Use of chemically defined diets in the management of patients with acute inflammatory bowel disease

Use of Chemically

Defined Diets in the Management

Patients with Acute Inflammatory

Michael A, Rocchio, Chung-Ja

MD, MS, Providence,

MO Cha, PhD, Providence,

Klaus F. Haas, MD, Providence,

Rhode island

Rhode Island Rhode Island

with chronic inflammatory bowel disease are often nutritionally depleted. During periods of remission compensation for insufficient caloric intake is made by utilization of endogenous fat supplies and by a decreased metabolic rate. However, with acute exacerbations of inflammatory bowel disease a marked increase in energy requirements strips away these compensatory mechanisms. During an exacerbation an acute increase in metabolic rate occurs concurrent with a decreased caloric intake and therefore a demand for endogenous substrate for energy and an increased secretion of urinary nitrogen, indicating heightened protein catabolism. Most patients will not tolerate a high caloric diet and many cannot eat for several days to a few weeks, resulting in an obligatory dependence on endogenous sources. Since body reserves of carbohydrates are limited and rapidly exhausted, major sources of energy become amino acids derived from protein breakdown and fatty acids and glycerol derived from neutral fat [I]. Therefore, without adequate caloric intake, utilization of lean body mass is necessary to meet Patients

From the Division of Surgical Research, Department of Surgery, Rhode Island Hospital, and Division of Bio-Medical Science, Brown University, Providence, Rhode Island. Reprint requests should be addressed to Dr Rocchio, Rhode island Hospkl, Providence. Rhode Island 02902. Presented at the Fifty-Fourth Annual Meeting of the New England Surgical Society, Portsmouth, New Hampshire, September 27-29, 1973.

1974

Bowel Disease

Rhode Island

Henry T. Randall, MD, FACS, Providence,

Volume 127, April

of

the demands of increased metabolism caused by acute inflammatory bowel disease. Rapid depletion of lean body mass results in acute starvation with prolongation of the primary disease process, impaired wound healing, and increased susceptibility to infection. To prevent this sequence of events elemental diets have been used successfully during acute exacerbations of inflammatory bowel disease in fort? patients. Anabolism with this form of enteric nutrition has been documented despite sepsis, ste.roid therapy, and surgery. Material

and Methods

In the four and a half year period from July 1968 to January 1973, forty patients with acute inflammatoq bowel disease were treated with chemically defined elemental diets at Rhode Island Hospital. Fifteen patients had ileocolitis, nine had ulcerative colitis, five each had diverticulitis, granulomatous enterocolitis, and regional enteritis, and one had ulcerative proctitis. Severity ol illness in this group is manifested by a mortality of 1.’ per cent (six of forty patients). High caloric intravenous feedings followed by enterically administered, chemically defined elemental diet were used in twenty-two patients. Eighteen patients received only elemental diets as their maior food source. Elemental diets were used as the major or only source of nutrition in all forty patients for 5 to 120 days with a mean of 35.1 days and a median of 28 davs. The ages of the patients ranged between 12 _, and 76 years, with a mean of 42.8 years and a median of’ :%I years. (Figure 1.)

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Rocchio et al

IO

20

30

I

I

40

50

60

70

00

AGE

Figure 1. Age distributton of patients with acute inftammatory bowel disease treated with elemental diet.

Diet compositions are illustrated in Table I. Elemental diet was administered through a number 8 nasogastric feeding tube or a gastrostomy. A Barron pump was used to infuse diet at a constant rate, with a gradual increase in the volume and concentration of diet to tolerable limits. All patients were weighed frequently, usually daily, and urine was monitored for sugar and acetone levels four times a day. Blood glucose and electrolyte

levels were determined frequently at first and then two to three times weekly after stabilizatir,V-! of dietary intake. Nitrogen balance studies were performed in fourteen patients and body composition studies in seven. Results

IJlceratiue Colitis. Nine patients, five male and four female, had acute ulcerative colitis and were treated with elemental diets. There was one death in this group, a sixty-seven year old man who died of overwhelming sepsis related to the primary disease. Five patients underwent total colectomy, perineal resection, and ileostomy. Prior to surgery TABLE I

Composition (per 1,000 Calories) of the Two High Nitrogen, Chemically Diets Used for Nutritional Vivonex@ High Nitrogen

Carbohydrate (gm) Nitrogen (pm) Protein (gm) Fat (gm) Sodium (mEq) Potassium (mEq) Chloride (mEq) Magnesium (mEq) Calcium (mEq)

