Small intestinal mucosal cell proliferation and bacterial flora in the conventionalization of the germfree mouse.

The relationship between intestinal colonization and the small bowel mucosal cellular proliferation rate during conventionalization of the germfree mouse was examined. 16 mice were maintained under standard germfree conditions, and 54 others were conventionalized. Migration of the small bowel epithelial cells was followed by radioautography with administration of tritiated thymidine. Colonization was followed by qualitative and quantitative bacteriological fecal analyses. The percentages of the villi labeled (as determined by cell count) 24, 48, and 72 hr following thymidine administration showed immediate progression in the conventionalized animals from the germfree villus migration time (4 days) toward the conventional villus migration time (2 days). The epithelial migration rate of animals conventionalized for 8 days was comparable to that of conventional animals. After conventionalization, aerobic and anaerobic organisms undergo a period of extensive multiplication; however, 72 hr later the number of these microorganisms cultured in the stool decrease and are similar to those recovered from normal animals. Coliforms and streptococci are recovered in large numbers only in the first days after conventionalization, while the Bacteroides are first recovered in significant numbers on the fifth day of conventionalization. Except for smaller numbers of Bacteroides, the bacterial populations in the stools of the conventionalized animals are qualitatively and quantitatively similar by the eighth day of conventionalization to those of true conventional mice. Adaptive balance between cell proliferation and sloughing, and thus migration rate, begins immediately after conventionalization of germfree animals as bacterial populations establish themselves throughout the gastrointestinal tract, and results in a doubling of the mucosal cell turnover after 8 days. At this time both the small intestinal epithelial cell migration rate and the intestinal microflora are similar to those of conventional animals.

Nasogastric hyperalimentation through a polyethylene catheter: an alternative to central venous hyperalimentation.

We performed nasogastric hyperalimentation with polyethylene catheters and appropriate feeding solutions in 12 cachectic patients who had been referred as candidates for central venous hyperalimentation. Most patients had primary gastrointestinal disease. The duration of hyperalimentation averaged 31 days. Seven patients obtained rapid weight gain (average 0.3 kg/day) with the nasogastric hyperalimentation alone. An additional two were successfully repleted with the addition of parenteral fluids via peripheral veins. In the nine repleted patients, serum albumin rose by average 19%, 24-hr urine creatinine by average 21%, and triceps skinfold by average 46%. The nature of the weight gain in the nine successful cases was analyzed by the metabolic balance study technique. Average composition of the increment in weight was: 50% protoplasm, 48% extracellular fluid, 19% adipose tissue, and less than 1% bone. We conclude that nasogastric hyperalimentation can replace central venous hyperalimentation in a substantial proportion of patients now receiving the latter type of treatment.

Parenteral nutrition of adults with a 900 milliosmolar solution via peripheral veins.

UNLABELLED: The objective of this study was to compare the nutritional value of three parenteral fluids: a conventional solution (400 milliosmoles/liter, containing Na, K, and Cl in 5% glucose); the concentrated hyperalimentation solution of Dudrick (1,800 milliosmoles/liter, containing Na, K, Cl, Mg, Ca, P, and amino acids in 20% glucose); and an experimental solution (900 millisomoles/liter, containing Na, K, Cl, Mg, Ca, P, and amino acids in 6.5% glucose). These three solutions are termed P400, C1,800, and P900, respectively. Preliminary studies showed that when 5 mg of cortisol/liter were added to P900, this fluid could be infused through peripheral veins for as long a time (average 114 hr) as P400 before local reaction necessitated changing the site. When P400 was infused in undernourished subjects without oral intake, balances of N, P, Mg, and Ca/70 kg of body weight per day were strongly negative (-4 g, -0.4 g, -6 mEq, and -0.2 g, respectively), whereas balances of K were about zero and those of Na and Cl were positive. Weight loss occurred. In the same patients, P900 containing 5 mg of cortisol/liter converted balances of N, P, Mg, and K to positive, and stimulated weight gain. Comparison of P900 (containing cortisol) and C1,800 in three emaciated subjects showed that the latter fluid caused a 2 to 4 times greater degree of positive balance in N, P, K, and Mg than the former. Comparison of P900 (containing cortisol) + 670-1700 cal by mouth with C1,800 in four undernourished subjects showed no statistically significant difference between these two programs. CONCLUSIONS: by adding 5 mg of cortisol/liter to P900, the fluid can be infused through peripheral veins. P900 is intermediate in nutritional value between P400 and C1,800. P900 without oral supplement prevents negative balance of all elements except Ca. P900 + daily oral intake of 670-1700 cal is nutritionally equivalent to C1,800.

