ESPEN Guidelines on Enteral Nutrition: Gastroenterology.

Undernutrition as well as specific nutrient deficiencies have been described in patients with Crohn's disease (CD), ulcerative colitis (UC) and short bowel syndrome (SBS). The present guideline gives evidence-based recommendations for the indication, application and type of formula of enteral nutrition (EN) (oral nutritional supplements (ONS) or tube feeding (TF)) in these patients. It was developed in an interdisciplinary consensus-based process in accordance with officially accepted standards and is based on all relevant publications since 1985. ONS and/or TF in addition to normal food is indicated in undernourished patients with CD or CU to improve nutritional status. In active CD EN is the first line therapy in children and should be used as sole therapy in adults mainly when treatment with corticosteroids is not feasible. No significant differences have been shown in the effects of free amino acid, peptide-based and whole protein formulae for TF. In remission ONS is recommended only in steroid dependent patients in CD. In patients with SBS TF should be introduced in the adaptation phase and should be changed with progressing adaptation to ONS in addition to normal food.

The effect of trospium chloride on oesophageal motility.

Trospium chloride is a muscarinergic antagonist acting on oesophageal smooth muscle and on ganglionic and/or myenteric neurons. The effect of this drug on oesophageal motility was tested in 16 healthy male subjects in a double-blind randomized cross-over examination of trospium chloride or placebo following phentolamine or placebo application. Each subject underwent two separate investigations at least one week apart. Trospium chloride was effective in the oesophagus to reduce contractile activity (amplitude and duration of peristalsis) in all parts of the oesophageal body, and this effect was not blocked by phentolamine. Its potent action and its minor side-effects appear to be promising for clinical use in patients with motility disorders such as the hypercontractile oesophagus.

Effects of nutrient solutions on concentration analysis of non-absorbable dilution markers--implications for studies of gastric emptying.

Gastrointestinal luminal contents may interfere with concentration analysis of non-absorbable dyes. However, non-absorbable markers are broadly used for studies of gastric emptying rates of nutrient solutions. This prompted us to evaluate the properties of non-absorbable markers to mark such nutrient solutions. In vitro concentrations of polyethylene glycol, phenol red, dextran blue, two anthroquinone dyes and inulin were determined spectrophotometrically in the presence or absence of a formula diet, single compounds of the diet or an oligo-peptide diet, and the reproducibility and validity of the analyses were evaluated. The presence of the formula diet or the oligopeptide diet seriously impaired the analyses of marker concentrations, whereas single nutrient compounds did not uniformly interfere. The analysis of polyethylene glycol and phenol red concentrations was impaired by proteins, while the analysis of inulin concentration was impaired by carbohydrates. Dextran blue and the anthroquinones were completely eliminated by protein-precipitation procedures. In conclusion, phenol red and polyethylene glycol should only be used as marker substances for protein-free meals or nutrient solutions, while inulin should not be used with meals or nutrient solutions containing carbohydrates. Marker dilution techniques cannot be recommended for measurements of gastric emptying rates of complete meals.

Comparison between intraluminal multiple electric impedance measurement and manometry in the human oesophagus.

Conventional oesophageal manometry and intraluminal electrical impedance measurement were simultaneously applied in eight healthy volunteers to study the effect of wet and semisolid bolus viscosities on oesophageal motility and bolus transit. Contraction front velocity measured by electrical impedance and manometry were identical for wet and semisolid swallows and highly associated. Bolus front velocity as measured by electrical impedance was significantly faster than contraction front velocity in both wet and semisolid swallows. Bolus front velocity during semisolid swallows was significantly slower compared to wet swallows. It is concluded that intraluminal electrical impedance measurement is a reliable technique to detect oesophageal motility as well as to differentiate between transit of wet and semisolid bolus consistencies.

Palliative treatment of malignant esophageal stenosis: experience with plastic versus metal stents.

