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Dabsch S, Datz C, Dejaco C, Harpain F, Hütterer E, Kramer L, Loschko N, Moschen A, Stift A, Vogelsang H. [Practical guideline for short bowel syndrome]. ZEITSCHRIFT FUR GASTROENTEROLOGIE 2025; 63:502-511. [PMID: 40360142 PMCID: PMC12074862 DOI: 10.1055/a-2375-4601] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/29/2024] [Accepted: 02/24/2025] [Indexed: 05/15/2025]
Abstract
Short bowel syndrome is a rare complex disease that mainly develops due to extensive bowel resections and can lead to chronic intestinal failure. Due to the decreased intestinal surface absorption of macronutrient, micronutrient and/or fluids is reduced. Correspondingly manifold symptoms arise as diarrhoea, weight loss, vitamin deficiencies, chronic kidney disease, hepatopathy and others with great impact on quality of life of patients. Therapy is complex and needs interdisciplinary collaboration between dieticians, gastroenterologists, surgeons and also a dense monitoring of general practitioners. Commonly patients need permanent home-parenteral support. Therapies have to be decided individually and have to be reviewed regularly for effectivity and side effects. Furthermore, periodic monitoring of several clinical and laboratory tests should be performed. Morbidity and mortality of this disease complex is high and lead by appearance and management of complications. This practical guide should give an overview about the disease, diagnostics and management and should enable the best possible care of these complex patients.
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Affiliation(s)
- Stefanie Dabsch
- Klinische Abteilung für Gastroenterologie und Hepatologie, Universitätsklinik für Innere Medizin 3, Medizinische Universität Wien, Vienna, Austria
| | - Christian Datz
- Abteilung für Innere Medizin, Krankenhaus Oberndorf, Lehrkrankenhaus der Paracelsus Medizinischen Privatuniversität Salzburg, Salzburg, Austria
| | - Clemens Dejaco
- Klinische Abteilung für Gastroenterologie und Hepatologie, Universitätsklinik für Innere Medizin 3, Medizinische Universität Wien, Vienna, Austria
| | - Felix Harpain
- Klinische Abteilung für Viszeralchirurgie, Universitätsklinik für Allgemeinchirurgie, Medizinische Universität Wien, Vienna, Austria
| | - Elisabeth Hütterer
- Klinische Abteilung für Onkologie, Universitätsklinik für Innere Medizin 1, Medizinische Universität Wien, Vienna, Austria
| | - Ludwig Kramer
- 1. Medizinische Abteilung, Wiener Gesundheitsverbund Klinik Hietzing, Wien, Austria
| | - Nina Loschko
- Universitätsklinik für Innere Medizin 2, Johannes Kepler Universität Linz, Linz, Austria
| | - Alexander Moschen
- Universitätsklinik für Innere Medizin 2, Johannes Kepler Universität Linz, Linz, Austria
| | - Anton Stift
- Klinische Abteilung für Viszeralchirurgie, Universitätsklinik für Allgemeinchirurgie, Medizinische Universität Wien, Vienna, Austria
| | - Harald Vogelsang
- Klinische Abteilung für Gastroenterologie und Hepatologie, Universitätsklinik für Innere Medizin 3, Medizinische Universität Wien, Vienna, Austria
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Larson‐Nath C, Bashir A, Herdes RE, Kiernan B, Lai J, Martin N, Misner N, Pandey A, Puri K, Zong W, Duro D. Term infant formula macronutrient composition: An update for clinicians. J Pediatr Gastroenterol Nutr 2025; 80:751-759. [PMID: 39930711 PMCID: PMC12066912 DOI: 10.1002/jpn3.70002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/27/2024] [Revised: 12/07/2024] [Accepted: 12/14/2024] [Indexed: 05/13/2025]
Abstract
Protein, carbohydrates, and fats comprise the macronutrient components of infant formulas. While all infant formulas in the United States meet specific nutrition standards, the macronutrient composition of formulas is diverse. Each macronutrient in the formula may play a role in treating or managing the disease. In addition, many formulas are marketed as resembling the composition of human milk or improving symptoms such as colic and irritability. For these and other reasons, families are often interested in different formula properties. When choosing a formula for their infant families, they may reach out to clinicians for advice. Therefore, clinicians need to understand the macronutrient composition of the formulas their patients are using. This manuscript discusses the macronutrient composition of term infant formulas and indications of the use of different macronutrient components.
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Affiliation(s)
- Catherine Larson‐Nath
- Division of Pediatric Gastroenterology, Hepatology and Nutrition, Department of PediatricsUniversity of MinnesotaMinneapolisMinnesotaUSA
| | - Anam Bashir
- Division of Pediatric Gastroenterology, Hepatology and Nutrition, Department of PediatricsChildren's Hospital of PhiladelphiaPhiladelphiaPennsylvaniaUSA
| | - Rachel E. Herdes
- Division of Pediatric Gastroenterology, Hepatology and NutritionStanford University School of MedicineStanfordCaliforniaUSA
| | - Bridget Kiernan
- Division of Pediatric Gastroenterology, Hepatology and NutritionNYU Langone HealthNew YorkNew YorkUSA
| | - Joanne Lai
- Division of Pediatric Gastroenterology, Hepatology and NutritionIcahn School of Medicine at Mount SinaiNew YorkNew YorkUSA
| | - Nicole Martin
- Clinical Nutrition, Children's WisconsinMilwaukeeWisconsinUSA
| | - Nicole Misner
- Division of Pediatric Gastroenterology, Hepatology and NutritionUniversity of South FloridaTampaFloridaUSA
| | - Akash Pandey
- Division of Pediatric Gastroenterology, Hepatology and NutritionUniversity of Central FloridaOrlandoFloridaUSA
| | - Kanika Puri
- Division of Pediatric Gastroenterology, Hepatology and NutritionRiley Hospital for Children at Indiana University HealthIndianapolisIndianaUSA
| | - Wenjing Zong
- Division of Pediatric Gastroenterology, Hepatology and NutritionUT SouthwesternDallasTexasUSA
| | - Debora Duro
- Division of Pediatric Gastroenterology, Hepatology and Nutrition, Department of PediatricsSalah Foundation Children Hospital, Broward HealthFort LauderdaleFloridaUSA
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Vara-Luiz F, Glória L, Mendes I, Carlos S, Guerra P, Nunes G, Oliveira CS, Ferreira A, Santos AP, Fonseca J. Chronic Intestinal Failure and Short Bowel Syndrome in Adults: The State of the Art. GE PORTUGUESE JOURNAL OF GASTROENTEROLOGY 2024; 31:388-400. [PMID: 39633906 PMCID: PMC11614447 DOI: 10.1159/000538938] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 12/18/2023] [Accepted: 04/13/2024] [Indexed: 12/07/2024]
Abstract
Background Short bowel syndrome (SBS) is a devastating malabsorptive condition and the most common cause of chronic intestinal failure (CIF). During the intestinal rehabilitation process, patients may need parenteral support for months or years, parenteral nutrition (PN), or hydration/electrolyte supplementation, as a bridge for the desired enteral autonomy. Summary Several classification criteria have been highlighted to reflect different perspectives in CIF. The management of CIF-SBS in adults is a multidisciplinary process that aims to reduce gastrointestinal secretions, slow transit, correct/prevent malnutrition, dehydration, and specific nutrient deficiencies, and prevent refeeding syndrome. The nutritional support team should have the expertise to take care of these complex patients: fluid support; oral, enteral, and PN; disease/PN-related complications; pharmacologic treatment; and surgical prevention/treatment. Key Messages CIF-SBS is a complex disease with undesired consequences, if not adequately identified and managed. A comprehensive approach performed by a multidisciplinary team is essential to reduce PN dependence, promote enteral independence, and improve quality of life.
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Affiliation(s)
- Francisco Vara-Luiz
- GENE – Artificial Feeding Team, Gastroenterology Department, Hospital Garcia de Orta, Almada, Portugal
- Aging Lab, Egas Moniz Center for Interdisciplinary Research (CiiEM), Egas Moniz School of Health and Science, Almada, Portugal
| | - Luísa Glória
- Gastroenterology Department, Hospital Beatriz Ângelo, Loures, Portugal
| | - Ivo Mendes
- GENE – Artificial Feeding Team, Gastroenterology Department, Hospital Garcia de Orta, Almada, Portugal
| | - Sandra Carlos
- Surgery Department, Hospital Garcia de Orta, Almada, Portugal
| | - Paula Guerra
- Pediatrics Department, Centro Hospitalar Universitário de São João, Porto, Portugal
| | - Gonçalo Nunes
- GENE – Artificial Feeding Team, Gastroenterology Department, Hospital Garcia de Orta, Almada, Portugal
- Aging Lab, Egas Moniz Center for Interdisciplinary Research (CiiEM), Egas Moniz School of Health and Science, Almada, Portugal
| | - Cátia Sofia Oliveira
- GENE – Artificial Feeding Team, Gastroenterology Department, Hospital Garcia de Orta, Almada, Portugal
| | - Andreia Ferreira
- Nutrition Department, Hospital Lusíadas Lisboa, Lisboa, Portugal
| | | | - Jorge Fonseca
- GENE – Artificial Feeding Team, Gastroenterology Department, Hospital Garcia de Orta, Almada, Portugal
- Aging Lab, Egas Moniz Center for Interdisciplinary Research (CiiEM), Egas Moniz School of Health and Science, Almada, Portugal
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Ramírez-Ochoa S, Zepeda-Gutiérrez LA, Ambriz-Alarcón MA, Vicente-Hernández B, Cervantes-Guevara G, Castro Campos KD, Valencia-López K, Cervantes-Pérez G, Ruiz-León M, Hernández-Mora FJ, Cervantes-Nápoles TE, Flores-Villavicencio ME, Sánchez-Sánchez SO, Cervantes-Pérez E. A Multidisciplinary Approach to the Classification and Management of Intestinal Failure: Knowledge in Progress. Diagnostics (Basel) 2024; 14:2114. [PMID: 39410518 PMCID: PMC11475224 DOI: 10.3390/diagnostics14192114] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2024] [Revised: 09/06/2024] [Accepted: 09/20/2024] [Indexed: 10/20/2024] Open
Abstract
Intestinal failure (IF) is a debilitating condition characterized by the insufficient function of the gastrointestinal tract to absorb nutrients and fluids essential for life. This review consolidates recent advancements and challenges in managing IF among adult and pediatric populations, highlighting differences in etiology, management, and outcomes. Over the recent years, significant strides have been made in the nutritional and medical management of IF, significantly reducing mortality rates and improving the quality of life for patients. Key advancements include the development and availability of glucagon-like peptide-2 (GLP-2) analogs, improved formulations of parenteral nutrition, and the establishment of specialized interdisciplinary centers. Short bowel syndrome (SBS) remains the predominant cause of IF globally. The pediatric segment is increasingly surviving into adulthood, presenting unique long-term management challenges that differ from adult-onset IF. These include the need for tailored nutritional support, management of IF-associated liver disease, and addressing growth and neurodevelopmental outcomes. The therapeutic landscape for IF continues to evolve with the development of new treatment modalities and better understanding of the condition's pathophysiology. However, disparities in treatment outcomes between children and adults suggest the need for age-specific management strategies. This review underscores the importance of a nuanced approach to IF, incorporating advancements in medical science with a deep understanding of the distinct needs.
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Affiliation(s)
- Sol Ramírez-Ochoa
- Department of Internal Medicine, Hospital Civil de Guadalajara Fray Antonio Alcalde, Centro Universitario de Ciencias de la Salud, Universidad de Guadalajara, Guadalajara 44280, Jalisco, Mexico; (S.R.-O.); (L.A.Z.-G.); (B.V.-H.); (K.D.C.C.); (K.V.-L.); (G.C.-P.); (M.R.-L.); (S.O.S.-S.)
| | - Luis Asdrúval Zepeda-Gutiérrez
- Department of Internal Medicine, Hospital Civil de Guadalajara Fray Antonio Alcalde, Centro Universitario de Ciencias de la Salud, Universidad de Guadalajara, Guadalajara 44280, Jalisco, Mexico; (S.R.-O.); (L.A.Z.-G.); (B.V.-H.); (K.D.C.C.); (K.V.-L.); (G.C.-P.); (M.R.-L.); (S.O.S.-S.)
| | | | - Berenice Vicente-Hernández
- Department of Internal Medicine, Hospital Civil de Guadalajara Fray Antonio Alcalde, Centro Universitario de Ciencias de la Salud, Universidad de Guadalajara, Guadalajara 44280, Jalisco, Mexico; (S.R.-O.); (L.A.Z.-G.); (B.V.-H.); (K.D.C.C.); (K.V.-L.); (G.C.-P.); (M.R.-L.); (S.O.S.-S.)
| | - Gabino Cervantes-Guevara
- Department of Gastroenterology, Hospital Civil de Guadalajara Fray Antonio Alcalde, Guadalajara 44280, Jalisco, Mexico;
- Department of Welfare and Sustainable Development, Centro Universitario del Norte, Universidad de Guadalajara, Colotlán 46200, Jalisco, Mexico
| | - Karla D. Castro Campos
- Department of Internal Medicine, Hospital Civil de Guadalajara Fray Antonio Alcalde, Centro Universitario de Ciencias de la Salud, Universidad de Guadalajara, Guadalajara 44280, Jalisco, Mexico; (S.R.-O.); (L.A.Z.-G.); (B.V.-H.); (K.D.C.C.); (K.V.-L.); (G.C.-P.); (M.R.-L.); (S.O.S.-S.)
| | - Karla Valencia-López
- Department of Internal Medicine, Hospital Civil de Guadalajara Fray Antonio Alcalde, Centro Universitario de Ciencias de la Salud, Universidad de Guadalajara, Guadalajara 44280, Jalisco, Mexico; (S.R.-O.); (L.A.Z.-G.); (B.V.-H.); (K.D.C.C.); (K.V.-L.); (G.C.-P.); (M.R.-L.); (S.O.S.-S.)
| | - Gabino Cervantes-Pérez
- Department of Internal Medicine, Hospital Civil de Guadalajara Fray Antonio Alcalde, Centro Universitario de Ciencias de la Salud, Universidad de Guadalajara, Guadalajara 44280, Jalisco, Mexico; (S.R.-O.); (L.A.Z.-G.); (B.V.-H.); (K.D.C.C.); (K.V.-L.); (G.C.-P.); (M.R.-L.); (S.O.S.-S.)
| | - Mariana Ruiz-León
- Department of Internal Medicine, Hospital Civil de Guadalajara Fray Antonio Alcalde, Centro Universitario de Ciencias de la Salud, Universidad de Guadalajara, Guadalajara 44280, Jalisco, Mexico; (S.R.-O.); (L.A.Z.-G.); (B.V.-H.); (K.D.C.C.); (K.V.-L.); (G.C.-P.); (M.R.-L.); (S.O.S.-S.)
| | - Francisco Javier Hernández-Mora
- Department of Human Reproduction, Growth and Child Development, Health Sciences University Center, Universidad de Guadalajara, Guadalajara 44280, Jalisco, Mexico;
| | - Tania Elizabeth Cervantes-Nápoles
- Department of Philosophical, Methodological and Instrumental Disciplines, Centro Universitario de Ciencias de la Salud, Universidad de Guadalajara, Guadalajara 44340, Jalisco, Mexico;
| | - María Elena Flores-Villavicencio
- Departament of Social Sciences, Centro Universitario de Ciencias de la Salud, Universidad de Guadalajara, Guadalajara 44340, Jalisco, Mexico;
| | - Sandra O. Sánchez-Sánchez
- Department of Internal Medicine, Hospital Civil de Guadalajara Fray Antonio Alcalde, Centro Universitario de Ciencias de la Salud, Universidad de Guadalajara, Guadalajara 44280, Jalisco, Mexico; (S.R.-O.); (L.A.Z.-G.); (B.V.-H.); (K.D.C.C.); (K.V.-L.); (G.C.-P.); (M.R.-L.); (S.O.S.-S.)
| | - Enrique Cervantes-Pérez
- Department of Internal Medicine, Hospital Civil de Guadalajara Fray Antonio Alcalde, Centro Universitario de Ciencias de la Salud, Universidad de Guadalajara, Guadalajara 44280, Jalisco, Mexico; (S.R.-O.); (L.A.Z.-G.); (B.V.-H.); (K.D.C.C.); (K.V.-L.); (G.C.-P.); (M.R.-L.); (S.O.S.-S.)