470

210 (glucose) 6.7 42.0 0.44 33.5 17.9 52.2 9.6 13.3

Defined, Elemental Management

Codelid@72H 197 (sucrose) 6.0 37.0 0 25.0 24.0 37.0 7.2 24.0

these patients were fed an elemental diet for six to fourteen days. Immediately after surgery, parenteral nutrition was begun and elemental diet was again used postoperatively before institution of a regular diet. Surgery was avoided in three patients, one of whom presented with toxic megacolon. One of these patients was later readmitted and underwent elective colectomy. Nitrogen balance studies performed in four patients with ulcerative colitis demonstrated significant positive balance despite acute disease. Six of the eight surviving patients either gained weight or maintained their weight when the elemental diet was begun. Only one of these patients had a complicated postoperative course. Regional Enteritis. Five patients, three female and two male, were hospitalized for acute exacerbation of regional enteritis and were treated with elemental diet. Two patients required surgery, one for a bleeding gastric ulcer and the other for a sigmoid cutaneous fistula and intra-abdominal abscess. Body weight was maintained in all five patients, an increase being noted in four. Significant positive nitrogen balance was documented in two patients in whom balance studies were carried out. Body composition studies, total body water and exchangeable potassium, demonstrated an increased body cell mass in two patients despite acute inflammatory bowel disease. There was one death in this group, occurring in a patient with Crohn’s disease of the duodenum, the cause being massive upper gastrointestinal bleeding. This patient has been presented in detail in a previous publication [2]. The following case report illustrates the management of these cases.

The patient (AP), a forty-three year old white male musician (RIH 880513), had a thirty year history of Crohn’s enteritis. Nine years prior to admission he had undergone ileal bypass and seven years prior to admission had had 45 cm of terminal ileum resected and right hemicolectomy. He did reasonably well on a low residue diet, metamucil, and Azulfidinem until five months prior to admission when crampy abdominal pain and abdominal distention developed. He was treated for intestinal obstruction with a long tube and intravenous fluids. Symptoms resolved and the patient was discharged on a low residue diet, steroids, metamucil, and Azulfidine. Two months before admission to Rhode Island Hospital he again experienced crampy abdominal pain, nausea, and occasional vomiting and lost 20 pounds in six weeks. On admission he was dehydrated and cachectic, the abdomen was distended, and he had hyperactive

The American Journal of Surgery

Chemically

Defined

Diets for Inflammatory

2’4

2’7

HOSPITAL

DAY

Bowel

Disease

;c

Figure 2. (Patient AP) Stenotic segment of small bowel, causing complete obstruction.

Figure 3. (Patient AP) Nitrogen balance study and caloric intake while on elemental diet.

I)o~ei sounds. Flat plate of the abdomen demonstrated mt~ltiple loops of distended small bowel consistent with small bowel obstruction. After correction of dehydration and elec?rolytr imbalance and insertion of a Miller-Abbot t tube. intravenous nutrition through a percutaneous subclavian vein catheter was begun. On the tenth hospital day signs of small bowel obstrllction resolved and contrast material introduced into the small howel through the Miller-Abbott tube showed a stenosed segment of ileum. (Figure 2.) On the thirteenth hospital day a high nitrogen elemental diet (IO per cent weight volume) was administered through a number 8 French nasogastric feeding tube using a Harron pump to deliver the diet at a constant rate of 42 cc per hour. Over the next four days the rate and concentrat,ion of diet were increased to 110 cc per hour and a 25 per cent weight volume and the subclavian catheter was removed. Body composition studies demonstrated a considerably reduced body cell mass and relatively increased total body water level. Positive nitrogen halance was documented throughout the remainder of the hospitalization. (Figure 3.) The patient did not experience abdominal cramps, nausea, diarrhea, or distention while on the elemental diet despite the stenotic ileum. His weight and muscle t,one increased; his depression disappeared and he took a lively interest in his surroundings, concurrent with anat)olism. A repeated upper gastrointestinal series l)rior to discharge demonstrated improvement in the sterrosed segment of small bowel and improvement in the remaining small bowel. On the forty-eighth hospital day he was discharged, At with the elemental diet his only source of nutrition.

home the patient gradually started a low residue diet with elemental diet supplementation. After one month of diet in the hospital and two months of continuation of the diet at home, repeated body composition studies showed an increase in body cell mass and a return of body water to normal proportions. (Table II.) He has been asymptomatic for the last two and a half years.

