[Large iatrogenic colonic perforation treated by endoscopic suturing]. / Large perforation colique au cours d'une coloscopie traitée par fermeture endoscopique: rapport de deux observations.

Perforation of the colon during colonoscopy is still one of the most severe complications of this technique and occurs with a frequency of between 0.12 % and 0.2 % of cases after diagnostic colonoscopy and in up to 3 % of patients after therapeutic colonoscopy. The site of perforation is usually the sigmoid colon. The gold standard for treatment of this complication is surgery to be performed as rapidly as possible: a simple suture and peritoneal cleaning, with limited resection and anastomosis or colostomy only in case of confirmed fecal peritonitis. However, interventional endoscopy has made progress, in particular endoscopic suturing and Natural Orifice Transluminal Endocopic Surgery (NOTES) has been developed. There are several reports of endoscopically sutured perforated colons, most less than 10mm. We report our experience of two colonic perforations which were at least 10mm treated by endoscopic suturing with hemoclips: a perforated sigmoid diverticulum during simple colonoscopy in the first case and a large polypectomy by endoscopic mucosal resection of the ascending colon in the second.

Review article: yeast as probiotics -- Saccharomyces boulardii.

BACKGROUND: Probiotics are defined as live micro-organisms which confer a health benefit on the host. Although most probiotics are bacteria, one strain of yeast, Saccharomyces boulardii, has been found to be an effective probiotic in double-blind clinical studies. AIMS: To compare the main properties that differentiates yeast from bacteria and to review the properties of S. boulardii explaining its potential benefits as a probiotic. METHODS: The PubMed and Medline databases were searched using the keywords 'probiotics', 'yeast', 'antibiotic associated diarrhea', 'Saccharomyces boulardii','bacterial diarrhea' and 'inflammatory bowel disease' in various combinations. RESULTS: Several clinical studies have been conducted with S. boulardii in the treatment and prevention of various forms of diarrhoea. Promising research perspectives have been opened in terms of maintenance treatment of inflammatory bowel diseases. The mechanism of S. boulardii's action has been partially elucidated. CONCLUSION: Saccharomyces boulardii is a strain of yeast which has been extensively studied for its probiotic effects. The clinical activity of S. boulardii is especially relevant to antibiotic-associated diarrhoea and recurrent Clostridium difficile intestinal infections. Experimental studies clearly demonstrate that S. boulardii has specific probiotic properties, and recent data has opened the door for new therapeutic uses of this yeast as an 'immunobiotic'.

Low risk of irritable bowel syndrome after Clostridium difficile infection.

OBJECTIVE: The incidence of postinfectious irritable bowel syndrome (IBS) ranges between 4% and 32% of individuals after bacterial or parasitic infection. This study analyzed IBS symptoms in hospitalized patients three months after a symptomatic Clostridium difficile infection. PATIENTS AND METHODS: All patients with a proven, symptomatic C difficile infection identified in the department of bacteriology over a four-month period were considered for enrolment. Patients were excluded in cases of pre-existing IBS or other organic gastrointestinal diseases. Patients completed both modified Talley and Rome II questionnaires within five days of clinical improvement with metronidazole and at three months postinfection, when stools were cultured and C difficile toxins were examined to exclude ongoing infection. RESULTS: Twenty-three patients were evaluated three months after infection with C difficile. Just after infection, 15 patients were symptom free, whereas eight patients exhibited symptoms suggestive of IBS. Three months after infection, 22 patients remained symptom free, whereas one patient presented with symptoms indicative of IBS. That female patient had a prolonged infection without vomiting. CONCLUSIONS: We have shown that while transient functional bowel disorder occurred in 34.7% of patients (eight of 23 patients) recently infected with C difficile, only 4.3% of patients (one of 23 patients) had symptoms indicative of IBS after three months (ie, postinfectious IBS). Because an age-related reduction in immune responsiveness has been documented, it can be speculated that the low incidence of postinfectious IBS may be explained by the older age of the study population. Therefore, it cannot be excluded that the findings may be different in younger patients.

