Hydration by colonic enteroclysis: An alternative to parenteral hydration in patients with high-output double enterostomy.

BACKGROUND: High-output double enterostomies (DESs) result in sodium and fluid loss responsible for frequent episodes of dehydration and hospitalizations. Hydration by enteroclysis (HE) is an alternative to parenteral hydration when the small bowel, or the downstream colon, is accessible and functional. METHODS: A retrospective analysis was conducted on all consecutive patients admitted in our institution with high-output (≥1200 ml per 24 h) DES and access to downstream intestine (including colon), who were treated by enteroclysis between 2015 and 2019. A sodium chloride and bicarbonate solution was instilled through a tube inserted in the colon. The objectives were diuresis >1 L, natriuresis >40 mmol/24 h, and urinary sodium-to-potassium ratio >1. RESULTS: HE was conducted in 52 patients (24 female, 28 male). Initially, 30 patients received intravenous support. Fifteen patients (50%) were weaned from all parenteral support, of whom 11 of 12 (92%) received fluid and electrolyte support and 4 of 18 (22%) received parenteral nutrition (PN). When intravenous fluids were still required, daily volumes decreased from 2714 ± 1424 to 1578 ± 1000 ml per 24 h (P = .001), as did the energetic intake (NS), from 1439 ± 556 to 1230 ± 362 kcal per 24 h (P = .096). CONCLUSION: HE through the efferent intestine limits the requirement for parenteral hydration in patients with high-output DES. For patients with intestinal failure dependent on PN, it reduces daily infused volumes.

Chyme Reinfusion Restores the Regulatory Bile Salt-FGF19 Axis in Patients With Intestinal Failure.

BACKGROUND AND AIMS: Automated chyme reinfusion (CR) in patients with intestinal failure (IF) and a temporary double enterostomy (TDE) restores intestinal function and protects against liver injury, but the mechanisms are incompletely understood. The aim was to investigate whether the beneficial effects of CR relate to functional recovery of enterohepatic signaling through the bile salt-FGF19 axis. APPROACH AND RESULTS: Blood samples were collected from 12 patients, 3 days before, at start, and 1, 3, 5, and 7 weeks after CR initiation. Plasma FGF19, total bile salts (TBS), 7-α-hydroxy-4-cholesten-3-one (C4; a marker of bile salt synthesis), citrulline (CIT), bile salt composition, liver tests, and nutritional risk indices were determined. Paired small bowel biopsies prior to CR and after 21 days were taken, and genes related to bile salt homeostasis and enterocyte function were assessed. CR induced an increase in plasma FGF19 and decreased C4 levels, indicating restored regulation of bile salt synthesis through endocrine FGF19 action. TBS remained unaltered during CR. Intestinal farnesoid X receptor was up-regulated after 21 days of CR. Secondary and deconjugated bile salt fractions were increased after CR, reflecting restored microbial metabolism of host bile salts. Furthermore, CIT and albumin levels gradually rose after CR, while abnormal serum liver tests normalized after CR, indicating restored intestinal function, improved nutritional status, and amelioration of liver injury. CR increased gene transcripts related to enterocyte number, carbohydrate handling, and bile salt homeostasis. Finally, the reciprocal FGF19/C4 response after 7 days predicted the plasma CIT time course. CONCLUSIONS: CR in patients with IF-TDE restored bile salt-FGF19 signaling and improved gut-liver function. Beneficial effects of CR are partly mediated by recovery of the bile salt-FGF19 axis and subsequent homeostatic regulation of bile salt synthesis.

Distribution of ticks, tick-borne pathogens and the associated local environmental factors including small mammals and livestock, in two French agricultural sites: the OSCAR database.