- Department of Philosophical, Methodological and Instrumental Disciplines, Centro Universitario de Ciencias de la Salud, Universidad de Guadalajara, Guadalajara 44340, Jalisco, Mexico;
- Centro Universitario de Tlajomulco, Universidad de Guadalajara, Tlajomulco de Zúñiga 45641, Jalisco, Mexico
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Awouters M, Vanuytsel T, Huysentruyt K, De Bruyne P, Van Hoeve K, Hoffman I. Nutritional management of high-output ileostomies in paediatric patients is vital and more evidence-based guidelines are needed. Acta Paediatr 2024; 113:861-870. [PMID: 38389122 DOI: 10.1111/apa.17163] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/16/2023] [Accepted: 02/12/2024] [Indexed: 02/24/2024]
Abstract
AIM Paediatric patients with high-output ileostomies (HOI) face an elevated risk of complications. This study aimed to comprehensively review the existing literature and offer nutritional management recommendations for paediatric patients with an HOI. METHODS PubMed and Embase were searched for relevant English or French language papers up to 31 June 2022. The emphasis was placed on studies involving paediatric ileostomy patients, but insights were obtained from adult literature and other intestinal failure pathologies when these were lacking. RESULTS We identified 16 papers that addressed nutritional issues in paediatric ileostomy patients. Currently, no evidence supports a safe paediatric HOI threshold exceeding 20 mL/kg/day on two consecutive days. Paediatric HOI patients were at risk of dehydration, electrolyte disturbances, micronutrient deficiencies and growth failure. The primary dietary choice for neonates is bolus feeding with breastmilk. In older children, an enteral fluid restriction should be installed favouring isotonic or slightly hypotonic glucose-electrolyte solutions. A diet that is high in calories, complex carbohydrates and proteins, low in insoluble fibre and simple carbohydrates, and moderate in fat is recommended. CONCLUSION Adequate nutritional management is crucial to prevent complications in children with an HOI. Further research is needed to establish more evidence-based guidelines.
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Affiliation(s)
- Marijke Awouters
- Department of Paediatrics, University Hospitals Leuven, Leuven, Belgium
| | - Tim Vanuytsel
- Department of Gastroenterology, University Hospitals Leuven, Leuven, Belgium
| | - Koen Huysentruyt
- Department of Paediatric Gastroenterology, Universitair Ziekenhuis Brussel, Brussels, Belgium
| | - Pauline De Bruyne
- Department of Paediatric Gastroenterology, Ghent University Hospital, Ghent, Belgium
| | - Karen Van Hoeve
- Department of Paediatric Gastroenterology, University Hospitals Leuven, Leuven, Belgium
| | - Ilse Hoffman
- Department of Paediatric Gastroenterology, University Hospitals Leuven, Leuven, Belgium
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Hirsch TI, Wang SZ, Fligor SC, Quigley M, Gura KM, Puder M, Tsikis ST. Fat malabsorption in short bowel syndrome: A review of pathophysiology and management. Nutr Clin Pract 2024; 39 Suppl 1:S17-S28. [PMID: 38429962 PMCID: PMC10914324 DOI: 10.1002/ncp.11119] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2023] [Revised: 11/13/2023] [Accepted: 12/28/2023] [Indexed: 03/03/2024] Open
Abstract
Fat malabsorption is central to the pathophysiology of short bowel syndrome (SBS). It occurs in patients with insufficient intestinal surface area and/or function to maintain metabolic and growth demands. Rapid intestinal transit and impaired bile acid recycling further contribute to fat malabsorption. A significant portion of patients require parenteral nutrition (PN) for their survival but may develop sepsis and liver dysfunction as a result. Despite advancements in the treatment of SBS, fat malabsorption remains a chronic issue for this vulnerable patient population. Peer-reviewed literature was assessed on the topic of fat malabsorption in SBS. Current management of patients with SBS involves dietary considerations, PN management, antidiarrheals, glucagon-like peptide 2 agonists, and multidisciplinary teams. Clinical trials have focused on improving intestinal fat absorption by facilitating fat digestion with pancreatic enzymes. Targeting fat malabsorption in SBS is a potential pathway to improving lifestyle and reducing morbidity and mortality in this rare disease.
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Affiliation(s)
- Thomas I. Hirsch
- Vascular Biology Program, Department of Surgery, Boston Children’s Hospital, Harvard Medical School, Boston, MA, USA
| | - Sarah Z. Wang
- Vascular Biology Program, Department of Surgery, Boston Children’s Hospital, Harvard Medical School, Boston, MA, USA
| | - Scott C. Fligor
- Vascular Biology Program, Department of Surgery, Boston Children’s Hospital, Harvard Medical School, Boston, MA, USA
| | - Mikayla Quigley
- Vascular Biology Program, Department of Surgery, Boston Children’s Hospital, Harvard Medical School, Boston, MA, USA
| | - Kathleen M. Gura
- Department of Pharmacy and the Division of Gastroenterology and Nutrition, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
| | - Mark Puder
- Vascular Biology Program, Department of Surgery, Boston Children’s Hospital, Harvard Medical School, Boston, MA, USA
| | - Savas T. Tsikis
- Vascular Biology Program, Department of Surgery, Boston Children’s Hospital, Harvard Medical School, Boston, MA, USA
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Catron H, Hanson C, Beerman L, Carney J, Janiak K, Gerhardt B, Rochling F, Mercer D. Sustained elimination of parenteral support in adult patients with under 60 cm of small intestine: A case series. Nutr Clin Pract 2024; 39:227-234. [PMID: 37898826 DOI: 10.1002/ncp.11078] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2023] [Revised: 08/10/2023] [Accepted: 08/27/2023] [Indexed: 10/30/2023] Open
Abstract
Patients with short bowel syndrome (SBS) are often managed by expert multidisciplinary teams. One of the main goals in the management of SBS is the weaning of parenteral support (PS). Weaning of PS removes the risks associated with long-term central line placement and eliminates the need for intestinal transplant. Whereas several papers detail the ongoing care and management of patients with SBS who are dependent on PS, there are few reports discussing the successful weaning of PS in this patient population. We present five case studies examining weaning of PS in adult patients with <60-cm small bowel and partial or full colon who were enrolled in a multidisciplinary adult intestinal rehabilitation program. The case studies demonstrate weaning can occur >2 years after initial assessment and enrollment in an expert program. The ability of the program to focus on individualized care and frequent patient communication is key to PS weaning in patients with SBS.
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Affiliation(s)
- Hilary Catron
- Department of Clinical Nutrition, The Nebraska Medical Center, Omaha, NE, USA
| | - Corrine Hanson
- CAHP Medical Nutrition, University of Nebraska Medical Center, Omaha, NE, USA
| | - Laura Beerman
- Department of Clinical Nutrition, The Nebraska Medical Center, Omaha, NE, USA
| | - Jaime Carney
- Department of Transplant: Liver-Intestine, The Nebraska Medical Center, Omaha, NE, USA
| | - Kathryn Janiak
- Department of Transplant: Liver-Intestine, The Nebraska Medical Center, Omaha, NE, USA
- Departement of Surgery, The Nebraska Medical Center, Omaha, NE, USA
| | - Brandi Gerhardt
- Department of Transplant: Liver-Intestine, The Nebraska Medical Center, Omaha, NE, USA
| | - Fedja Rochling
- Department of Internal Medicine, University of Nebraska Medical Center, Omaha, NE, USA
| | - David Mercer
- Department of Surgery/Transplant, University of Nebraska Medical Center, Omaha, NE, USA
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Fligor SC, Tsikis ST, Hirsch TI, Pan A, Mitchell PD, Quigley M, Carbeau S, Nedder A, Gura KM, Puder M. Absorption of an engineered medium-chain fatty acid analogue in two short bowel syndrome minipig models. JPEN J Parenter Enteral Nutr 2023; 47:1028-1037. [PMID: 37726175 PMCID: PMC10872891 DOI: 10.1002/jpen.2563] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2023] [Revised: 08/07/2023] [Accepted: 09/13/2023] [Indexed: 09/21/2023]
Abstract
BACKGROUND Enteral drug therapy is challenging in short bowel syndrome with intestinal failure (SBS-IF) because of unpredictable absorption. SEFA-6179 is an enterally administered medium-chain fatty acid analogue under development for intestinal failure-associated liver disease. We investigate the pharmacokinetics of two SEFA-6179 formulations in two large-animal models of SBS-IF, including a new pseudojejunostomy model. METHODS Twenty Yucatan minipigs were obtained. Half underwent pre-resection pharmacokinetic study with single-dose SEFA-6179 administration. All minipigs then underwent 90% jejunoileal resection, with either a jejunoileal anastomosis or bypass of the intraperitoneal colon with anastomosis just proximal to the rectum (pseudojejunostomy). On postoperative day 3, a single-dose pharmacokinetic study was performed. RESULTS Both SBS-IF models were well tolerated. Compared with the jejunoileal anastomosis minipigs, pseudojejunostomy minipigs had a more severe malabsorptive phenotype with weight loss by postoperative day 4 (+0.1 vs -0.9 kg, P = 0.03) and liquid diarrhea (Bristol 5 vs Bristol 7, P = 0.0007). Compared with pre-resection minipigs, both jejunoileal and pseudojejunostomy minipigs had lower total plasma exposure of SEFA-6179 measured by area under the curve (jejunoileal: 37% less, P = 0.049; pseudojejunostomy: 74% less, P = 0.0001). Peak plasma concentration was also lower in the pseudojejunostomy group compared with pre-resection (65% less, P = 0.04), but not lower in the jejunoileal group (P = 0.47). CONCLUSION In two SBS-IF minipig models, SEFA-6179 had substantially decreased absorption compared with pre-resection minipigs. Dose optimization for different intestinal anatomy and function may be required. We describe a new SBS-IF pseudojejunostomy model that may improve the translation of preclinical research to patients with SBS-IF who have enterostomies.
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Affiliation(s)
- Scott C. Fligor
- Vascular Biology Program, Department of Surgery, Boston Children’s Hospital, Boston, MA
- Harvard Medical School, Boston, MA
| | - Savas T. Tsikis
- Vascular Biology Program, Department of Surgery, Boston Children’s Hospital, Boston, MA
- Harvard Medical School, Boston, MA
| | - Thomas I. Hirsch
- Vascular Biology Program, Department of Surgery, Boston Children’s Hospital, Boston, MA
- Harvard Medical School, Boston, MA
| | - Amy Pan
- Vascular Biology Program, Department of Surgery, Boston Children’s Hospital, Boston, MA
| | - Paul D. Mitchell
- Institutional Centers for Clinical and Translational Research, Boston Children’s Hospital, Boston, MA
| | - Mikayla Quigley
- Vascular Biology Program, Department of Surgery, Boston Children’s Hospital, Boston, MA
| | - Sarah Carbeau
- Vascular Biology Program, Department of Surgery, Boston Children’s Hospital, Boston, MA
| | - Arthur Nedder
- Animal Resources Children’s Hospital, Boston Children’s Hospital, Boston, MA
| | - Kathleen M. Gura
- Harvard Medical School, Boston, MA
- Department of Pharmacy and the Division of Gastroenterology, Hepatology, and Nutrition, Boston Children’s Hospital, Boston, MA
| | - Mark Puder
- Vascular Biology Program, Department of Surgery, Boston Children’s Hospital, Boston, MA
- Harvard Medical School, Boston, MA
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Pironi L, Cuerda C, Jeppesen PB, Joly F, Jonkers C, Krznarić Ž, Lal S, Lamprecht G, Lichota M, Mundi MS, Schneider SM, Szczepanek K, Van Gossum A, Wanten G, Wheatley C, Weimann A. ESPEN guideline on chronic intestinal failure in adults - Update 2023. Clin Nutr 2023; 42:1940-2021. [PMID: 37639741 DOI: 10.1016/j.clnu.2023.07.019] [Citation(s) in RCA: 71] [Impact Index Per Article: 35.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2023] [Accepted: 07/21/2023] [Indexed: 08/31/2023]
Abstract
BACKGROUND & AIMS In 2016, ESPEN published the guideline for Chronic Intestinal Failure (CIF) in adults. An updated version of ESPEN guidelines on CIF due to benign disease in adults was devised in order to incorporate new evidence since the publication of the previous ESPEN guidelines. METHODS The grading system of the Scottish Intercollegiate Guidelines Network (SIGN) was used to grade the literature. Recommendations were graded according to the levels of evidence available as A (strong), B (conditional), 0 (weak) and Good practice points (GPP). The recommendations of the 2016 guideline (graded using the GRADE system) which were still valid, because no studies supporting an update were retrieved, were reworded and re-graded accordingly. RESULTS The recommendations of the 2016 guideline were reviewed, particularly focusing on definitions, and new chapters were included to devise recommendations on IF centers, chronic enterocutaneous fistulas, costs of IF, caring for CIF patients during pregnancy, transition of patients from pediatric to adult centers. The new guideline consist of 149 recommendations and 16 statements which were voted for consensus by ESPEN members, online in July 2022 and at conference during the annual Congress in September 2022. The Grade of recommendation is GPP for 96 (64.4%) of the recommendations, 0 for 29 (19.5%), B for 19 (12.7%), and A for only five (3.4%). The grade of consensus is "strong consensus" for 148 (99.3%) and "consensus" for one (0.7%) recommendation. The grade of consensus for the statements is "strong consensus" for 14 (87.5%) and "consensus" for two (12.5%). CONCLUSIONS It is confirmed that CIF management requires complex technologies, multidisciplinary and multiprofessional activity, and expertise to care for the underlying gastrointestinal disease and to provide HPN support. Most of the recommendations were graded as GPP, but almost all received a strong consensus.