Volume

127,

April

1974

Comment:

Despite

partial

intestinal

obstruc-

could be provided to this patient during an acute exacerbation of Crohn’s ileitis. Provision of an average of 50 cal per kilogram of body weight per day with an elemental diet was a critical factor in his care. Body cell. mass increased and total body water returned to normal levels despite extensive small bowel disease. Surgery was averted in this starving patient, and after hospital discharge he was able to continue the nutritional regimen. tion,

enteric

nutrition

Body Composition Studies (Patient AP) before and after Elemental Diet Compared with Noimal Values Based on Age, Weight, and Sex

TABLE II

Exchangeable Potassiuni

Date

Weight (kg)

Total Body Water (L)

9-71 12-71

41 47.7

33.3 30.0

1,860 2,035

47.7

30.0

2,545

Normal (age,

(mQ)

weight)

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30

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DAY

Acute Diverticulitis with Fistulas. Five patients, two male and three female, with acute diverticulitis were treated with elemental diet. Four of these patients had developed a colocutaneous fistula and the fifth had developed a cutaneous fistula of the small bowel after colectomy. All fistulas closed spontaneously. As a group, these patients required an average of five and a half weeks of nutritional support with elemental diet. Maintenance of body weight, ability to tolerate surgery successfully, and control of sepsis were noted in all patients concurrent with provision of adequate caloric substrate. Although the natural course of divertitular disease was unchanged by adequate nutrition, these patients were better prepared to deal with the acute illness and operative trauma. Granulomatous Colitis. Five patients, four female and one male, with granulomatous colitis were treated with elemental diet. Three of the five underwent total colectomy. One patient, previously presented in detail, was transferred from another hospital because of extreme malnutrition and multiple abdominal and perineal wounds secondary to the primary disease and surgical treatment. Two months of alimentation with elemental diet resulted in a 15 pound weight gain after which she underwent an uneventful total colectomy [3]. Granulomatous Enterocolitis. Fifteen patients, eight female and seven male, with enterocolitis were treated with elemental diet. Three died and five required surgery. These patients were the most critically ill and most nutritionally depleted of all patients in the study. Their earlier history was characterized by recurrent acute episodes of inflammatory bowel disease, sepsis, and progressive cachexia. Five patients had a “short gut”

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Figure 4. (Patient ML) Nitrogen balance study and caloric intake in a patient with the short gut syndrome.

problem, with remaining small bowel varying in length between 65 and 175 cm. Causes of death were pulmonary embolus, sepsis, an‘d electrolyte imbalance. Among the twelve surviving patients five had nitrogen balance studies, the results of which confirmed our clinical impression of anabolism concurrent with abatement of sepsis, subsidence of active bowel disease, and weight gain. A twenty-two year old woman (MB, RIH 909425) who had a four year history of inflammatory bowel disease, a 60 pound weight loss, sepsis, an open infected wound, and a colocutaneous fistula received elemental diet by a nasogastric tube for sixty days. She received an average of 3,350 cal and 22 gm of nitrogen per day. Anabolism was documented by daily nitrogen balance studies and paired body composition studies. The acute disease subsided and the wound healed. She gained 10 pounds and was discharged on a low residue diet with elemental diet supplementation. A detailed summary of this case is published elsewhere [4]. Another patient (AD, RIH 866245) was a twelve year old boy who presented with crampy abdominal pain, voluminous diarrhea, a perianal ulcer, and extensive inflammatory disease of the colon and small bowel. Positive nitrogen balance was achieved with elemental diet. Anabolism was documented by weight gain, regression of all symptoms, and healing of the perianal ulcer. Although a five year remission was achieved, he was recently rehospitalized with recurrent disease. He is among the earliest cases studied [5].

The most difficult complication presented by enterocolitis and its treatment is short bowel syndrome secondary to multiple and often unavoidable resections. Management of this problem with elemental diet is illustrated in the following case.

