Ophthalmologic evaluation in vitamin-E deficiency: A case report.

A 41-year-old woman has come to our attention complaining of decreased visual acuity and monocular diplopia associated with upper and lower limb hypoesthesia. Malabsorption syndrome with vitamin A and E deficiency developed after a bariatric biliopancreatic diversion. The clinical ophthalmological signs and symptoms improved after oral vitamin supplementation therapy. The past medical history is essential in the case of a patient complaining of visual symptoms compatible with vitamin deficiency in order to detect the cause and to start a prompt therapy to avoid irreversible neurological and visual sequelae. The clinical features of our case closely resemble other cases described in the literature of patients affected by vitamin A and E deficiency secondary to malabsorption syndrome.

Choice of Lipid Emulsion Determines Inflammation of the Gut-Liver Axis, Incretin Profile, and Insulin Signaling in a Murine Model of Total Parenteral Nutrition.

SCOPE: The aim of this study is to test whether the choice of the lipid emulsion in total parenteral nutrition (TPN), that is, n-3 fatty acid-based Omegaven versus n-6 fatty acid-based Intralipid, determines inflammation in the liver, the incretin profile, and insulin resistance. METHODS AND RESULTS: Jugular vein catheters (JVC) are placed in C57BL/6 mice and used for TPN for 7 days. Mice are randomized into a saline group (saline infusion with oral chow), an Intralipid group (IL-TPN, no chow), an Omegaven group (OV-TPN, no chow), or a chow only group (without JVC). Both TPN elicite higher abundance of lipopolysaccharide binding protein in the liver, but only IL-TPN increases interleukin-6 and interferon-γ, while OV-TPN reduces interleukin-4, monocyte chemoattractant protein-1, and interleukin-1α. Insulin plasma concentrations are higher in both TPN, while glucagon and glucagon-like peptide-1 (GLP-1) were higher in IL-TPN. Gluconeogenesis is increased in IL-TPN and the nuclear profile of key metabolic transcription factors shows a liver-protective phenotype in OV-TPN. OV-TPN increases insulin sensitivity in the liver and skeletal muscle. CONCLUSION: OV-TPN as opposed to IL-TPN mitigates inflammation in the liver and reduces the negative metabolic effects of hyperinsulinemia and hyperglucagonemia by "re-sensitizing" the liver and skeletal muscle to insulin.

[Moderate anaemia refractory to oral iron in a pregnant woman with a history of bariatric surgery]. / Anemia moderada refractaria al hierro oral en una gestante con antecedente de cirugía bariátrica.

INTRODUCTION: Introduction: bariatric surgery involves nutritional and trace element deficiencies that may have a negative impact if not treated properly, especially in situations such as pregnancy. Case report: a patient who underwent biliopancreatic diversion surgery without subsequent therapeutic adherence consults due to edema; findings included 29-week gestation (type 1 intrauterine growth restriction) and moderate anemia. Vitamin supplementation, oligoelements, enteral nutrition, and intravenous iron were restarted. Due to poor hemoglobin response with repleted iron deposits, recombinant human erythropoietin was associated. Discussion: the most frequent nutritional deficiencies after malabsorptive bariatric surgery are sideropenia and hypoproteinemia. Sideropenia and anemia increase the risk of preterm delivery, low weight, and perinatal mortality. In patients with inadequate response to intravenous iron, treatment with recombinant human erythropoietin may be considered, although its use in pregnant women without chronic renal failure has no indication in the prescribing information of this drug.

INTRODUCCIÓN: Introducción: la cirugía bariátrica (CB) implica déficits nutricionales y de oligoelementos que pueden tener una repercusión negativa en caso de no tratarse adecuadamente, especialmente en situaciones como la gestación. Caso clínico: paciente sometida a CB del tipo de la derivación biliopancreática, sin adherencia terapéutica posterior, que acude por edemas, confirmándose la presencia de una gestación de 29 semanas (feto CIR de tipo I) y de anemia moderada. Se reinició la suplementación de vitaminas, oligoelementos, nutrición enteral y hierro intravenoso (FEIV). Debido a la escasa respuesta de la hemoglobina con depósitos de hierro repletados, se asoció eritropoyetina humana recombinante (rHuEPO). Discusión: los déficits nutricionales más frecuentes tras una CB malabsortiva son la ferropenia y la hipoproteinemia. La ferropenia y la anemia incrementan el riesgo del parto pretérmino, el bajo peso y la mortalidad perinatal. En las pacientes sin adecuada respuesta al FEIV puede plantearse el tratamiento con rHuEPO, aunque su uso en gestantes sin insuficiencia renal crónica no dispone de indicación en la ficha técnica.

