Selecting the most appropriate route of feeding.

This article provides an overview of the various methods available for providing nutritional support. The various techniques available for both enteral and parenteral access are discussed. The selection of the most appropriate route of nutritional support is highly individual and recommendations are made regarding the factors that should be considered by the patient and the clinician in the decision-making process.

A double-blind, randomised, controlled trial to study the effects of an enteral feed supplemented with glutamine, arginine, and omega-3 fatty acid in predicted acute severe pancreatitis.

CONTEXT: Current best evidence is in favour of early institution of enteral feeding in acute severe pancreatitis with promising results from trials in immunonutrition on other patient groups. OBJECTIVE: To identify which groups of patients and products are associated with benefit, we investigated immunonutrition in patients with predicted acute severe pancreatitis. DESIGN: A randomised trial of a study feed containing glutamine, arginine, tributyrin and antioxidants versus an isocaloric isonitrogenous control feed was undertaken. PATIENTS: Thirty-one patients with a diagnosis of acute pancreatitis predicted to develop severe disease: 15 study feeds and 16 control feeds. INTERVENTIONS: Enteral feeding via nasojejunal tube for 3 days. If patients required further feeding the study was continued up to 15 days. MAIN OUTCOME MEASURES: Reduction in C-reactive protein (CRP) by 40 mg/L after 3 days of enteral feeding was the primary endpoint. Carboxypeptidase B activation peptide (CAPAP) levels were taken at regular intervals. RESULTS: After 3 days of feeding, in the study group 2/15 (13%) of patients had reduced their CRP by 40 mg/L or more. In the control group 6/16 (38%) of patients had reduced their CRP by this amount. This difference was found to be near the statistical significant limit (P=0.220). CONCLUSIONS: The cause of the unexpectedly higher CRP values in the study group is unclear. The rise in CRP was without a commensurate rise in CAPAP or outcome measures so there was no evidence that this represented pancreatic necrosis. The contrast between the CRP and CAPAP results is of interest and we believe that specific pancreatic indices such as CAPAP should be considered in larger future studies.

Using the polymerase chain reaction coupled with denaturing gradient gel electrophoresis to investigate the association between bacterial translocation and systemic inflammatory response syndrome in predicted acute severe pancreatitis.

AIM: To investigate the use of PCR and DGGE to investigate the association between bacterial translocation and systemic inflammatory response syndrome in predicted severe AP. METHODS: Patients with biochemical and clinical evidence of acute pancreatitis and an APACHE II score > or = 8 were enrolled. PCR and DGGE were employed to detect bacterial translocation in blood samples collected on d 1, 3, and 8 after the admission. Standard microbial blood cultures were taken when there was clinical evidence of sepsis or when felt to be clinically indicated by the supervising team. RESULTS: Six patients were included. Of all the patients investigated, only one developed septic complications; the others had uneventful illness. Bacteria were detected using PCR in 4 of the 17 collected blood samples. The patient with sepsis was PCR-positive in two samples (taken on d 1 and 3), despite three negative blood cultures. Using DGGE and specific primers, the bacteria in all blood specimens which tested positive for the presence of bacterial DNA were identified as E coli. CONCLUSION: Our study confirmed that unlike traditional microbiological techniques, PCR can detect the presence of bacteria in the blood of patients with severe AP. Therefore, this latter method in conjunction with DGGE is potentially an extremely useful tool in predicting septic morbidity and evaluating patients with the disease. Further research using increased numbers of patients, in particular those patients with necrosis and sepsis, is required to assess the reliability of PCR and DGGE in the rapid diagnosis of infection in AP.

Use of the anti-endomysial antibody test to diagnose coeliac disease in clinical practice.

BACKGROUND: Guidelines suggest that duodenal biopsies should be taken in patients with iron deficiency anaemia. OBJECTIVE: To examine anti-endomysial antibody (anti-EMA) and duodenal biopsy testing in Portsmouth, UK. To evaluate if the current pathology workload can be reduced by anti-EMA replacing some duodenal biopsies. To determine to what extent doctors in Portsmouth are confirming a positive anti-EMA test by small bowel biopsy. DESIGN: Patients' records were examined firstly from whom duodenal biopsies were taken between April 1999 and September 2000, and secondly who had anti-EMA tested between December 1999 and September 2000. SETTING: Queen Alexandra Hospital, UK. District General Hospital. Medical Outpatients Department. RESULTS: In the first group, of 354 patients undergoing duodenal biopsy, 108 patients had anti-EMA tested. Of these 108 patients, 25 had positive IgA anti-EMA and 83 had negative IgA anti-EMA. Of these 83 patients who had negative IgA EMA, 8 patients had a duodenal biopsy suggestive of Coeliac Disease. 4 of these 8 patients were on gluten free diets at the time of anti-EMA testing so were excluded. 1 of the 4 patients who had a duodenal biopsy indicative of Coeliac Disease had a positive IgG anti-EMA despite negative IgA anti-EMA. Therefore 3 false negative IgG anti-EMA were ultimately identified giving a sensitivity of 89% and a specificity of 100%. On follow up one has subsequently been found to have T-cell lymphoma; if this patient is taken into account the sensitivity of anti-EMA increases to 93%. In the second group; 1450 patients had anti-EMA tested. Of the 67 positive anti-EMA tests in this group only 12 had a duodenal biopsy. CONCLUSIONS: Many patients who have been tested for anti-EMA are not offered duodenal biopsy in Portsmouth despite current British Society of Gastroenterology (BSG) guidelines, although it should be noted that the BSG guidelines on iron-deficiency anaemia recommend using anti-EMA without histology to exclude Coeliac Disease in menstruating women (biopsy would still be recommended if anti-EMA were positive). Our study has found a high sensitivity and specificity of anti-EMA; there may therefore be some circumstances where duodenal biopsy is unnecessary in the investigation of Coeliac Disease. Patients with suspected Coeliac Disease and negative anti-EMA should be evaluated for other causes of villous atrophy.