Regulation of cholesterol synthesis and binding of lipoproteins in cultured rat intestinal epithelial cells.

The regulation of cholesterol synthesis has been studied using a rat epithelial intestinal cell line (IRD 98) as a cellular model. As observed in other cell types, mevinolin increases the levels of 3-hydroxy-3-methylglutaryl coenzyme A reductase (EC 1.1.1.34) and concomitantly reduces the incorporation of [14C]acetate into cholesterol. Free cholesterol is able to suppress reductase activity. In contrast, when cells are shifted from standard culture medium to lipoprotein-deficient medium, an increase in hydroxymethylglutaryl-CoA reductase specific activity (2-5-fold) is observed. The possible regulatory roles of the different classes of human lipoproteins were thus compared. The effects of a long-term exposure to LDL and HDL vary according to cell density. In actively growing cells, VLDL and LDL cause a decrease in the level of hydroxymethylglutaryl-CoA reductase, whereas HDL do not have a significant effect. In contrast, in subconfluent preresting cells, HDL provoke large decreases in hydroxymethylglutaryl-CoA reductase activity as compared to VLDL and LDL. While LDL binding is constant, the maximal binding capacity of HDL in subconfluent cells is seven times that of actively growing cells. Altogether, these results suggest an important role for HDL in the regulation of intestinal cholesterol synthesis.

Purification and biological properties of an epithelial intestinal cell growth inhibitor from a human small intestine.

Endogenous mitotic inhibitors act as control-mechanisms in intestinal epithelium proliferation. The presence of an inhibitor of cultured intestinal epithelial cell from a villous extract of rat jejunum has been reported in one of our papers. The object of the study now reported was to find the presence of a growth inhibitor in the villous extract from man's small intestine and to purify and characterize this factor when found. Our results reveal that: (1) Such an inhibitor was found in a supernatant preparation obtained from human intestinal epithelial cells. The inhibition of the proliferation of epithelial cells (IRD-98) it induced was seem to be dose-dependent and non-cytotoxic. (2) After chromatography on hydroxylapatite, on DEAE and then on ACA 54 (gel permeation), a low-molecular-weight protein (15 kDa) called purified intestinal inhibitor (PII) was isolated (purification factor of approx. 50,000 with respect to the supernatant fraction). This fraction proved to inhibit the IRD-98 cells in a reversible manner. When cells are incubated with this protein, cells prove to be arrested in phase G1 of the cell cycle as is revealed by the flow cytometry studies. The results obtained support the hypothesis that regulation of cell proliferation is mediated by endogenous inhibitors at the epithelial level.

Regulation of cholesterol uptake in the rat intestinal cell line.

A new model to study cholesterol absorption in the rat intestinal cells is described. Rat intestine epithelial cells IRD98 were incubated with mixed micelles containing bile acid, phospholipid, cholesterol or its nonabsorbable analogue, sitosterol, and trace amounts of [3H]cholesterol or [14C]sitosterol. Cholesterol and sitosterol uptake was then determined following lipid extraction; specific cholesterol uptake was determined as the difference between cholesterol and sitosterol uptake. Cholesterol, but not sitosterol, uptake was time- and dose-dependent and saturable. Loading of cells with non-lipoprotein cholesterol reduced cholesterol, but not sitosterol, uptake in a dose-dependent manner. In contrast, treatment of cells with an inhibitor of cholesterol synthesis, lovastatin, stimulated cholesterol, but not sitosterol, uptake in a dose-dependent manner. Treatment of cells with palmitic, caproic and oleic acids up-regulated specific cholesterol uptake, while linoleic and stearic acids had an opposite effect. None of the fatty acids affected sitosterol uptake.

Cholesterol uptake in the human intestine. Hypo- and hyperresponsiveness.

Cholesterol uptake was studied at the small intestine biopsies taken from patients without intestinal malfunction. Three distinct groups of patients were described: those with low (146 +/- 19) nmol/mm2 per 2 h), medium (455 +/- 18 nmol/mm2 per 2 h) and high (833 +/- 24 nmol/mm2 per 2 h) rates of cholesterol uptake. Positive correlation between cholesterol uptake and intestinal cholesterol synthesis was observed in the last two groups.