Dose-response relationship between dietary choline and lipid accumulation in pyloric enterocytes of Atlantic salmon (Salmo salar L.) in seawater.

Foamy, whitish appearance of the pyloric caeca, reflecting elevated lipid content, histologically visible as hypervacuolation, is frequently observed in Atlantic salmon fed high-plant diets. Lipid malabsorption syndrome (LMS) is suggested as term for the phenomenon. Earlier studies have shown that insufficient supply of phospholipids may cause similar symptoms. The objective of the present study was to strengthen knowledge on the role of choline, the key component of phosphatidylcholine, in development of LMS as well as finding the dietary required choline level in Atlantic salmon. A regression design was chosen to be able to estimate the dietary requirement level of choline, if found essential for the prevention of LMS. Atlantic salmon (456 g) were fed diets supplemented with 0, 392, 785, 1177, 1569, 1962, 2354, 2746 and 3139 mg/kg choline chloride. Fish fed the lowest-choline diet had pyloric caeca with whitish foamy surface, elevated relative weight, and the enterocytes were hypervacuolated. These characteristics diminished with increasing choline level and levelled off at levels of 2850, 3593 and 2310 mg/kg, respectively. The concomitant alterations in expression of genes related to phosphatidylcholine synthesis, cholesterol biosynthesis, lipid transport and storage confirmed the importance of choline in lipid turnover in the intestine and ability to prevent LMS. Based on the observations of the present study, the lowest level of choline which prevents LMS and intestinal lipid hypervacuolation in post-smolt Atlantic salmon is 3·4 g/kg. However, the optimal level most likely depends on the feed intake and dietary lipid level.

Vitamin B12 Deficiency Anemia and Polyneuropathy Due to Chronic Radiation Enteritis.

A 62-year-old Japanese woman developed numbness of the extremities and megaloblastic anemia. She had undergone total abdominal hysterectomy, whole-pelvis radiation therapy and chemotherapy for gynecological cancer 10 years before. Chronic abdominal pain, diarrhea and intermittent small-bowel obstruction had afflicted her for a long time. We diagnosed her with vitamin B12 deficiency anemia and polyneuropathy due to chronic radiation enteritis causing malabsorption. Vitamin B12 injections improved her numbness and anemia. The early diagnosis and treatment of deficiency of vitamin B12 are important. Physicians should regularly measure vitamin B12 levels and supplement vitamin B12 as needed in patients with chronic radiation enteritis.

Do Specialized Bariatric Multivitamins Lower Deficiencies After Sleeve Gastrectomy?

BACKGROUND: Vitamin and mineral deficiencies are common after a sleeve gastrectomy (SG). The aim of this study is to examine the effectiveness of a specialized bariatric multivitamin (WLS Optimum) for SG patients on deficiencies compared with a regular multivitamin (MVS) for up to 5 years. METHODS: Data of all patients who underwent a SG procedure in the Catharina Hospital Eindhoven (CZE) between July 2011 and July 2016 were collected and retrospectively analyzed. All patients who completed a preoperative blood test and at least one blood withdrawal during the first operative year were included in this study. RESULTS: This study included 970 patients; 291 patients in the WLS-user group and 679 patients in the non-WLS-user group. In favor of the user group, significantly less de novo deficiencies were found of vitamin B1 (2 years) and vitamin B6 (two and three), folic acid (1 and 2 years), and vitamin B12 (at 1 year). Binomial logistic regression showed a significant influence of multivitamin supplementation mainly on ferritin; vitamins B1, B6, B12, and D; and folic acid, (all p < 0.05). The total number of de novo deficiencies was significantly reduced during the whole study for all WLS Optimum users. CONCLUSIONS: Vitamin deficiencies are common, and postoperative nutritional management after SG is underestimated. The use of a specialized multivitamin supplement resulted in higher mean serum concentrations and less deficiencies of vitamin B1, folic acid, and vitamin B12. This study shows that SG patients benefit from the specialized multivitamin supplements, but adjustments are required for iron and vitamin B6 content.