BACKGROUND/AIMS: We report on the palliative treatment of 44 patients with malignant dysphagia by placement of plastic (Celestin tubes, n = 24) vs metal stents (Wall stents, Nitinol stents, Gianturco stents, n = 20). METHODOLOGY: Prior to stent insertion, esophageal stenosis was dilated stepwise to 16 mm (plastic tube) and to 10 mm (metal stent). RESULTS: Stent insertion was technically successful in all cases and led to a reduction of dysphagia. Risk of perforation was comparable in both groups (n = 1 in each group). Most of the plastic stents were placed when the tumor was localized in the proximal part of the esophagus close to the upper esophageal sphincter, when esophageal-bronchial fistula was present and in the risk of fistula development after radiation. During follow-up, tumor ingrowth (TI) and stent migration (SM) were the major complications. Whereas tumor ingrowth predominantly occurred in metal stents (TI after 6 weeks, 45% vs. SM, 10%) that required repeated argon beamer therapy, tube migration and bolus impaction (BI) often occurred in patients with plastic stents (TI, 0% vs. SM, 16%; BI, 4%). CONCLUSIONS: The findings of the study suggest that the decision whether plastic tubes or metal stents used should be taken individually considering tumor localization, axis deviation and the presence of esophago-respiratory fistulas. When stepwise dilation of malignant stenoses is performed carefully, perforation risk appears not to be different between placement of plastic prostheses and metal stents.

[Endoscopic ultrasound in routine clinical practice for staging adenocarcinomas of the stomach and distal esophagus]. / Endosonographie in der klinischen Routine beim Adenokarzinom des distalen Osophagus und Magens. Eine ernüchternde Bilanz.

PROBLEM: Endoscopic ultrasound (EUS) is an important diagnostic tool for determining the best therapeutic strategy (primary resection, neoadjuvant therapy or palliation only) to offer esophageal or gastric cancer patients. PATIENTS AND METHODS: In the present study (1992-2001),we evaluated the accuracy of EUS in adenocarcinomas of the distal esophagus and stomach and compared our results with pathologists findings as the gold standard. RESULTS: Of the 222 patients studied, the precise examination of 11% EUS was not completely possible due to severe tumor stenosis. The accuracy of EUS with respect to T, N+/- and TN+/- amounted to 51%, 65% and 34% in 131 patients with adenocarcinomas of the esophageal gastric junction and to 50%, 66% and 37% in 91 patients with adenocarcinomas located in the fundus, corpus or antrum of the stomach respectively. With respect to T-stage, the overstaging of tumors was more common than understaging, especially in pT2b-carcinomas. The subgroup analysis of the 131 EGJ adenocarcinoma patients showed that the results obtained by EUS were slightly better in type I (distal esophageal cancer) than in type II and III cardia carcinomas (proximal gastric cancer).When comparing two observation periods (1992-1996 and 1997-2001), the accuracy of endoscopic ultrasound staging was very similar in both periods for T-category (51% vs 49%) and N-category (63% vs 64%) as well as for combined TN-staging (36% vs 35%) respectively. CONCLUSIONS: In clinical routine examinations of adenocarcinomas of the stomach and the distal esophagus, the accuracy of EUS is not as good as the excellent results in the past--mostly obtained under study conditions--may suggest.

[Irritable colon and colonic disease due to laxatives]. / Colon irritabile und Laxantienkolon.

Diarrhea of colonic origin is fairly common in irritable colon and after long term abuse of laxatives. This form of diarrhea causes difficulties not only in diagnosis but also in treatment. Irritable colon is a functional disorder sometimes involving other segments of the bowel. The term "irritable bowel disease" is thus more appropriate. Extraintestinal symptoms are in addition quite common. Although the diagnosis can be established with great reliability using an index we consider some laboratory tests, recto-sigmoidoscopy and abdominal sonography essential to rule out organic lesions. Therapy comprises (small) psychotherapy, dietary measures and eventually transient medication. Symptoms usually persist but tolerance of the disorder should be improved. Laxative-induced colonic dysfunction results usually from false assumptions about normal defecation. Loss of water and potassium deteriorates the symptomatology leading to a vicious circle. Alterations of neurons in the enteric nervous system of the colon can be the cause but eventually the consequence of chronic intake of laxatives. Hidden abuse of laxatives can cause great diagnostic difficulties. The therapy of choice is weaning which usually is only possible gradually. Cisapride can be a useful adjuvant.