Pain and quality of life in patients with acute duodenal ulcer treated with ranitidine.

BACKGROUND: The various components of pain and quality of life in duodenal ulcer patients receiving antisecretory drugs have not been studied to date. METHODS: Ninety-five patients with epigastric pain and duodenal ulcer at endoscopy completed this prospective, multicenter, open-study. All were treated with effervescent ranitidine 300 mg daily for 4 weeks. The following parameters were assessed: (a) disappearance of duodenal ulcer pain by self-evaluation and on a weekly visual analogue scale (VAS) from 0 to 100; (b) evolution of sensory and affective components of ulcer pain by the Validated French Version of the McGill Pain Questionnaire (Questionnaire Douleur de Saint-Antoine, QDSA); (c) quality of life by the Nottingham Health Profile (NHP) which includes six criteria: pain, mobility, energy, emotions, sleep and social isolation. RESULTS: Forty-nine, 66 and 87% of the patients were pain-free during the day-time after 7, 14 and 28 days, respectively. Corresponding figures for the night-time were 80%, 88% and 97% respectively. Median time to disappearance of ulcer pain was 8 days. VAS self-assessment showed a significant decrease each week throughout the treatment period (P = 0.001). Sensory and affective QDSA scores were significantly improved after the second day and at each assessment during the 28 days of treatment (P = 0.001). Physical as well as affective aspects of quality of life were significantly improved after 28 days for each of the six criteria explored (P = 0.001). The duodenal ulcer healing rate was 86% after 4 weeks of treatment. CONCLUSIONS: Using complementary scales measuring different aspects of ulcer pain, sensory and affective components improved significantly from the second day of treatment with ranitidine 300 mg. A significant improvement in quality of life is observed after a 4-week treatment. QDSA and NHP appear to be useful evaluation tools of duodenal ulcer pain and quality of life.

Decreasing oesophageal acid exposure in patients with GERD: a comparison of rabeprazole and omeprazole.

BACKGROUND: Rabeprazole has been shown to be more potent and faster than other proton pump inhibitors in in vitro studies and highly effective in decreasing oesophageal acid exposure in patients with gastro-oesophageal reflux disease (GERD). AIM: This study was a multicentre, double-blind, placebo-controlled, randomized, parallel-group comparison of three active treatment regimens utilizing two different proton pump inhibitors, or placebo, administered over 7 days in patients with GERD. METHODS: Eighty-two patients with symptomatic GERD were given placebo, rabeprazole 10 mg b.d., rabeprazole 20 mg o.m., or omeprazole 20 mg o.m. for 7 days. Twenty-four hour oesophageal pH monitoring was performed at baseline and repeated at the conclusion of the treatment period. RESULTS: At the end of study, the percentage time (mean +/- s.d.) with pH < 4 over a 24-h period was significantly decreased by the three active regimens but without significant difference between them (9.27 +/- 4.77; 2.53 +/- 4.27; 2.02 +/- 1.71 and 2.91 +/- 4.06 for placebo, rabeprazole 10 mg b.d., rabeprazole 20 mg o.m. and omeprazole 20 mg o.m., respectively). Acid exposure was normalized in 90% of patients treated with rabeprazole 10 mg b.d., 95% treated with rabeprazole 20 mg o.m., 78% treated with omeprazole 20 mg o.m., and only 9.5% of patients treated with placebo. Both rabeprazole and omeprazole were well-tolerated. CONCLUSIONS: Although rabeprazole 20 mg o.m. showed greater activity numerically, this study demonstrates that rabeprazole 10 mg b.d. and 20 mg o.m. are equivalent to omeprazole 20 mg o.m. in decreasing oesophageal acid exposure.

Glucocorticoids upregulate high-affinity, high-density lipoprotein binding sites in rat hepatocytes.

