ACE inhibitor-induced angioedema causing small bowel obstruction.

Mucosal angioedema of the face, lips, tongue, and throat is a well-recognized adverse reaction to angiotensin-converting enzyme (ACE) inhibitors that is experienced by a minority of patients. Rarely, this angioedema can involve the small bowel, and patients commonly present with abdominal pain and small bowel obstruction. Due to the increasing number of patients being treated for hypertension, clinicians should consider the diagnosis of small bowel angioedema secondary to ACE inhibitor use in all patients with this presentation who are using this class of medications.

Palliative home parenteral nutrition in patients with ovarian cancer and malignant bowel obstruction: experiences of women and family caregivers.

BACKGROUND: Malnutrition is a problem in advanced cancer, particularly ovarian cancer where malignant bowel obstruction (MBO) is a frequent complication. Parenteral nutrition is the only way these patients can received adequate nutrition and is a principal indication for palliative home parenteral nutrition (HPN). Giving HPN is contentious as it may increase the burden on patients. This study investigates patients' and family caregivers' experiences of HPN, alongside nutritional status and survival in patients with ovarian cancer and MBO. METHODS: This mixed methods study collected data on participant characteristics, clinical details and body composition using computed tomography (CT) combined with longitudinal in-depth interviews underpinned by phenomenological principles. The cohort comprised 38 women with ovarian cancer and inoperable MBO admitted (10/2016 to 12/ 2017) to a tertiary referral hospital. Longitudinal interviews (n = 57) were carried out with 20 women considered for HPN and 13 of their family caregivers. RESULTS: Of the 38 women, 32 received parenteral nutrition (PN) in hospital and 17 were discharged on HPN. Nutritional status was poor with 31 of 33 women who had a CT scan having low muscle mass, although 10 were obese. Median overall survival from admission with MBO for all 38 women was 70 days (range 8-506) and for those 17 on HPN was 156 days (range 46-506). Women experienced HPN as one facet of their illness, but viewed it as a "lifeline" that allowed them to live outside hospital. Nevertheless, HPN treatment came with losses including erosion of normality through an impact on activities of daily living and dealing with the bureaucracy surrounding the process. Family caregivers coped but were often left in an emotionally vulnerable state. CONCLUSIONS: Women and family caregivers reported that the inconvenience and disruption caused by HPN was worth the extended time they had at home.

Ultrasound follow-up in a patient with intestinal obstruction due to post-traumatic intramural duodenal hematoma.

We report the case of a 7-year-old girl with intestinal obstruction due to post-traumatic intramural duodenal hematoma. She had fallen from the monkey bars the day before presenting to our hospital, and was admitted with signs of abdominal pain, vomiting, and nausea. Abdominal ultrasonography, computed tomography (CT), and magnetic resonance imaging (MRI) demonstrated a heterogeneous solid mass located within the duodenal wall, compressing the descending part of the duodenum. The inferior vena cava was also compressed by the mass lesion, although no associated symptoms were evident. Based on these findings, the mass lesion was considered to represent intramural hematoma causing intestinal obstruction. She was managed conservatively with total parenteral nutrition. Although CT and MRI are useful for differentiating hematoma from other intestinal tumors, ultrasonography is minimally invasive and easier to perform repeatedly. In case of duodenal hematoma, ultrasonography may be quite helpful for diagnosis and follow-up by monitoring tumor size and characteristics, and the degree of duodenal compression during conservative treatment.

Nutrition and pancreatic enzyme intake in patients with cystic fibrosis with distal intestinal obstruction syndrome.

BACKGROUND: The etiology of distal intestinal obstruction syndrome (DIOS) remains unclear. Food intake and pancreatic enzyme replacement therapy (PERT) are often blamed for its occurrence. This study evaluates the nutrition intake and PERT of patients with cystic fibrosis (CF) at a first episode of DIOS. METHODS: All patients with CF perform annually a 3-day intake diary to evaluate their caloric, protein, fat, dietary fiber, liquid, and PERT intake. Patients diagnosed with a first episode of DIOS (n = 12) retrospectively completed an intake diary of the 3 days preceding the DIOS episode supervised by an expert dietitian. RESULTS were compared with those of 1 year before and also with 36 CF controls matched for age, sex, genotype, and disease severity. All were pancreatic insufficient. RESULTS: A first DIOS episode was diagnosed in 12 patients with CF. Only the absolute median fat intake (P = .015) and pancreatic enzyme intake (P = .035) were higher at the time of the DIOS attack in comparison to the preceding year. This could result from the difference in data collection or from the recommendations to increase fat intake and concomitant enzyme intake, since this trend was also found in the control group. The significant difference disappears when enzyme intake is expressed as units of lipase/g of fat. No other significant dietary differences were found. CONCLUSIONS: This study provides no indications for a potential role of nutrition factors or pancreatic enzymes in the first occurrence of DIOS.