[Enteral feeding]. / Enterale Ernährung.

In patients with normal gastrointestinal functions, enteral nutrition is safe, efficious and inexpensive. The knowledge of enteral products and the correct selection of application techniques are important for a successful therapy. Long-term enteral nutrition of different subgroups of patients is possible by percutaneous endoscopic gastrostomy (PEG). Many complications may be avoided by changing the modalities of application.

[Protection of the mucosal barrier by nutritional strategies. What are the therapeutic options?]. / Protektion der Mukosabarriere durch Strategien der Ernährung. Welche therapeutischen Optionen gibt es?

The dysfunction of intestinal barrier allows the translocation of both endotoxin and whole bacterial organisms. It plays an important role in the development of multiple organ failure (MOF). The mucosa ia one component of this barrier. Trauma, atrophy and the "systemic inflammatory response syndrome" increase gastrointestinal permeability. These abnormalities may contribute to the pathophysiology of sepsis. Malnutrition per se compromises the gut's barrier function. Maintenance of gastrointestinal blood flow may be facilitated by (glutamine-enriched?) enteral diets. The most important conclusions of the majority of controlled trials support the concept of the very early enteral nutrition (within 24 hours after trauma): the outcome of seriously ill patients is improved, the rate of complications and infections is reduced. Gastrointestinal motility disorders may interfere with the initiation and tolerance of early enteral nutrition. They may be managed by prokinetic agents (cisapride, erythromycin) or by bypassing the stomach with a nasoenteric tube.

[Motility and peptic ulcer--possible pathogenetic relations]. / Motilität und peptisches Ulkus--Mögliche pathogenetische Verbindungen.

The most important causes of peptic ulcers are increased gastric acid secretion, impaired mucosal circulation and damages to the mucosa. In contrast, motility plays only a minor role. The following motility disturbances are discussed in peptic ulcers: 1. Impaired gastric emptying may favor the development of gastric ulceration, if it is grossly delayed, and that of duodenal ulceration, if it is inappropriately accelerated. 2. Disturbances of duodenal motility in the fasted state may disturb bicarbonate secretion and, thus, become theoretically ulcerogenic. 3. Duodenogastric reflux has been discussed as a cause of gastric ulceration for a long time; yet, the proof is still missing. 4. According to own studies gastric ulcer is frequently accompanied by morphological and functional changes in the antrum; the cause-effect relationship, however, has yet to be elucidated.

[Diet therapy in cancer]. / Ernährungstherapie bei Tumorerkrankungen.

Cancer cachexia is a syndrome with weight loss, anorexia, and loss of host body cell mass. Tumor cachexia may be an early symptom of a neoplasm. Low food intake is the main reason for weight loss. Surgery, chemotherapy and radiation remain primary therapeutic modalities to overcome cancer cachexia. Artificial nutrition is able to avoid progressive weight loss; nutrition alone may not preserve fat-free body cell mass. Parenteral nutrition reduces perioperative morbidity and mortality. Nutritional support failed to show a benefit in patients with malignancies which are treated with therapeutic radiation or chemotherapy. For patients with unresectable neoplasms of the upper GI-tract conventional palliative regimens (bougienage, laser, etc.) do not support a satisfactory nutritional state. Ambulatory enteral tube feeding via percutaneous endoscopic gastrotomy (PEG) as an adjunct to therapy is useful and safe in providing adequate fluid and substrates.