BACKGROUND: In Europe, ticks are major vectors of both human and livestock pathogens (e.g. Lyme disease, granulocytic anaplasmosis, bovine babesiosis). Agricultural landscapes, where animal breeding is a major activity, constitute a mosaic of habitat types of various quality for tick survival and are used at different frequencies by wild and domestic hosts across seasons. This habitat heterogeneity, in time and space, conditions the dynamics of these host-vector-pathogen systems and thus drives acarological risk (defined as the density of infected ticks). The principal objective of the OSCAR project (2011-2016) was to examine the links between this heterogeneity and acarological risk for humans and their domestic animals. Here, we present the data associated with this project. NEW INFORMATION: This paper reports a database on the distribution and densities of I. ricinus ticks - the most common tick species in French agricultural landscapes - and the prevalence of three tick-borne pathogens (Anaplasma phagocytophilum, Borrelia spp. and Babesia spp.) in two sites in north-western ("Zone Atelier Armorique": ZA site) and south-western ("Vallées et Coteaux de Gascogne": VG site) France. The distribution and density of ticks along a gradient of wooded habitats, as well as biotic variables, such as the presence and abundance of their principal domestic (livestock) and wild hosts (small mammals), were measured from forest cores and edges to more or less isolated hedges, all bordering meadows. Ticks, small mammals and information on local environmental conditions were collected along 90 transects in each of the two sites in spring and autumn 2012 and 2013 and in spring 2014, corresponding to the main periods of tick activity. Local environmental conditions were recorded along each tick and small mammal transect: habitat type, vegetation type and characteristics, slope and traces of livestock presence. Samples consisted of questing ticks collected on the vegetation (mainly I. ricinus nymphs), biopsies of captured small mammals and ticks fixed on small mammals. In the VG site, livestock occurrence and abundance were recorded each week along each tick transect.A total of 29004 questing ticks and 1230 small mammals were captured during the study across the two sites and over the five field campaigns. All questing nymphs (N = 12287) and questing adults (N = 646) were identified to species. Ticks from small mammals (N = 1359) were also identified to life stage. Questing nymphs (N = 4518 I. ricinus) and trapped small mammals (N = 908) were analysed for three pathogenic agents: A. phagocytophilum, Borrelia spp. and Babesia spp.In the VG site, the average prevalence in I. ricinus nymphs for A. phagocytophilum, Borrelia spp. and Babesia spp. were, respectively 1.9% [95% CI: 1.2-2.5], 2.5% [95% CI: 1.8-3.2] and 2.7% [95% CI: 2.0-3.4]. In small mammals, no A. phagocytophilum was detected, but the prevalence for Borrelia spp. was 4.2% [95% CI: 0.9-7.5]. On this site, there was no screening of small mammals for Babesia spp. In ZA site, the average prevalence in nymphs for A. phagocytophilum, Borrelia spp. and Babesia were, respectively 2.2% [95% CI: 1.6-2.7], 3.0% [95% CI: 2.3-3.6] and 3.1% [95% CI: 2.5-3.8]. In small mammals, the prevalence of A. phagocytophilum and Borrelia spp. were, respectively 6.9% [95% CI: 4.9-8.9] and 4.1% [95% CI: 2.7-5.9]. A single animal was found positive for Babesia microti at this site amongst the 597 tested.

Chyme Reinfusion in Intestinal Failure Related to Temporary Double Enterostomies and Enteroatmospheric Fistulas.

