Survival rate and prognostic factors in patients with intestinal failure.

BACKGROUND: Intestinal failure impairs nutritional status and survival expectance. Though intestinal adaptation and enteral independence may be achieved, artificial nutrition is needed in about half of the patients. AIMS: This study is aimed at assessing the causes of death, survival rate, enteral independence in time, and factors affecting the clinical outcome in a group of patients with intestinal insufficiency. PATIENTS: Sixty-eight patients with intestinal insufficiency, due to major intestinal resection in 60 cases (short bowel syndrome) (remnant intestine length 101-150 cm in 31 cases, 50-100 cm in 23 cases, <50 cm in 6 cases), and due to chronic idiopathic pseudo-obstruction in 8 cases, were enrolled and followed-up for (median) 36 months (25th and 75th percentile in 12 and 60 months, respectively). In 60 short bowel syndrome patients, the main conditions that led to intestinal failure were ischemic bowel (28), major surgery complications or severe adhesions (17), radiation enteritis (10), Chron's disease, intestinal tuberculosis, small bowel lymphoma and trauma (others). METHODS: Seventeen variables age, underlying disorders, length of remnant bowel, type of surgery, hospital stay, type of nutrition (hospital and home) and its variations in time, causes of death, survival rate and time were considered. Statistical analysis was carried out by Mann-Whitney U-test, Pearson chi2, Spearman correlation test, Kaplan-Meyer method and Cox's proportion hazards regression model. RESULTS: At the time of admission to the hospital, none of the patients had nutritional independence, 54 (79.4%) were on parenteral nutrition and 14 (20.6%) were on enteral nutrition. At the time of discharge, 23 (33.8%) patients showed enteral independence, 39 were on home parenteral nutrition, 3 on enteral nutrition + i.v. feeding, 1 on enteral nutrition, and 2 needed oral supplementation with hydroelectrolyte solutions only. After a median value of 36 months, 30 and 2 patients were on home parenteral nutrition and enteral nutrition + i.v. feeding, respectively, 2 on enteral nutrition, 2 on oral supplementation with hydroelectrolyte solutions, and 26 cases reached enteral independence. A significant relationship was detected between the length of remnant bowel and types of nutrition at both admission (r = 0.38; P = 0.001) and discharge (r = 0.48; P = 0.001), parenteral nutrition being more frequent in patients with very short bowel. Twenty-two patients (32.4%) died (4 from newly occurring malignancies), 40 (58.8%) survived, and 6 (8.8%) were lost to the follow-up. Eleven of 22 patients died from conditions related to intestinal failure (8 cases) and/or home parenteral nutrition complications (3 cases). At 12, 24, 36, 48, 60 and 72 months, survival rates were 95.4, 93.3, 88.1, 78.6, 78.6 and 65.5%, respectively, but it was significantly lower for patients with <50 cm of remnant bowel than those with longer residual intestine (P < 0.05), and in patients who started home parenteral nutrition above the age of 45 years (P < 0.02). Survival rate was higher in patients with enteral independence than those with enteral dependence (P < 0.05). Better survival rates were registered in patients with chronic obstructive intestinal pseudo-obstruction and major surgery complications, whereas ischemic bowel and even more radiation enteritis were associated with a lower survival expectance. CONCLUSIONS: Actuarial survival rate of patients with intestinal failure quotes 88 and 78% at 3 and 5 years, respectively. It is influenced by the length of remnant intestine, age at the start of home parenteral nutrition, enteral independence and, to some extent at least, by the primary disorder. Enteral independence can be achieved in time by about 40% of the patients with intestinal insufficiency, but for home parenteral nutrition-dependent cases, intravenous feeding can be stopped in less than one out of five patients during a median 3-year period.

[In vitro study of a new pancreatic enzyme with high lipase content in enteric coated microtablets]. / Studio in vitro di un nuovo enzima pancreatico ad elevato contenuto lipasico, in microcompresse gastroprotette.