The American Journal of Surgery

Chemically

The patient iML, RlH 914404), a thirty-six year old white marrird woman, had a twenty year history of inflammatory bowel disease. Thirteen years prior to admission she had right ileocolect.omg and ileotransverse colostom>- for progression of the disease. The resected specimen inclt:ded 100 cm of terminal ileum and 22 cm of ascending colon. She did f’airly well on a medical regimen, requiring occasional hospitalization, until five months prior to admission when she noted abdominal cramps and severe diarrhea despit,e a daily dose of 60 mg of prednisone. She was operated on for intestinal obstruction. Thr remaining small bowel, excluding 65 cm of proximal je,iunum, was densely inflamed. The remaining colon was also involved. All grossly involved small bowel was removed, leaving 65 cm of jejunum ending in a jejunostomy. Most of the transverse colon was resected

and the remaining colon was closed proximally and left intraperitoneally. Microscopic examination of the specimen revealed Crohn’s disease throughout. Thirty days postoperatively she was transferred to Rhode Island Hospital for nutritional management. Initial therapy consisted of rehydration and correction of mild prerenal azotemia. Thereafter, intravenous nutrition was begun and continued to the seventieth postoperative day. On the sixtieth postoperative day a constant intragastric infusion of a 5 per cent glucose and water solution was started. Subsequently, elemental diet at 12.5 per cent weight volume was begun. Feedings were administered through a number 8 French nasogastric feeding tuhe, delivered at a constant rate by a Barron pump. Atropine and tincture of opium were also administered. Concentration and daily volume of diet were gradually increased over ten days to a level of 3,000 cal and 18 gm of nitrogen. (Figure 4.) With the elemental diet the jejunostomy output decreased by ‘i0 per cent, positive nitrogen balance was attained, and body cell mass was maintained. On the ninety-fifth postoperative day, the patient was discharged and continued on elemental diet as her major source of nutrition at home. Two months after discharge she had adapted sufficiently to permit ingestion of solid, low fat foods in small quantities. In the five months since discharge the patient has been able to carry out her household duties and care for her family. She had required two subsequent admissions for rehydration during hot spells in summer months but otherwise has been reasonably well.

Comments Inflammatory bowel disease is characterized by exacerbations that often render the patient nutritionally depleted. Surgery is generally reserved for complications of this disease including obstruction, perforation, toxic megacolon, bleeding, and unremitting inflammation. Unfortunately, when surgery is necessary, the patient is often a very poor candidate because of nutritional deprivation.

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Defined

Diets for Inflammatorv

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Disease

Marginal metabolic status engendered I)y yrars 01 gastrointestinal disease renders him particularI> susceptible to postoperative complical ions. Most patients with acute inflammatory bowel disease are unable voluntarily to ingest or absorb a. high caloric, high protein diet. Two alternatives are available: intravenous nutrition VIB a central15 placed catheter and elemental diet. I3ac terial and fungal blood infections are the major and often unavoidable problems associated with prolonged parenteral nutrition in critically ill, cachectic patients. The problem is intensified in patients who have sepsis accompanying the primary illness. In a recent study of infectious complications of intravenous nutrition at Rhode Island Hospital, 6.3 per cent of 126 critically ill patients had either fungemia or septicemia concurrent with the administration of high caloric intravenous feedings. The mortality of these patients with infection was 63 per cent. Other investigators have reported higher rates of infection associated wit.h intravenous nutrition [6]. The second alternative, enteric nutrition with elemental diet, is quite often possible despite active inflammatory bowel disease. -4lthough the gastrointestinal tract is unable to tolerate a standard diet, it. can often absorb simple sugars and amino acids if they are provided as a slow constant infusion. Even with a partially functional gastrointestinal tract, elemental diets can be used. However, if the gastrointestinal tract becomes totally incapacitated because of ileus or obstruction, parenteral alimentation is necessary until some portion of the small bowel becomes capable of absorption. The most successful method of delivering elemental diet in adults is the use of a number 8 French nasogastric feeding tube. The diet must be delivered at a slow constant rate. A mechanical roller pump has been the most convenient method of delivery, although a gravity drip is also effective. Under no circumstances should the diet be administered by bolus injection. Initially a 10 to 15 per cent weight volume solution is started at a rate of 40 to 50 cc per hour. The diet is given continuously over a twenty-four hour period, and for three to five days both the rate and concentration are increased. A continuously variable speed pump is ideal for meeting these requirements. The goal is 2,500 to 3,000 cal a day in adult women with 125 gm of protein (20 gm of nitrogen) and 3,000 to 4,000 cal a day with 1%) gm or more of protein in adult men. Diarrhea, high gastric residue, and high blood sugar levels with glycosuria

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TABLE III

Paired Studies in Eight Critically on Low and High Nitrogen Diets*

Diet Low nitrogen diet High nitrogen diet

Average Average Daily Daily Nitrogen Number of Caloric Intake Patients Intake (gm) _ ~~ 2,175 7.5 -8 8

2,090

13.2

~.

