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Total parenteral nutrition and bowel rest result in change of cecal flora
Aim: To prospectively compare the clinical and nutritional effects of TEN and TPN in patients with acute attacks of either ulcerative (UC) or Crohn’s colitis
P.111 Prospectbe random&l trial comparing small pep tides v/s whole proteins in patknts with a high jejunostomy
(CC). Methods: Forty-two (21m, 21f, aged 36+13yrs) out of 76 consecutive patients admitted because of acute ICD were included in the study when, after 46h on steroid therapy, were still on a moderate or severe attack (Truelove’s index). Patients were randcmiied to receive either TEN (22 cases: 17 UC, 5 CC, polymeric diet) cr TPN (20 cases: 16 UC, 4CC) as the sole nutritional support. The diets were identical in caloric-nitrogenous composition. Prednisone (1 mcjkg/day) was administered in all cases, and i.v. albumin and packed red cells when necessary. Energy requirements were calculated by the Long’s equation modified for ideal weight. TSF, MAMC, and serum albumin (SA) were used to assess nutritional status. Results: Groups were comparable in terms of age, sex, nutritional status, time from onset of the disease, duration of the present attack, disease activity and time on ANS (TEN: 17.6k2.3, TPN: 16.421 days). Truelove’s index and clinical parameters of disease activity improved similarly in both groups. Likewise there were no differences regarding the need for surgery, complications of surgery and i.v. albumin and blood needs. Only in the TEN group a significant improvement in SA occurred (p = 0.02). No other nutriiional changes were detected in either TEN or TPN groups. Adverse effects due to ANS occurred in 7 TPN and in 2 TEN patients (p = 0.04). In 2 TPN patients, adverse effects were severe enough to force its withdrawal, Conclusion:The results suggest that withholding of nutrients from the intestinal lumen is not a prerequisite in achieving remission in patients with acute ICD who are also receiving steroids. Moreover, TEN have to be considered a safer and better tolerated nutriiional therapy than TPN in these patients.
J. Cosms, D. Evard, L. Beaugerie, J.G. Gobert, Y. Le Quintrec. Service de Gaatroent&mlogie, H&M Rot&child, Park, France
P.110 Altered portal drained viscera ammonia and glutamine metabolismduringacute hepatic encephalopathyin the rat
Patients with high jejunostomy have severe protein malabsorption and often require nitrogen parenteral supply. Small peptides containktg diets (SPD) have been developed to improve absorption in malabsorption syndromes. However, the absorptive advantage for SFD compared to whole protein diets (WPD) has not been demonstrated in man. Six short bowel patiits (3 males, 3 females, 45-77yrs) with 90-150cms residual jejunum ending in a stoma were studii. All patients were in astable state while receiving exclusive enteral nutrition for more than two weeks and had a mean daily fecal weight of 3711 + 3779. Patients were prospectively randomized in two consecutive 3-day periods. SPD and WPD were derived from the same source and provided daily identical amounts of energy (2607f54kcal; carbohydrate 57.6%, fat 42.4%) nitrogen (22.121tO.469) minerals and water. They differed only by the degree of hydrolysis of proteins. Beeults: Patients remained stable throughout the study. There was no statistically significant differences in urinary and fecal excretions of water, Na, K, Ca, Mg, fecal fat, and fecal total calories during the two periods. Measured fecal nitrogen was lower with SPD compared to WPD (7.66+1.2Og/day v/s 10.63?1.02g/day, p = 0.014) which resulted in a mean apparent protein absorption value of 6525% SPD v/s 49 + 5% WPD (p = 0.006). Conclusion:Jejunal absorption of SPD is better than that of the equivalent intact protein (WPD) in patients with high jejunostomy. Absorption of other nutrients and minerals was unchanged. The use of SPD may be beneficial when protein absorption is limited or daily requirements increased.
N.E.P. Da&, C.H.C. Dejong, MT. Kampman and P.B. Soeters Dept. Surg., Univ. Limburg, Maastricht, The Netherlands. Intro: During acute hepatic encephalopathy (AHE), the arterial concentration of ammonia (Am) and glutamine (Gn) rise. It has been stated that the hyperglutaminemia causes increased Am liberation in the portal drained viscera (PDV), thus aggravating hyperammonemia and AHE. M 6 M: Therefore, we measured PDV ammonia and amino acid (AA) fluxes (table) in 16 h fasted anesthetized previously unoperated (CONO) and portacaval shunted rats, before (PCSO) and 2, 4 or 6h after acute liver ischemia induction (ALI 2,4,6) of sham operation (PCS 2,4,6). Reeutbn The already increased arterial concentrations (PM) of ammonia (147 + 14 -+ 413 + 27) and glutamine (493 2 23 -+ 615 f 53) in PCS0 rats, rose in ALI rats to 1555 f 147 resp. 3177 f 294 (p < 0.001). During acute hepatic encephalopathy, net PDV glutamine Rux switched from uptake to release. This net glutamine efflux coincided with enhanced release of most other amino acids (OA. table) as well as ammonia. Pofwl~ylranF*urlnmcumhllalsbcdyweighs Am Gfl OA Am Gn CA
Cow0 399+147 -37exa 42e85
PCs0 314k74 -363+82 12W277
PCs2 234t47 -363+64 427+263
PCs4 243t56 -309eJ2 247+222
FcS8 Au4 Au2 Au6 l&+39 459HJ9 332k106 834~219 -390~100 -432%4 8?101 388t117t 214t440 23t272 1025t450 45Mt591t Means_iSEM;ANOVAIOto#.AUverrusPCs.'~
C~lueion: These results confirm increased PDV ammonia liberation during AHE. During late phases ofAHE the stolchiometry between ammonia release and glutamine uptake disappeared. PDV proteolysis, suggested by amino acid release (OA), could account for the observed net glutamine release.