In vitro behaviour of the enteric-coating of a new pancreatic enzyme containing preparation in enteric-coated microtablets was evaluated, by incubating at 37 degrees C, under gentle agitation, the preparation under study in buffered gastric (pH 2, 3, 4, 5, 6) and in buffered duodenal juice (pH 3, 4, 5, 6, 7, 8) for 30, 60, 90, 120 minutes. Lipase and chymotripsin activities were measured at each time and pH in the solution and in the undissolved microtablets. The drug under study showed a good enteric-coating, preserving about 100% of the enzyme content, when incubated in buffered gastric juice, up to pH 6, and releasing in the solution, during incubation in buffered duodenal juice, 75% of its enzyme content at pH 7 and 8. Therefore, the pancreatic enzymes contained in this new enteric-coated microtablet preparation are well protected against inactivation from acid and are bioavailable for digestion of alimentary substrates at optimal or near optimal pH in duodenal juice.

Cross-clade protection against H5N1 HPAI strains recently isolated from commercial poultry in Egypt with a single dose of a baculovirus based vaccine.

The current avian influenza epidemic in Egypt caused by circulation of genetically and antigenically diverse H5N1 HPAI viruses in poultry is controlled by applying vaccination among other measures. In this context, the use of a DIVA (differentiating infected from vaccinated animals) vaccination strategy utilizing a vaccine capable of inducing protection against multiple antigenic variants may result as an additional control tool to the existing ones. In this study the efficacy of a single-shot recombinant baculovirus-based vaccine in specific-pathogen-free chickens was tested by experimental challenge with genetically and antigenically diverse H5N1 HPAI viruses belonging to clades 2.2.1 and 2.2.1.1, which have been circulating in Egypt since 2010. A single dose of vaccine, administration at 10 days of age, was shown to confer 100% clinical protection, with a decrease or suppression of virus shedding.

Liquid stool incontinence with severe urgency: anorectal function and effective biofeedback treatment.

The motor and sensory function of the anorectum is well characterised in patients with solid stool incontinence. Fewer data are available in the case of liquid stool incontinence. Anorectal sensorimotor function was studied in 16 patients with liquid stool incontinence and severe urgency (10 with diarrhoea) unresponsive to conventional medical treatment, and in 16 healthy volunteers. The only significant difference found between incontinent patients and controls was a reduction in squeeze duration (p < 0.0001). Fourteen patients were selected to receive biofeedback treatment. Treatment was associated with a substantial improvement in continence in 12 patients and with a significant decrease in urgency (p < 0.05). Bowel frequency was not significantly influenced. Most patients showed a persistent improvement in anal motor function. Functional parameters were not predictive of outcome of treatment; the poor responders showed major psychological problems. In conclusion, an anal motor deficit is often present in disabling liquid stool incontinence. Biofeedback may improve anal continence in 75% of patients.

Pancreatic extracts are necessary for the absorption of elemental and polymeric enteral diets in severe pancreatic insufficiency.

Tube feeding nutrition, either elemental or polymeric, is increasingly used in patients with digestive problems. Pancreatic insufficiency is a widely accepted indication for the use of an elemental formula, which requires less residual digestive capacity. To confirm this assumption, we have compared the absorption of elemental and polymeric diets and the effect of exogenous pancreatic enzymes in a patient on long-term total enteral feeding after total pancreatectomy. Malabsorption of both formulas was observed without enzyme supplementation. A marked improvement of fat and nitrogen absorption was obtained when pancreatic enzymes were added to both enteral diets. It is concluded that pancreatic enzymes should always be added to liquid diets in pancreatic insufficiency. No clear advantage is to be anticipated by the use of elemental as compared with polymeric diets.

Gastric emptying of realistic meals with and without gluten in patients with coeliac disease. Effect of jejunal mucosal recovery.

BACKGROUND: Few data are available on disturbed gastric emptying in patients with coeliac disease. The aims of the study were to investigate (a) the presence of delayed gastric emptying: (b) the acute effect on gastric emptying of gliadin; and (c) the effect of jejunal recovery on gastric emptying of meals with or without gluten in such patients. METHODS: We measured gastric emptying of two meals in 16 patients with coeliac disease; one meal contained gliadin. Results were compared with those obtained in 24 controls. In 12 patients, both measurements were repeated after mucosal recovery. Statistical analysis was performed using the analysis of variance for repeated measurements and Student's t test. Mean +/- 1 s(mean) (standard error of the mean) are shown. RESULTS: No difference was found in fasting and in maximal antral sections after the two meals. On entry, gastric emptying was significantly (P < 0.001) delayed compared to controls both after the meal containing gluten (326.9 +/- 12.4 min versus controls 213.5 +/- 11.5) and after the gluten-free meal (315.3 +/- 16.7 min). After jejunal recovery, emptying of the meal containing gluten remained unchanged (337 +/- 18.9 min), whereas emptying of the gluten-free meal was significantly shortened (280.6 +/- 10.5 min; P < 0.001). CONCLUSIONS: In coeliac disease there is an impairment of gastric emptying which is at least partially reversible. This suggests either an immunological disorder or that unabsorbed meal constituents are responsible for an ileal-brake effect.