Growth and Nutrition in Cystic Fibrosis.

Optimal nutrition support has been integral in the management of cystic fibrosis (CF) since the disease was initially described. Nutritional status has a clear relationship with disease outcomes, and malnutrition in CF is typically a result of chronic negative energy balance secondary to malabsorption. As the mechanisms underlying the pathology of CF and its implications on nutrient absorption and energy expenditure have been elucidated, nutrition support has become increasingly sophisticated. Comprehensive nutrition monitoring and treatment guidelines from professional and advocacy organizations have unified the approach to nutrition optimization around the world. Newborn screening allows for early nutrition intervention and improvement in short- and long-term growth and other clinical outcomes. The nutrition support goal in CF care includes achieving optimal nutritional status to support growth and pubertal development in children, maintenance of optimal nutritional status in adult life, and optimizing fat soluble vitamin and essential fatty acid status. The mainstay of this approach is a high calorie, high-fat diet, exceeding age, and sex energy intake recommendations for healthy individuals. For patients with exocrine pancreatic insufficiency, enzyme replacement therapy is required to improve fat and calorie absorption. Enzyme dosing varies by age and dietary fat intake. Multiple potential impediments to absorption, including decreased motility, altered gut luminal bile salt and microbiota composition, and enteric inflammation must be considered. Fat soluble vitamin supplementation is required in patients with pancreatic insufficiency. In this report, nutrition support across the age and disease spectrum is discussed, with a focus on the relationships among nutritional status, growth, and disease outcomes.

Laparoscopic Magenstrasse and Mill Gastroplasty (M&M): Midterm Results.

BACKGROUND: The Magenstrasse and Mill gastroplasty (M&M) is a gastric restrictive procedure without band or stomach resection. Short-term evaluation of the laparoscopic procedure showed low morbidity and satisfactory results on weight loss. Evidence of the validity of the technique in the longer term is scarce. METHODS: Data from patients who underwent M&M procedure from May 2012 to September 2015 were retrospectively reviewed. Preoperative clinical characteristics and data up to 4 years after operation were analyzed. RESULTS: A total of 132 patients were included in this study with a mean age of 46 ± 13.4 years. The mean body mass index (BMI) at the time of procedure was 43 ± 4.5 kg/m2. Mean percentage of excess weight loss (%EWL) was 67, 67, 58, and 57% at 1, 2, 3, and 4 years, respectively. The remission rate for diabetes was 36%. About half of the insulin-dependent patients could stop their insulin treatment. Hypertension was resolved in 33.8% of the patients after 4 years. Incidence of vitamin and mineral deficiency was low throughout the study period, less than or equal to 3% for vitamin B12 and 1% for ferritin. Incidence of gastroesophageal reflux did not exceed 15% during the study. Over 75% of the patients reported a good or very good quality of life following the surgery. CONCLUSION: These results confirm the validity of M&M as a bariatric procedure. The low incidence of vitamin deficiencies and gastroesophageal reflux might be the important asset of M&M over other existing techniques.

Renal lithiasis and inflammatory bowel diseases, an update on pediatric population.

