhosis. Methods: We randomized 63 patients with decompensated liver cirrhosis (Child Pugh score B or C) to receive either high protein enteral nutrition via nasogastric tube (31 patients, 23 male) or standard hospital diet for 2 weeks (32 patients, 17 male). Patients with malignant or terminal disease were not included. Liver function (prothrombin time, bilirubin and serum albumin), hepatic encephalopathy (HE, psychometric paper-pencil tests), nutritional status (subjective global assessment) muscle function (expiratory peak flow) were assessed before and after nutritional intervention. Complications such as infections or variceal bleedings were documented. Results: 51 (80 %) patients were classified as malnourished (SGA B or C). Intervention (tube feeding, TF) and control group (C-group) did not differ regarding age, nutritional status, muscle function, and severity of disease. Enteral nutrition significantly improved expiratory muscle function in the TF group (from 292.1±131.71 to 326.4±120.3 l/min, p=0.035), whereas it did not change in the C-group (from 329.3±110.5 to 355.4±98.7 l/min, n.s.). Simultaneously, prothrombin time increased significantly in the TF group (from 56.3±15.8 % to 62.2±18.7 %, p<0.05) but not in the C-group (58.0±14.6 to 59.2±16.6%, n.s.). Bilirubin decreased in the TF group (from 7.9±8.5 to 5.2±4.9 mg/dl p=0.042) with no alterations in the C-group (5.3±5.6 to 5.1±5.3 mg/dl, n.s.). Albumin was improved in the TF group (2.5±0.5 to 2.8±0.6 mg/dl, p=0.022) and remained unchanged in the C-group (2.9±0.3 to 2.9±0.4 mg/dl, n.s.). There was no difference between patients regarding infections (16 in TF group vs. 22 in C-group, n.s.) or variceal bleedings (7 in TF group vs. 6 in C-group, n.s.). There was no deterioration in HE in either group (-8.0±4.8 to -7.7± 4.5 pts in IP, n.s. vs. -7.7 ±4.1 to -8.1±5.4 pts in CP, n.s.) Conclusion: The majority of our patients with advanced liver cirrhosis were classified malnourished (80%). Short term enteral nutrition initiated on
Acyl Ghrelin Improves Selective Serotonin Reuptake Inhibitor-Induced Gastrointestinal Motility in Rats Akihiro Asakawa, Haruka Amitani, Marie Sameshima, Shinya Kojima, Mizuki Hayashi, Naoki Fujitsuka, Akio Inui Background & Aims: Nausea, vomiting and anorexia are the common side effects caused by selective serotonin reuptake inhibitors (SSRIs), and lead to early discontinuation of treatments in patients with depressive disorder. We examined the effects of SSRIs on gastrointestinal (GI) motility and whether acyl ghrelin improves SSRI-induced GI symptoms in rats. Methods: SSRIs (20 mg/kg fluvoxamine, 10 mg/kg paroxetine, 10 mg/kg fluoxetine and 5 mg/kg fenfluramine) were intraperitoneally administered to 24 h food-deprived rats, respectively. GI motility was measured in conscious, freely moving rats by a strain gauge force transducer method. Plasma acyl ghrelin levels were determined by EIA. Phenol red retention in the stomach at 15 min was calculated to assess the gastric emptying. Effects of acyl ghrelin (0.3 - 3 nmol/rat, iv) and Rikkunshito, a traditional Japanese medicine, (62.5 - 1000 mg/kg, po), which releases endogenous acyl ghrelin on these functions were examined. Results: The fasted motor patterns in both the antrum and duodenum were disrupted by the treatments of SSRIs and replaced by the fed-like pattern. The motor activity was increased in the antrum, whereas decreased in the duodenum, and the duodenal phase III-like contractions of fasted motility was decreased. All of the SSRIs significantly decreased plasma acyl ghrelin concentration. When acyl ghrelin or Rikkunshito was administered to fluvoxamine or fenfluramine-treated rats, the motor activity in the antrum was not changed, while the motor activity and the phase III-like contractions in the duodenum were significantly increased. In addition, acyl ghrelin or Rikkunshito improved the decrease in food intake and gastric emptying rate. The pretreatment with GHS-R antagonist (D-Lys3) GHRP-6 blocked the effects of Rikkunshito on theses parameters. Conclusions: These results indicate
A-563
AGA Abstracts
AGA Abstracts
T1474
that SSRIs decrease plasma acyl ghrelin and induce GI motility similar to anorexigenic peptides. Acyl ghrelin may be effective in relieving SSRI-induced GI symptoms.