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Affiliation(s)
- Loris Pironi
- Department of Medical and Surgical Sciences, University of Bologna, Bologna, Italy; Center for Chronic Intestinal Failure, IRCCS AOUBO, Bologna, Italy.
| | - Cristina Cuerda
- Nutrition Unit, Hospital General Universitario Gregorio Marañón, Madrid, Spain
| | | | - Francisca Joly
- Center for Intestinal Failure, Department of Gastroenterology and Nutritional Support, Hôpital Beaujon, Clichy, France
| | - Cora Jonkers
- Nutrition Support Team, Amsterdam University Medical Centers, Location AMC, Amsterdam, the Netherlands
| | - Željko Krznarić
- Center of Clinical Nutrition, Department of Medicine, University Hospital Center, Zagreb, Croatia
| | - Simon Lal
- Intestinal Failure Unit, Salford Royal Foundation Trust, Salford, United Kingdom
| | | | - Marek Lichota
- Intestinal Failure Patients Association "Appetite for Life", Cracow, Poland
| | - Manpreet S Mundi
- Division of Endocrinology, Diabetes, Metabolism, and Nutrition, Mayo Clinic College of Medicine, Rochester, MN, USA
| | | | - Kinga Szczepanek
- General and Oncology Surgery Unit, Stanley Dudrick's Memorial Hospital, Skawina, Poland
| | | | - Geert Wanten
- Intestinal Failure Unit, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Carolyn Wheatley
- Support and Advocacy Group for People on Home Artificial Nutrition (PINNT), United Kingdom
| | - Arved Weimann
- Department of General, Visceral and Oncological Surgery, St. George Hospital, Leipzig, Germany
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10
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Itriago E, Trahan KF, Massieu LA, Garg PM, Premkumar MH. Current Practices, Challenges, and Recommendations in Enteral Nutrition After Necrotizing Enterocolitis. Clin Perinatol 2023; 50:683-698. [PMID: 37536772 DOI: 10.1016/j.clp.2023.04.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/05/2023]
Abstract
Necrotizing enterocolitis (NEC) is a neonatal disease with high mortality and morbidity. There is a lack of evidence-based recommendations on nutritional rehabilitation following NEC, and much of the current practice is guided by institutional policies and expert opinions. After a diagnosis of NEC, infants are exposed to an extended period of bowel rest and a prolonged course of antibiotics. Recognizing the patient characteristics that predict nutritional tolerance, early initiation of enteral nutrition, minimizing periods of bowel rest and antibiotic exposure, and standardization of dietary practices are the mainstay of post-NEC nutrition.
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Affiliation(s)
- Elena Itriago
- Department of Pediatrics, Section of Neonatology, Baylor College of Medicine, Texas Children's Hospital, Houston, TX, USA
| | - Kimberly Fernandez Trahan
- Department of Pediatrics, Section of Neonatology, Baylor College of Medicine, Texas Children's Hospital, Houston, TX, USA
| | - Leonor Adriana Massieu
- Department of Pediatrics, Section of Neonatology, Baylor College of Medicine, Texas Children's Hospital, Houston, TX, USA
| | - Parvesh M Garg
- Wake Forest School of Medicine, Brenner Children's Hospital, Atrium Health Wake Forest Baptist, Winston-Salem, NC, USA
| | - Muralidhar H Premkumar
- Department of Pediatrics, Section of Neonatology, Baylor College of Medicine, Texas Children's Hospital, Houston, TX, USA.
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11
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Yan J, Zhao Y, Jiang L, Wang Y, Cai W. Decreased Expression of KLF4 Leading to Functional Deficit in Pediatric Patients with Intestinal Failure and Potential Therapeutic Strategy Using Decanoic Acid. Nutrients 2023; 15:2660. [PMID: 37375564 DOI: 10.3390/nu15122660] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2023] [Revised: 06/01/2023] [Accepted: 06/05/2023] [Indexed: 06/29/2023] Open
Abstract
Pediatric intestinal failure (IF) is the reduction in gut function to below the minimum necessary for the absorption of macronutrients and/or water and electrolytes, such that intravenous supplementation is required to maintain health and/or growth. The overall goal in treating IF is to achieve intestinal adaptation; however, the underlying mechanisms have not been fully understood. In this study, by performing single-cell RNA sequencing in pediatric IF patients, we found that decreased Kruppel-Like Factor 4 (KLF4) may serve as the hub gene responsible for the functional deficit in mature enterocytes in IF patients, leading to the downregulation of solute carrier (SLC) family transporters (e.g., SLC7A9) and, consequently, nutrient malabsorption. We also found that inducible KLF4 was highly sensitive to the loss of certain enteral nutrients: in a rodent model of total parenteral nutrition mimicking the deprivation of enteral nutrition, the expression of KLF4 dramatically decreased only at the tip of the villus and not at the bottom of crypts. By using IF patient-derived intestinal organoids and Caco-2 cells as in vitro models, we demonstrated that the supplementation of decanoic acid (DA) could significantly induce the expression of KLF4 along with SLC6A4 and SLC7A9, suggesting that DA may function as a potential therapeutic strategy to promote cell maturation and functional improvement. In summary, this study provides new insights into the mechanism of intestinal adaptation depending on KLF4, and proposed potential strategies for nutritional management using DA.
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Affiliation(s)
- Junkai Yan
- Division of Pediatric Gastroenterology and Nutrition, Xinhua Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai 200092, China
- Shanghai Institute for Pediatric Research, Shanghai 200092, China
- Shanghai Key Laboratory of Pediatric Gastroenterology and Nutrition, Shanghai 200092, China
| | - Yuling Zhao
- Department of Pediatric Surgery, Xinhua Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai 200092, China
| | - Lu Jiang
- Shanghai Institute for Pediatric Research, Shanghai 200092, China
- Shanghai Key Laboratory of Pediatric Gastroenterology and Nutrition, Shanghai 200092, China
| | - Ying Wang
- Division of Pediatric Gastroenterology and Nutrition, Xinhua Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai 200092, China
- Shanghai Institute for Pediatric Research, Shanghai 200092, China
- Shanghai Key Laboratory of Pediatric Gastroenterology and Nutrition, Shanghai 200092, China
| | - Wei Cai
- Division of Pediatric Gastroenterology and Nutrition, Xinhua Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai 200092, China
- Shanghai Institute for Pediatric Research, Shanghai 200092, China
- Shanghai Key Laboratory of Pediatric Gastroenterology and Nutrition, Shanghai 200092, China
- Department of Pediatric Surgery, Xinhua Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai 200092, China
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12
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Roberts K, Shah ND, Parrish CR, Wall E. Navigating nutrition and hydration care in the adult patient with short bowel syndrome. Nutr Clin Pract 2023; 38 Suppl 1:S59-S75. [PMID: 37115029 DOI: 10.1002/ncp.10951] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2022] [Revised: 12/12/2022] [Accepted: 12/17/2022] [Indexed: 04/29/2023] Open
Abstract
Attending diligently to the nutrition and hydration needs of patients with short bowel syndrome (SBS) is a key tenet of their care, both postoperatively and in the years that follow. For, without each, patients are left to themselves to navigate the nutrition consequences of SBS, including malnutrition, nutrient deficiencies, renal compromise, osteoporosis, fatigue, depression, and impaired quality of life. The intent of this review is to discuss the initial nutrition assessment, oral diet, hydration, and home nutrition support for the patient with SBS.
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Affiliation(s)
- Kristen Roberts
- College of Medicine, Department of Medical Dietetics, The Ohio State University, Columbus, Ohio, USA
| | - Neha D Shah
- Colitis and Crohn's Disease Center, University of California, San Francisco, California, USA
| | | | - Elizabeth Wall
- GI/Nutrition Support Team, The University of Chicago Medicine, Chicago, Illinois, USA
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13
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Wauters L, Joly F. Treatment of short bowel syndrome: Breaking the therapeutic ceiling? Nutr Clin Pract 2023; 38 Suppl 1:S76-S87. [PMID: 37115030 DOI: 10.1002/ncp.10974] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2022] [Revised: 01/26/2023] [Accepted: 02/04/2023] [Indexed: 04/29/2023] Open
Abstract
Short bowel syndrome (SBS) is the most common cause of chronic intestinal failure, requiring home parenteral support (intravenous fluid, parenteral nutrition, or parenteral nutrition with intravenous fluid) to compensate for severe malabsorption. The loss of mucosal absorptive area after extensive intestinal resection is accompanied by an accelerated transit and hypersecretion. Changes in physiology and clinical outcomes differ between patients with SBS with or without the distal ileum and/or colon-in-continuity. This narrative review summarizes the treatments used in SBS, with a focus on novel approaches with intestinotrophic agents. During the early postoperative years, spontaneous adaptation occurs and can be induced or accelerated with conventional therapies, which include dietary and fluid modifications and antidiarrheal and antisecretory drugs. Based on the proadaptive role of enterohormones (eg, glucagon-like peptide [GLP]-2), analogues have been developed to allow enhanced or hyperadaptation after a period of stabilization. Teduglutide is the first GLP-2 analogue developed and commercialized with proadaptive effects resulting in reduced parenteral support needs; however, the potential for weaning of parenteral support is variable. Whether early treatment with enterohormones or accelerated hyperadaptation would further improve absorption and outcomes remains to be shown. Longer-acting GLP-2 analogues are currently being investigated. Encouraging reports with GLP-1 agonists require confirmation in randomized trials, and dual GLP-1 and GLP-2 analogues have yet to be clinically investigated. Future studies will prove whether the timing and/or combinations of different enterohormones will be able to break the ceiling of intestinal rehabilitation in SBS.
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Affiliation(s)
- Lucas Wauters
- Department of Gastroenterology and Hepatology, University Hospitals Leuven, Leuven, Belgium
- Department of Gastroenterology and Nutrition Support, Assistance Publique des Hopitaux de Paris, University of Paris, Clichy, France
| | - Francisca Joly
- Department of Gastroenterology and Nutrition Support, Assistance Publique des Hopitaux de Paris, University of Paris, Clichy, France
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14
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Lomer MCE, Wilson B, Wall CL. British Dietetic Association consensus guidelines on the nutritional assessment and dietary management of patients with inflammatory bowel disease. J Hum Nutr Diet 2023; 36:336-377. [PMID: 35735908 PMCID: PMC10084145 DOI: 10.1111/jhn.13054] [Citation(s) in RCA: 29] [Impact Index Per Article: 14.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2021] [Accepted: 06/07/2022] [Indexed: 01/19/2023]
Abstract
BACKGROUND Despite increased awareness of diet and nutrition being integral to the management of patients with inflammatory bowel disease (IBD), there are gaps in the knowledge of IBD healthcare providers regarding nutrition. Furthermore, high quality evidence on nutritional assessment and dietary management of IBD is limited. A Delphi consensus from a panel of experts allows for best-practice guidelines to be developed, especially where high quality evidence is limited. The aim was to develop guidelines for the nutritional assessment and dietary management of IBD using an eDelphi online consensus agreement platform. METHODS Seventeen research topics related to IBD and nutrition were systematically reviewed. Searches in Cochrane, Embase®, Medline® and Scopus® electronic databases were performed. GRADE was used to develop recommendations. Experts from the IBD community (healthcare professionals and patients with IBD) were invited to vote anonymously on the recommendations in a custom-built online platform. Three rounds of voting were carried out with updated iterations of the recommendations and evaluative text based on feedback from the previous round. RESULTS From 23,824 non-duplicated papers, 167 were critically appraised. Fifty-five participants completed three rounds of voting and 14 GRADE statements and 42 practice statements achieved 80% consensus. Comprehensive guidance related to nutrition assessment, nutrition screening and dietary management is provided. CONCLUSIONS Guidelines on the nutritional assessment and dietary management of IBD have been developed using evidence-based consensus to improve equality of care. The statements and practice statements developed demonstrate the level of agreement and the quality and strength of the guidelines.
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Affiliation(s)
- Miranda C E Lomer
- Department of Nutrition and Dietetics, Guy's and St Thomas' NHS Foundation Trust, London, UK.,Department of Nutritional Sciences, King's College London, London, UK
| | - Bridgette Wilson
- Department of Nutrition and Dietetics, Guy's and St Thomas' NHS Foundation Trust, London, UK.,Department of Nutritional Sciences, King's College London, London, UK
| | - Catherine L Wall
- Department of Nutritional Sciences, King's College London, London, UK.,Department of Medicine, University of Otago, Christchurch, New Zealand
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15
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The Role of a Colon-in-Continuity in Short Bowel Syndrome. Nutrients 2023; 15:nu15030628. [PMID: 36771335 PMCID: PMC9918966 DOI: 10.3390/nu15030628] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2022] [Revised: 01/11/2023] [Accepted: 01/20/2023] [Indexed: 01/28/2023] Open
Abstract
Short bowel syndrome (SBS) is a rare gastrointestinal condition that is defined as having less than 200 cm of remaining small intestine. SBS results from extensive surgical resection and is associated with a high risk for intestinal failure (IF) with a need for parenteral support (PS). Depending on the region of intestinal resection, three different main anatomy types can be distinguished from each other. In this review, we synthesize the current knowledge on the role of the colon in the setting of SBS-IF with a colon-in-continuity (SBS-IF-CiC), e.g., by enhancing the degree of intestinal adaptation, energy salvage, and the role of the microbiota. In addition, the effect of the disease-modifying treatment with glucagon-like peptide-2 (GLP-2) analogs in SBS-IF-CiC and how it differs from patients without a colon will be discussed. Overall, the findings explained in this review highlight the importance of preservation of the colon in SBS-IF.