BACKGROUND AND AIM OF THE WORK: Historical studies have demonstrated that the prevalence of symptomatic nephrolithiasis is higher in patients with inflammatory bowel disease (IBD), compared to general population. The aim of the review was to analyze literature data in order to identify the main risk conditions described in literature and the proposed treatment. METHODS: A research on the databases PubMed, Medline, Embase and Google Scholar was performed by using the keywords "renal calculi/lithiasis/stones" and "inflammatory bowel diseases". A research on textbooks of reference for Pediatric Nephrology was also performed, with focus on secondary forms of nephrolithiasis. RESULTS: Historical studies have demonstrated that the prevalence of symptomatic nephrolithiasis is higher in patients with inflammatory bowel disease (IBD), compared to general population, typically in patients who underwent extensive small bowel resection or in those with persistent severe small bowel inflammation. In IBD, kidney stones may arise from chronic inflammation, changes in intestinal absorption due to inflammation, surgery or intestinal malabsorption. Kidney stones are more closely associated with Crohn's Disease (CD) than Ulcerative Colitis (UC) in adult patients for multiple reasons: mainly for malabsorption, but in UC intestinal resection may be an additional risk. Nephrolithiasis is often under-diagnosed and might be a rare but noticeable extra-intestinal presentation of pediatric IBD. Secondary enteric hyperoxaluria the main risk factor of UL in IBD, this has been mainly studied in CD, whether in UC has not been completely explained. In the long course of CD recurrent urolithiasis and calcium-oxalate deposition may cause severe chronic interstitial nephritis and, as a consequence, chronic kidney disease. ESRD and systemic oxalosis often develop early, especially in those patients with multiple bowel resections. Even if we consider that many additional factors are present in IBD as hypomagnesuria, acidosis, hypocitraturia, and others, the secondary hyperoxaluria seems to finally have a central role. Some medications as parenteral vitamin D, long-term and high dose steroid treatment, sulfasalazine are reported as additional risk factors. Hydration status may also play an important role in this process. Intestinal surgery is a widely described independent risk factor. Patients with ileostomy post bowel resection may have relative dehydration from liquid stool, which, added to the acidic pH from bicarbonate loss, is responsible for this process. In this acidic pH, the urinary citrate level excretion reduces. The stones most commonly seen in these patients contain uric acid or are mixed. In addition, the risk of calcium containing stones also increases with ileostomy. The treatment of UL in IBD involves correction of the basic gastrointestinal tract inflammation, restricted dietary oxalate intake, and, at times, increased calcium intake. Citrate therapy that increases both urine pH and urinary citrate could also provide an additional therapeutic benefit. Finally, patients with IBD in a pediatric study had less urologic intervention for their calculosis compared with pediatric patients without IBD.

Intestinal Phosphorus Absorption in Chronic Kidney Disease.

Chronic kidney disease (CKD) affects approximately 10% of adults worldwide. Dysregulation of phosphorus homeostasis which occurs in CKD leads to development of CKD-Mineral Bone Disorder (CKD-MBD) and contributes to increased morbidity and mortality in these patients. Phosphorus is regulated by multiple hormones (parathyroid hormone (PTH), 1,25-dihyxdroxyvitamin D (1,25D), and fibroblast growth factor 23 (FGF23)) and tissues (kidney, intestine, parathyroid glands, and bone) to maintain homeostasis. In health, the kidneys are the major site of regulation for phosphorus homeostasis. However, as kidney function declines, the ability of the kidneys to adequately excrete phosphorus is reduced. The hormonal changes that occur with CKD would suggest that the intestine should compensate for impaired renal phosphorus excretion by reducing fractional intestinal phosphorus absorption. However, limited studies in CKD animal models and patients with CKD suggest that there may be a break in this homeostatic response where the intestine fails to compensate. As many existing therapies for phosphate management in CKD are aimed at reducing absolute intestinal phosphorus absorption, better understanding of the factors that influence fractional and absolute absorption, the mechanism by which intestinal phosphate absorption occurs, and how CKD modifies these is a much-needed area of study.

[Nutritional management of functional chronic diarrhea associated to malnutrition with peptide diet: a case report]. / Manejo nutricional de la diarrea crónica funcional asociada a desnutrición con una dieta peptídica: un caso clínico.

BACKGROUND: functional bowel disorders are characterized by an absence of structural or biochemical damage, but can lead to chronic diarrhea and intestinal malabsorption. If not properly treated, they predispose to a state of malnutrition that, depending on the underlying pathologies, could affect the evolution of other concomitant diseases. CASE REPORT: the relevance of this case stems from the fact that our 43-year-old patient, with multiple comorbidities, with progressive weight and muscle mass loss, after five years of inefficiency in the treatment of chronic diarrhea, achieves, on a peptide enteral formula basis, a good nutritional status and quality of life, which finally leads to the control of the chronic diarrhea and malnutrition. DISCUSSION: in the unintentional weight loss caused by long-term functional diarrhea, the choice of a peptide diet may have a fundamental role for a satisfactory patient's progress.

Response to oral sucrosomial iron supplementation in patients undergoing bariatric surgery. The BARI-FER study.

BACKGROUND: Chronic intravenous iron administration is often required after bariatric surgery. Oral sucrosomial iron has a particular form of absorption and may represent an alternative treatment. OBJECTIVE: To assess the effect of switching to oral sucrosomial iron in patients receiving intravenous iron supplementation after bariatric surgery. PATIENTS AND METHODS: A case-control study was conducted on 40 women of childbearing age, of whom 20 were switched to oral sucrosomial iron, while 20 patients continued on intravenous iron sucrose every three months. RESULTS: No significant differences were seen in Hb, ferritin, and TSI levels before and after three months of treatment with sucrosomial iron. CONCLUSION: Oral sucrosomial iron could be an alternative in patients who require parenteral treatment with iron after bariatric surgery.