Glucocorticoid hormones (GL) regulate high-density lipoprotein (HDL) plasma concentrations by increasing synthesis and secretion of HDL by the liver. However, little is known about the effect of GL on the uptake and processing of HDL by hepatocytes (HEP). To investigate this question, we studied the effects of dexamethasone (DEX) on the expression of high-affinity HDL-binding sites via the specific binding and internalization of iodine-labeled apolipoprotein E (apo E)-free HDL3 in a culture of rat HEP. Specific binding and internalization of HDL3 decreased by 60% in cells cultured in the absence of DEX for 48 hours. At concentrations of 10(-7) and 10(-5) mol/L, DEX prevented the decrease, maintaining specific binding and internalization versus the control level (at 24 hours). HDL-binding sites with a Kd of 20 micrograms/mL were revealed on the surface of cultured HEP. HEP demonstrated a greater binding capacity in the presence of DEX at concentrations of 10(-7) and 10(-5) mol/L (125 v 45 ng/mg cell protein). The effect of the hormone has demonstrated to be dose-dependent at concentrations between 10(-9) and 10(-7) mol/L, leveling off at 10(-7). Higher concentrations did not induce a further increase in specific binding and internalization. Withdrawal of the hormone from culture medium was associated with a decrease in specific binding of the ligand by 60% in the following 24 hours. To investigate the effect of glucocorticoid deficiency on liver uptake of HDL in vivo, specific binding and internalization were studied in a culture of HEP isolated from adrenalectomized rats (AER) at 2 hours after seeding.(ABSTRACT TRUNCATED AT 250 WORDS)

Effects of eicosapentaenoic acid, gamma-linolenic acid and prostaglandin E1 on three human colon carcinoma cell lines.

Several studies have demonstrated that certain essential fatty acids present a specific cytotoxicity for tumor cells. However, no investigation of this type has been performed on human colon cancer cells to date. This study investigated the effect of gamma-linolenic acid (GLA), eicosapentaenoic acid (EPA) and prostaglandin (PG) E1 on the proliferation and metabolism of three human colon cancer cell lines: HT 29, HRT 18, and CACO 2. GLA, EPA and PGE1 all inhibited the proliferation of the three cell lines, but with a decreasing gradient of sensitivity: HRT 18 > HT 29 > CACO 2, and with different IC50 values. PGE1 was markedly less effective than the other two. GLA and EPA increased lipid peroxidation and membrane fluidity in a dose-dependent manner. The presence of indomethacin did not modify the effects of GLA and EPA. In addition, PGE1 had little effect on membrane fluidity and lipid peroxidation. The antitumoral effect thus does not appear to be mediated by PGE1. Addition of vitamin E decreased the effects of GLA and EPA, which supports the hypothesis of direct action by these fatty acids. In conclusion, while EPA and GLA have an antitumoral effect in vitro, their effect on primary cultures of normal human colon cells must be investigated to determine whether this effect is specific to tumoral cells, as has been observed for other cell types.

Quality of life in long-term home enteral nutrition patients.

BACKGROUND AND AIMS: Few data are available on the quality of life of home enteral nutrition (HEN) patients. This study was designed to assess both the quality of life of long-term HEN patients and the evolution of quality of life after initiation of HEN. METHODS: Quality of life-related parameters were analysed in 38 patients (24M, 14F) aged 56 +/- 5 years who had been on HEN for more than 2 months (mean 25 +/- 5 months). Patients or close relatives were asked to answer a subjective assessment questionnaire, and patients with normal consciousness (n+ 24) answered the self-administered SF-36 and EuroQol questionnaires. RESULTS: Since the initiation of HEN, patients had spent 1.9 +/- 0.5% of the time in the hospital, in 54% of cases because of HEN-related complications. Analysis of the generic questionnaires revealed poorer quality of life parameters in comparison to a general population, although better results were sometimes observed in younger patients (under 45 years), patients without cancer, and patients with more than one care-giver. Nevertheless, the patients' subjective assessment of the changes in their quality of life since beginning HEN was generally good, with most patients reporting improved or stable mental and physical well-being. CONCLUSIONS: Quality of life is poor in HEN patients, but subgroups of patients who score better in some quality of life dimensions can be identified. Most patients describe an improvement in their quality of life following the initiation of HEN that needs to be confirmed by a prospective study.