Minimizing unnecessary parenteral nutrition after appendectomy in children.

BACKGROUND: Consensus guidelines have indicated that postoperative parenteral nutrition (PN) might provide benefit when patients are expected to be nil per os (NPO) ≥7 d and when PN is administered ≥5 d. We hypothesized that most children receiving PN after appendectomy do not satisfy these criteria. METHODS: The medical records of the patients who had undergone appendectomy for perforated appendicitis from 2006-2011 were analyzed, and the proportion meeting the criteria for beneficial PN was determined. The clinical parameters independently associated with the criteria for beneficial PN (PN therapy ≥5 d, ileus ≥5 d, NPO ≥7 d) were identified using multiple regression analysis. RESULTS: A total of 1612 patients were treated for appendicitis. Of these, 587 met the inclusion criteria (age <16 y, perforated appendicitis, appendectomy within 24 h, no previous indication for PN). Of the 587 patients, 12.1% received PN; 43.8% of these received PN for ≥5 d. The predictors of PN duration of ≥5 d included preoperative symptoms for ≥3 d (P < 0.01) and initiation of PN by postoperative day 3 (P = 0.047). Preoperative symptoms for ≥3 d, imaging showing a discrete abscess or bowel obstruction, and operative findings of diffuse peritonitis predicted ileus of ≥5 d and NPO of ≥7 d (P < 0.01 for all). Major complications were more common in patients with ileus lasting ≥5 d. CONCLUSIONS: Fewer than one-half of patients receiving PN in the present cohort met the consensus-based guidelines for postoperative PN. The preoperative symptom duration, preoperative imaging findings demonstrating abscess and/or bowel obstruction, and intraoperative findings of diffuse peritonitis might predict prolonged ileus and longer recovery periods for children undergoing surgery for perforated appendicitis.

[Treatment of intestinal insufficiency syndrome in patients with peritonitis]. / Lechenie sindroma kishechnoi nedostatochnosti u bol'nykh s peritonitom.

Results of the treatment of 90 patients with generalized peritonitis and syndrome of intestinal insufficiency were analyzed. In the study group (45 patients) enteral administration of 1% pectin solution and glutamin solution (15-30 g/day) were included in combined therapy. Clinical and laboratory control, radiation monitoring and bacteriological studies carried out for evaluation of efficacy of therapy established. A decrease of endogenous intoxication and time of repair of functional activity of the gastrointestinal tract, immunomodulation, normalization of microbiocenosis of the small intestine. This therapy diminishes the number of complications and lethality.

Can a soft diet prevent bowel obstruction in advanced pancreatic cancer?

Although many patients are advised to follow a high-fiber diet to avoid constipation, it seems that a soft diet such as that recommended after bowel surgery may well be more helpful in avoidance of intestinal obstruction.

Technically difficult colonoscopy, a non-radiologic sign of sigmoidal obstruction: value of sigmoid colectomy for intractable symptoms.

Technical difficulty in passing the colonoscope was assessed in 371 patients undergoing 627 colonoscopies during 1989-91 and were graded as 0: no difficulty and cecum reached (71.43%); 1: difficult but cecum reached (20.22%); 2: difficult and cecum not reached although lumen beyond seen (4.85%); and 3: difficult and cecum not reached as lumen beyond could not be seen (3.5%). Frequency of patients with chronic lower abdominal pain and/or disturbed bowel habits in each grade increased as grade of obstruction increased: 0 (25.66%), 1 (36%), 2 (77.77%), and 3 (100%). During 1983-91, 54 patients with lower abdominal pain and/or disturbed bowel habits for a mean of 30.5 months, unresponsive to conventional medical measures, and who also had a grade 2 or 3 sigmoidal obstruction, elected to undergo sigmoid colectomy. Operative and pathologic studies showed that the primary cause was fixation of the sigmoid colon to the pelvis in two or three loops by adhesions from previous pelvic surgery, endometriosis, ovarian cyst, or diverticulitis. All patients had relief of symptoms that was maintained during the 1-9 year follow-up.

[Pathophysiological substantiation of using fasting-diet therapy in the treatment of certain categories of patients]. / Patofiziologicheskoe obosnovanie primeneniia razgruzochno-dieticheskoi terapii dlia lecheniia nekotorykh kategoriibol'nykh.

