Intestinal Failure: Adaptation, Rehabilitation, and Transplantation.

Intestinal failure (IF) is a state in which the nutritional demands are not met by the gastrointestinal absorptive surface. A majority of IF cases are associated with short-bowel syndrome, which is a result of malabsorption after significant intestinal resection for numerous reasons, some of which include Crohn's disease, vascular thrombosis, and radiation enteritis. IF can also be caused by obstruction, dysmotility, and congenital defects. Recognition and management of IF can be challenging, given the complex nature of this condition. This review discusses the management of IF with a focus on intestinal rehabilitation, parenteral nutrition, and transplantation.

Management of gastroparesis-associated malnutrition.

Gastroparesis (GP) is a chronic debilitating dysmotility characterized by unrelenting nausea, vomiting, bloating, early satiety, postprandial fullness and abdominal pain. Patients with GP experience other associated conditions, including gastroesophageal reflux disease, gastric bezoars and small bowel bacterial overgrowth. Furthermore, GP is associated with poor quality of life, increased emergency room visits, hospitalizations and subsequent increased healthcare costs. Currently, the managements of GP consist of glycemic control, antiemetics, prokinetics and the use of gastric electrical stimulation. However, most GP patients are at risk for significant nutritional abnormalities. As such, it is essential to screen and diagnose malnutrition in these patients. Poor oral intake in such patients could be supplemented by enteral tube feeding. Parenteral nutrition, although a last resort, is associated with a number of complications and should be used only for the short term. In summary, a systematic approach including initial nutritional screening, diet recommendations, medical therapy, nutritional re-evaluation and enteral and parental nutrition should be considered in complex GP patients.

Update on the management of intestinal failure.

Intestinal failure is a serious complication of conditions such as inflammatory bowel disease, mesenteric ischemia, and radiation enteritis--and of extensive bowel resection performed because of these diseases. Imbalances of fluids and electrolytes and poor nutritional status manifest as chronic diarrhea or increased ostomy output. Prompt referral to a center specializing in intestinal rehabilitation is key to achieving nutritional homeostasis and, in some cases, can help the patient return to oral food intake. We review the intestinal sequelae of bowel resection and provide an update on intestinal rehabilitation with dietary modification, drug therapy, and parenteral nutrition. We also review current experience with intestinal transplant, a potentially lifesaving option in select patients when intestinal rehabilitation fails or parenteral nutrition causes severe complications.

Efficacy of morning-only 4 liter sulfa free polyethylene glycol vs 2 liter polyethylene glycol with ascorbic acid for afternoon colonoscopy.

AIM: To compare the bowel cleansing efficacy of same day ingestion of 4-L sulfa-free polyethylene glycol (4-L SF-PEG) vs 2-L polyethylene glycol solution with ascorbic acid (2-L PEG + Asc) in patients undergoing afternoon colonoscopy. METHODS: 206 patients (mean age 56.7 years, 61% male) undergoing outpatient screening or surveillance colonoscopies were prospectively randomized to receive either 4-L SF-PEG (n = 104) or 2-L PEG + Asc solution (n = 102). Colonoscopies were performed by two blinded endoscopists. Bowel preparation was graded using the Ottawa scale. Each participant completed a satisfaction and side effect survey. RESULTS: There was no difference in patient demographics amongst groups. 4-L SF-PEG resulted in better Ottawa scores compared to 2-L PEG + Asc, 4.2 vs 4.9 (P = 0.0186); left colon: 1.33 vs 1.57 respectively (P = 0.0224), right colon: 1.38 vs 1.63 respectively (P = 0.0097). No difference in Ottawa scores was found for the mid colon or amount of fluid. Patient satisfaction was similar for both arms but those assigned to 4-L SF-PEG reported less bloating: 23.1% vs 11.5% (P = 0.0235). Overall polyp detection, adenomatous polyp and advanced adenoma detection rates were similar between the two groups. CONCLUSION: Morning only 4-L SF-PEG provided superior cleansing with less bloating as compared to 2-L PEG + Asc bowel preparation for afternoon colonoscopy. Thus, future studies evaluating efficacy of morning only preparation for afternoon colonoscopy should use 4-L SF-PEG as the standard comparator.

Role of high definition colonoscopy in colorectal adenomatous polyp detection.

AIM: To investigate the rates of polyp detection in a mixed risk population using standard definition (SDC) vs high definition colonoscopes (HDC). METHODS: This was a retrospective cohort comparative study of 3 colonoscopists who each consecutively performed 150 SDC (307, 200 pixel) and 150 HDC (792, 576 pixels) in a community teaching hospital. RESULTS: A total of 900 colonoscopies were evaluated (mean age 56, 46.8% men), 450 with each resolution. Polyps of any type were detected in 46.0% of patients using SDC and 43.3% with HDC (P = 0.42). There was no significant difference between the overall number of polyps, HDC (397) and SDC (410), detected among all patients examined, (P = 0.73). One or more adenomatous polyps were detected in 24.2% of patients with HDC and 24.9% of patients with SDC colonoscopy (P = 0.82). There was no significant difference between HDC (M = 0.41) and SDC (M = 0.42) regarding adenomatous polyp (P = 0.88) or advanced adenoma (P = 0.56) detection rate among all patients examined. CONCLUSION: HDC did not improve yield of adenomatous polyp, advanced adenoma or overall polyp detection in a population of individuals with mixed risk for colorectal cancer.