Some temporary double enterostomies (DES) or entero-atmospheric fistulas (EAF) have high output and are responsible for Type 2 intestinal failure. Intravenous supplementations (IVS) for parenteral nutrition and hydration compensate for intestinal losses. Chyme reinfusion (CR) artificially restores continuity pending surgical closure. CR treats intestinal failure and is recommended by European Society for Clinical Nutrition and Metabolism (ESPEN) and American Society for Parenteral and Enteral Nutrition (ASPEN) when possible. The objective of this study was to show changes in nutritional status, intestinal function, liver tests, IVS needs during CR, and the feasibility of continuing it at home. A retrospective study of 306 admitted patients treated with CR from 2000 to 2018 was conducted. CR was permanent such that a peristaltic pump sucked the upstream chyme and reinfused it immediately in a tube inserted into the downstream intestine. Weight, plasma albumin, daily volumes of intestinal and fecal losses, intestinal nitrogen, and lipid absorption coefficients, plasma citrulline, liver tests, and calculated indices were compared before and during CR in patients who had both measurements. The patients included 185 males and 121 females and were 63 ± 15 years old. There were 37 (12%), 269 (88%) patients with EAF and DES, respectively. The proximal small bowel length from the duodeno-jejunal angle was 108 ± 67 cm (n = 232), and the length of distal small intestine was 117 ± 72 cm (n = 253). The median CR start was 5 d (quartile 25-75%, 2-10) after admission and continued for 64 d (45-95), including 81 patients at home for 47 d (28-74). Oral feeding was exclusive 171(56%), with enteral supplement 122 (42%), or with IVS 23 (7%). Before CR, 211 (69%) patients had IVS for nutrition (77%) or for hydration (23%). IVS were stopped in 188 (89%) 2 d (0-7) after the beginning of CR and continued in 23 (11%) with lower volumes. Nutritional status improved with respect to weight gain (+3.5 ± 8.4%) and albumin (+5.4 ± 5.8 g/L). Intestinal failure was cured in the majority of cases as evidenced by the decrease in intestinal losses by 2096 ± 959 mL/d, the increase in absorption of nitrogen 32 ± 20%, of lipids 43 ± 30%, and the improvement of citrulline 13.1 ± 8.1 µmol/L. The citrulline increase was correlated with the length of the distal intestine. The number of patients with at least one liver test >2N decreased from 84-40%. In cases of Type 2 intestinal failure related to DES or FAE with an accessible and functional distal small bowel segment, CR restored intestinal functions, reduced the need of IVS by 89% and helped improve nutritional status and liver tests. There were no vital complications or infectious diarrhea described to date. CR can become the first-line treatment for intestinal failure related to double enterostomy and high output fistulas.

Management of entero-atmospheric fistulas by chyme reinfusion: A retrospective study.

BACKGROUND & AIMS: High output entero-cutaneous fistulas may lead to intestinal failure with parenteral nutrition (PN) as the gold standard treatment to prevent dehydration and malnutrition. However in case of entero-atmospheric fistula (EAF) with the distal limb of the fistula accessible, chyme reinfusion (CR), a technique that restores artificially digestive continuity can be performed until the surgical repair. Our aim was to study the efficacy of CR in EAF regarding nutritional status, intestinal function, PN weaning and liver tests. METHODS: Retrospective study of 37 patients admitted for EAF and treated by CR from 1993 to 2017. Delays were expressed in median (25%-75% quartiles) and other data on mean ± SD. RESULTS: Location of EAF: jejunum (29), ileum (8). The length of the upstream intestine was estimated in 21 patients: 19 had a bowel length <150 cm of which 16 had less than 100 cm. During CR, mean digestive losses decreased from 1734 ± 578 to 443 ± 487 ml/24 h (p < 0.000001), nitrogen absorption increased from 45.3 ± 18.6 to 81.8 ± 12.9% of ingesta (p < 0.001). The percentage of patients with plasma citrulline <20 µmol/l decreased from 71 to 10%. PN was stopped in all patients within 3 (0-14) days after CR initiation, 2 patients required an intravenous hydration and 20 had an additional enteral support. The nutritional status improved: albumin (33.1 ± 5.1 g/L vs 28.4 ± 6.5, p < 0.001), NRI (decrease of the number of patients at risk of severe malnutrition from 22 to 10 (p < 0.001)). The number of patients who had one or several liver tests abnormalities (>2 N) decreased from 94 to 41% (p < 0.001). CONCLUSION: When the efferent part of the small bowel is accessible, CR is a safe and inexpensive method that restores bowel function. In most cases, it makes it possible to stop PN and helps to improve the nutritional status until surgical reconstruction.

Effect of oral citrulline supplementation on whole body protein metabolism in adult patients with short bowel syndrome: A pilot, randomized, double-blind, cross-over study.

