Primary sclerosing cholangitis in the presence of a lupus anticoagulant.

Lupus anticoagulant, an immunoglobulin that prolongs the partial thromboplastin time, has been associated with thrombotic events, including deep venous thrombosis, pulmonary emboli, and Budd-Chiari syndrome. In this report, primary sclerosing cholangitis was diagnosed in a man with a 10-year history of multiple thrombotic events related to a circulating lupus anticoagulant. Progressive jaundice and pruritus developed, and sclerosing cholangitis was confirmed by direct cholangiography. Sclerosing cholangitis is the second hepatobiliary disease reported in association with a lupus anticoagulant.

Enteral feeding in critical care, gastrointestinal diseases, and cancer.

This article discusses the many advantages and changes that have occurred in the nutritional management of critically-ill patients, patients with gastrointestinal diseases, and patients with selected cancers. Mechanical obstruction is the only absolute contraindication to enteral nutrition. This article reviews the present aggressive approach to the use of enteral nutrition.

Decisions for enteral access in the intensive care unit.

When making decisions regarding nutrition support, many factors must be considered before committing a patient to receive parenteral or enteral nutrition. Parenteral nutrition (PN) is more expensive and technically more difficult to administer than enteral nutrition (EN). The charge for PN can range from US 200 dollars to 1000 dollars per day, where a standard hospital diet or enteral tube feedings might cost less than US 25 dollars/d. PN is also associated with a much higher incidence of biochemical complications such as hyperglycemia and other electrolyte abnormalities and catheter-related complications such as infection, thrombosis, or pneumothorax. For many years PN was preferred to EN because it was believed to be unwise to feed a critically ill patient into the gut. It has now been shown in multiple studies that it is not only feasible to feed critically ill patients early, but also it may be immunologically advantageous to feed enterally. The cost effectiveness of the nutrition support team approach to monitoring PN and EN should not be underestimated by hospital administrators. If enteral therapy can be instituted, significant patient-care cost savings may be realized. This presentation will discuss decisions that must be addressed in the intensive care unit. With more physician education, protocols can be designed to provide the most advantageous use of nutrition support for the benefit of the hospitalized patient.

Short-bowel syndrome: a review of the role of nutrition support.

Advances in long-term venous access devices and in parenteral nutrition solutions have made it possible for patients with severe short bowel syndrome to survive and to live in our society. The spectrum of this disease is such that some patients may be able to lessen their dependence or even become free from parenteral therapy. This review will discuss the role of nutrition support in the patient with short bowel syndrome.

The refeeding syndrome: a review.

Refeeding syndrome has been used to describe those phenomena, such as severe hypophosphatemia and other metabolic complications, seen in malnourished patients receiving concentrated calories via total parenteral nutrition. The purpose of this review is to clarify and broaden this definition, as well as to make recommendations for its recognition and, more importantly, prevention.

Medication delivery in the short-bowel syndrome.

Technologic advances such as total parenteral nutrition have prolonged the lives of individuals with short-bowel syndrome who previously would not have survived. However, the day-to-day management of these patients presents a significant challenge to those who take care of them. Providing medications on either an acute or chronic basis without the use of their central catheters is a difficult clinical problem. This article reviews the approach and methods of treating short-bowel patients on the basis of their individual circumstances and physiology.

Pulmonary embolism as a complication of long-term total parenteral nutrition.

Although much has been written concerning the complications of long-term total parenteral nutrition, little or no mention of pulmonary embolism is made in the literature. We present two patients maintained on home total parenteral nutrition who suffered pulmonary emboli, one while receiving standard heparin therapy. No potential source other than their indwelling total parenteral nutrition catheter was identified. Studies have revealed catheter-related thrombosis in up to 50% of patients with indwelling central venous catheters. Although early surgical literature suggested that upper extremity deep vein thromboses rarely embolize, more recent investigations have proven this false. In fact, the risk of pulmonary emboli appeared to be greatest in those thrombi that were catheter related. Because of this risk, we suggest a hypercoaguable work-up in any patient with a history of recurrent thrombosis. Heparin is central to the current preventive regimens; however, further study is needed to determine the most efficacious dose. Future development of less thrombogenic catheters will also be of assistance. Thrombolytic agents currently have an expanding role in the treatment of thrombotic complications. Whether they will have a future role in prevention remains unknown.

Early enteral nutrition after brain injury by percutaneous endoscopic gastrojejunostomy.

Twenty-seven patients in a series of 52 patients with severe brain injury (Glasgow Coma Scale score less than or equal to 8) underwent insertion of intestinal feeding tubes at the bedside. The technique required endoscopy with externalization of gastric and intestinal ports through the abdominal wall. Feedings were begun through the intestinal tube with Vital HN within 4 hours of its insertion with simultaneous gastric decompression via the gastric tube. Tubes were placed 2.3 (range 0-5) days after injury. Full caloric intake (3020 kcal/24 h) was achieved by 6.8 (range 2-8) days after injury to 4.2 (range 2-8) days after placement of the feeding tube. Only 1 patient failed to tolerate feedings immediately after tube insertion. Technical inability to insert the tubes occurred in 3 patients and the intestinal tube migrated into the stomach in 2 patients; diarrhea occurred in only 1 patient. With this technique, it was possible to deliver an average daily intake of 1.2 g/kg of protein in 8-day balance periods beginning at the time of tube insertion. These data included 3- to 4-day periods in which feedings were steadily increased. In 16 patients in whom nitrogen balance was measured for 8-day balance periods, average nitrogen balance was -5.7 (range -11.3 to +3.5) g/24 h. The reduction in nitrogen loss by this technique appears equal to or superior to either gastric feeding or TPN. This technique provides the ability to enterally feed a high proportion of brain-injured patients (except those in barbiturate coma) very early after injury using a bedside procedure.(ABSTRACT TRUNCATED AT 250 WORDS)

The clinical evaluation of plasma fibronectin as a marker for nutritional depletion and repletion and as a measure of nitrogen balance.