Percutaneous Endoscopic Gastrostomy (PEG) Insertion Rate Is Falling But Early Mortality Remains High Reshma C. Rakshit, Jeremy M. Nightingale INTRODUCTION Percutaneous endoscopic gastrostomies have been inserted in Leicester Royal Infirmary (LRI), a large teaching hospital in United Kingdom since 1990, where the numbers had been increasing each year till 2000. AIMS A retrospective study between January 2001 and December 2006 of the number, indications and mortality after PEG insertion. METHODS Data collection was from endoscopy reports and a hospital patient information database. The indications included cerebrovascular disease (CVD), trauma and head injury (THI), ear, nose and throat and maxillofacial disease (EAM), general and vascular surgery (GVS), motor neuron disease (MND), multiple sclerosis (MS), retroviral disease (HIV) and others (OTH). Data was analysed using the Statistical Package for Social Sciences version 14.0. RESULTS 522 patients were identified (57.5% males) with a mean age of 66 years (+/- 18). The most common reason was CVD. The annual number of procedures reduced from 93 in 2001 to 59 in 2006. The number of PEGs inserted for CVD, THI, MS and MND decreased partly due to a more rigourous selection process and partly due to a relocation of the stroke and neurology units in 2004 (Table 1). The procedure completion rate was 97.7 % (511 of 522)with no procedural complications in 98.4% (514 of 520). Total mortality rate was 68.7% (359 of 517) while 30-day mortality was 17.4 % (91 of 515) of which the GVS group was the highest (27.8%). Mortality at one year fell from 64.5% (60 of 93) in 2001 to 50.8% (30 of 59) in 2006. Median survival time post PEG insertion was 105 days. See Table 2 for details. SUMMARY AND CONCLUSIONS There is a fall in the annual number of PEGs inserted especially for CVAs. The 30-day all cause mortality post-PEG was 17.4% which has not changed over time though the 1-year mortality has fallen from 64.5% to 50.8%. Total deaths have reduced from 86%(80 of 93 in 2001) to 54% (32 of 59)in 2006. TABLE 2: DETAILS OF MORTALITY IN EACH CATEGORY
T1472 Feeding Tube Preferences and Knowledge of Published Literature of Intensive Care Unit Physicians a Single Center Experience At the Johns Hopkins Hospital Ghazaleh Aram, Kerry B. Dunbar, Francis M. Giardiello, John H. Kwon Background: Multiple modalities for enteric feeding exist in the intensive care unit (ICU), including nasogastric (NG), nasoduodenal (ND), percutaneous endoscopic gastrostomy (PEG), and percutaneous endoscopic jejunostomy (PEJ) tubes. There are no established guidelines for the mode of enteric feeding in critically ill patients. Aim: To determine the preference for enteric feeding modality and interpretation of published literature between medical (MICU) and surgical (SICU) physicians. Methods: A 26 question multiple choice survey, including 3 case vignettes, opinion, and knowledge questions was designed. MICU (pulmonologists) and SICU (surgeons and anesthesiologists) faculty and ICU fellows from Johns Hopkins Hospital were surveyed. Data were analyzed using the Fisher's exact test and the Wilcoxon rank sum test. Results: 27 MICU & 11 SICU surveys were obtained. Overall, 64% of SICU physicians rated starting enteral nutrition within the first 3 days of admission as very to extremely important while 30% of MICU physicians (p=.08). Accordingly, 93% of MICU physicians agreed that intra-gastric feeding was safe as compared to 36.4% of SICU physicians (p=0.003). For short (< 3 days) ICU stays, 59% of MICU physicians preferred to initiate NG feeding as compared to 9% of SICU physicians (p=0.005). In this setting, 27% of SICU physicians chose post-pyloric feeding as compared to 4% of MICU physicians (p=0.005). For ICU stays between 3 days and 2 weeks, 89% of MICU physicians preferred using NG tubes while 82% of SICU physicians preferred ND tubes (p<0.0001). For prolonged ICU stays (> 2 weeks), 52% of MICU physicians preferred PEG tube placement while 64% of SICU physicians preferred either ND or PEJ tubes (27% and 36%, respectively) (p=0.06). Regardless of the patient characteristics presented in vignettes, MICU physicians preferred intra-gastric feeding while SICU physicians preferred post-pyloric feeding. Although published studies suggest that post-pyloric feeding does not reduce pneumonia, 30% of MICU physicians and 73 % of SICU physicians believe it does, and half believe that post-pyloric feeding reduces ICU length of stay. Both MICU (97%) and SICU (81%) physicians agreed that treatment guidelines for enteric feeding of critically ill patients would be helpful. Conclusion: There are significant differences in opinion and implementation of enteric feeding modalities between medical and surgical ICUs. Studies of ICU patient outcomes for the different enteral feeding methods followed by the development of treatment guidelines may help standardize the approach to initiating and maintaining the nutritional status of ICU patients.