63
P.112 Total parenteral nutrition and bowel rest result in change of cecal flora. Habert ft. Freund,Michael Mu&a-Sullam, EHiot M. Seny and Herve Becovier. Hebrew University Hadassah Medical School, Jerusalem, Israel The origin of TPN-associated liver function derangements is yet poorly understood. We examined the effect of bowel rest and TPN on cecal flora in 20 male Sabra rats (270 + 41 g). Group I (n = 12) was continuously infused with 25% dextrose and 4.25% amino acids at 66 + 13 ml/day/rat. Group II (n = 6) was not infused through the implanted line but allowed fcod and water ad lib. On day 7-9 all animals were aseptically laparotomized in an anaerobic chamber, the cecum removed, plated, and the number of colonies determined. Liver tissue was assayed for total lipid, phospholipids, cholesterol and triglycerides. Total hepatic lipid content was significantly higher @ < O.OOl)inTPN rats(133.7 f 252mg/gliver) comperedwithcatheterizedfree feeding controls (44.4 k 9.1 mq/g liver). Similarly different were also cholesterol and triglyceride levels (p < 0.001). Cultures of the cecum revealed significantly (p < 0.05) increased concentrations of aerobic and facultative anaerobic (lactose negative and positive) gram negative bacteria in TPN rats (1.5 x 10” & 1.1 x 107 compared with catheterized free-feeding controls (3.1 x lo7 f 4.9 x 107. There were only mild differences between control and TPN rats as to gram positive bacteria, and no differences for gram positive and negative anaerobes. We suggest that the significant overgrowth of aerobic and facuftative anaerobic gram negative bacteria is responsible for the release of a hepatotoxic substance i.e. endotoxin and/or tumor necrosis factor, resulting in liver function derangements.
P.111 Prospectbe random&l trial comparing small pep tides v/s whole proteins in patknts with a high jejunostomy
(CC). Methods: Forty-two (21m, 21f, aged 36+13yrs) out of 76 consecutive patients admitted because of acute ICD were included in the study when, after 46h on steroid therapy, were still on a moderate or severe attack (Truelove’s index). Patients were randcmiied to receive either TEN (22 cases: 17 UC, 5 CC, polymeric diet) cr TPN (20 cases: 16 UC, 4CC) as the sole nutritional support. The diets were identical in caloric-nitrogenous composition. Prednisone (1 mcjkg/day) was administered in all cases, and i.v. albumin and packed red cells when necessary. Energy requirements were calculated by the Long’s equation modified for ideal weight. TSF, MAMC, and serum albumin (SA) were used to assess nutritional status. Results: Groups were comparable in terms of age, sex, nutritional status, time from onset of the disease, duration of the present attack, disease activity and time on ANS (TEN: 17.6k2.3, TPN: 16.421 days). Truelove’s index and clinical parameters of disease activity improved similarly in both groups. Likewise there were no differences regarding the need for surgery, complications of surgery and i.v. albumin and blood needs. Only in the TEN group a significant improvement in SA occurred (p = 0.02). No other nutriiional changes were detected in either TEN or TPN groups. Adverse effects due to ANS occurred in 7 TPN and in 2 TEN patients (p = 0.04). In 2 TPN patients, adverse effects were severe enough to force its withdrawal, Conclusion:The results suggest that withholding of nutrients from the intestinal lumen is not a prerequisite in achieving remission in patients with acute ICD who are also receiving steroids. Moreover, TEN have to be considered a safer and better tolerated nutriiional therapy than TPN in these patients.