Effects of refeeding by cyclic enteral nutrition on body composition: comparative study of elderly and younger patients.

Previous reports suggest that correcting the malnourished state may be more difficult in elderly people than in younger people. The aim of this study was to evaluate the effect of 21 days of cyclic enteral nutrition (CyEN) on nutritional and body composition parameters in elderly, compared with younger patients. Twenty-four patients younger than 65 years (mean age 50 years) and 26 patients 65 years of age and older (mean age 75 years) referred for refeeding, having lost at least 20% of their body weight or at least 10% in 3 months, were studied. All patients were ambulatory. Cyclic enteral nutrition was administered nocturnally via a nasogastric tube; in the daytime patients were allowed to eat normally and to walk. Resting energy expenditure was measured at day 0 by indirect calorimetry. Ten anthropometric and biological nutritional parameters and a global nutritional deficiency (GND) were measured at day 0 and 21. Body composition was measured at day 0 and 21 by bioelectric impedance analysis. Total energy intakes were 286% and 280% of resting energy expenditure in groups 1 and 2, respectively. Body weight, serum prealbumin, serum transferrin, 24 h urinary creatinine, and the GND (39.9% vs 23.3%; P < 0.01) improved significantly more in younger than in elderly patients. Fat free mass (3.9 vs 2.4 kg; P < 0.05) and body cell mass (2.7 vs 1.6 kg; P < 0.01) but not fat mass improved significantly more in younger than in elderly patients. In conclusion, 21 days refeeding by cyclic enteral nutrition with similar energy amounts is less effective to correct malnutrition in elderly than in younger patients.

Correction of protein-energy malnutrition in older adults: effects of a short-term aerobic training program.

Twenty malnourished subjects (average age 67 years old) treated by cyclic enteral nutrition were assigned to an active or control group according to whether they took part or not in a 3-week aerobic training program. Subjects underwent the following tests on d(0)-d(1) and d(20)-d(21): calculation of a global nutritional deficiency index (GND), bioelectrical impedance analysis, evaluation of daily energy expenditures using a 24 h heart rate (HR) recorder and a pedometer, maximal voluntary isometric strength assessment (MVIS), and symptoms limited maximal oxygen uptake ((.)VO(2 max. SL) estimation. Although energy intakes were similar in both groups, active subjects showed greater improvements (P < 0.05) than control subjects regarding GND (-9.8 vs -4.8%), serum albumin and prealbumin. Active subjects also showed a greater increase (P < 0.05) in pedometer readings compared to control subjects. Reduction of resting HR was observed in active (-5 beat/mn, P < 0.05) whereas no significant changes in average HR were noted in either group, reflecting increased metabolic activity. Compared to control, active subjects showed significant (P < 0.05) improvements in MVIS (0.8 vs 0.1 N/kg) and (.)VO(2 max. SL) (5.5 vs 1.4 mL/min/kg). Short-term aerobic training has positive effects on nutritional recovery and functional capacities in elderly malnourished subjects and should be recommended whenever possible.

Lipid metabolism by the intestinal mucosa in malnourished subjects following enteral nutrition supplemented with omega3 fatty acids.