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16
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Wauters L, Dermine S, de Dreuille B, Bettolo J, Hutinet C, Mohamed A, Lecoq E, Billiauws L, Nuzzo A, Corcos O, Joly F. Malnutrition with Low Muscle Mass Is Common after Weaning off Home Parenteral Nutrition for Chronic Intestinal Failure. Nutrients 2023; 15:338. [PMID: 36678209 PMCID: PMC9860702 DOI: 10.3390/nu15020338] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2022] [Revised: 01/07/2023] [Accepted: 01/09/2023] [Indexed: 01/12/2023] Open
Abstract
The differences in outcomes after weaning off intravenous support (IVS) for chronic intestinal failure (IF) are unclear. Adult IF patients who are weaned off IVS at a tertiary care center (June 2019−2022) were included in this study, and nutritional and functional markers were assessed before, during, and after weaning. Short bowel syndrome (SBS) was present in 77/98 of the IF patients, with different outcomes according to the final anatomy. The body weight and the BMI increased during IVS in those with a jejunocolonic (JC) anastomosis (p < 0.001), but weight loss was significant during follow-up (p < 0.001). Malnutrition was present in >60%, with a reduced muscle mass, which was found using bioelectrical impedance analysis (BIA), in >50% of SBS-JC patients. Although reduced hand-grip strength and sarcopenia were less common, the muscle quality, or phase angle (BIA), decreased during follow-up, also correlating with serum albumin and muscle mass (p ≤ 0.01). The muscle quality and albumin were low in the patients restarting IVS, which was only the case with ≤60 cm of small bowel. Closer follow-up and earlier treatment with teduglutide (TED) should be considered in these patients, as none of the TED-treated patients were malnourished or sarcopenic. Studies on the potential benefits of nutritional and physical interventions for low muscle mass and associations with outcomes are needed in chronic IF patients.
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Affiliation(s)
- Lucas Wauters
- Department of Gastroenterology and Hepatology, University Hospitals Leuven, 3000 Leuven, Belgium
- Department of Gastroenterology and Nutrition Support, APHP Beaujon Hospital, 92110 Clichy, France
- Institut National de la Santé et de la Recherche Médicale (INSERM), University of Paris, UMR 1149, 75890 Paris, France
| | - Solène Dermine
- Department of Gastroenterology and Nutrition Support, APHP Beaujon Hospital, 92110 Clichy, France
| | - Brune de Dreuille
- Institut National de la Santé et de la Recherche Médicale (INSERM), University of Paris, UMR 1149, 75890 Paris, France
| | - Joanna Bettolo
- Department of Gastroenterology and Nutrition Support, APHP Beaujon Hospital, 92110 Clichy, France
| | - Coralie Hutinet
- Department of Gastroenterology and Nutrition Support, APHP Beaujon Hospital, 92110 Clichy, France
| | - Ashiq Mohamed
- Department of Gastroenterology and Nutrition Support, APHP Beaujon Hospital, 92110 Clichy, France
| | - Emilie Lecoq
- Department of Gastroenterology and Nutrition Support, APHP Beaujon Hospital, 92110 Clichy, France
| | - Lore Billiauws
- Department of Gastroenterology and Nutrition Support, APHP Beaujon Hospital, 92110 Clichy, France
| | - Alexandre Nuzzo
- Department of Gastroenterology and Nutrition Support, APHP Beaujon Hospital, 92110 Clichy, France
- Laboratoire de Recherche Vasculaire Translationnelle (LVTS), Institut National de la Santé et de la Recherche Médicale (INSERM), Université Paris Cité, Bichat Hospital, U1148, 75018 Paris, France
| | - Olivier Corcos
- Department of Gastroenterology and Nutrition Support, APHP Beaujon Hospital, 92110 Clichy, France
- Laboratoire de Recherche Vasculaire Translationnelle (LVTS), Institut National de la Santé et de la Recherche Médicale (INSERM), Université Paris Cité, Bichat Hospital, U1148, 75018 Paris, France
| | - Francisca Joly
- Department of Gastroenterology and Nutrition Support, APHP Beaujon Hospital, 92110 Clichy, France
- Institut National de la Santé et de la Recherche Médicale (INSERM), University of Paris, UMR 1149, 75890 Paris, France
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17
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Nutritional Management of Intestinal Failure due to Short Bowel Syndrome in Children. Nutrients 2022; 15:nu15010062. [PMID: 36615720 PMCID: PMC9823779 DOI: 10.3390/nu15010062] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2022] [Revised: 12/19/2022] [Accepted: 12/20/2022] [Indexed: 12/24/2022] Open
Abstract
BACKGROUND The most common cause of intestinal failure (IF) in childhood remains short bowel syndrome (SBS), where bowel mass is significantly reduced due to a congenital atresia or resection and parenteral nutrition (PN) needed. Home PN has improved outcome and quality of life, but the long-term therapeutic goal is to achieve enteral autonomy whilst avoiding long term complications. This paper is aimed at discussing nutritional strategies available to clinicians caring for these patients. METHODS A literature search was performed from 1992 to 2022 using Pubmed, MEDLINE and Cochrane Database of Systematic Reviews, and recent guidelines were reviewed. In the absence of evidence, recommendations reflect the authors' expert opinion. RESULTS Consensus on the best possible way of feeding children with IF-SBS is lacking and practice varies widely between centres. Feeding should commence as soon as possible following surgery. Oral feeding is the preferred route and breast milk (BM) the first milk of choice in infants. Donor BM, standard preterm or term formula are alternatives in the absence of maternal BM. Extensively hydrolysed or amino acid-based feeds are used when these are not tolerated. Solids should be introduced as soon as clinically appropriate. Children are encouraged to eat by mouth and experience different tastes and textures to avoid oral aversion. Aggressive weaning of PN and tube (over-) feeding are now discouraged. CONCLUSIONS To date, uniform agreement on the optimal type of feed, timing of food introduction and feeding regime used is lacking and great difference in practice remains. There is need for more research to establish common treatment protocols.
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18
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Lakkasani S, Seth D, Khokhar I, Touza M, Dacosta TJ. Concise review on short bowel syndrome: Etiology, pathophysiology, and management. World J Clin Cases 2022; 10:11273-11282. [PMID: 36387822 PMCID: PMC9649563 DOI: 10.12998/wjcc.v10.i31.11273] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/05/2022] [Revised: 08/12/2022] [Accepted: 09/20/2022] [Indexed: 02/05/2023] Open
Abstract
Adults have approximately 20 feet of small intestine, which is the primary site for absorbing essential nutrients and water. Resection of the intestine for any medical reason may result in short bowel syndrome (SBS), leading to loss of major absorptive surface area and resulting in various malabsorption and motility disorders. The mainstay of treatment is personalized close dietary management. Here we present SBS with its pathophysiology and different nutritional management options available. The central perspective of this paper is to provide a concise review of SBS and the treatment options available, along with how proper nutrition can solve major dietary issues in SBS and help patients recover faster.
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Affiliation(s)
- Saraswathi Lakkasani
- Gastroenterology and Hepatology, Saint Michael’s Medical Center in Affiliation with New York Medical College, Newark, NJ 07102, United States
| | - Deeksha Seth
- Gastroenterology, Chandan Institute of Liver and Biliary Sciences, Lucknow 226001, India
| | - Imran Khokhar
- Medicine, Suburban Medical Center, Norristown, PA 19401, United States
| | - Masara Touza
- Medicine, Saint Michael’s Medical Center in Affiliation with New York Medical College, Newark, NJ 07102, United States
| | - Theodore Jr Dacosta
- Gastroenterology and Hepatology, Saint Michael’s Medical Center in Affiliation with New York Medical College, Newark, NJ 07102, United States
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19
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Stojanović O, Miguel-Aliaga I, Trajkovski M. Intestinal plasticity and metabolism as regulators of organismal energy homeostasis. Nat Metab 2022; 4:1444-1458. [PMID: 36396854 DOI: 10.1038/s42255-022-00679-6] [Citation(s) in RCA: 24] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/21/2022] [Accepted: 10/06/2022] [Indexed: 11/18/2022]
Abstract
The small intestine displays marked anatomical and functional plasticity that includes adaptive alterations in adult gut morphology, enteroendocrine cell profile and their hormone secretion, as well as nutrient utilization and storage. In this Perspective, we examine how shifts in dietary and environmental conditions bring about changes in gut size, and describe how the intestine adapts to changes in internal state, bowel resection and gastric bypass surgery. We highlight the critical importance of these intestinal remodelling processes in maintaining energy balance of the organism, and in protecting the metabolism of other organs. The intestinal resizing is supported by changes in the microbiota composition, and by activation of carbohydrate and fatty acid metabolism, which govern the intestinal stem cell proliferation, intestinal cell fate, as well as survivability of differentiated epithelial cells. The discovery that intestinal remodelling is part of the normal physiological adaptation to various triggers, and the potential for harnessing the reversible gut plasticity, in our view, holds extraordinary promise for developing therapeutic approaches against metabolic and inflammatory diseases.
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Affiliation(s)
- Ozren Stojanović
- Department of Cell Physiology and Metabolism, Centre Medical Universitaire (CMU), Faculty of Medicine, University of Geneva, Geneva, Switzerland
- Diabetes Centre, Faculty of Medicine, University of Geneva, Geneva, Switzerland
- Department of Physiology, Anatomy and Genetics, University of Oxford, Oxford, UK
| | - Irene Miguel-Aliaga
- MRC London Institute of Medical Sciences, London, UK.
- Institute of Clinical Sciences, Faculty of Medicine, Imperial College London, London, UK.
| | - Mirko Trajkovski
- Department of Cell Physiology and Metabolism, Centre Medical Universitaire (CMU), Faculty of Medicine, University of Geneva, Geneva, Switzerland.
- Diabetes Centre, Faculty of Medicine, University of Geneva, Geneva, Switzerland.
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20
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Wang J, Yan W, Lu L, Tao Y, Huang L, Cai W, Wang Y. Intestinal Continuity Alleviates Pediatric Intestinal Failure-Associated Liver Disease. Front Surg 2022; 9:881782. [PMID: 35651678 PMCID: PMC9149254 DOI: 10.3389/fsurg.2022.881782] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2022] [Accepted: 04/18/2022] [Indexed: 11/13/2022] Open
Abstract
Background Type I short bowel syndrome (SBS) occurs after a critical reduction in the functional gut mass and resection of intestinal continuity after ileostomy or jejunostomy for necrotizing enterocolitis (NEC), intestinal atresia or other causes. SBS is often accompanied with intestinal failure-associated liver disease (IFALD) who requires long-term parenteral nutrition (PN). Our study aimed to observe the effect of intestinal continuity on the hepatic function of pediatric intestinal failure (IF) patients with type I SBS. Methods The pre-and post-anastomosis medical records of 35 pediatric patients with type I SBS from April 2013 to April 2019 were reviewed retrospectively. The average growth (cm/month) in the proximal and distal small bowel lengths was calculated as the growth in intestinal length (cm)/the duration (month) from enterostomy to anastomosis. The changes in hepatic function from enterostomy to anastomosis were evaluated by assessment of hepatic function before anastomosis for 6 weeks and after anastomosis for 4 weeks. Results The average growth in proximal intestinal length was 9.3 cm/month (±7.2) in neonates and 2.8 cm/month (1.3, 11.9) in infants and children, and in distal intestinal length was 1.5 cm/month (0, 2.7) in neonates and 0.4 cm/month (0, 1.4) in infants and children. The incidence of IFALD was 28.6% 1 month before anastomosis and 20.0% 1 month after anastomosis (p < 0.05). Conclusion In pediatric type I SBS with IFALD, restoration of intestinal continuity may alleviate liver injury. There was an intestinal compensatory effect on the growth in the intestinal length after resection, and better results were seen in neonates in terms of intestinal length growth.
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Affiliation(s)
- Jinling Wang
- Division of Pediatric Gastroenterology and Nutrition; Xinhua Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Weihui Yan
- Division of Pediatric Gastroenterology and Nutrition; Xinhua Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
- Shanghai Key Laboratory of Pediatric Gastroenterology and Nutrition, Shanghai, China
| | - Lina Lu
- Division of Pediatric Gastroenterology and Nutrition; Xinhua Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Yijing Tao
- Division of Pediatric Gastroenterology and Nutrition; Xinhua Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Liufang Huang
- Division of Pediatric Gastroenterology and Nutrition; Xinhua Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Wei Cai
- Division of Pediatric Gastroenterology and Nutrition; Xinhua Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
- Shanghai Key Laboratory of Pediatric Gastroenterology and Nutrition, Shanghai, China
- Department of Pediatric Surgery; Xinhua Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
- Shanghai Institute for Pediatric Research, Shanghai, China
| | - Ying Wang
- Division of Pediatric Gastroenterology and Nutrition; Xinhua Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
- Shanghai Key Laboratory of Pediatric Gastroenterology and Nutrition, Shanghai, China
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21
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Manful CF, Pham TH, Spicer H, Thomas RH. A multimodal analytical method to simultaneously determine monoacetyldiacylglycerols, medium and long chain triglycerides in biological samples during routine lipidomics. Lipids Health Dis 2022; 21:42. [PMID: 35538477 PMCID: PMC9092795 DOI: 10.1186/s12944-022-01650-w] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2021] [Accepted: 04/19/2022] [Indexed: 12/02/2022] Open
Abstract
Background Monoacetyldiglycerides (MAcDG), are acetylated triglycerides (TG) and an emerging class of bioactive or functional lipid with promising nutritional, medical, and industrial applications. A major challenge exists when analyzing MAcDG from other subclasses of TG in biological matrices, limiting knowledge on their applications and metabolism. Methods Herein a multimodal analytical method for resolution, identification, and quantitation of MAcDG in biological samples was demonstrated based on thin layer chromatography-flame ionization detection complimentary with C30-reversed phase liquid chromatography-high resolution accurate mass tandem mass spectrometry. This method was then applied to determine the MAcDG molecular species composition and quantity in E. solidaginis larvae. The statistical method for analysis of TG subclass composition and molecular species composition of E. solidaginis larvae was one-way analysis of variance (ANOVA). Results The findings suggest that the proposed analytical method could simultaneously provide a fast, accurate, sensitive, high throughput analysis of MAcDG from other TG subclasses, including the fatty acids, isomers, and molecular species composition. Conclusion This method would allow for MAcDG to be included during routine lipidomics analysis of biological samples and will have broad interests and applications in the scientific community in areas such as nutrition, climate change, medicine and biofuel innovations. Graphical abstract ![]()
Supplementary Information The online version contains supplementary material available at 10.1186/s12944-022-01650-w.
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Affiliation(s)
- Charles F Manful
- School of Science and the Environment/ Boreal Ecosystem Research Initiative, Grenfell Campus, Memorial University of Newfoundland, Corner Brook, NL, A2H 5G4, Canada.
| | - Thu H Pham
- School of Science and the Environment/ Boreal Ecosystem Research Initiative, Grenfell Campus, Memorial University of Newfoundland, Corner Brook, NL, A2H 5G4, Canada
| | - Heather Spicer
- School of Science and the Environment/ Boreal Ecosystem Research Initiative, Grenfell Campus, Memorial University of Newfoundland, Corner Brook, NL, A2H 5G4, Canada
| | - Raymond H Thomas
- School of Science and the Environment/ Boreal Ecosystem Research Initiative, Grenfell Campus, Memorial University of Newfoundland, Corner Brook, NL, A2H 5G4, Canada.