III Patients

Average Nitrogen Balance &m/day)

~

/0.5

P <.0025

+4.1 i

essary because of complications of inflammatory bowel disease. In any event, patients in an anabolic state are bet,ter able to tolerate the disease and its complications and treatment than are debilitated, starved persons. Morbidity and mortality appear to be decreased by treatment of starvation as a major part of the management of patients with inflammatory bowel disease. Summary and Conclusion

* Each patient

was used as his or her own control.

indicators of the need to decrease intake or to stop and start at a slower rate [2]. In acutely ill catabolic patients a diet with a nitrogen to nonprotein calorie ratio of 1:140 is more effective than are diets with a ratio of 1:280. This clinical impression has been documented in a formal study of eight acutely ill patients. With each patient as his own control, elemental diets with a high and low nitrogen content were alternated Nitrogen balance studies over six day periods. were performed on the last three days, after a change of diet. Significant positive nitrogen balance occurred with administration of a high nitrogen elemental diet (1 gm of nitrogen per 140 nonprotein calories). With a low nitrogen elemental diet (1 gm of nitrogen per 280 nonprotein calories) and the same number of calories, nitrogen balance was barely maintained. (Table III.) The success of these diets in meeting nutritional requirements of patients with acute inflammatory bowel disease can be attributed to the diet’s composition. Simple sugars and amino acids do not require digestion and are absorbed in the duodenum and jejunum. Oligosaccharides require only hydrolysis. The minimal amount of fat in these diets eliminates the complex fat absorption process. The lack of bulk minimizes the fecal stream. Absence of stimulation of exocrine secretions is also important [7,8]. No doubt these characteristics are also responsible for the success noted with gastrointestinal cutaneous fistula, short bowel syndrome, and pancreatitis [4,9-111. In the treatment of inflammatory bowel disease, Voitk et al [12] have reported similar success with elemental diets that contain more fat and question whether this is primary therapy. Fischer et al [13] pose the same question for high caloric intrave. nous feedings. Fifteen of forty patients referred to Rhode Island Hospital required surgery during the same admission or had had surgery shortly before transfer. In some others, surgery was subsequently nec-

are

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majar

Forty patients with acute inflammatory bowel disease, including ileocolitis (fifteen), ulcerative colitis (nine), regional enteritis (five), granulomatous colitis (five), diverticulitis (five), and ulcerative proctitis (one), were treated with elemental diets. Adherence to a specific protocol has permitted administration of 2,000 to 5,000 calories daily for as long as six months without significant complication. Four of six patients with massive small bowel resection, one having only 65 cm of remaining jejunum ending in a jejunostomy, are doing reasonably well at home. Nitrogen balance studies in fourteen patients and body composition studies in seven patients have confirmed clinical observation of a marked anabolic response followed by clinical improvement in patients fed elemental diet despite extensive gastrointestinal disease. Several characteristics of elemental diets make them uniquely applicable in inflammatory bowel disease. They provide a high caloric, high nitrogen substrate with zero residue and most are virtually fat free. Absorption takes place in the upper part of the small bowel with minimal digestion and minimal stimulation of exocrine secretions. Elemental diets may be administered to almost all patients with inflammatory bowel disease even during acute exacerbations. The ability to maintain positive nitrogen balance with enteric nutrition is a significant contribution to the treatment of patients with acute and subacute inflammatory bowel disease, obviating surgery in some and significantly reducing the operative risk in others. References 1. Randall, HT: Nutrition in surgical patients. Am J Surg 119: 530, 1970. 2. Stephens RV. Randall HT: Use of a concentrated, balanced, liquid elemental diet for nutritional management of catabolic states. Ann Surg 170: 642, 1969. 3. Bury KD, Turnier E, Randall HT: Nutritional management of granulomatous colitis with perineal ulceration. Can J Surg 15: 108, 1972.