UNLABELLED: Chronic malnutrition results in severe metabolic imbalance in man as the body modifies its modes of regulation of different nutrients, and in particular lipids. This study of the modifications in lipid metabolism induced by 15 days of enteral renutrition include: 12 malnourished patients (global nutritional deficit (GND) <20%) were given a cyclical enteral diet for 15 days under two conditions: ternary diet (Sondalis) or a similar diet whose lipid concentration was enriched by 5.3 g omega3 fatty acid per day. On Day 0 and Day 15, the serum lipid values were assayed and duodenal biopsies were taken to measure HMG-CoA reductase and (14)C acetate incorporation in the various classes of lipids. After 15 days of refeeding, the GND had been corrected by an average of 27% and HMG-CoA reductase activity had increased by 37% (60.2 +/- 7.46 vs 82.88 +/- 14.8 pmol/min/mg protein; p < 0.05). In 7 12 patients, the serum cholesterol values had increased (p < 0.01). No difference was observed in synthesis of FA, DG or cholesterol. Synthesis of phosphatidylcholines (PC) and phosphatidylglycerols (PG) was reduced by 12% and 23% respectively. Triglyceride synthesis (TG) increased by 20% (p < 0.05). The only difference between the two diets was in TG synthesis in organ-specific culture, which was increased only by the standard diet. IN CONCLUSION: (i) refeeding is accompanied by an increase in intestinal HMG-CoA reductase activity, a decrease in PC and PG synthesis, and an increase in TG synthesis; (ii) a diet enriched in omega3 FA increases TG synthesis less than the standard diet.

Effects of cyclic enteral nutrition on the immunological status of malnourished patients.

The effects of 2 weeks of refeeding by cyclic enteral nutrition on chronically malnourished (mean global nutritional deficiency 19.9 +/- 1.1%) hospitalized patients were assessed in a prospective study with special attention paid to immunological status. All patients were immunodeficient, with cell-mediated immunity being more affected than humoral immunity. After 2 weeks of refeeding, nutritional status had improved by 29.8%. Initially abnormal parameters of humoral immunity (IgM, C3 and C4) improved significantly (P < 0.05) between day 0 and day 15. The following cell-mediated immunity parameters also improved significantly (P < 0.05): CD8, monocyte count, natural killer cell activity and skin tests. Short-term refeeding by cyclic enteral nutrition appears to be a safe and effective way of improving immunodeficiency in chronically malnourished patients, with predictable consequences on infection.

Chondrex (YKL-40), a potential new serum fibrosis marker in patients with alcoholic liver disease.

OBJECTIVES: Chondrex (YKL-40) is a mammalian member of a protein family that includes bacterial chitinases. The pattern of its expression in certain tissues such as human liver or cartilage suggests a function in remodelling or degradation of extracellular matrix. The purpose of this study was to assess whether circulating YKL-40 might be a serum fibrosis marker in alcoholics. METHODS: Plasma YKL-40 was determined in 146 consecutive heavy drinkers (106 men, 40 women; mean age, 49.2 +/- 9.0 years). Liver biochemical parameters and serum fibrosis markers such as hyaluronate were also measured. Fibrosis and inflammation in liver biopsy were evaluated using a semi-quantitative scoring system. RESULTS: Plasma YKL-40 increased in parallel with the severity of fibrosis (P<0.00001). YKL-40 also increased in the presence of hepatic inflammation (P<0.01). Receiver operating characteristic curves of Chondrex revealed that a threshold of 330 microg/l gave a specificity of 88.5%; however, the sensitivity was only 50.8%. Only 11.5% of patients without severe fibrosis displayed a Chondrex plasma level above this threshold. A positive correlation was found between Chondrex and hyaluronate (r=0.40, P<0.0001), and a negative correlation was shown between Chondrex and the prothrombin index (r=-0.37, P<0.0001). CONCLUSIONS: The severity of liver fibrosis is associated with elevated circulating Chondrex levels. The overlap in YKL-40 values prevents use of Chondrex in a screening programme. High levels of Chondrex (above 330 microg/l) are predictive of severe liver fibrosis. Increased plasma YKL-40 may reflect the remodelling of liver fibrosis in alcoholics.

Energy metabolism and substrate oxidation in patients with Crohn's disease.