[The Metabolic Optimized Fast Track Concept: preoperative preparation for abdominal surgery]. / Kontseptsiia 'Bystraia Metabolicheskaia Optimizatsiia' pri predoperatsionnoi podgotovke patsientov v abdominal'noi khirurgii.

In recent years the protocols of Enhanced Recovery After Surgery (E.R.A.S.) have been introduced into clinical practice and actively used. The goal of E.R.A.S. is to increase recovery, decrease complications and reduce length of stay after surgery through optimization of perioperative management. One of the key elements of E.R.A.S. is Metabolic Optimized Fast Track Concept (MOFA). It is aimed at the reduction of the period of preoperative fasting and at the activation of glucose transport inside the cell. It involves the administration of combined carbohydrate-protein-glutamine drinks which results into decreased insulin resistance in the early postoperative period. The implementation of MOFA within the structure of perioperative nutrition and metabolic support in abdominal surgery may actually be beneficial by reducing postoperative complications, length of hospital stay and mortality rate.

Effects of Laparoscopic Sleeve Gastrectomy on Parathyroid Hormone, Vitamin D, Calcium, Phosphorus, and Albumin Levels.

BACKGROUND: Laparoscopic sleeve gastrectomy (LSG) reduces obesity-related co-morbidities, such as diabetes, hypertension, and hyperlipidemia. Endocrinological abnormalities may occur as undesired side effects. Most centers routinely prescribe folic acid, cyanocobalamin (vitB12), and protein replacement in the postoperative period, but 25-OH-vitamin-D3 (vitD) and intact parathyroid hormone (iPTH) levels are not routinely followed up. The aim of this study was to identify the effects of LSG on iPTH, vitD, calcium (Ca), phosphorus (P), alkaline phosphatase (ALP), and albumin levels. METHODS: Data of morbidly obese patients who underwent LSG between January and December 2014 were studied in this prospectively designed study. Serum levels of iPTH, vitD, Ca, P, folic acid, vitB12, ALP, and albumin were measured preoperatively and postoperatively at the 3rd, 6th, and 12th months. RESULTS: In total, 119 patients were analyzed. All patients had normal iPTH, vitD, Ca, P, folic acid, vitB12, ALP, and albumin values preoperatively, and 31.6% had received vitD supplementation during their nutritionist observation time before surgery. At the 3rd, 6th, and 12th postoperative months, 21 (17.6%), 17 (17.3%), and 1 (0.8%) patients, respectively, had increased iPTH and ALP and decreased vitD levels. A total of 39 (32.7%) patients needed high-dose vitD treatment during a 1 year follow-up. Approximately 37.5% of the patients who received vitD supplementation preoperatively needed vitD supplementation postoperatively. Hospital records of 101 of 119 patients who underwent LSG could be screened to determine their vitD supplementation requirements previously ordered by their nutritionist for a 1-year period before LSG. Thirty-two (31.6%) of the 101 patients had received vitD supplementation during the 1-year period preoperatively. CONCLUSIONS: Although serum levels of iPTH, vitD, Ca, P, vitB12, ALP, and albumin may be normal preoperatively, severe vitD insufficiency requiring high-dose vitD replacement may develop in morbidly obese patients postoperatively. Instead of iPTH and vitD, which are expensive to measure, ALP serum level, which is correlated with iPTH levels, can be a good indicator to monitor calcium metabolism.

Timeline of Intestinal Adaptation After Malabsortive Surgery: Effect of Luminal Nutrients, Biliopancreatic Secretion, and Glutamine Supplementation.