The American Journal of Surgery

Chemically

4

?ci:chlu

Mfi

.:hemlcaIIj/

( ha CJM, defined

Haas

K, Randall

HT: The

diets in the management

use of

of patients

nrlth high :lutput gastrointestinal-cutaneous flstulas. Am J Surg 127 148. 1974 5 Stephen< R%i Rury KD, DeLuca FG. Randall HT: Use of an elemental diet 111the nutritional management of catabolic diseases in infants. Am J Surg 123: 374, 1972. 6. Curry CR. Oue PG. Fungal septicemia in patients receiving parenteral hyperalimentation. N Engl J Med 285: 1221. 1971 7

Brown RA. Thompson AG. McArdle AH, Gurd ot exocrinf? pancreatic

storage

enzymes

FN: Alteration by feeding on an

elemental diet: biochemical and ultrastructural study. Surg Forurn21. 391, 1970. 8. McArdle AH. Brown RA. Echave V, Rivilis J. Thompson AG: Alterations in gastric and pancreatic secretion induced by

9.

10.

11.

12.

13.

the feeding of an elemental diet. Arch F.- Ma/ App Dig 61: 1 I%, 1972 Thompson WR. Stephens RV, Randall HT. Bowen JR: Use of the “space diet” in the management of a patient with extreme short bowel syndrome. Am J Surg 117: 449, 1969. Bury KD. Stephens RV. Randall HT: Use of a chemically defined liquid elemental diet for nutritional management of fistulas of the alimentary tract. Am J Surg 121: 174, 1971 Voltk A. Brown RA. Echave V. McArdle AH, Gurd FN, Thompson AG: Use of an elemental diet in the treatment of complicated pancreatitis. Am J Surg 125: 223, 1973. Voitk AJ, Echave V. Feller JH, Brown RA, Gurd FN: Experience with elemental diet in the treatment of inflammatory bowel disease: is this primary therapy? Arch Surg 107: 329, 197’? Fischer JE. Foster GS, Abel RM. Abbott WM, Ryan JA: Hyperalimentation as primary therapy for inflammatory bowel disease. Am J Surg 125: 165. 1973.

Discussion Claude Welch (Boston, Mass): This report is typical of the very careful work turned out by Dr Randall and his group in l’rovidence. It, deserves our careful consideration. rZbout twenty years ago I was in Detroit visiting Dr Fallis. Hr said: “I am going to show you one of the most remarkable things you have ever seen in your life.” We then went. to the wards, and he said “Look at this pump developed hy my resident Dr Barron. It is constantly delivering hlenderized food through this tiny nasogastric tube to this hadly nourished patient.” This was the first use of the p\unp and of constant infusion, which is so important. Doctor Randall and his group have now brought this method up to date using the space age diet. They have pointed out that it is an alternative method to intravenous hyperalimentation. These methods are not necessarily competitive but are sometimes judged to be so. It is highly proba!)le that in many instances we could use t.he stomach rather than the vein much more frequently than we have in the recent past.

Volume 127, April 1974

Defined

Diets

for Inflammatorv

Bowel

Disease

‘l’he authors point out that intravenotth\~~raiimtr: c,arrirs a definite hazard of 1n1c*(,t!:rn I zm +llr,’ that the rate of complications t’rorn this i iili
merits

the use of the oral item

that

of the space

diet.

route

whenever

pt)ssi!)le

thev did not cover. howe\,t*r. was lost. We do know that the intravenous solutions are almost liquid gold. I hope they will discuss the c,omprative cost One

W. Johnson (Boston, Mass): It is our c,linlcal impre:)sion that when an acute exacerbation of IIlct~rative c,olitis is treated by elemental diet, the results are better than those obtained with nasogastric decomprrssio~~ and intravenous supportive therapy. Our gast rornterologisl s do not believe us. 1 wonder what voI1r t>anerience has been in this group of patients My second comment concerns inflammatory disease of the small bowel, with its mucosal abnormality anti rapid transit time. 1s there any abnormalitv in absorl)tion of the elemental diet‘? Michael A. Rocchio (closing): I appreciate the conments of the discussers. In answer to I)r Welch, we are present,ly using Rarron pumps, which have four fixed speeds, and Holter pumps, which have variable speeds. Elemental diets are not compet,itive with high caloric parenteral nutrition. Hoth are valuable and have their own specific indications. We use intravenous alimentation until some par: of the small bowel is able to absorb, at which time we begin elemental diet and remove our central W~(WS catheter. When the gastrointestinal tract is fr~ll,v functional, we begin a regular diet. We make our parent,eral alimentation solutions at Rhode Island Hospital instead of buying those c’ommercially available. The cost of elemental diet, hased on an equivalent amount of calories, is approximately half that of intravenous hyperalimentation. Doctor
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