Effect of nifedipine on mouth-to-cecum transit of liquid meal in normal subjects.

Nifedipine has been shown to inhibit small bowel motility and to increase ileal water and electrolyte absorption in animals, but few reports are available in human subjects. The drug has been reported to influence esophageal and colon motility in man, without affecting gastric emptying. We performed a double-blind, controlled, crossover, randomized study to investigate the effect of oral nifedipine 30 mg vs placebo on the orocecal transit time of a lactulose-labeled, liquid caloric meal in nine healthy volunteers, and its correlation with plasma nifedipine concentration. The transit time was measured using the breath hydrogen test. The drug study was preceded by a reproducibility study, which showed a mean variation in transit time of 8.3% (+/- 1%, SE). Nifedipine significantly increased orocecal transit time compared to placebo (nifedipine 131 +/- 16; placebo 104 +/- 14.5 min; P < 0.05). This effect correlated well with plasma nifedipine concentration expressed as area under the curve (r = 0.92, P < 0.004). Nifedipine 30 mg significantly delays orocecal transit of a liquid caloric meal. The small bowel is likely to be the site of action. These findings may afford a rational basis for investigating a possible antidiarrheal role of nifedipine.

Fecal fat concentration in the screening of steatorrhea.

We studied if the fecal fat concentration as measured by the near infrared reflectance analysis in a spot sample is an acceptable screening test for malabsorption. This measurement was compared with the more complex fat balance in 120 patients with a suspected malabsorption [53 with chronic pancreatic disorders (CP), 67 with other digestive disorders (nCP)]. The fecal fat concentration proved to be well correlated with steatorrhea in CP (r = 0.86) but not in nCP (r = 0.35). A fat concentration of 9 g% had a sensitivity and a specificity for steatorrhea of 88.8% and of 97.1% in CP, but only of 53.8% and of 94.4% respectively in nCP. The fecal fat concentration was significantly higher in CP than in nCP, even considering patients with steatorrhea only; however, the overlap between the two groups was too high to suggest a clinical usefulness of this test in the differential diagnosis of steatorrheas. It is concluded that the fat concentration in a small sample, easily obtained also in outpatients, is useful in the selection of patients with chronic pancreatitis to submit to a proper fat balance study.

Impaired colonic motor response to cholinergic stimulation in patients with severe chronic idiopathic (slow transit type) constipation.

Chronic idiopathic constipation, especially the slow transit type, is a troubling problem often afflicting young women. The pathophysiological basis for this entity is unknown, although a defective cholinergic innervation has been postulated. We tested the hypothesis that cholinergic colonic innervation is deranged in this condition by studying colonic motor activity after strong cholinergic stimulation with edrophonium chloride in 14 women complaining of slow transit constipation. Unlike healthy subjects, constipated patients showed minimal or no response to edrophonium injection. It is concluded that in slow transit constipation there is an important alteration of colonic cholinergic activity and that edrophonium chloride may represent a useful test drug for colonic pathophysiological investigations.

Near infrared reflectance measurement of nitrogen faecal losses.

Chemical methods of measuring nitrogen in stools are complex, unpleasant, and therefore rarely performed. Recently, near infrared reflectance (NIRA) has been suggested for stool analysis. The aim of this study was to evaluate the possible application of this method in routine faecal nitrogen measurement. Nitrogen concentration and daily output were measured in the stools of 83 patients using NIRA and, for comparison, the Kjeldahl method. Nitrogen concentration and output ranged between 0.4-2.72 g% and 0.45-8.96 g/day respectively. Correlation coefficients (r), of 0.89 and 0.97 were found between the two methods for concentration and output respectively, and similar values were found in patients on enteral nutrition. Repeated measurements from the same stool collection, requiring only a few minutes, allowed homogenisation to be avoided. NIRA seems to be an easy, fast, and reliable alternative to chemical assays of nitrogen measurement in the management of patients with digestive disorders.