BACKGROUND: The aim of this study was to study the process of intestinal adaptation in the three limbs of the small intestine after malabsorptive bariatric surgery: the biliopancreatic limb, the alimentary limb, and the common channel. These limbs are exposed to different stimuli, namely, gastrointestinal transit and nutrients in the alimentary limb, biliopancreatic secretions in the biliopancreatic limb, and a mix of both in the common channel. We also wished to investigate the effect of glutamine supplementation on the adaptation process. METHODS: Three types of surgery were performed using a porcine model: biliopancreatic bypass (BPBP), massive (75%) short bowel resection as the positive control, and a sham operation (transection) as the negative control. We measured the height and width of intestinal villi, histidine decarboxylase (HDC) activity, and amount of HDC messenger RNA (mRNA) (standard diet or a diet supplemented with glutamine). RESULTS: An increase in HDC activity and mRNA expression was observed in the BPBP group. This increase coincided with an increase in the height and width of the intestinal villi. The increase in villus height was observed immediately after surgery and peaked at 2 weeks. Levels remained higher than those observed in sham-operated pigs for a further 4 weeks. CONCLUSIONS: The intestinal adaptation process in animals that underwent BPBP was less intense than in those that underwent massive short bowel resection and more intense than in those that underwent transection only. Supplementation with glutamine did not improve any of the parameters studied, although it did appear to accelerate the adaptive process.

Dietary Carbohydrates and Childhood Functional Abdominal Pain.

Childhood functional gastrointestinal disorders (FGIDs) affect a large number of children throughout the world. Carbohydrates (which provide the majority of calories consumed in the Western diet) have been implicated both as culprits for the etiology of symptoms and as potential therapeutic agents (e.g., fiber) in childhood FGIDs. In this review, we detail how carbohydrate malabsorption may cause gastrointestinal symptoms (e.g., bloating) via the physiologic effects of both increased osmotic activity and increased gas production from bacterial fermentation. Several factors may play a role, including: (1) the amount of carbohydrate ingested; (2) whether ingestion is accompanied by a meal or other food; (3) the rate of gastric emptying (how quickly the meal enters the small intestine); (4) small intestinal transit time (the time it takes for a meal to enter the large intestine after first entering the small intestine); (5) whether the meal contains bacteria with enzymes capable of breaking down the carbohydrate; (6) colonic bacterial adaptation to one's diet, and (7) host factors such as the presence or absence of visceral hypersensitivity. By detailing controlled and uncontrolled trials, we describe how there is a general lack of strong evidence supporting restriction of individual carbohydrates (e.g., lactose, fructose) for childhood FGIDs. We review emerging evidence suggesting that a more comprehensive restriction of fermentable oligosaccharides, disaccharides, monosaccharides and polyols (FODMAP) may be effective. Finally, we review how soluble fiber (a complex carbohydrate) supplementation via randomized controlled intervention trials in childhood functional gastrointestinal disorders has demonstrated efficacy.

Bariatric surgery and vitamin D: key messages for surgeons and clinicians before and after bariatric surgery.

Obesity is the most widespread nutritional problem globally. Bariatric surgery is the preeminent long-term obesity treatment. Bariatric procedures manipulate the intestines to produces malabsorption and/or restrict the size of the stomach. The most enduring bariatric procedure is the Roux-en-Y gastric bypass, which utilizes both restriction (small stomach pouch) and malabsorption (duodenum bypass). The in-vogue procedure is the vertical sleeve gastrectomy - resection of the greater curvature of the stomach (predominantly restrictive). Malabsorptive procedures function by decreasing nutrient absorption, primarily fat and fat-soluble nutrients (vitamins A, D, E, and K). Most studies of vitamin D status in bariatric surgery candidates reported a prevalence of over 50% vitamin D deficiency (<50 nmol/L), enduring post-operatively with one study reporting 65% deficient at 10 years post-bariatric surgery. Obesity is associated with chronic inflammation, which may contribute to adverse surgical outcomes, e.g. poor healing and infection. Since vitamin D deficiency is also associated with chronic inflammation, obese individuals with vitamin D deficiency have extraordinary risk of adverse surgical outcomes, particularly delayed wound healing and infection due to the role of vitamin D in re-epithelialization and innate immunity. When the risk of adverse surgical outcomes in obesity is combined with that of vitamin D deficiency, there is likely an additive or potentially a synergistic effect. Furthermore, deficiency in fat-soluble vitamins, such as vitamin D, is considered a metabolic complication of bariatric surgery. Thus, determining the vitamin D status of bariatric surgery candidates and amending it preoperatively may prove greatly beneficial acutely and lifelong.

ESPEN-ESPGHAN-ECFS guidelines on nutrition care for infants, children, and adults with cystic fibrosis.