TABLE 1: Number of procedures each year based on indications
T1475 Early Enteral Nutrition Improves Functional Parameters in Liver Cirrhosis Kristina Norman, Christine Smoliner, Nicole Stobaeus, Tatjana Schuetz, Herbert Lochs, Johann Ockenga, Matthias Pirlich
T1473
Introduction: Malnutrition is a frequent problem in liver cirrhosis affecting morbidity and mortality. Both physical and metabolic functions are severely compromised. Aim: We investigated whether short term enteral nutrition is useful in improving physical and metabolic parameters in patients with advanced liver cirrhosis. Methods: We randomized 63 patients with decompensated liver cirrhosis (Child Pugh score B or C) to receive either high protein enteral nutrition via nasogastric tube (31 patients, 23 male) or standard hospital diet for 2 weeks (32 patients, 17 male). Patients with malignant or terminal disease were not included. Liver function (prothrombin time, bilirubin and serum albumin), hepatic encephalopathy (HE, psychometric paper-pencil tests), nutritional status (subjective global assessment) muscle function (expiratory peak flow) were assessed before and after nutritional intervention. Complications such as infections or variceal bleedings were documented. Results: 51 (80 %) patients were classified as malnourished (SGA B or C). Intervention (tube feeding, TF) and control group (C-group) did not differ regarding age, nutritional status, muscle function, and severity of disease. Enteral nutrition significantly improved expiratory muscle function in the TF group (from 292.1±131.71 to 326.4±120.3 l/min, p=0.035), whereas it did not change in the C-group (from 329.3±110.5 to 355.4±98.7 l/min, n.s.). Simultaneously, prothrombin time increased significantly in the TF group (from 56.3±15.8 % to 62.2±18.7 %, p<0.05) but not in the C-group (58.0±14.6 to 59.2±16.6%, n.s.). Bilirubin decreased in the TF group (from 7.9±8.5 to 5.2±4.9 mg/dl p=0.042) with no alterations in the C-group (5.3±5.6 to 5.1±5.3 mg/dl, n.s.). Albumin was improved in the TF group (2.5±0.5 to 2.8±0.6 mg/dl, p=0.022) and remained unchanged in the C-group (2.9±0.3 to 2.9±0.4 mg/dl, n.s.). There was no difference between patients regarding infections (16 in TF group vs. 22 in C-group, n.s.) or variceal bleedings (7 in TF group vs. 6 in C-group, n.s.). There was no deterioration in HE in either group (-8.0±4.8 to -7.7± 4.5 pts in IP, n.s. vs. -7.7 ±4.1 to -8.1±5.4 pts in CP, n.s.) Conclusion: The majority of our patients with advanced liver cirrhosis were classified malnourished (80%). Short term enteral nutrition initiated on
Acyl Ghrelin Improves Selective Serotonin Reuptake Inhibitor-Induced Gastrointestinal Motility in Rats Akihiro Asakawa, Haruka Amitani, Marie Sameshima, Shinya Kojima, Mizuki Hayashi, Naoki Fujitsuka, Akio Inui Background & Aims: Nausea, vomiting and anorexia are the common side effects caused by selective serotonin reuptake inhibitors (SSRIs), and lead to early discontinuation of treatments in patients with depressive disorder. We examined the effects of SSRIs on gastrointestinal (GI) motility and whether acyl ghrelin improves SSRI-induced GI symptoms in rats. Methods: SSRIs (20 mg/kg fluvoxamine, 10 mg/kg paroxetine, 10 mg/kg fluoxetine and 5 mg/kg fenfluramine) were intraperitoneally administered to 24 h food-deprived rats, respectively. GI motility was measured in conscious, freely moving rats by a strain gauge force transducer method. Plasma acyl ghrelin levels were determined by EIA. Phenol red retention in the stomach at 15 min was calculated to assess the gastric emptying. Effects of acyl ghrelin (0.3 - 3 nmol/rat, iv) and Rikkunshito, a traditional Japanese medicine, (62.5 - 1000 mg/kg, po), which releases endogenous acyl ghrelin on these functions were examined. Results: The fasted motor patterns in both the antrum and duodenum were disrupted by the treatments of SSRIs and replaced by the fed-like pattern. The motor activity was increased in the antrum, whereas decreased in the duodenum, and the duodenal phase III-like contractions of fasted motility was decreased. All of the SSRIs significantly decreased plasma acyl ghrelin concentration. When acyl ghrelin or Rikkunshito was administered to fluvoxamine or fenfluramine-treated rats, the motor activity in the antrum was not changed, while the motor activity and the phase III-like contractions in the duodenum were significantly increased. In addition, acyl ghrelin or Rikkunshito improved the decrease in food intake and gastric emptying rate. The pretreatment with GHS-R antagonist (D-Lys3) GHRP-6 blocked the effects of Rikkunshito on theses parameters. Conclusions: These results indicate
A-563
AGA Abstracts
AGA Abstracts
T1474