It is not advisable to prescribe any types of the diet to patients with acute surgical diseases of the abdominal cavity in the early postoperative period because of membranous digestion disturbances and intestinal motility dysfunction. The fasting of the patients with the normal nutritional status may be based physiologically in such cases till the recovery of digestive function, since it favours significant desensitization, namely a decrease of the number of postoperative complications and creation of functional rest for the intestine.

The age-related incidence of meconium ileus equivalent in a cystic fibrosis population: the impact of high-energy intake.

During the decade from 1976 to 1986, the age-related incidence of meconium ileus equivalent (MIE) was calculated on the basis of 240 Danish cystic fibrosis (CF) patients. In the first 5 years, the patients were given enteric-coated granules of pancreatic enzymes (Pancreatin, Rosco, Denmark), and a low fat diet was recommended. In the last 5 years, the Center recommended supplementation with acid-resistant, enteric-coated, encapsulated microspheres (Pancrease, Cilag, Birkerød, Denmark), and high-energy intake with a 40% fat content and no dietary restrictions. There was no difference in the incidence of MIE when these two 5-year periods were compared, and the overall incidence of MIE was low (5.4 MIEs/1,000 patient years). This may, at least in part, be due to the rather high intake of exocrine pancreas enzyme supplementation (EPES) (a mean intake of 0.9 capsules/kg/day). MIE occurred almost exclusively among patients greater than 15 years old and peaked in young adults aged 20-25 years (35.5 MIEs/1,000 patient years). The daily intake of EPES/kg of body weight declined significantly with age, and the patients who developed MIE received even less than average per day. Both of these points strengthen the view that a low enzyme dosage is likely to have an effect on the incidence of MIE.

[Status of elemental diets in the therapy of Crohn disease in childhood]. / Stellung von Elementardiäten in der Therapie des Morbus Crohn im Kindesalter.

Since the seventieth low molecular weight formulas, "elemental diets", are applied in acute Crohn's disease in addition to drug therapy. In small bowel involvement, therapeutic efficiency in active disease is as good as salazosulfapyridine combined with corticosteroids. Physiological changes under elemental diet have been reported: decrease of gastric and pancreatic secretion, changes of bacterial bowel flora and in patients with Crohn's disease decreased fecal bile acid excretion and decreased intestinal losses of lymphocytes were described. Further, the absence of allergens in the formula and the quick and complete resorption are discussed to be important to clinical improvement in Crohn's disease. Indications for elemental diet are acute small bowel disease, intestinal obstruction, malnourishment and growth retardation. Further studies are needed to examine if elemental diets are effective in gastrointestinal fistulas and extraintestinal symptoms in Crohn's disease.

Bran diet for an earlier resolution of post-operative ileus.

The effect of a pre-operative high fibre diet on the resolution of ileus following cholecystectomy has been evaluated. The time needed to restore canalization of the gastro-intestinal tract has been compared in two random groups of patients (a total of thirty-eight) one treated with wheat bran and the other as control without the diet supplementation. The average persistence of ileus was 24 hours in the treated group and 54 hours in the control group. These results suggest that a bran-enriched diet could be an inexpensive and simple treatment to shorten the duration of ileus after abdominal surgery.

Cardiac arrest in two children with nonfamilial chronic intestinal pseudoobstruction on total parenteral nutrition.

Two children with nonfamilial chronic intestinal pseudoobstruction are reported. Both had no family history. They had an exploratory laparotomy to rule out mechanical intestinal obstruction, and required long-term parenteral nutrition to obtain sufficient nutrients. These two children had dilatation of the whole length of the small intestine, which differs from short segmental dilatation (megaduodenum) in patients with familial chronic intestinal pseudoobstruction. There were also differences in the histology of the gastrointestinal tract between these two patients although they had similar clinical manifestations. Both patients died from cardiac arrest, one after 2 years and the other after 4 months on long-term parenteral hyperalimentation. At autopsy, heart examination was normal in one patient, and a small infarction (0.4 mm diameter) was found in the other. Although mild hypokalemia was found in one case, and mild hyperkalemia in the other, the cause of cardiac arrest in these two children is not known.

Total management of short gut secondary to midgut volvulus without prolonged total parenteral alimentation.

Absorption studies in rats have shown that intestinal adaptation after catastrophic injury can be stimulated by early enteral feeding. Using this concept, we have devised a technique of early initiation and advancement of oral feedings that begins with Cho-Free and Polycose and gradually adds sucrose and MCT in increasing proportions. The increasing complexity and caloric density of this diet provide sufficient nutrition to allow weaning from total parenteral alimentation within 2--3 wk. Our preliminary experience in babies with midgut volvulus, necrotizing enterocolitis, and gastroschisis has been successful and uncomplicated. These patients have demonstrated consistent weight gain and have been spared the complications associated with prolonged parenteral alimentation.