BACKGROUND & AIMS: As citrulline is produced by small intestine, plasma citrulline concentration is decreased and may become essential in patients with short bowel syndrome (SBS). In a rat model of SBS, citrulline supplementation enhanced muscle protein synthesis. The aim of the study was to determine whether citrulline impacts whole body protein metabolism in patients with SBS. METHODS: Nine adults with non-malignant SBS (residual small bowel 90 ± 48 cm; mean ± SD) who were in near-normal nutritional status without any artificial nutrition, were recruited long after surgery. They received 7-day oral supplementation with citrulline (0.18 g/kg/day), or an iso-nitrogenous placebo in a randomized, double-blind, cross-over design with a 13-day wash-out between regimens, and an intravenous 5-h infusion of L-[1-13C]-leucine in the postabsorptive state to assess protein metabolism after each regimen. RESULTS: Plasma citrulline concentration rose 17-fold (25 ± 9 vs. 384 ± 95 µmol/L) and plasma arginine 3-fold after oral citrulline supplementation (both p < 4 × 10-6). Supplementation did not alter leucine appearance rate (97 ± 5 vs. 97 ± 5 µmol kg-1.h-1; p = 0.88), leucine oxidation (14 ± 1 vs. 12 ± 1 µmol kg-1.h-1; p = 0.22), or non-oxidative leucine disposal (NOLD), an index of whole-body protein synthesis (83 ± 4 vs. 85 ± 5 µmol kg-1.h-1; p = 0.36), nor insulin or IGF-1 plasma concentrations. In each of the 3 patients with baseline citrulline<20 µmol/L, citrulline supplementation increased NOLD. Among the 7 patients with plasma citrulline <30 µmol/L, the effect of supplementation on NOLD correlated inversely (r2 = 0.81) with baseline plasma citrulline concentration. CONCLUSION: 1) Oral citrulline supplementation enhances citrulline and arginine bioavailability in SBS patients. 2) Oral citrulline supplementation does not have any anabolic effect on whole body protein metabolism in patients with SBS in good nutritional status, in the late phase of intestinal adaptation, and with near-normal baseline citrulline homeostasis. 3) Whether oral citrulline would impact whole body protein anabolism in severely malnourished SBS patients in the early adaptive period, and with baseline plasma citrulline below 20 µmol/L, warrants further study. Registered under ClinicalTrials.gov Identifier no. NCT01386034.

Host specificity, pathogen exposure, and superinfections impact the distribution of Anaplasma phagocytophilum genotypes in ticks, roe deer, and livestock in a fragmented agricultural landscape.

Anaplasma phagocytophilum is a bacterial pathogen mainly transmitted by Ixodes ricinus ticks in Europe. It infects wild mammals, livestock, and, occasionally, humans. Roe deer are considered to be the major reservoir, but the genotypes they carry differ from those that are found in livestock and humans. Here, we investigated whether roe deer were the main source of the A. phagocytophilum genotypes circulating in questing I. ricinus nymphs in a fragmented agricultural landscape in France. First, we assessed pathogen prevalence in 1837 I. ricinus nymphs (sampled along georeferenced transects) and 79 roe deer. Prevalence was dramatically different between ticks and roe deer: 1.9% versus 76%, respectively. Second, using high-throughput amplicon sequencing, we characterized the diversity of the A. phagocytophilum genotypes found in 22 infected ticks and 60 infected roe deer; the aim was to determine the frequency of co-infections. Only 22.7% of infected ticks carried genotypes associated with roe deer. This finding fits with others suggesting that cattle density is the major factor explaining infected tick density. To explore epidemiological scenarios capable of explaining these patterns, we constructed compartmental models that focused on how A. phagocytophilum exposure and infection dynamics affected pathogen prevalence in roe deer. At the exposure levels predicted by the results of this study and the literature, the high prevalence in roe deer was only seen in the model in which superinfections could occur during all infection phases and when the probability of infection post exposure was above 0.43. We then interpreted these results from the perspective of livestock and human health.

Chyme reinfusion in patients with intestinal failure due to temporary double enterostomy: A 15-year prospective cohort in a referral centre.