Nutrient bioavailability from nasojejunally administered enteral formulas: comparison to solid food.

The net absorption and retention of energy, fat, nitrogen, and six elements (potassium, phosphorus, calcium, magnesium, sodium, and chloride) from two intrajejunally infused enteral formulas were compared to solid food. Undernourished patients (group 1) underwent two consecutive 7-day balance studies on a predigested protein-low fat (elemental) formula and an intact protein-standard fat (polymeric) formula, the initial diet selected randomly. Periods were isocaloric and isonitrogenous, but differed in the amounts of remaining elements. The undernourished patients in group 2 ate a solid food standard hospital diet for the 7-day balance study in an amount equal in energy and protein to group 1. There were no major differences in the nutrient absorption between the three diets. Nitrogen balance was similar for the two formulas (mean +/- SD) (elemental 6.1 +/- 3.5 g/day; polymeric 4.8 +/- 3.2 g/day) and solid food (5.2 +/- 3.5 g/day), and the balance for the six remaining elements was approximately proportional to the amount supplied. Subjective tolerance of both formulas was good, with a tendency for superior tolerance of the polymeric formula. We conclude that for the nutrients investigated, 1) intrajejunally administered enteral formulas are capable of renourishing hospitalized patients with an efficacy similar to that of solid food, and 2) predigestion of the formula does not improve absorption.

Pathophysiology and significance of malabsorption after Roux-en-Y reconstruction.

Extensive metabolic studies were conducted in five normal controls and in five study patients after total gastric resection with Roux-en-Y (RY) reconstruction to determine the nutritional consequences of this particular technique of restoring gastrointestinal continuity. Although malabsorption of fat (19.2 +/- 2.2%) and nitrogen (22 +/- 2.5%) demonstrated in the study patients was moderate, it was significantly greater than normal ( less than 0.01). In spite of the demonstrated malabsorption, however, positive nitrogen balances (+ 0.33 +/- 0.18 gm/day) were maintained in the RY patients throughout the investigative period. These observations suggest that malabsorption after RY is infrequently of clinical significance, even in this "worst-case" situation characterized by complete removal of gastric tissue. Malnutrition should occur in only those patients with more limited gastric resections and RY reconstruction who are unable to increase caloric intake to cover losses due to malabsorption. A significant decrease in both trypsin and lipase concentrations and a marked delay in secretion of these enzymes was noted in the RY patients in response to a test meal (p less than 0.01). Malabsorption of fat and nitrogen in RY patients improved after exogenous pancreatic enzymes, but not after administration of tetracycline. Bacterial overgrowth as a cause of postoperative malabsorption may be less important than previously thought. Malabsorption after RY is due primarily to maldigestion brought about by duodenal bypass which, in turn, results in either an absolute or a relative pancreatic enzyme insufficiency.

Colon interposition for advanced nonmalignant esophageal stricture: experience with 40 patients.