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22
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McKee RF, Knight K, Leitch EF, Stevens P. The role of surgery in weaning patients from home parenteral support - A cohort study. Colorectal Dis 2022; 24:621-630. [PMID: 35066961 DOI: 10.1111/codi.16066] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/09/2021] [Revised: 12/18/2021] [Accepted: 01/11/2022] [Indexed: 02/08/2023]
Abstract
AIM Some patients with intestinal failure requiring home parenteral support (HPS) may be weaned. This study considered all abdominal surgery in a cohort of HPS patients over a 25-year period. Our aim was to identify how many patients can be weaned from HPS and by what means, and to identify what makes weaning more likely. METHOD A prospectively collected database of HPS patients to December 2018 was analysed for outcomes of care. RESULTS At 5 years 56% of 205 patients remained on HPS. Fifty eight patients (28%), who had 68 operations, stopped HPS after surgery. Patients stopping HPS had a longer median final small bowel length (155 cm, range 45-350 cm) and were more likely to have colon in circuit (84%) than patients who had reconstructive surgery but did not stop HPS (median small bowel length 50 cm, range 15-135 cm; 50% colon in circuit). The median period between HPS discharge and reconstructive surgery was 238 days. There were no deaths, but 18 Clavien-Dindo grade 3-4 complications occurred within 30 days. Ninety per cent of patients who stopped HPS survived for 5 years from the start of HPS in comparison with 53% of those who remained on HPS. CONCLUSIONS No previous study has examined surgery in an entire cohort of HPS patients. More than a quarter of HPS patients can be weaned after reconstructive surgery. The length of bowel available for recruitment at surgery is the main determinant of the ability to stop HPS. The possibility of reconstruction should be considered, since patients who stop HPS appear to have a survival advantage.
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Affiliation(s)
- Ruth F McKee
- Department of Colorectal Surgery, Glasgow Royal Infirmary, Glasgow, UK
| | - Katrina Knight
- Department of Colorectal Surgery, Glasgow Royal Infirmary, Glasgow, UK
| | - E Fiona Leitch
- Department of Colorectal Surgery, Glasgow Royal Infirmary, Glasgow, UK
| | - Phil Stevens
- Department of Colorectal Surgery, Glasgow Royal Infirmary, Glasgow, UK
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23
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Cuerda C, Pironi L, Arends J, Bozzetti F, Gillanders L, Jeppesen PB, Joly F, Kelly D, Lal S, Staun M, Szczepanek K, Van Gossum A, Wanten G, Schneider SM, Bischoff SC. ESPEN practical guideline: Clinical nutrition in chronic intestinal failure. Clin Nutr 2021; 40:5196-5220. [PMID: 34479179 DOI: 10.1016/j.clnu.2021.07.002] [Citation(s) in RCA: 87] [Impact Index Per Article: 21.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2021] [Accepted: 07/02/2021] [Indexed: 10/20/2022]
Abstract
BACKGROUND This practical guideline is based on the ESPEN Guidelines on Chronic Intestinal Failure in Adults. METHODOLOGY ESPEN guidelines have been shortened and transformed into flow charts for easier use in clinical practice. The practical guideline is dedicated to all professionals including physicians, dieticians, nutritionists, and nurses working with patients with chronic intestinal failure. RESULTS This practical guideline consists of 112 recommendations with short commentaries for the management and treatment of benign chronic intestinal failure, including home parenteral nutrition and its complications, intestinal rehabilitation, and intestinal transplantation. CONCLUSION This practical guideline gives guidance to health care providers involved in the management of patients with chronic intestinal failure.
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Affiliation(s)
- Cristina Cuerda
- Nutrition Unit, Hospital General Universitario Gregorio Marañón, Madrid, Spain.
| | - Loris Pironi
- Alma Mater Studiorum - University of Bologna, Department of Medical and Surgical Sciences, Italy; IRCCS Azienda Ospedaliero-Universitaria di Bologna, Centre for Chronic Intestinal Failure - Clinical Nutrition and Metabolism Unit, Italy
| | - Jann Arends
- Department of Medicine I, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Germany
| | | | - Lyn Gillanders
- Emeritus of Auckland City Hospital, Auckland, New Zealand
| | - Palle Bekker Jeppesen
- Rigshospitalet, Department of Intestinal Failure and Liver Diseases Gastroenterology, Copenhagen, Denmark
| | - Francisca Joly
- Centre for Intestinal Failure, Department of Gastroenterology and Nutritional Support, Hôpital Beaujon, Clichy, France
| | - Darlene Kelly
- Emeritus of Mayo Graduate School of Medicine, Rochester, Minnesota
| | - Simon Lal
- Intestinal Failure Unit, Salford Royal Foundation Trust, Salford, UK
| | - Michael Staun
- Rigshospitalet, Department of Intestinal Failure and Liver Diseases Gastroenterology, Copenhagen, Denmark
| | - Kinga Szczepanek
- General and Oncology Surgery Unit, Stanley Dudrick's Memorial Hospital, Skawina, Poland
| | - André Van Gossum
- Medico-Surgical Department of Gastroenterology, Hôpital Erasme, Free University of Brussels, Belgium
| | - Geert Wanten
- Intestinal Failure Unit, Department of Gastroenterology and Hepatology, Radboud University Nijmegen Medical Centre, Nijmegen, the Netherlands
| | - Stéphane Michel Schneider
- Gastroenterology and Clinical Nutrition, CHU of Nice, University of Nice Sophia Antipolis, Nice, France
| | - Stephan C Bischoff
- Department of Nutritional Medicine and Prevention, University of Hohenheim, Stuttgart, Germany
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Folwaczny A, Waldmann E, Altenhofer J, Henze K, Parhofer KG. Postprandial Lipid Metabolism in Normolipidemic Subjects and Patients with Mild to Moderate Hypertriglyceridemia: Effects of Test Meals Containing Saturated Fatty Acids, Mono-Unsaturated Fatty Acids, or Medium-Chain Fatty Acids. Nutrients 2021; 13:nu13051737. [PMID: 34065380 PMCID: PMC8160756 DOI: 10.3390/nu13051737] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2021] [Revised: 05/12/2021] [Accepted: 05/17/2021] [Indexed: 12/12/2022] Open
Abstract
Fasting and postprandial hypertriglyceridemia are causal risk factors for atherosclerosis. The prevalence of hypertriglyceridemia is approximately 25–30% and most hypertriglyceridemic patients suffer from mild to moderate hypertriglyceridemia. Data regarding dietary interventions on postprandial triglyceride metabolism of mildly to moderately hypertriglyceridemic patients is, however, sparse. In a randomized controlled trial, eight mildly hypertriglyceridemic patients and five healthy, normolipidemic controls received three separate standardized fat-meals containing either saturated fatty acids (SFA), mono-unsaturated fatty acids (MUFA), or medium-chain fatty acids (MCFA) in a randomized order. Fasting and postprandial lipid parameters were determined over a 10 h period and the (incremental) area under the curve (AUC/iAUC) for plasma triglycerides and other parameters were determined. MCFA do not lead to a significant elevation of postprandial total plasma triglycerides and other triglyceride parameters, while both SFA (patients: p = 0.003, controls: p = 0.03 compared to MCFA) and MUFA (patients: p = 0.001; controls: p = 0.14 compared to MCFA) do lead to such an increase. Patients experienced a significantly more pronounced increase of plasma triglycerides than controls (SFA: patients iAUC = 1006 mg*h/dL, controls iAUC = 247 mg*h/dL, p = 0.02; MUFA: patients iAUC = 962 mg*h/dL, controls iAUC = 248 mg*h/dL, p = 0.05). Replacing SFA with MCFA may be a treatment option for mildly to moderately hypertriglyceridemic patients as it prevents postprandial hypertriglyceridemia.
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Naimi RM, Hvistendahl MK, Thomassen LM, Johnsen H, Christiansen CB, Holst JJ, Hartmann B, Jeppesen PB. Sitagliptin, a dipeptidyl peptidase-4 inhibitor, in patients with short bowel syndrome and colon in continuity: an open-label pilot study. BMJ Open Gastroenterol 2021; 8:e000604. [PMID: 33975891 PMCID: PMC8117993 DOI: 10.1136/bmjgast-2021-000604] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/15/2021] [Revised: 03/29/2021] [Accepted: 04/08/2021] [Indexed: 01/19/2023] Open
Abstract
OBJECTIVE Patients with short bowel syndrome (SBS) and colon in continuity have better adaptation potential compared with patients with jejunostomy. Adaptation may involve enhanced postprandial secretion of the enteroendocrine hormones glucagon-like peptide (GLP)-1 and GLP-2 which are normally degraded by dipeptidyl peptidase (DPP)-4. Nevertheless, some patients with SBS with colon in continuity suffer from high-volume faecal excretions and have been shown to benefit from treatment with GLP-2. Therefore, we aimed to evaluate efficacy of sitagliptin, a DPP-4 inhibitor, on reducing faecal excretions in this patient group. DESIGN In an open-label, case series, proof-of-concept pilot study, 100 mg oral sitagliptin was given two times per day for 8 weeks to patients with SBS with ≥50% colon in continuity with or without the need for parenteral support (PS). To assess intestinal function, metabolic balance studies were done at baseline and following 8 weeks of treatment. RESULTS Of the 10 patients planned for enrolment, 8 patients were included; 7 patients completed the study. Although postprandial endogenous GLP-2 concentrations increased by 49 hours×pmol/L (39, 105; p=0.018) (median (min, max)), sitagliptin did not significantly reduce median faecal wet weight (-174 g/day (-1510, 675; p=0.176)) or increase intestinal wet weight absorption. However, heterogeneity in the treatment effect was observed: intestinal wet weight absorption increased in all four patients with intestinal failure. One patient achieved a reduction in PS by 500 mL per administration day. CONCLUSION Following this negative, small pilot study, larger, placebo-controlled, studies are needed to establish the therapeutic potential of DPP-4 inhibition in patients with SBS.
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Affiliation(s)
- Rahim Mohammad Naimi
- Department of Medical Gastroenterology and Hepatology, Rigshospitalet, Copenhagen, Denmark
| | - Mark Krogh Hvistendahl
- Department of Medical Gastroenterology and Hepatology, Rigshospitalet, Copenhagen, Denmark
| | | | - Hanna Johnsen
- Department of Medical Gastroenterology and Hepatology, Rigshospitalet, Copenhagen, Denmark
| | - Charlotte Bayer Christiansen
- NNF Centre for Basic Metabolic Research and Department of Biomedical Sciences, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Jens Juul Holst
- NNF Centre for Basic Metabolic Research and Department of Biomedical Sciences, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Bolette Hartmann
- NNF Centre for Basic Metabolic Research and Department of Biomedical Sciences, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Palle Bekker Jeppesen
- Department of Medical Gastroenterology and Hepatology, Rigshospitalet, Copenhagen, Denmark
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Nightingale JMD. How to manage a high-output stoma. Frontline Gastroenterol 2021; 13:140-151. [PMID: 35300464 PMCID: PMC8862462 DOI: 10.1136/flgastro-2018-101108] [Citation(s) in RCA: 40] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/09/2020] [Revised: 01/13/2021] [Accepted: 02/08/2021] [Indexed: 02/04/2023] Open
Abstract
A high-output stoma (HOS) or fistula is when small bowel output causes water, sodium and often magnesium depletion. This tends to occur when the output is >1.5 -2.0 L/24 hours though varies according to the amount of food/drink taken orally. An HOS occurs in up to 31% of small bowel stomas. A high-output enterocutaneous fistula may, if from the proximal small bowel, behave in the same way and its fluid management will be the same as for an HOS. The clinical assessment consists of excluding causes other than a short bowel and treating them (especially partial or intermittent obstruction). A contrast follow through study gives an approximate measurement of residual small intestinal length (if not known from surgery) and may show the quality of the remaining small bowel. If HOS is due to a short bowel, the first step is to rehydrate the patient so stopping severe thirst. When thirst has resolved and renal function returned to normal, oral hypotonic fluid is restricted and a glucose-saline solution is sipped. Medication to slow transit (loperamide often in high dose) or to reduce secretions (omeprazole for gastric acid) may be helpful. Subcutaneous fluid (usually saline with added magnesium) may be given before intravenous fluids though can take 10-12 hours to infuse. Generally parenteral support is needed when less than 100 cm of functioning jejunum remains. If there is defunctioned bowel in situ, consideration should be given to bringing it back into continuity.
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27
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Matarese LE, Harvin G. Nutritional Care for Patients with Intestinal Failure. Gastroenterol Clin North Am 2021; 50:201-216. [PMID: 33518165 DOI: 10.1016/j.gtc.2020.10.004] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
Intestinal failure is a debilitating, complex disorder associated with loss of portions of intestine or loss of intestinal function. Short bowel syndrome is the most common form of intestinal failure and results in inability to maintain nutritional, fluid, and electrolyte status while consuming a regular diet. Nutrition interventions to treat short bowel syndrome include enteral and parenteral nutrition, intestinal rehabilitation techniques to enhance absorptive capacity of remnant bowel, and surgical reconstruction designed to provide more surface area for absorption. These therapies are interrelated services to restore nutritional status through the safest most effective therapy consistent with patient lifestyle and wishes.
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Affiliation(s)
- Laura E Matarese
- Division of Gastroenterology, Hepatology and Nutrition, Department of Internal Medicine, Brody School of Medicine, East Carolina University, 600 Moye Boulevard, Vidant MA 342, Mail Stop 734, Greenville, NC 27834, USA.
| | - Glenn Harvin
- Division of Gastroenterology, Hepatology and Nutrition, Department of Internal Medicine, Brody School of Medicine, East Carolina University, 600 Moye Boulevard, Vidant MA 342, Mail Stop 734, Greenville, NC 27834, USA
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28
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Abstract
Abstract
Introduction Short bowel syndrome (SBS) refers to the malabsorptive state that occurs following extensive intestinal resection and is associated with several complications.
Methods The research for this review was conducted in the Pubmed database. Relevant scientific articles dated between 1991 and 2015 and written in Portuguese, Spanish or English were selected.
Results Several therapies, including nutritional support, pharmacological options and surgical procedures have been used in these patients.
Conclusions Over the last decades new surgical and pharmacological approaches emerged, increasing survival and quality of life (QoL) in patients with SBS. All SBS patients ought to have an individualized and multidisciplinary care that promotes intestinal rehabilitation.