BACKGROUND & AIMS: Patients with double temporary enterostomy may suffer from intestinal failure (IF). Parenteral nutrition (PN) is the gold standard treatment until surgical reestablishment of intestinal continuity. Chyme reinfusion (CR) is a technique consisting in an extracorporeal circulation of the chyme. The aims were to determine: i) whether CR could restore intestinal absorption, decrease PN needs, improve nutritional status and plasma liver tests; ii) the feasibility of home CR. METHODS: From the 232 patients IF consecutively referred for CR from 2000 to 2014, the 212 patients with IF, technical feasibility of CR, and effectively treated by CR, were included. Were collected prospectively before and during CR: daily stomal and fecal outputs, coefficients of nitrogen (CNDA) and fat (CFDA) digestive absorption, weight loss, body mass index (BMI), Nutritional Risk Index (NRI), plasma albumin, citrulline, and liver tests. RESULTS: 183 patients had temporary double enterostomy and 29 exposed enterocutaneous fistulas. CR reduced the intestinal output (2444 ± 933 vs 370 ± 457 ml/day, P < 0.001), improved CNDA (46 ± 16 vs 80 ± 14%, P < 0.001) and CFDA (48 ± 25 vs 86 ± 11%, P < 0.001), and normalized plasma citrulline concentration (17.6 ± 8.4 vs 30.3 ± 11.8 µmol/l, P < 0.001). PN was stopped in 126/139 (91%) patients within 2 ± 8 d. Nutritional status improved (P < 0.001): weight (+4.6 ± 8.6%), BMI (+3.8 ± 7.7%), plasma albumin (+6.2 ± 6.1 g/l), and NRI (+10.9 ± 9.5). The proportion of patients with plasma liver tests abnormalities decreased (88 vs 51%, P < 0.01). Home CR was feasible without any serious complications in selected patients. CONCLUSIONS: CR corrected the intestinal failure by restoring intestinal absorption, allowing PN weaning in 91% of patients. CR contributes to improve nutritional status and to reduce plasma liver tests abnormalities, and is feasible at home.

Individual variation in an acute stress response reflects divergent coping strategies in a large herbivore.

Individuals differ in the manner that they cope with risk. When these behavioral differences are manifested in risky or challenging environments (i.e. stressful situations), they are generally interpreted within the "coping style" framework. As studying inter-individual variability in behavior is particularly challenging in the wild, we used a captive facility to explore consistency in the individual behavioral response to an acute stress in roe deer (Capreolus capreolus). Using behavioral and physiological parameters measured six times across a calendar year, we first quantified individual repeatability and, second, explored the correlations among these parameters that might indicate a coherent stress response. Finally, we analyzed the link between the stress response and individual body mass, a reliable indicator of phenotypic quality in roe deer. We found that the measured parameters were highly repeatable across seasons, indicating that the individual stress response is consistent over time. Furthermore, there was considerable covariation among the stress response parameters, describing a proactivity-reactivity gradient at the individual level. Finally, proactive individuals had higher body mass than reactive individuals. We suggest that consistent individual differences in energy metabolism and physiology may promote consistent individual differences in behavioral traits, providing a mechanistic link between food acquisition tactics and demographic performance.

Chyme reinfusion or enteroclysis in nutrition of patients with temporary double enterostomy or enterocutaneous fistula.

PURPOSE OF REVIEW: Patients with double temporary enterostomy or enterocutaneous fistula may suffer from intestinal failure. Parenteral nutrition is the gold standard treatment until surgical re-establishment of intestinal continuity, but serious complications may arise. Chyme reinfusion or enteroclysis are indicated. RECENT FINDINGS: Chyme reinfusion corrects the intestinal failure by restoring intestinal absorption, allowing parenteral nutrition weaning in 91% of patients. Chyme reinfusion contributes to improve nutritional status and reduce plasma liver test abnormalities. Chyme reinfusion is feasible at home without any serious complications in selected patients. Mechanisms underlying chyme reinfusion effectiveness on intestinal function, such as restoration of ileal brake, are suggested but most remain to be demonstrated. When the downstream small bowel is exposed, enteroclysis of enteral nutrition or hydration could be helpful to reduce parenteral nutrition needs, or in case of insufficient food intake during chyme reinfusion. SUMMARY: Chyme reinfusion or enteroclysis are less expensive, well tolerated, and easy-to-use nutrition support techniques, which may allow reducing parenteral nutrition-related healthcare costs. The latter remains to be demonstrated in the setting of a prospective randomized controlled trial. This review may contribute to improve the awareness of intensivists, digestive surgeons, and gastroenterologists involved in intestinal failure management to spread the use of chyme reinfusion or enteroclysis.