[Intramural diverticulosis of the esophagus (author's transl)]. / Die intramurale Divertikulose des Oesophagus.

The first case report of a patient with intramural diverticulosis was given in 1960 by Mendl et al. Since then at least 32 cases have been described. In this paper another case report is given, whose clinical symptomatology differs from most other cases described. The etiology and the pathogenetic significance of candidiasis in this disorder still remains unclear. Differential diagnosis and etiology are discussed.

[Chemotherapy and enteral nutrition in stomach cancer]. / Chemotherapie und enterale Ernährung beim Magenkarzinom.

Malnutrition is a frequent problem in cancer patients. About 45% of them lose more than 10% of their original weight at the various stages of their disease. The importance of nutritional support was repeatedly pointed out. In our study, 10 patients with metastatic gastrointestinal cancer received a combination treatment of long-term tube feeding with elemental diets and chemotherapy. The initially low Karnofsky index improved significantly. The results of the chemotherapy are comparable to those of 9 international studies between 1976 and 1979, using a comparable therapeutic scheme in patients with initially higher Karnofsky index. Ingestion-dependent abdominal pain disappeared in responders and non-responders during the time of tube feeding.

[Exudative enteropathy in Klippel-Trenaunay syndrome]. / Exsudative Enteropathie beim Klippel-Trenaunay-Syndrom.

The triad of the Klippel-Trénaunay Syndrome consists of varicose veins, "port-wine" haemangioma of the skin and bone and soft-tissue hypertrophy with a different extension. Often an obstruction of lymphatic vessels and lymphoedema accompany the syndrome. We observed for the first time a patient with an impressive Klippel-Trénaunay-Syndrome in combination with a symptomatic exudative enteropathy. In spite of a regular intravenous protein substitution for many years, this patient had developed a monstrous elephantiasis of the lower extremities. A lymphography demonstrated a blockade of the lymph flow at the height of the middle paraaortic lymph nodes. The cysterna chyli and the Ductus thoracicus were not visualised. The measurement of 51Cr-labelled albumin excretion in the stool for two days after the intravenous injection of 3.07 MBq 51Cr showed an excretion of 17.9% of the total dose, which means an elevated gastrointestinal protein-loss. However, intestinal lymphangiectasia was not seen on histologic examination of bioptic material of duodenal and jejunal mucosa. These results show that the Klippel-Trénaunay Syndrome may be accompanied by a protein-loosing enteropathy due to obstruction of the gastrointestinal lymph flow. As the intestinal lymphangiectasia may occur locally, it is not always demonstrable directly on pathologic examination of biopsies.

Sonographic, manometric, and myographic evaluation of the anal sphincters morphology and function.

PURPOSE: A direct comparison of anal sphincter physiology (muscle performance and anatomy-muscle thickness) has not yet been undertaken but may be of importance in patients with defecation disorders. METHODS: We evaluated 15 healthy volunteers by means of anorectal manometry to determine pressure functions of the internal and external and sphincter. Transcutaneous electromyography was recorded to assess the electrical activity of the external anal sphincter. Thickness of the anal sphincter muscles was measured sonographically from within the anal canal with dorsal projection using a 7.5-MHz 360 degrees rectal panorama scanner. RESULTS: It was shown that neither is the muscle thickness of the external anal sphincter during rest (6.26 +/- 1.02 mm) or during squeezing (7.40 +/- 1.39 mm) correlated to its squeeze pressure (138.8 +/- 15.2 mmHg), nor is the diameter of the internal anal sphincter (2.09 +/- 0.58 mm) correlated to its resting pressure (61.1 +/- 15.2 mmHg). Finally, the thicker the internal and sphincter muscle, the lower the electrical activity of the external anal sphincter during squeezing (r = 0.74, P < 0.001). CONCLUSION: It is concluded that both manometry to assess sphincter function and sonography to determine sphincter morphology are important measures in the evaluation of continence function.