BACKGROUND: Malnutrition is both a frequent feature and a comorbidity of cystic fibrosis (CF), with nutritional status strongly associated with pulmonary function and survival. Nutritional management is therefore standard of care in CF patients. ESPEN, ESPGHAN and ECFS recommended guidelines to cover nutritional management of patients with CF. METHODS: The guidelines were developed by an international multidisciplinary working group in accordance with officially accepted standards. The GRADE system was used for determining grades of evidence and strength of recommendation. Statements were discussed, submitted to Delphi rounds, reviewed by ESPGHAN and ECFS and accepted in an online survey among ESPEN members. RESULTS: The Working Group recommends that initiation of nutritional management should begin as early as possible after diagnosis, with subsequent regular follow up and patient/family education. Exclusive breast feeding is recommended but if not possible a regular formula is to be used. Energy intake should be adapted to achieve normal weight and height for age. When indicated, pancreatic enzyme and fat soluble vitamin treatment should be introduced early and monitored regularly. Pancreatic sufficient patients should have an annual assessment including fecal pancreatic elastase measurement. Sodium supplementation is recommended and a urinary sodium:creatinine ratio should be measured, corresponding to the fractional excretion of sodium. If iron deficiency is suspected, the underlying inflammation should be addressed. Glucose tolerance testing should be introduced at 10 years of age. Bone mineral density examination should be performed from age 8-10 years. Oral nutritional supplements followed by polymeric enteral tube feeding are recommended when growth or nutritional status is impaired. Zinc supplementation may be considered according to the clinical situation. Further studies are required before essential fatty acids, anti-osteoporotic agents, growth hormone, appetite stimulants and probiotics can be recommended. CONCLUSION: Nutritional care and support should be an integral part of management of CF. Obtaining a normal growth pattern in children and maintaining an adequate nutritional status in adults are major goals of multidisciplinary cystic fibrosis centers.

Acquired causes of intestinal malabsorption.

This review focuses on the acquired causes, diagnosis, and treatment of intestinal malabsorption. Intestinal absorption is a complex process that depends on many variables, including the digestion of nutrients within the intestinal lumen, the absorptive surface of the small intestine, the membrane transport systems, and the epithelial absorptive enzymes. Acquired causes of malabsorption are classified by focussing on the three phases of digestion and absorption: 1) luminal/digestive phase, 2) mucosal/absorptive phase, and 3) transport phase. Most acquired diseases affect the luminal/digestive phase. These include short bowel syndrome, extensive small bowel inflammation, motility disorders, and deficiencies of digestive enzymes or bile salts. Diagnosis depends on symptoms, physical examination, and blood and stool tests. There is no gold standard for the diagnosis of malabsorption. Further testing should be based on the specific clinical context and the suspected underlying disease. Therapy is directed at nutritional support by enteral or parenteral feeding and screening for and supplementation of deficiencies in vitamins and minerals. Early enteral feeding is important for intestinal adaptation in short bowel syndrome. Medicinal treatment options for diarrhoea in malabsorption include loperamide, codeine, cholestyramine, or antibiotics.

Refeeding Syndrome: An Important Complication Following Obesity Surgery.

BACKGROUND: Refeeding syndrome (RFS) is an important and well-known complication in malnourished patients, but the incidence of RFS after obesity surgery is unknown and the awareness of RFS in obese patients as a postsurgical complication must be raised. We present a case of RFS subsequent to biliopancreatic diversion in a morbidly obese patient. CASE REPORT: A 48-year-old female patient with a BMI of 41.5 kg/m2 was transferred to our hospital due to Wernicke's Encephalopathy in a global malabsorptive syndrome after biliopancreatic diversion. Parenteral nutrition, vitamin supplementation and high-dosed intravenous thiamine supplementation were initiated. After 14 days, the patient started to develop acute respiratory failure, and neurological functions were impaired. Blood values showed significant electrolyte disturbances. RFS was diagnosed and managed according to the NICE guidelines. After 14 days, phosphate levels had returned to normal range, and neurological symptoms were improved. CONCLUSION: Extreme weight loss following obesity surgery has been shown to be associated with undernutrition. These patients are at high risk for evolving RFS, even though they may still be obese. Awareness of RFS as a postsurgical complication, the identification of patients at risk as well as prevention and correct management should be routinely performed at every bariatric center.