Weight loss and malnutrition are common features in patients with Crohn's disease. This study was designed to evaluate diet-induced thermogenesis and substrate oxidation in patients with Crohn's disease. Twenty-three patients (17 women, 6 men; age 34 +/- 2 y) and 17 healthy control subjects (13 women, 4 men; age 36 +/- 3 y) were studied. Resting energy expenditure and fasting substrate oxidation were measured by indirect calorimetry in the morning after an overnight fast. After a standard homogenized test meal (10 kcal/kg), indirect calorimetry was performed every 30 min for 3 h to measure the diet-induced thermogenesis and the postprandial substrate oxidation. In the fasting state, resting energy expenditure was significantly higher in patients than in control subjects (1433 +/- 43 versus 1279 +/- 53 kcal/24 h). Lipid oxidation was higher in patients with Crohn's disease than in control subjects (1.17 +/- 0. 07 versus 0.61 +/- 0.11 mg. kg(-1). min(-1), P < 0.01). Postprandially, diet-induced thermogenesis was significantly lower in patients with Crohn's disease than in control subjects (4.6% +/- 0.5 versus 6.3% +/- 0.5 of energy intake, P < 0.01). Lipid oxidation was significantly higher in patients with Crohn's disease than in control subjects (0.78 +/- 0.05 versus 0.56 +/- 0.08 mg. kg(-1). min(-1), P < 0.05), and glucose oxidation was lower in patients with Crohn's disease than in control subjects. In patients with Crohn's disease, lipid oxidation positively correlates with the disease activity evaluated by the Crohn's Disease Activity Index (r = 0.48, P150), fasting and postprandial lipid oxidation was significantly higher than in patients with inactive Crohn's disease (P < 0.05). In conclusion, patients with Crohn's disease have increased fat oxidation, which correlates with disease activity and this may explain the reduced fat stores in patients with Crohn's disease.

Priapism in a patient treated with total parenteral nutrition.

Venous thrombosis is a common complication of total parenteral nutrition. We report a case of priapism in a 40-year-old man after administration of total parenteral nutrition for chronic idiopathic intestinal pseudo-obstruction. The patient received glucose, amino acids, and 20% fat emulsion; 12 hours after administration, the patient complained of a persistent, painful penile erection lasting 5 hours. Bilateral corpora cavernosa spongiosum shunts achieved immediate and sustained detumescence, but the patient remained impotent. There was no history of penile or pelvic trauma, hemoglobinopathy, coagulopathy, venous thrombosis, or leukemia. The medical literature describes seven other cases of priapism related to total parenteral nutrition. All of the patients received 20% fat emulsion; two patients developed priapism during the weekly infusion of fat emulsion. Among the multiple factors that can favor thrombosis and therefore priapism during total parenteral nutrition, fat infusion appears to be the most important. Three different mechanisms have been postulated: increase in blood coagulability, effects on red blood cells, and fat embolism. In this patient, platelet function was estimated in vivo by the levels of antiheparin platelet factor 4 and beta-thromboglobulin. These two parameters were both elevated before 20% lipid emulsion and were even higher after the 20% fat-emulsion infusion. Therefore, even if a direct thromboplastic effect is possible, 20% fat emulsion increases platelet activity, which was already high in our patient, and thereby favors priapism.

Outcome of patients treated with home enteral nutrition.

BACKGROUND: The aims of this study were to prospectively analyze the 1-month mortality and long-term outcome of home enteral nutrition (HEN) patients in order to determine the benefits of this treatment. METHODS: Between 1990 and 1996, 417 patients, aged 64 +/- 25 years, were discharged on HEN and followed up until December 31, 1998, when outcome was assessed, which allowed us to determine survival probabilities and conditions associated with survival. RESULTS: The mean duration of HEN was 242 +/- 494 days, with a 24- to 103-month follow-up. Probabilities of being alive at 1 month, 1 year, and 5 years were 80%, 41.7%, and 25%, respectively. Factors associated with death were dementia, neurologic disease, head and neck cancer, AIDS, and age over 70 years. A total of 5.5% of patients remained dependent on HEN, 32.6% resumed full oral nutrition, 20.2% of patients died during the first month on HEN, and 35% died after more than 1 month on HEN (219 +/- 257 days). A total of 6.7% of patients stopped HEN for other reasons. CONCLUSIONS: HEN provides well-tolerated long-term nutritional support in many patients. However, because of their likelihood of being old and the nature of the underlying disease, these patients as a group tend to have a modest prognosis. This calls for the determination of more accurate selection criteria, and the measurement of the impact of HEN on quality of life.