Immunonutrition in patients undergoing major upper gastrointestinal surgery: a prospective double-blind randomised controlled study.

INTRODUCTION: current studies suggest immunonutrition decreases the inflammatory process, infection rates and reduces length of hospital stay in surgical patients, however studies are often conducted on heterogeneous groups of patients with varying composition of the immuno-nutrition. We aim to investigate the effect of immunonutrition on patients undergoing major upper gastrointestinal surgery by assessment of (i) the inflammatory and immune response and (ii) changes in clinical outcome when compared to a randomised control receiving conventional feeding. METHOD: a prospective double-blind randomised controlled study was undertaken to compare a feed supplemented with glutamine, arginine, -3 fatty acids and tributyrin, vitamin C, E and B-carotene and micronutrients (zinc, selenium and chromium) to an isonitrogenous, isocaloric control feed in patients undergoing major upper GI surgery. The primary end-points were defined as C-reactive protein (CRP), prealbumin and retinol binding protein (RBP) levels. Secondary end-points included performance scoring systems, length of hospital stay, adverse events and protein and nutrient assays. Variables were measured pre-operatively and routinely up to the 4th post-operative day. RESULTS: there was no statistically significant change in primary end-points between the immunonutrition group and the control group. There was no difference in length of hospital stay between the groups. The vitamin C level in the study group was significantly higher at the end of the study period. Both groups tolerated the feeds well with adequate target feeding rate. There were no other significant changes in clinical outcomes between the two groups. CONCLUSION: this study has not shown a benefit of immunonutrition through changes in inflammatory or nutritional markers, a decrease in length of hospital stay, or other morbidity. This may be because of inadequate numbers recruited to the study. Further, multi-centre, randomised trials on homogeneous patient groups are necessary to investigate the role of immunonutrition in major upper GI surgery.

Enteral feeding. Nasogastric, nasojejunal, percutaneous endoscopic gastrostomy, or jejunostomy: its indications and limitations.

The following article is intended to provide a review of the current state of enteral feeding; a rapidly changing and developing field. It covers the type of feed, the routes of access, and the problems that can occur with enteral feeding.

Enteral nutrition by nasojejunal tube in hyperemesis gravidarum.

We describe two cases in which self-propelling, blind placed nasojejunal tubes were placed in severe hyperemesis gravidarum. This method provides an alternative to parenteral nutrition and to percutaneous endoscopic tubes, is well tolerated, cost effective and with a low rate of complication. Both mothers were given nutritional support at home, had normal subsequent pregnancies and normal babies.

Colonic lymphoid hyperplasia in melanosis coli.

We describe the case of a patient with Rett syndrome, a syndrome characterized by progressive infant encephalopathy, developmental delay, dementia, autism, ataxia, microcephaly, spastic paraparesis, and autonomic neuropathy with constipation. At colonoscopy, multiple foci of tiny white, sessile, polypoid lesions were seen throughout the colon and rectum, mimicking the appearances of small hyperplastic or adenomatous polyps, associated with generalized melanosis coli. This is the first case to our knowledge describing melanosis coli in a patient with Rett syndrome. As melanosis pigment deposition is characteristically not seen in lymphoid tissue, the lymphoid tissue was identifiable at endoscopy as multiple white nodules mimicking generalized colonic polyposis throughout the colon. We discuss the likely mechanisms of lymphoid hyperplasia and coexistent melanosis coli in Rett syndrome.

The 'cut and push' method of percutaneous endoscopic gastrostomy tube removal.

BACKGROUND AND AIMS: The standard method of removing percutaneous endoscopic gastrostomy tubes is by gastroscopy. This has implications for endoscopy time and resources, and we believe is not always necessary. Depending on the type of percutaneous endoscopic gastrostomy tube used we often used the 'cut and push' method. This involves cutting the catheter at skin level and allowing the tube and internal bumper to spontaneously pass. The cut and push method also represents a considerable resource saving compared to the endoscopic method that we think warrants further discussion. METHOD: We reviewed all the files of the percutaneous endoscopic gastrostomy tubes removed in our unit over the last 4 years. RESULTS: During the period of July 1995 to July 1999, we have inserted 384 percutaneous endoscopic gastrostomy tubes. Seven tubes have been removed endoscopically and 73 tubes have been removed with the cut and push method. Only two possible complications have been recorded (2.7%). CONCLUSIONS: We believe that we have provided further evidence that percutaneous endoscopic gastrostomy tubes can be removed safely using the cut and push method. Patients who are often frail and who have multiple medical problems are saved an often-long journey to the endoscopy unit as well as the hazards of an endoscopy. The saving in resources in what is already an overworked system by not performing endoscopies is also considerable.

Assessment of the prevalence of infection with Helicobacter pylori in patients with inflammatory bowel disease.

OBJECTIVE: To determine the prevalence of Helicobacter pylori in patients with inflammatory bowel disease (IBD) and compare this to the prevalence in a control population with non-organic bowel symptoms, and to investigate the effect of sulphasalazine and other 5-aminosalicylic acid (5-ASA) drugs on the prevalence of H. pylori in IBD patients. DESIGN: Prospective, controlled trial. SETTING: Gastroenterology out-patient department, City General Hospital, North Staffordshire Hospitals NHS Trust, Stoke-on-Trent. PARTICIPANTS: The population comprised 51 patients with ulcerative colitis, 42 patients with Crohn's disease and 40 patients with irritable bowel syndrome as controls. Patients with X-ray- and/or biopsy-proven disease were eligible to be entered into the study. INTERVENTIONS: Subjects filled in a detailed questionnaire, were assessed for seropositivity of H. pylori and underwent a C13 urea breath test (UBT). MAIN OUTCOME MEASURES: Seropositivity for H. pylori and a positive C13 UBT result. RESULTS: A quarter of the irritable bowel syndrome controls were seropositive for H. pylori. Of the ulcerative colitis patients, 21.6% were currently H. pylori-positive on C13 UBT; 17.6% of the ulcerative colitis patients who had been previously treated with sulphasalazine were positive while 23.1% of the ulcerative colitis patients who had been treated with a non-sulphasalazine 5-ASA drug were positive. Of the Crohn's patients, 11.9% were currently H. pylori-positive; 3.6% of the Crohn's patients who had been previously treated with sulphasalazine were positive while 12.5% of the Crohn's patients who had been treated with a non-sulphasalazine 5-ASA drug were positive. CONCLUSIONS: Patients with IBD and Crohn's disease in particular were less likely to be H. pylori-positive than controls. Sulphasalazine treatment further decreased the prevalence of H. pylori, although the reduced prevalence of H. pylori in IBD patients could not be accounted for by this alone.

A case of peripartum eosinophilic myocarditis.

A 19-year-old postpartum patient with a previous history of asthma and eosinophilic myocarditis is described. Eosinophilic myocarditis is thought to be caused by exacerbation of the idiopathic hypereosinophilic syndrome by pregnancy. The diagnosis was made by a right ventricular endomyocardial biopsy, which showed an eosinophilic infiltrate with a few scattered foci of myonecrosis, but no fibrosis, vasculitis or granulomas. The patient's myocardial function continued to decline over a two-year follow-up period, despite normal levels of eosinophils. She developed echocardiographic evidence of diastolic and systolic dysfunction.