Plasma fibronectin has been suggested as a possible marker for nutritional repletion or depletion. This study was undertaken to evaluate the usefulness of plasma fibronectin in patients who received intense nutritional support. Twenty-seven patients referred to our Nutritional Support Services were followed for 3 to 5 wk; 22 received parenteral hyperalimentation alone, two received enteral alone, and three received a combination of both. Plasma fibronectin, serum albumin, serum transferrin, total lymphocyte counts, and 24-hr urine nitrogen balance studies were performed weekly; anthropometric measurements were performed every other week. Plasma fibronectin concentration, measured by laser nephelometry, showed a significant rise (p less than 0.005) in all patients after 1 wk of nutritional therapy; however, there was no significant difference among the subsequent weeks. Plasma fibronectin did not correlate with nitrogen balance studies, serum albumin, or total lymphocyte counts. A correlation between serum transferrin and plasma fibronectin was found not to be clinically useful. Thus, plasma fibronectin is sensitive to nutritional repletion after 1 wk of therapy, but is not useful thereafter. The relationship among nutritional status, immunologic function, plasma fibronectin, and other serum proteins are discussed.

Percutaneous endoscopic gastrostomies: a prospective evaluation and review of the literature.

The results of the first 55 consecutive percutaneous endoscopic gastrostomies (PEGs) that were performed over an 18-month period in a tertiary care center are presented. We followed these cases prospectively to assess the morbidity, mortality, staff acceptance, short-and long-term complications, and cost effectiveness of the technique. Fifty-one (93%) were successful with no mortality. Long-term morbidity included 6/55 (11%) tube extrusions; 5/55 (9%) cellulitis around the catheter site; 5/55 (9%) aspiration pneumonias; and 2/55 (3.6%) clogged tubes requiring replacement. Morbidity was considered minor and easily dealt with in all but five instances (9%) where more prolonged treatment was required. A review of the literature including other techniques used for percutaneous gastrostomy is also presented. It is concluded that percutaneous gastrostomies are relatively safe, cost-effective, and should be given first consideration for long-term enteral therapy in appropriate patients.

Percutaneous endoscopic gastrojejunostomy: a dual center safety and efficacy trial.

Although jejunal tube placement through a percutaneous endoscopic gastrostomy (PEG) has not been proven to be preferable to PEG feeding, it would be theoretically advantageous for those patients prone to gastrointestinal aspiration. However, reliable placement of a small bowel feeding tube through a PEG has been technically difficult. We have previously reported successful placement of a percutaneous endoscopic gastrojejunostomy (PEG/J) with minimal complications. These results are in contrast to other series that report technical difficulty, frequent tube dysfunction and gastric aspiration. We describe an over-the-wire PEG/J technique performed by multiple operators at two medical centers. Gastrostomy tube placement was successful in 94% of patients. Initial placement of the jejunal tube was successful in 88% of patients. Second attempts were 100% successful. The average procedure time was 36 minutes. The distal duodenal and jejunal placement of the jejunal tube resulted in no episodes of gastroduodenal reflux. Complications included jejunal tube migration (6%), clogging (18%), and unintentional removal (11%). The majority of patients were ultimately converted to either oral or intragastric feedings. We conclude that the PEG/J system is a reliable, reproducible method of small bowel feeding and is associated with no episodes of tube feeding reflux when the jejunal tube is positioned in the distal duodenum or beyond. Furthermore, it provides a temporary nutritional bridge for those patients who are later transitioned to either PEG or oral feeding.

A prospective assessment of the Garren-Edwards Gastric Bubble and bariatric surgery in the treatment of morbid obesity.

Morbid obesity is a serious medical hazard, and effective alternatives to surgery have been unsuccessful. In 1985, the Garren-Edwards Gastric Bubble (GEGB) was offered as an adjunct to dietary and behavioral therapy for weight loss treatment. The safety and efficacy of the GEGB were compared with bariatric surgery, the current standard for the treatment of morbid obesity. Fifty-seven patients received GEGB and 77 underwent bariatric surgery. GEGB patients were divided into two groups: those who attended group therapy and those who did not. This study showed that bariatric surgery was far more effective in reducing excess body weight during a 12-month period compared with the GEGB plus group therapy and the GEGB alone. The morbidity from bariatric surgery was greater than in the GEGB-treated groups, while the cost for uncomplicated cases for a year's treatment was comparable. It is concluded that the GEGB does not offer an effective alternative to bariatric surgery in the treatment of morbid obesity.

Nutrition support in pancreatitis.

Nutrition support in patients with pancreatitis has created a challenge for clinicians. Because the pancreas is normally stimulated by the ingestion of food, particularly fat, patients are often denied oral nutrition. This reduction in the ingestion of food, together with the increased metabolic demands of this disease, often results in a negative energy balance and occasionally undernutrition or malnutrition. This review summarizes the etiologies and methods for staging pancreatitis, the physiology of pancreatic exocrine secretion and the response of the pancreas to different methods of nutrition support. The results of clinical trials, which examine both parenteral and enteral nutrition in animals and humans with this disease, are reviewed. Recommendations for nutrition management of patients with acute and chronic pancreatitis and areas for future research are discussed.