Detection of atypical Chlamydiaceae in roe deer (Capreolus capreolus).

Investigations on fecal samples, vaginal swabs and sera from roe deer (Capreolus capreolus) in south-western France led to the detection of a non-classified Chlamydiaceae strain. A total of 85 vaginal swabs were sampled from roe deer that had been captured in 2012 (n=42) and 2013 (n=43). Using a Chlamydiaceae family-specific real-time PCR, only one vaginal swab out of the 42 samples done in 2012 tested positive and was subsequently identified as Chlamydia (C.) psittaci. In contrast, 6/43 vaginal swab samples were positive in 2013. Four of these positive samples came from a single group of roe deer, captured in the Fabas plain. Fecal samples from this group of 9 females were subsequently analyzed, with 6 of them testing positive with the Chlamydiaceae-specific PCR. All positive samples collected in 2013 were negative when re-tested with C. abortus-, C. pecorum- and C. suis-specific real-time PCR assays. Sera from this group of 9 females were analyzed with two immunoassays (recomLine and ELISA). Whereas intense positive reactions with C. pneumoniae antigens were observed for all sera when tested with the recomLine test, none was positive with the C. abortus specific ELISA test. Comparative sequence analysis of the 16S, 23S rRNA and ompA gene sequences from 3 animals, as well as the MLST analysis from 2 animals, showed that this roe deer group likely harbored the same bacterium related to members of the family Chlamydiaceae. Notably, the roe deer strain formed a separate entity different from the currently recognized chlamydial species, with C. trachomatis, C. suis and C. muridarum appearing as its closest relatives.

Temporal dynamics of seed excretion by wild ungulates: implications for plant dispersal.

Dispersal is a key process in metapopulation dynamics as it conditions species' spatial responses to gradients of abiotic and biotic conditions and triggers individual and gene flows. In the numerous plants that are dispersed through seed consumption by herbivores (endozoochory), the distance and effectiveness of dispersal is determined by the combined effects of seed retention time in the vector's digestive system, the spatial extent of its movements, and the ability of the seeds to germinate once released. Estimating these three parameters from experimental data is therefore crucial to calibrate mechanistic metacommunity models of plant-herbivore interactions. In this study, we jointly estimated the retention time and germination probability of six herbaceous plants transported by roe deer (Capreolus capreolus), red deer (Cervus elaphus), and wild boar (Sus scrofa) through feeding experiments and a Bayesian dynamic model. Retention time was longer in the nonruminant wild boar (>36 h) than in the two ruminant species (roe deer: 18-36 h, red deer: 3-36 h). In the two ruminants, but not in wild boar, small and round seeds were excreted faster than large ones. Low germination probabilities of the excreted seeds reflected the high cost imposed by endozoochory on plant survival. Trait-mediated variations in retention time and germination probability among animal and plant species may impact plant dispersal distances and interact with biotic and abiotic conditions at the release site to shape the spatial patterns of dispersed plant species.

[Magnesium: a supercation misunderstood? Overview and survey of GPs in "Ille-et-Vilaine"]. / Le magnésium: un super cation méconnu? Revue générale et enquête auprès des généralistes d'Ille-et-Vilaine.