J. Cosms, D. Evard, L. Beaugerie, J.G. Gobert, Y. Le Quintrec. Service de Gaatroent&mlogie, H&M Rot&child, Park, France
P.110 Altered portal drained viscera ammonia and glutamine metabolismduringacute hepatic encephalopathyin the rat
Patients with high jejunostomy have severe protein malabsorption and often require nitrogen parenteral supply. Small peptides containktg diets (SPD) have been developed to improve absorption in malabsorption syndromes. However, the absorptive advantage for SFD compared to whole protein diets (WPD) has not been demonstrated in man. Six short bowel patiits (3 males, 3 females, 45-77yrs) with 90-150cms residual jejunum ending in a stoma were studii. All patients were in astable state while receiving exclusive enteral nutrition for more than two weeks and had a mean daily fecal weight of 3711 + 3779. Patients were prospectively randomized in two consecutive 3-day periods. SPD and WPD were derived from the same source and provided daily identical amounts of energy (2607f54kcal; carbohydrate 57.6%, fat 42.4%) nitrogen (22.121tO.469) minerals and water. They differed only by the degree of hydrolysis of proteins. Beeults: Patients remained stable throughout the study. There was no statistically significant differences in urinary and fecal excretions of water, Na, K, Ca, Mg, fecal fat, and fecal total calories during the two periods. Measured fecal nitrogen was lower with SPD compared to WPD (7.66+1.2Og/day v/s 10.63?1.02g/day, p = 0.014) which resulted in a mean apparent protein absorption value of 6525% SPD v/s 49 + 5% WPD (p = 0.006). Conclusion:Jejunal absorption of SPD is better than that of the equivalent intact protein (WPD) in patients with high jejunostomy. Absorption of other nutrients and minerals was unchanged. The use of SPD may be beneficial when protein absorption is limited or daily requirements increased.
N.E.P. Da&, C.H.C. Dejong, MT. Kampman and P.B. Soeters Dept. Surg., Univ. Limburg, Maastricht, The Netherlands. Intro: During acute hepatic encephalopathy (AHE), the arterial concentration of ammonia (Am) and glutamine (Gn) rise. It has been stated that the hyperglutaminemia causes increased Am liberation in the portal drained viscera (PDV), thus aggravating hyperammonemia and AHE. M 6 M: Therefore, we measured PDV ammonia and amino acid (AA) fluxes (table) in 16 h fasted anesthetized previously unoperated (CONO) and portacaval shunted rats, before (PCSO) and 2, 4 or 6h after acute liver ischemia induction (ALI 2,4,6) of sham operation (PCS 2,4,6). Reeutbn The already increased arterial concentrations (PM) of ammonia (147 + 14 -+ 413 + 27) and glutamine (493 2 23 -+ 615 f 53) in PCS0 rats, rose in ALI rats to 1555 f 147 resp. 3177 f 294 (p < 0.001). During acute hepatic encephalopathy, net PDV glutamine Rux switched from uptake to release. This net glutamine efflux coincided with enhanced release of most other amino acids (OA. table) as well as ammonia. Pofwl~ylranF*urlnmcumhllalsbcdyweighs Am Gfl OA Am Gn CA
Cow0 399+147 -37exa 42e85
PCs0 314k74 -363+82 12W277
PCs2 234t47 -363+64 427+263
PCs4 243t56 -309eJ2 247+222
FcS8 Au4 Au2 Au6 l&+39 459HJ9 332k106 834~219 -390~100 -432%4 8?101 388t117t 214t440 23t272 1025t450 45Mt591t Means_iSEM;ANOVAIOto#.AUverrusPCs.'~
C~lueion: These results confirm increased PDV ammonia liberation during AHE. During late phases ofAHE the stolchiometry between ammonia release and glutamine uptake disappeared. PDV proteolysis, suggested by amino acid release (OA), could account for the observed net glutamine release.
63
P.112 Total parenteral nutrition and bowel rest result in change of cecal flora. Habert ft. Freund,Michael Mu&a-Sullam, EHiot M. Seny and Herve Becovier. Hebrew University Hadassah Medical School, Jerusalem, Israel The origin of TPN-associated liver function derangements is yet poorly understood. We examined the effect of bowel rest and TPN on cecal flora in 20 male Sabra rats (270 + 41 g). Group I (n = 12) was continuously infused with 25% dextrose and 4.25% amino acids at 66 + 13 ml/day/rat. Group II (n = 6) was not infused through the implanted line but allowed fcod and water ad lib. On day 7-9 all animals were aseptically laparotomized in an anaerobic chamber, the cecum removed, plated, and the number of colonies determined. Liver tissue was assayed for total lipid, phospholipids, cholesterol and triglycerides. Total hepatic lipid content was significantly higher @ < O.OOl)inTPN rats(133.7 f 252mg/gliver) comperedwithcatheterizedfree feeding controls (44.4 k 9.1 mq/g liver). Similarly different were also cholesterol and triglyceride levels (p < 0.001). Cultures of the cecum revealed significantly (p < 0.05) increased concentrations of aerobic and facultative anaerobic (lactose negative and positive) gram negative bacteria in TPN rats (1.5 x 10” & 1.1 x 107 compared with catheterized free-feeding controls (3.1 x lo7 f 4.9 x 107. There were only mild differences between control and TPN rats as to gram positive bacteria, and no differences for gram positive and negative anaerobes. We suggest that the significant overgrowth of aerobic and facuftative anaerobic gram negative bacteria is responsible for the release of a hepatotoxic substance i.e. endotoxin and/or tumor necrosis factor, resulting in liver function derangements.