[Effect of body position and food composition on esophageal motility in healthy probands]. / Einfluss von Körperposition und Nahrungsbeschaffenheit auf die Osophagusmotilität bei Gesunden.

In this study we investigated the influence of body position and bolus consistency on esophageal motility. Esophageal motility was investigated during randomized swallowing (10 women, 10 men) of liquid (5 ml water) and solid boluses (piece of apple). Esophageal motility was altered by body position and bolus consistency: Contraction amplitude, duration, percentage of multipeaked and repetitive contraction and the resting pressure of the lower sphincter were significantly reduced and the relaxation duration of the lower sphincter was significantly prolonged in sitting as compared to supine position. With a food bolus compared to swallows of water we found significantly higher values for the contraction amplitude and the percentage of repetitive contractions, for the duration and for the percentage of multipeaked contractions at some orifices and for the relaxation duration of the lower esophageal sphincter. Propagation velocity and the resting pressure of the lower esophageal sphincter were significantly reduced with the food as compared to the water bolus. The alterations of esophageal motility by body position and bolus consistency has to be taken into account in clinical manometry.

Drug-induced oesophageal lesions.

Persisting retrosternal pain of sudden onset is suggestive of a drug-induced oesophageal lesion, particularly if it starts at night. After exclusion of a myocardial infarction, a carefully taken history and oesophagoscopy will rapidly clarify the cause and severity of the injury. Since almost any pill may produce oesophageal lesions, care has to be taken that tablets, capsules and other pills are always taken in an upright position together with a fluid chaser of at least 120 ml. If possible, less harmful liquid preparations of the drugs should be preferred. Lesions in the oesophageal wall and perioesophageal tissue are almost unavoidable side-effects of sclerotherapy of oesophageal varices. The patient and the doctor should be particularly aware of bleeding from oesophageal ulcers during the first week after sclerotherapy. Numerous drugs may weaken or strengthen contractions of the oesophagus and lower oesophageal sphincter. These potentially unwanted motor effects of the drugs have to be kept in mind, especially in patients with pre-existing gastro-oesophageal reflux disease and hypermotility states.

Prophylactic antibiotic treatment in therapeutic or complicated diagnostic ERCP: results of a randomized controlled clinical study.

The present study evaluated the effects of prophylactic administration of cefotaxime in patients undergoing therapeutic or complicated diagnostic ERCP. One hundred patients were randomized to two groups of 50 patients each. Patients in group 1 received an intravenous infusion of 2 g cefotaxime 15 minutes before endoscopy; patients in group 2 did not receive an intravenous antibiotic before ERCP (control group). Blood samples were drawn for bacteriologic cultures before endoscopy and 5, 15, 30, and 120 minutes after beginning the procedure. Bacteremia was detected by blood cultures (15- and 30-minute samples) in 4 patients who did not receive prophylactic antibiotics (Escherichia coli in 2 cases, Peptostreptococcus in 1, and Staphylococcus aureus in 1). Cholangitis or sepsis did not occur after the bacteremic episodes in any of these patients. In 4 other patients who did not receive cefotaxime-all of whom had biliary obstruction-clinical cholangitis or sepsis developed during the 3-day follow-up; ERCP had failed to decompress the biliary system completely in these 4 cases. Blood cultures identified bacteria in 3 of these 4 patients (Pseudomonas aeruginosa in 1, E. coli in 2). Thus, bacteremia or clinical sepsis developed in 8/50 patients (16%) in the control group without antibiotic prophylaxis, whereas no such episode was observed in patients who had received prophylactic treatment (chi 2 = 8.7; p < 0.01). The present results indicate that prophylactic administration of an antibiotic such as cefotaxime can reduce the incidence of bacteremia and sepsis in patients who undergo therapeutic or complicated diagnostic ERCP.(ABSTRACT TRUNCATED AT 250 WORDS)