Since the introduction of the first magnesium pharmaceutical specialty in 1928, multiple medical indications were attributed to magnesium supplementation, despite rigorous scientific researches, leading to a very confuse therapeutic chapter. Real hypomagnesemia, acute or chronic, is rare, however oral magnesium drugs are numerous and widely prescribed. Moreover, in France, only proven magnesium deficiency, isolated or combined, are accepted by the HAS for magnesium supplementation. The purpose of this article is to review current knowledges on magnesium and analyze the prescribing practices of GPs. After telephone agreement, 100 doctors of Ille-et-Vilaine received an e-questionnaire that included 27 questions (38 items). These questions concerned the prescribing practices of magnesium, magnesium knowledge, and demographic data: 70% of responders say that prescribing magnesium shows an interest in their daily practice and 96% of responders that they often prescribe magnesium leading to 26% who prescribe magnesium even if they do not see the point! In only 7% of cases, prescription is the renewal of a specialist, and in 7% of cases, the request comes from the patient. GPs report that their knowledge on magnesium and its treatment indications come from the pharmaceutical industry. There is also a significant number of requirements driven by the patient himself, probably under the influence of the media especially Internet forums.

Oral citrulline does not affect whole body protein metabolism in healthy human volunteers: results of a prospective, randomized, double-blind, cross-over study.

BACKGROUND & AIMS: Citrulline increases protein synthesis during refeeding in rodents with short bowel syndrome, aging and malnutrition, and improves nitrogen balance in fed healthy humans. The aim of the current study therefore was to determine whether citrulline had affected protein metabolism in healthy volunteers. METHODS: In a randomized, double-blind, cross-over study, 12 healthy adults received a 5-h intravenous infusion of L-[1-(13)C]-leucine in the post-absorptive state, after a 7-day oral supplementation with 0.18 g/kg/day citrulline, or an iso-nitrogenous placebo. Treatment order was randomized, treatment periods were separated by 13-day wash out. Leucine appearance rate (Ra) was determined from plasma [1-(13)C]-keto-iso-caproate enrichment and leucine oxidation from expired (13)CO(2), and nitrogen balance was estimated from 6-h urinary urea excretion. RESULTS: Compared with placebo, oral citrulline supplementation increased plasma citrulline, arginine and ornithine concentrations, but failed to affect albumin, transthyretin, free insulin and insulin-like growth factor (IGF)-1 plasma concentrations, urinary nitrate excretion, or nitrogen balance. Citrulline supplementation did not alter leucine Ra, leucine oxidation, nor whole-body protein synthesis. CONCLUSION: In healthy, well nourished volunteers, oral citrulline increases plasma citrulline and arginine availability but does not affect whole-body protein kinetics in the post-absorptive state.

Plasma citrulline is a marker of absorptive small bowel length in patients with transient enterostomy and acute intestinal failure.

BACKGROUND & AIMS: Small bowel disruption is often complicated by acute intestinal failure and can be corrected by chyme reinfusion (CR). Plasma citrulline ([Cit]) is a biomarker of the enterocyte mass. Our aim was to determine whether [Cit] could be a marker of absorptive intestinal mass or function by assessing whether CR could affect intestinal absorptive function and [Cit]. METHODS: Twenty-six patients with small bowel disruption and double enterostomy were treated with CR. Fecal wet weight, nitrogen and fat absorption, parenteral nutrition delivery and [Cit] were measured before and after the initiation of CR with a median follow-up of 30 days. RESULTS: CR decreased the intestinal wet weight output (median+/-IQ, 2384+/-969 vs. 216+/-242mLd(-1), P<0.0001) and parenteral nutrition dependence (65% vs. 8%, P<0.01). CR was associated with a rise in net nitrogen and fat digestive absorption and [Cit] (17.0+/-10.0 vs. 31.0+/-12.0micromolL(-1), P=0.0001). Before the initiation of CR, [Cit] correlated positively with the absorptive post-duodenal small bowel length (r=0.39, P=0.04), but not with the total post-duodenal small bowel length (r=0.11, P=0.60). CONCLUSION: CR allows for a dramatic improvement of intestinal absorptive function and a near doubling in [Cit] level. [Cit] is not a marker of overall intestinal mass, but of the absorptive small bowel function.