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Affiliation(s)
- Rosário Eça
- Universidade do Porto, Faculdade de Medicina, Porto, Portugal
| | - Elisabete Barbosa
- Universidade do Porto, Faculdade de Medicina, Porto, Portugal
- Centro Hospitalar de São João, Serviço de Cirurgia Geral, Porto, Portugal
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29
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Chiplunker AJ, Chen L, Levin MS, Warner BW, Davidson NO, Rubin DC. Increased Adiposity and Reduced Lean Body Mass in Patients with Short Bowel Syndrome. Dig Dis Sci 2020; 65:3271-3279. [PMID: 31907775 PMCID: PMC7924810 DOI: 10.1007/s10620-019-06032-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/13/2019] [Accepted: 12/24/2019] [Indexed: 01/25/2023]
Abstract
BACKGROUND Few studies have examined the metabolic consequences of short bowel syndrome (SBS) and its effects on body composition in adults. We hypothesized that body composition of SBS patients is altered compared to a normal age-, race-, and sex-matched population, regardless of parenteral nutrition (PN) dependence. AIM To compare the body composition of adult patients with SBS to age-, sex-, and race-matched healthy controls. METHODS Twenty patients with SBS underwent body composition analysis using the GE Lunar iDXA scanner. Patients were age-, sex-, and race-matched to controls from the National Health and Nutrition Examination Survey (1999-2004). Mean differences in body mass index, fat-free mass, fat mass, percent body fat, visceral adipose tissue mass and volume, and bone mineral density were measured. Statistical analysis was performed using SAS 9.4 software. RESULTS Fifty-five percent of subjects had a history of PN use, and 30% were current PN users. Mean percent body fat for SBS patients was 35.1% compared to 30.9% for healthy controls (p = 0.043). Fat-free mass was reduced in SBS (p = 0.007). Patients with reduced bone mass had a trend toward significantly more years of PN exposure compared to those with normal bone mass (p = 0.094), and a trend toward older age (p = 0.075). CONCLUSIONS SBS is associated with increased percent body fat and reduced fat-free mass, suggesting that improved dietary and therapeutic interventions are needed to restore normal metabolic indices and avoid risk of metabolic syndrome in SBS patients.
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Affiliation(s)
- Adeeti J. Chiplunker
- Department of Medicine, Division of Gastroenterology, Washington University in St. Louis School of Medicine
| | - Ling Chen
- Division of Biostatistics, Washington University in St. Louis School of Medicine
| | - Marc S. Levin
- Department of Medicine, Division of Gastroenterology, Washington University in St. Louis School of Medicine.,VA St. Louis Health Care System, Washington University in St. Louis School of Medicine
| | - Brad W. Warner
- Division of Pediatric Surgery St. Louis Children’s Hospital, Washington University in St. Louis School of Medicine
| | - Nicholas O. Davidson
- Department of Medicine, Division of Gastroenterology, Washington University in St. Louis School of Medicine.,Department of Developmental Biology; Washington University in St. Louis School of Medicine
| | - Deborah C. Rubin
- Department of Medicine, Division of Gastroenterology, Washington University in St. Louis School of Medicine.,Department of Developmental Biology; Washington University in St. Louis School of Medicine
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Le Beyec J, Billiauws L, Bado A, Joly F, Le Gall M. Short Bowel Syndrome: A Paradigm for Intestinal Adaptation to Nutrition? Annu Rev Nutr 2020; 40:299-321. [PMID: 32631145 DOI: 10.1146/annurev-nutr-011720-122203] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
Short bowel syndrome (SBS) is a rare disease that results from extensive resection of the intestine. When the remaining absorption surface of the intestine cannot absorb enough macronutrients, micronutrients, and water, SBS results in intestinal failure (IF). Patients with SBS who suffer from IF require parenteral nutrition for survival, but long-term parenteral nutrition may lead to complications such as catheter sepsis and metabolic diseases. Spontaneous intestinal adaptation occurs weeks to months after resection, resulting in hyperplasia of the remnant gut, modification of gut hormone levels, dysbiosis, and hyperphagia. Oral nutrition and presence of the colon are two major positive drivers for this adaptation. This review aims to summarize the current knowledge of the mechanisms underlying spontaneous intestinal adaptation, particularly in response to modifications of luminal content, including nutrients. In the future, dietary manipulations could be used to treat SBS.
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Affiliation(s)
- Johanne Le Beyec
- Centre de Recherche sur l'Inflammation, INSERM UMRS-1149, Assistance Publique-Hôpitaux de Paris, Université de Paris, 75018 Paris, France; .,Service de Biochimie Endocrinienne et Oncologique, Hôpital Pitié-Salpêtrière-Charles Foix, Assistance Publique-Hôpitaux de Paris, Sorbonne Université, 75013 Paris, France
| | - Lore Billiauws
- Centre de Recherche sur l'Inflammation, INSERM UMRS-1149, Assistance Publique-Hôpitaux de Paris, Université de Paris, 75018 Paris, France; .,Service de Gastroentérologie, MICI et Assistance Nutritive, Groupe Hospitalier Universitaire Paris Nord Val de Seine (GHUPNVS), Hôpital Beaujon, Assistance Publique-Hôpitaux de Paris, Université de Paris, 92110 Clichy, France
| | - André Bado
- Centre de Recherche sur l'Inflammation, INSERM UMRS-1149, Assistance Publique-Hôpitaux de Paris, Université de Paris, 75018 Paris, France;
| | - Francisca Joly
- Centre de Recherche sur l'Inflammation, INSERM UMRS-1149, Assistance Publique-Hôpitaux de Paris, Université de Paris, 75018 Paris, France; .,Service de Gastroentérologie, MICI et Assistance Nutritive, Groupe Hospitalier Universitaire Paris Nord Val de Seine (GHUPNVS), Hôpital Beaujon, Assistance Publique-Hôpitaux de Paris, Université de Paris, 92110 Clichy, France
| | - Maude Le Gall
- Centre de Recherche sur l'Inflammation, INSERM UMRS-1149, Assistance Publique-Hôpitaux de Paris, Université de Paris, 75018 Paris, France;
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Olieman J, Kastelijn W. Nutritional Feeding Strategies in Pediatric Intestinal Failure. Nutrients 2020; 12:E177. [PMID: 31936393 PMCID: PMC7019898 DOI: 10.3390/nu12010177] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2019] [Revised: 12/31/2019] [Accepted: 01/04/2020] [Indexed: 12/20/2022] Open
Abstract
Intestinal failure is defined as a critical reduction of the gut mass or function, below the minimum needed to absorb nutrients and fluids. The ultimate goal in intestinal failure is to promote bowel adaptation and reach enteral autonomy while a healthy growth and development is maintained. The condition is heterogeneous and complex. Therefore, recommendations for the type and duration of parenteral, enteral, and oral nutrition are variable, with the child's age as an additional key factor. The aim of this review is to provide an overview of nutritional feeding strategies in this heterogeneous population. Different perspectives on nutritional management, nutrition and adaptation, and microbiome and nutrition will be discussed.
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Affiliation(s)
- Joanne Olieman
- Department of Internal Medicine, Division of Dietetics, Erasmus MC, University Medical Center Rotterdam, Wytemaweg 40, 3015 GD Rotterdam, The Netherlands;
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Six-month outcomes of teduglutide treatment in adult patients with short bowel syndrome with chronic intestinal failure: A real-world French observational cohort study. Clin Nutr 2019; 39:2856-2862. [PMID: 31932048 DOI: 10.1016/j.clnu.2019.12.019] [Citation(s) in RCA: 49] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2018] [Revised: 10/28/2019] [Accepted: 12/15/2019] [Indexed: 12/14/2022]
Abstract
BACKGROUND & AIMS Teduglutide, a GLP-2-analog, has proven effective in two placebo-controlled studies in reducing parenteral support (PS) in patients with short bowel syndrome-associated intestinal failure (SBS-IF) after 24 weeks. The aim of this study was to describe in a real-life situation the effects of teduglutide treatment and their predictive factors. METHODS We included 54 consecutive SBS-IF patients treated with teduglutide in France for at least 6 months from 10 expert centers. Small bowel length was 62 ± 6 cm and 65% had colon in continuity. PS was 4.4 ±0 .2 infusions per week, started 9.8 ± 1.2 years before. Response (PS reduction ≥ 20%) and PS discontinuation rates were assessed at week 24. Adjusted p values of factors associated with response and weaning were calculated using a multivariate logistic regression model. RESULTS At week 24, 85% of patients were responders and 24% had been weaned off PS, with a 51% reduction of PS needs and 1.5 ± 0.2 days off PS per week. Response to teduglutide was influenced by a higher baseline oral intake (p = 0.02). Weaning off PS was influenced by the presence of colon (p = 0.04), a lower PS volume (p = 0.03) and a higher oral intake (p = 0.01). There were no differences based on age, bowel length or SBS-IF causes. CONCLUSIONS Our study confirms the effectiveness of teduglutide in reducing PS needs in SBS-IF patients. We associated reduced parenteral support volume with baseline parenteral volume support, bowel anatomy, and oral intake. These findings underline the role of nutritional optimization when starting the treatment.
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Abstract
The ultimate goal of treatment of short bowel syndrome/intestinal failure patients is to achieve enteral autonomy by eliminating parenteral nutrition (PN)/intravenous fluids (IV). After optimization of diet, oral hydration and anti-diarrheal medications, attempt should be made to eliminate PN/IV. Weaning from PN/IV should be individualized for each patient. Although teduglutide is the preferred agent for PN/IV volume reduction or successful weaning, optimal patient selection and long-term safety need further evaluation. Following PN/IV elimination, patients need long-term monitoring for nutritional deficiencies. This article will address clinical considerations before, during, and after PN/IV weaning to facilitate safe and successful PN/IV weaning process.
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Affiliation(s)
- Andrew Ukleja
- Division of Gastroenterology and Hepatology, Beth Israel Deaconess Medical Center/Beth Israel Lahey Health, 330 Brookline Ave., Boston, MA 02215, USA.
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Lambe C, Goulet O, Norsa L. Colon importance in short bowel syndrome. Aging (Albany NY) 2019; 11:9961-9962. [PMID: 31733102 PMCID: PMC6914415 DOI: 10.18632/aging.102447] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2019] [Accepted: 10/24/2019] [Indexed: 01/02/2023]
Affiliation(s)
- Cecile Lambe
- Pediatric Gastroenterology Hepatology and Nutrition Necker Enfants Malades Hospital, Paris, France
| | - Olivier Goulet
- Pediatric Gastroenterology Hepatology and Nutrition Necker Enfants Malades Hospital, Paris, France
| | - Lorenzo Norsa
- Pediatric Hepatology Gastroenterology and Transplantation, ASST Papa Giovanni XXIII, Bergamo, Italy
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Lauro A, Cirocchi R, Cautero N, Dazzi A, Pironi D, Di Matteo FM, Santoro A, Pironi L, Pinna AD. Reconnection surgery in adult post-operative short bowel syndrome < 100 cm: is colonic continuity sufficient to achieve enteral autonomy without autologous gastrointestinal reconstruction? Report from a single center and systematic review of literature. G Chir 2019; 38:163-175. [PMID: 29182898 DOI: 10.11138/gchir/2017.38.4.163] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
A systematic bibliographic research concerning patients operated on for SBS was performed: inclusion criteria were adult age, reconnection surgery and SBS < 100 cm. Autologous gastrointestinal reconstruction represented an exclusion criteria. The outcomes of interest were the rate of total parenteral nutrition (TPN) independence and the length of follow-up (minimum 1 year) after surgery. We reviewed our experience from 2003 to 2013 with minimum 1-year follow-up, dealing with reconnection surgery in 13 adults affected by < 100 cm SBS after massive small bowel resection: autologous gastrointestinal reconstruction was not feasible. Three (out of 5168 screened papers) non randomized controlled trials with 116 adult patients were analysed showing weaning from TPN (40%, 50% and 90% respectively) after reconnection surgery without autologous gastrointestinal reconstruction. Among our 13 adults, mean age was 54.1 years (53.8 % ASA III): 69.2 % had a high stomal output (> 500 cc/day) and TPN dependence was 100%. We performed a jejuno-colonic anastomosis (SBS type II) in 53.8%, in 46.1% of cases without ileo-cecal valve, leaving a mean residual small bowel length of 75.7 cm. In-hospital mortality was 0%. After a minimum period of 1 year of intestinal rehabilitation, all our patients (100%) went back to oral intake and 69.2% were off TPN (9 patients). No one was listed for transplantation. A residual small bowel length of minimum 75 cm, even if reconnected to part of the colon, seems able to produce a TPN independence without autologous gastrointestinal reconstruction after a minimum period of 1 year of intestinal rehabilitation.
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Norsa L, Lambe C, Abi Abboud S, Barbot-Trystram L, Ferrari A, Talbotec C, Kapel N, Pigneur B, Goulet O. The colon as an energy salvage organ for children with short bowel syndrome. Am J Clin Nutr 2019; 109:1112-1118. [PMID: 30924493 DOI: 10.1093/ajcn/nqy367] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2018] [Accepted: 12/03/2018] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND The main cause of intestinal failure is short bowel syndrome (SBS). The management goal for children with SBS is to promote intestinal adaptation while preserving growth and development with the use of parenteral nutrition (PN). OBJECTIVES This study evaluated the intestinal absorption rate in children with SBS, focusing on the role of the remnant colon. In addition, the relation between intestinal absorption rate, citrulline concentration, and small bowel length was studied. METHODS Thirty-two children with SBS on PN were included. They were divided into 3 groups according to the European Society for Clinical Nutrition and Metabolism (ESPEN) anatomical classification system: type 1 SBS (n = 9), type 2 (n = 13), and type 3 (n = 10). Intestinal absorption rate was assessed by a stool balance analysis of a 3-d collection of stools. Plasma citrulline concentrations were measured and the level of PN dependency was calculated. RESULTS The total energy absorption rate did not differ significantly between the 3 groups: 68% (61-79% ) for type 1, 60% (40-77%) for type 2, and 60% (40-77%) for type 3 ( P = 0.45). Children with type 2 or 3 SBS had significantly shorter small bowel length than children with type 1: 28 cm (19-36 cm) and 16 cm (2-29 cm), respectively, compared with 60 cm (45-78 cm) ( P = 0.04). Plasma citrulline concentrations were lower in type 3 SBS but not significantly different: 15 µmol/L (11-25 µmol/L) in type 1, 14 µmol/L (7-21 µmol/L) in type 2 , and 9 µmol/L (6-14 µmol/L) in type 3 ( P = 0.141). A multivariate analysis confirmed the role of the remnant colon in providing additional energy absorption. CONCLUSION This study demonstrated the importance of the colon as a salvage organ in children with SBS. Plasma citrulline concentrations should be interpreted according to the type of SBS. Efforts should focus on conservative surgery, early re-establishment of a colon in continuity, and preserving the intestinal microbiota.