This report details our experience in 40 patients with benign strictures of the esophagus who underwent colon (or gastric) interposition with our without esophageal resection between 1972 and 1980. There were 23 men and 17 women ranging from 5 to 76 years old. Twenty-seven patients had fibrotic strictures secondary to reflux esophagitis including 12 after failure of antireflux procedures; 4 had caustic strictures; 3 had a Barrett's esophagus; 2 had systemic candidiasis; 2 had scleroderma; and in 2 the etiology was undetermined. the right colon was used in 27 patients, the left colon in 4, the transverse colon in 1, and the jejunum in 1. In 7 patients the stomach was employed because of vascular insufficiency of the colon. Three surgical approaches were utilized. Manometric studies were done post-operatively in 10 patients. Complications occurred in 7 patients: cervical leaks, 4; reflux colitis, 2; and a late cervical stricture, 1. There were 4 deaths, only 1 of which was related directly to technique. This report summarizes the beneficial effect of right colon interposition for long esophageal strictures. Its vasculature is adequate, and it functions properly to propel food into the stomach irrespective of the peristaltic orientation.

Vasculitis associated with intestinal bypass surgery.

We report two cases in which necrotizing vasculitis with tenosynovitis arthralgia/arthritis syndrome developed after intestinal bypass surgery. Each of these patients had jejunoileostomies, and the excluded segment was placed in an ileal-colonic anastomosis. We speculate that since the attachment of the excluded segment to the large intestine predisposes it to increased bowel overgrowth of bacteria, these bacteria or their debris may have served as antigens for circulating immune complexes, which were detected in both patients by one or more techniques. Patients who have had an end-to-side anastomosis may be less predisposed to the more severe vasculitis syndrome because there is less likelihood of bacterial overgrowth in the bypassed intestinal segment.

The mortality of bleeding esophageal varices in a private university hospital.

The mortality of patients with bleeding esophageal varices was studied in a private hospital where the modalities of treatment are considered optimal. Of the sixty-two patients in the study, twenty (32 per cent) died. Mortality was higher (p is less than 0.02) for those who had ascites or bilirubin more than 5 mg/dl, albumin less than 3 gm/dl, prothrombin time more than 4 seconds of control, or blood transfusions of more than 5 liters. The lower mortality in this study as compared with other studies among indigent population is the result of either private patients having less severe liver disease or having more effective care of both.

Maintenance of nutritional competence after gastric partitioning for morbid obesity.

Can normal nutritional status, as indicated by albumin, transferrin and lean body mass values, be maintained during a 100 lb weight loss after gastric partitioning? Fifteen morbidly obese patients with normal nutritional status were fed three diets before (diet A) and after (diets B and C) gastric partitioning, and changes in albumin, transferrin, and lean body mass were monitored. Diets A and C were compositionally equal and contained 40 to 60 g of protein and 600 to 900 calories administered in six to eight equally divided portions per day. Diet B contained 20 to 40 g of protein and 600 to 800 calories per day and was given through a gastrostomy tube for three months after surgery while oral input was limited to noncaloric liquids. Results showed that weight loss was more rapid before surgery with diet A, than after surgery with diet B or C (diet A versus diet B, p less than 0.05; diet A versus diet C, p less than 0.05). Lean body mass was maintained with each diet, but transferrin (p less than 0.01) and albumin (p less than 0.05) decreased while patients were fed diet B. When gastrostomy tube feedings were discontinued, diet C restored albumin and transferrin to preoperative values (diet C versus diet B, p less than 0.05, diet C versus diet A, p greater than 0.1). Total postoperative weight loss averaged 106 +/- 20 lb after 2 years. These data show that in carefully selected patients with morbid obesity who demonstrate compliance to diet A before surgery, a 100 lb weight loss may be achieved while nutritional competence is maintained.

Clinical application of the manofluorogram.

The purpose of this paper is to illustrate the clinical usefulness of simultaneous fluoroscopy and manometry, as analyzed by the manofluorogram, in the evaluation of dysphagia. Four quantitative parameters calculated from the manofluorogram are analyzed and compared in six representative cases of dysphagia. The manofluorogram adds diagnostic information which cannot be obtained by barium swallow or standard manometry.