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Affiliation(s)
- Lorenzo Norsa
- Department of Pediatric Gastroenterology-Hepatology-Nutrition, Hôpital Necker-Enfants Malades, Université Paris Descartes, Paris, France.,Pediatric Gastroenterology, Hepatology and Nutrition, Ospedale Papa Giovanni XXIII, Bergamo, Italy
| | - Cécile Lambe
- Department of Pediatric Gastroenterology-Hepatology-Nutrition, Hôpital Necker-Enfants Malades, Université Paris Descartes, Paris, France
| | - Sabine Abi Abboud
- Department of Pediatric Gastroenterology-Hepatology-Nutrition, Hôpital Necker-Enfants Malades, Université Paris Descartes, Paris, France
| | - Laurence Barbot-Trystram
- Department of Coprology, Assistance Publique-Hôpitaux de Paris, Hopital de la Pitié-Salpêtrière and Université Paris Descartes, Paris, France
| | - Alberto Ferrari
- FROM Research Foundation (Fondazione per la Ricerca Ospedale Maggiore), ASST Papa Giovanni XXIII, Bergamo, Italy
| | - Cécile Talbotec
- Department of Pediatric Gastroenterology-Hepatology-Nutrition, Hôpital Necker-Enfants Malades, Université Paris Descartes, Paris, France
| | - Nathalie Kapel
- Department of Coprology, Assistance Publique-Hôpitaux de Paris, Hopital de la Pitié-Salpêtrière and Université Paris Descartes, Paris, France
| | - Benedicte Pigneur
- Department of Pediatric Gastroenterology-Hepatology-Nutrition, Hôpital Necker-Enfants Malades, Université Paris Descartes, Paris, France
| | - Olivier Goulet
- Department of Pediatric Gastroenterology-Hepatology-Nutrition, Hôpital Necker-Enfants Malades, Université Paris Descartes, Paris, France
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Teresa C, Antonella D, de Ville de Goyet Jean. New Nutritional and Therapeutical Strategies of NEC. Curr Pediatr Rev 2019; 15:92-105. [PMID: 30868956 DOI: 10.2174/1573396315666190313164753] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/05/2018] [Revised: 10/09/2018] [Accepted: 03/06/2019] [Indexed: 11/22/2022]
Abstract
Necrotizing enterocolitis (NEC) is an acquired severe disease of the digestive system affecting mostly premature babies, possibly fatal and frequently associated to systemic complications. Because of the severity of this condition and the possible long-term consequences on the child's development, many studies have aimed at preventing the occurrence of the primary events at the level of the bowel wall (ischemia and necrosis followed by sepsis) by modifying or manipulating the diet (breast milk versus formula) and/or the feeding pattern (time for initiation after birth, continuous versus bolus feeding, modulation of intake according clinical events). Feeding have been investigated so far in order to prevent NEC. However, currently well-established and shared clinical nutritional practices are not available in preventing NEC. Nutritional and surgical treatments of NEC are instead well defined. In selected cases surgery is a therapeutic option of NEC, requiring sometimes partial intestinal resection responsible for short bowel syndrome. In this paper we will investigate the available options for treating NEC according to the Walsh and Kliegman classification, focusing on feeding practices in managing short bowel syndrome that can complicate NEC. We will also analyze the proposed ways of preventing NEC.
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Affiliation(s)
- Capriati Teresa
- Artificial Nutrition in Pediatric Children's Hospital, Bambino Gesu, Rome, Italy
| | - Diamanti Antonella
- Artificial Nutrition in Pediatric Children's Hospital, Bambino Gesu, Rome, Italy
| | - de Ville de Goyet Jean
- Pediatric Department for the Treatment and Study of abdominal Disease and Abdominal Transplants, ISMETT-UPMC, Palermo, Italy
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Dietary Fatty Acids Sustain the Growth of the Human Gut Microbiota. Appl Environ Microbiol 2018; 84:AEM.01525-18. [PMID: 30242004 DOI: 10.1128/aem.01525-18] [Citation(s) in RCA: 57] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2018] [Accepted: 08/27/2018] [Indexed: 02/07/2023] Open
Abstract
While a substantial amount of dietary fats escape absorption in the human small intestine and reach the colon, the ability of resident microbiota to utilize these dietary fats for growth has not been investigated in detail. In this study, we used an in vitro multivessel simulator system of the human colon to reveal that the human gut microbiota is able to utilize typically consumed dietary fatty acids to sustain growth. Gut microbiota adapted quickly to a macronutrient switch from a balanced Western diet-type medium to its variant lacking carbohydrates and proteins. We defined specific genera that increased in their abundances on the fats-only medium, including Alistipes, Bilophila, and several genera of the class Gammaproteobacteria In contrast, the abundances of well-known glycan and protein degraders, including Bacteroides, Clostridium, and Roseburia spp., were reduced under such conditions. The predicted prevalences of microbial genes coding for fatty acid degradation enzymes and anaerobic respiratory reductases were significantly increased in the fats-only environment, whereas the abundance of glycan degradation genes was diminished. These changes also resulted in lower microbial production of short-chain fatty acids and antioxidants. Our findings provide justification for the previously observed alterations in gut microbiota observed in human and animal studies of high-fat diets.IMPORTANCE Increased intake of fats in many developed countries has raised awareness of potentially harmful and beneficial effects of high fat consumption on human health. Some dietary fats escape digestion in the small intestine and reach the colon where they can be metabolized by gut microbiota. We show that human gut microbes are able to maintain a complex community when supplied with dietary fatty acids as the only nutrient and carbon sources. Such fatty acid-based growth leads to lower production of short-chain fatty acids and antioxidants by community members, which potentially have negative health consequences on the host.
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Carrott P, Pearlman M, Allen K, Suwanabol P. Disease-Specific Diets in Surgical Diseases. CURRENT SURGERY REPORTS 2018. [DOI: 10.1007/s40137-018-0214-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
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Jeppesen PB, Fuglsang KA. Nutritional Therapy in Adult Short Bowel Syndrome Patients with Chronic Intestinal Failure. Gastroenterol Clin North Am 2018; 47:61-75. [PMID: 29413019 DOI: 10.1016/j.gtc.2017.10.004] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
Intestinal failure (IF) is the reduction of gut function below the minimum necessary for the absorption of macronutrients and/or water and electrolytes, such that parenteral support (PS) is required to maintain health and/or growth. This article critically revises the gaps in and evidence for providing general nutritional therapy recommendations in the Short Bowel Syndrome-IF population. It addresses the need for an individualized approach, aiming to reduce or even eliminate the need for PS, and emphasizes a need to focus on effects of dietary interventions on the quality of life of these patients.
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Affiliation(s)
- Palle Bekker Jeppesen
- Department of Medical Gastroenterology, University Hospital of Copenhagen, Rigshospitalet, Blegdamsvej 9, Copenhagen 2100, Denmark.
| | - Kristian Asp Fuglsang
- Department of Medical Gastroenterology, University Hospital of Copenhagen, Rigshospitalet, Blegdamsvej 9, Copenhagen 2100, Denmark
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41
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Freeman AJ, Hofmekler T, Berauer JP, Palle S. Update in Pediatric Gastroenterology, Hepatology and Nutrition. UPDATE IN PEDIATRICS 2018:267-311. [DOI: 10.1007/978-3-319-58027-2_10] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/03/2025]
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Werner K, Küllenberg de Gaudry D, Taylor LA, Keck T, Unger C, Hopt UT, Massing U. Dietary supplementation with n-3-fatty acids in patients with pancreatic cancer and cachexia: marine phospholipids versus fish oil - a randomized controlled double-blind trial. Lipids Health Dis 2017; 16:104. [PMID: 28578704 PMCID: PMC5455128 DOI: 10.1186/s12944-017-0495-5] [Citation(s) in RCA: 64] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2017] [Accepted: 05/23/2017] [Indexed: 01/24/2023] Open
Abstract
BACKGROUND Like many other cancer patients, most pancreatic carcinoma patients suffer from severe weight loss. As shown in numerous studies with fish oil (FO) supplementation, a minimum daily intake of 1.5 g n-3-fatty acids (n-3-FA) contributes to weight stabilization and improvement of quality of life (QoL) of cancer patients. Given n-3-FA not as triglycerides (FO), but mainly bound to marine phospholipids (MPL), weight stabilization and improvement of QoL has already been seen at much lower doses of n-3-FA (0,3 g), and MPL were much better tolerated. The objective of this double-blind randomized controlled trial was to compare low dose MPL and FO formulations, which had the same n-3-FA amount and composition, on weight and appetite stabilization, global health enhancement (QoL), and plasma FA-profiles in patients suffering from pancreatic cancer. METHODS Sixty pancreatic cancer patients were included into the study and randomized to take either FO- or MPL supplementation. Patients were treated with 0.3 g of n-3-fatty acids per day over six weeks. Since the n-3-FA content of FO is usually higher than that of MPL, FO was diluted with 40% of medium chain triglycerides (MCT) to achieve the same capsule size in both intervention groups and therefore assure blinding. Routine blood parameters, lipid profiles, body weight, and appetite were measured before and after intervention. Patient compliance was assessed through a patient diary. Quality of life and nutritional habits were assessed with validated questionnaires (EORTC-QLQ-C30, PAN26). Thirty one patients finalized the study protocol and were analyzed (per-protocol-analysis). RESULTS Intervention with low dose n-3-FAs, either as FO or MPL supplementation, resulted in similar and promising weight and appetite stabilization in pancreatic cancer patients. MPL capsules were slightly better tolerated and showed fewer side effects, when compared to FO supplementation. CONCLUSION The similar effects between both interventions were unexpected but reliable, since the MPL and FO formulations caused identical increases of n-3-FAs in plasma lipids of included patients after supplementation. The effects of FO with very low n-3-FA content might be explained by the addition of MCT. The results of this study suggest the need for further investigations of marine phospholipids for the improvement of QoL of cancer patients, optionally in combination with MCT.
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Affiliation(s)
- Kristin Werner
- Institute of Surgical Pathology, Medical Center-University of Freiburg, Freiburg, Germany. .,Institute of Pharmaceutical Science, University of Freiburg, Freiburg, Germany. .,Tumor Biology Center Freiburg, Freiburg, Germany.
| | - Daniela Küllenberg de Gaudry
- Cochrane Germany, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany.,Tumor Biology Center Freiburg, Freiburg, Germany.,Cochrane Deutschland, Universitätsklinikum Freiburg, Breisacher Str. 153, D - 79110, Freiburg, Germany
| | - Lenka A Taylor
- Pharmacy, Ruprecht-Karls-University Heidelberg, Heidelberg, Germany.,Tumor Biology Center Freiburg, Freiburg, Germany
| | - Tobias Keck
- Clinic for Surgery, Medical Center University of Lübeck, Lübeck, Germany
| | - Clemens Unger
- Cancer Center Freiburg, Freiburg, Germany.,Tumor Biology Center Freiburg, Freiburg, Germany
| | - Ulrich T Hopt
- Department of Surgery, Medical Center-University of Freiburg, Freiburg, Germany
| | - Ulrich Massing
- Institute of Pharmaceutical Science, University of Freiburg, Freiburg, Germany.,Tumor Biology Center Freiburg, Freiburg, Germany
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Ching YA, Gura K, Modi B, Jaksic T. Pediatric Intestinal Failure: Nutrition, Pharmacologic, and Surgical Approaches. Nutr Clin Pract 2017; 22:653-63. [DOI: 10.1177/0115426507022006653] [Citation(s) in RCA: 48] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022] Open
Affiliation(s)
| | - Kathleen Gura
- Children's Hospital of Boston, Boston, Massachusetts
| | - Biren Modi
- Children's Hospital of Boston, Boston, Massachusetts
| | - Tom Jaksic
- Children's Hospital of Boston, Boston, Massachusetts
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Matarese LE, O'Keefe SJ, Kandil HM, Bond G, Costa G, Abu-Elmagd K. Short Bowel Syndrome: Clinical Guidelines for Nutrition Management. Nutr Clin Pract 2017; 20:493-502. [PMID: 16207689 DOI: 10.1177/0115426505020005493] [Citation(s) in RCA: 62] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023] Open
Abstract
Intestinal failure is a condition in which inadequate digestion or absorption of fluid, electrolytes, and nutrients leads to dehydration or malnutrition. The most common cause of intestinal failure is short bowel syndrome (SBS) defined as <200 cm of functional small intestine. SBS may result from congenital abnormalities or from surgical resection. For the past 3 decades, patients with severe SBS were managed with home parenteral nutrition (HPN). With the emergence of new therapies, the clinician now has multiple options to treat these patients. These include intestinal rehabilitation regimens whereby patients are treated with specialized oral diets, soluble fiber, oral rehydration solutions (ORS), and trophic factors to enhance absorption. There are also a variety of surgical techniques available to preserve intestinal length. Small bowel and multivisceral transplantation has evolved during the last decade to be a valid therapeutic option for those patients who cannot be rehabilitated or who fail HPN. These are interrelated services designed to offer the patient the best therapeutic options to meet their individual needs. This article reviews the principles associated with the nutrition management of this very complex and diverse group of patients.
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Affiliation(s)
- Laura E Matarese
- Intestinal Rehabilitation and Transplant Center, Thomas E. Starzl Transplantation Institute, UPMC Montefiore, 7 South, 3459 Fifth Avenue, Pittsburgh, PA 15213, USA.
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Carroll RE, Benedetti E, Schowalter JP, Buchman AL. Management and Complications of Short Bowel Syndrome: an Updated Review. Curr Gastroenterol Rep 2016; 18:40. [PMID: 27324885 DOI: 10.1007/s11894-016-0511-3] [Citation(s) in RCA: 47] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/06/2023]
Abstract
Short bowel syndrome (SBS) is defined as loss of bowel mass from surgical resection, congenital defects, or disease. Intestinal failure (IF) includes the subset of SBS unable to meet nutrition needs with enteral supplements and requires parenteral nutrition (PN). The parenteral treatment of SBS is now a half-century old. Recent pharmacologic treatment (GLP-2 analogues) has begun to make a significant impact in the care and ultimate management of these patients such that the possibility of reducing PN requirements in formerly PN-dependent patients is a now a real possibility. Finally, newer understanding and possible treatment for some of the complications related to IF have more recently evolved and will be an emphasis of this report. This review will focus on developments over the last 10 years with the goal of updating the reader to new advances in our understanding of the care and feeding of the SBS patient.
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Affiliation(s)
- Robert E Carroll
- Intestinal Rehabilitation and Transplant Center, Departments of Medicine and Surgery, University of Illinois at Chicago and Chicago Veterans Administration Medical Center (West Side Division), 840 South Wood Street (M/C 787), Chicago, IL, 60612, USA.
| | - Enrico Benedetti
- Intestinal Rehabilitation and Transplant Center, Departments of Medicine and Surgery, University of Illinois at Chicago and Chicago Veterans Administration Medical Center (West Side Division), 840 South Wood Street (M/C 787), Chicago, IL, 60612, USA
| | - Joseph P Schowalter
- Intestinal Rehabilitation and Transplant Center, Departments of Medicine and Surgery, University of Illinois at Chicago and Chicago Veterans Administration Medical Center (West Side Division), 840 South Wood Street (M/C 787), Chicago, IL, 60612, USA
| | - Alan L Buchman
- Intestinal Rehabilitation and Transplant Center, Departments of Medicine and Surgery, University of Illinois at Chicago and Chicago Veterans Administration Medical Center (West Side Division), 840 South Wood Street (M/C 787), Chicago, IL, 60612, USA
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Avitzur Y, Courtney-Martin G. Enteral approaches in malabsorption. Best Pract Res Clin Gastroenterol 2016; 30:295-307. [PMID: 27086892 DOI: 10.1016/j.bpg.2016.03.009] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/26/2016] [Accepted: 03/05/2016] [Indexed: 01/31/2023]
Abstract
Enteral autonomy and freedom from parenteral nutrition dependency is the ultimate therapeutic goal in children with intestinal failure. This can be achieved following attainment of bowel adaptation in conditions such as short bowel syndrome. Enteral nutrition is a major therapeutic cornerstone in the management of children with intestinal failure. It promotes physiological development, bowel adaptation and enhances weaning from parenteral nutrition. The optimal method of delivery, type of nutrients, timing of initiation, promotion of feeds and transition to solid food in children with short bowel syndrome are debated. Lack of high quality human data hampers evidence based conclusions and impacts daily practices in the field. Clinical approaches and therapeutic decisions are regularly influenced by expert opinion and center practices. This review summarizes the physiological principles, medical evidence and practice recommendations on enteral nutrition approaches in short bowel syndrome and provides a practical framework for daily treatment of this unique group of patients. Oral and tube feeding, bolus and continuous feeding, type of nutrients, formulas, trace elements and solid food options are reviewed. Future collaborative multicenter, high quality clinical trials are needed to support enteral nutrition approaches in intestinal failure.
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Affiliation(s)
- Yaron Avitzur
- Research Institute, The Hospital for Sick Children, Toronto, Canada; Group for Improvement of Intestinal Function and Treatment (GIFT), The Hospital for Sick Children, Toronto, Canada; Transplant Centre, The Hospital for Sick Children, University of Toronto, Toronto, Canada; Division of Gastroenterology, Hepatology and Nutrition, Department of Pediatrics, The Hospital for Sick Children, University of Toronto, Toronto, Canada.
| | - Glenda Courtney-Martin
- Research Institute, The Hospital for Sick Children, Toronto, Canada; Group for Improvement of Intestinal Function and Treatment (GIFT), The Hospital for Sick Children, Toronto, Canada; Transplant Centre, The Hospital for Sick Children, University of Toronto, Toronto, Canada; The Faculty of Kinesiology and Physical Education, University of Toronto, Toronto, Canada
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47
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Promoting intestinal adaptation by nutrition and medication. Best Pract Res Clin Gastroenterol 2016; 30:249-61. [PMID: 27086889 DOI: 10.1016/j.bpg.2016.03.002] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/28/2016] [Accepted: 03/01/2016] [Indexed: 01/31/2023]
Abstract
The ultimate goal in the treatment of short bowel syndrome is to wean patients off parenteral nutrition, by promoting intestinal adaptation. Intestinal adaptation is the natural compensatory process that occurs after small bowel resection. Stimulating the remaining bowel with enteral nutrition can enhance this process. Additionally, medication can be used to either reduce factors that complicate the adaptation process or to stimulate intestinal adaptation, such as antisecretory drugs and several growth factors. The aim of this review was to provide an overview of the best nutritional strategies and medication that best promote intestinal adaptation.
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48
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Pironi L, Arends J, Bozzetti F, Cuerda C, Gillanders L, Jeppesen PB, Joly F, Kelly D, Lal S, Staun M, Szczepanek K, Van Gossum A, Wanten G, Schneider SM. ESPEN guidelines on chronic intestinal failure in adults. Clin Nutr 2016; 35:247-307. [PMID: 26944585 DOI: 10.1016/j.clnu.2016.01.020] [Citation(s) in RCA: 474] [Impact Index Per Article: 52.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2016] [Accepted: 01/27/2016] [Indexed: 12/11/2022]
Abstract
BACKGROUND & AIMS Chronic Intestinal Failure (CIF) is the long-lasting reduction of gut function, below the minimum necessary for the absorption of macronutrients and/or water and electrolytes, such that intravenous supplementation is required to maintain health and/or growth. CIF is the rarest organ failure. Home parenteral nutrition (HPN) is the primary treatment for CIF. No guidelines (GLs) have been developed that address the global management of CIF. These GLs have been devised to generate comprehensive recommendations for safe and effective management of adult patients with CIF. METHODS The GLs were developed by the Home Artificial Nutrition & Chronic Intestinal Failure Special Interest Group of ESPEN. The GRADE system was used for assigning strength of evidence. Recommendations were discussed, submitted to Delphi rounds, and accepted in an online survey of ESPEN members. RESULTS The following topics were addressed: management of HPN; parenteral nutrition formulation; intestinal rehabilitation, medical therapies, and non-transplant surgery, for short bowel syndrome, chronic intestinal pseudo-obstruction, and radiation enteritis; intestinal transplantation; prevention/treatment of CVC-related infection, CVC-related occlusion/thrombosis; intestinal failure-associated liver disease, gallbladder sludge and stones, renal failure and metabolic bone disease. Literature search provided 623 full papers. Only 12% were controlled studies or meta-analyses. A total of 112 recommendations are given: grade of evidence, very low for 51%, low for 39%, moderate for 8%, and high for 2%; strength of recommendation: strong for 63%, weak for 37%. CONCLUSIONS CIF management requires complex technologies, multidisciplinary and multiprofessional activity, and expertise to care for both the underlying gastrointestinal disease and to provide HPN support. The rarity of the condition impairs the development of RCTs. As a consequence, most of the recommendations have a low or very low grade of evidence. However, two-thirds of the recommendations are considered strong. Specialized management and organization underpin these recommendations.
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Affiliation(s)
- Loris Pironi
- Center for Chronic Intestinal Failure, Department of Digestive System, St. Orsola-Malpighi University Hospital, Bologna, Italy.
| | - Jann Arends
- Department of Medicine, Oncology and Hematology, University of Freiburg, Germany
| | | | - Cristina Cuerda
- Nutrition Unit, Hospital General Universitario Gregorio Marañón, Madrid, Spain
| | - Lyn Gillanders
- Nutrition Support Team, Auckland City Hospital, (AuSPEN) Auckland, New Zealand
| | | | - Francisca Joly
- Centre for Intestinal Failure, Department of Gastroenterology and Nutritional Support, Hôpital Beaujon, Clichy, France
| | - Darlene Kelly
- Division of Gastroenterology and Hepatology, Mayo Clinic College of Medicine, Rochester, MN, USA; Oley Foundation for Home Parenteral and Enteral Nutrition, Albany, NY, USA
| | - Simon Lal
- Intestinal Failure Unit, Salford Royal Foundation Trust, Salford, UK
| | - Michael Staun
- Rigshospitalet, Department of Gastroenterology, Copenhagen, Denmark
| | - Kinga Szczepanek
- General and Oncology Surgery Unit, Stanley Dudrick's Memorial Hospital, Skawina, Poland
| | - André Van Gossum
- Medico-Surgical Department of Gastroenterology, Hôpital Erasme, Free University of Brussels, Belgium
| | - Geert Wanten
- Intestinal Failure Unit, Department of Gastroenterology and Hepatology, Radboud University Nijmegen Medical Centre, Nijmegen, The Netherlands
| | - Stéphane Michel Schneider
- Gastroenterology and Clinical Nutrition, CHU of Nice, University of Nice Sophia Antipolis, Nice, France
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Arora T, Velagapudi V, Pournaras DJ, Welbourn R, le Roux CW, Orešič M, Bäckhed F. Roux-en-Y Gastric Bypass Surgery Induces Early Plasma Metabolomic and Lipidomic Alterations in Humans Associated with Diabetes Remission. PLoS One 2015; 10:e0126401. [PMID: 25946120 PMCID: PMC4422729 DOI: 10.1371/journal.pone.0126401] [Citation(s) in RCA: 53] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2014] [Accepted: 04/01/2015] [Indexed: 12/16/2022] Open
Abstract
Roux-en-Y gastric bypass (RYGB) is an effective method to attain sustained weight loss and diabetes remission. We aimed to elucidate early changes in the plasma metabolome and lipidome after RYGB. Plasma samples from 16 insulin-resistant morbidly obese subjects, of whom 14 had diabetes, were subjected to global metabolomics and lipidomics analysis at pre-surgery and 4 and 42 days after RYGB. Metabolites and lipid species were compared between time points and between subjects who were in remission and not in remission from diabetes 2 years after surgery. We found that the variables that were most discriminatory between time points were decanoic acid and octanoic acid, which were elevated 42 days after surgery, and sphingomyelins (18:1/21:0 and 18:1/23:3), which were at their lowest level 42 days after surgery. Insulin levels were lower at 4 and 42 days after surgery compared with pre-surgery levels. At 4 days after surgery, insulin levels correlated positively with metabolites of branched chain and aromatic amino acid metabolism and negatively with triglycerides with long-chain fatty acids. Of the 14 subjects with diabetes prior to surgery, 7 were in remission 2 years after surgery. The subjects in remission displayed higher pre-surgery levels of tricarboxylic acid cycle intermediates and triglycerides with long-chain fatty acids compared with subjects not in remission. Thus, metabolic alterations are induced soon after surgery and subjects with diabetes remission differ in the metabolic profiles at pre- and early post-surgery time points compared to patients not in remission.
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Affiliation(s)
- Tulika Arora
- Wallenberg Laboratory and Sahlgrenska Center for Cardiovascular and Metabolic Research, Department of Molecular and Clinical Medicine, Institute of Medicine, University of Gothenburg, Gothenburg, Sweden
| | - Vidya Velagapudi
- VTT Technical Research Centre of Finland, Espoo, Finland
- Metabolomics Unit, Institute for Molecular Medicine Finland FIMM, Helsinki, Finland
| | - Dimitri J. Pournaras
- Department of Bariatric Surgery, Musgrove Park Hospital, Taunton, United Kingdom
| | - Richard Welbourn
- Department of Bariatric Surgery, Musgrove Park Hospital, Taunton, United Kingdom
| | - Carel W. le Roux
- Diabetes Complications Research Centre, Conway Institute, School of Medicine and Medical Science, University College Dublin, Dublin, Ireland
- Gastrosurgical Laboratory, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Matej Orešič
- VTT Technical Research Centre of Finland, Espoo, Finland
- Steno Diabetes Center A/S, Gentofte, Denmark
| | - Fredrik Bäckhed
- Wallenberg Laboratory and Sahlgrenska Center for Cardiovascular and Metabolic Research, Department of Molecular and Clinical Medicine, Institute of Medicine, University of Gothenburg, Gothenburg, Sweden
- Novo Nordisk Foundation Center for Basic Metabolic Research, Section for Metabolic Receptology and Enteroendocrinology, Faculty of Health Sciences, University of Copenhagen, Copenhagen, Denmark
- * E-mail:
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Sangild PT, Ney DM, Sigalet DL, Vegge A, Burrin D. Animal models of gastrointestinal and liver diseases. Animal models of infant short bowel syndrome: translational relevance and challenges. Am J Physiol Gastrointest Liver Physiol 2014; 307:G1147-68. [PMID: 25342047 PMCID: PMC4269678 DOI: 10.1152/ajpgi.00088.2014] [Citation(s) in RCA: 53] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
Intestinal failure (IF), due to short bowel syndrome (SBS), results from surgical resection of a major portion of the intestine, leading to reduced nutrient absorption and need for parenteral nutrition (PN). The incidence is highest in infants and relates to preterm birth, necrotizing enterocolitis, atresia, gastroschisis, volvulus, and aganglionosis. Patient outcomes have improved, but there is a need to develop new therapies for SBS and to understand intestinal adaptation after different diseases, resection types, and nutritional and pharmacological interventions. Animal studies are needed to carefully evaluate the cellular mechanisms, safety, and translational relevance of new procedures. Distal intestinal resection, without a functioning colon, results in the most severe complications and adaptation may depend on the age at resection (preterm, term, young, adult). Clinically relevant therapies have recently been suggested from studies in preterm and term PN-dependent SBS piglets, with or without a functional colon. Studies in rats and mice have specifically addressed the fundamental physiological processes underlying adaptation at the cellular level, such as regulation of mucosal proliferation, apoptosis, transport, and digestive enzyme expression, and easily allow exogenous or genetic manipulation of growth factors and their receptors (e.g., glucagon-like peptide 2, growth hormone, insulin-like growth factor 1, epidermal growth factor, keratinocyte growth factor). The greater size of rats, and especially young pigs, is an advantage for testing surgical procedures and nutritional interventions (e.g., PN, milk diets, long-/short-chain lipids, pre- and probiotics). Conversely, newborn pigs (preterm or term) and weanling rats provide better insights into the developmental aspects of treatment for SBS in infants owing to their immature intestines. The review shows that a balance among practical, economical, experimental, and ethical constraints will determine the choice of SBS model for each clinical or basic research question.
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Affiliation(s)
- Per T. Sangild
- 1Department of Nutrition, Exercise and Sports, Faculty of Science, University of Copenhagen, Frederiksberg, Denmark; ,2Department of Paediatrics and Adolescent Medicine, Rigshospitalet, Copenhagen, Denmark;
| | - Denise M. Ney
- 3Department of Nutritional Sciences, University of Wisconsin-Madison, Madison, Wisconsin;
| | | | - Andreas Vegge
- 1Department of Nutrition, Exercise and Sports, Faculty of Science, University of Copenhagen, Frederiksberg, Denmark; ,5Diabetes Pharmacology, Novo Nordisk, Måløv, Denmark; and
| | - Douglas Burrin
- 6USDA-ARS Children's Nutrition Research Center, Baylor College of Medicine, Houston, Texas
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