Enteral nutrition as primary therapy in Crohn's disease

The developments in enteral feeding for Crohn's disease in the past decade are critically reviewed. The advent of amino acid based chemically defined elemental diets signalled the end of 'total bowel rest' in the management of these patients. Subsequently, controlled clinical trials showed that elemental diets were as effective as corticosteroids in inducing clinical remission in patients with acute exacerbations of Crohn's disease. The later use of peptide based elemental diets, in Crohn's disease produced somewhat conflicting results. The initial uncontrolled studies suggest that polymeric whole protein diets might also be effective in the management of acute exacerbations of the disease, casting in turn doubts concerning the role of dietary antigens in the pathogenesis of Crohn's disease. Results of controlled studies comparing the use of elemental and polymeric diets as primary therapy in Crohn's disease have, however, also produced conflicting results. The results of one recent controlled trial in which

Current status of pediatric home enteral nutrition in Spain: The importance of the NEPAD register

Home enteral nutrition (HEN) is a type of enteral nutrition (EN) which is becoming progressively more widespread in pediatrics due to the benefits it affords to patients, their families and to reducing hospital costs. However, the true extent of its use is unknown in Spain as the data-base set up for this purpose is still underused (Registro de Nutrición Enteral Pediátrica Ambulatoria y Domiciliaria -NEPAD-). More thorough registration of patients in the NEPAD online register will provide information about the characteristics of HEN in Spain: prevalence, diagnosis, the population sector being administered HEN, complications and developments. Likewise, forecast and planning of the necessary resources could be made while those in use could be analysed.

Impacto da adequação da oferta energética sobre a mortalidade em pacientes de UTI recebendo nutrição enteral

OBJETIVO: Investigar a relação entre adequação da oferta energética e mortalidade na unidade de terapia intensiva em pacientes sob terapia nutricional enteral exclusiva. MÉTODOS: Estudo observacional prospectivo conduzido em uma unidade de terapia intensiva em 2008 e 2009. Foram incluídos pacientes >18 anos que receberam terapia nutricional enteral por >72h. A adequação da oferta de energia foi estimada pela razão administrado/prescrito. Para a investigação da relação entre variáveis preditoras (adequação da oferta energética, escore APACHE II, sexo, idade e tempo de permanência na unidade de terapia intensiva e o desfecho mortalidade na unidade de terapia intensiva, utilizou-se o modelo de regressão logística não condicional. RESULTADOS: Foram incluídos 63 pacientes (média 58 anos, mortalidade 27%), 47,6% dos quais receberam mais de 90% da energia prescrita (adequação média 88,2%). O balanço energético médio foi de -190 kcal/dia. Observou-se associação significativa entre ocorrência de óbito e as variáveis idade e tempo de permanência na unidade de terapia intensiva, após a retirada das variáveis adequação da oferta energética, APACHE II e sexo durante o processo de modelagem. CONCLUSÃO: A adequação da oferta energética não influenciou a taxa de mortalidade na unidade de terapia intensiva. Protocolos de infusão de nutrição enteral seguidos criteriosamente, com adequação administrado/prescrito acima de 70%, parecem ser suficientes para não interferirem na mortalidade. Dessa forma, pode-se questionar a obrigatoriedade de atingir índices próximos a 100%, considerando a elevada frequência com que ocorrem interrupções no fornecimento de dieta enteral devido a intolerância gastrointestinal e jejuns para exames e procedimentos. Pesquisas futuras poderão identificar a meta ideal de adequação da oferta energética que resulte em redução significativa de complicações, mortalidade e custos.

Suplementação enteral e parenteral com glutamina em neonatos pré-termo e com baixo peso ao nascer

A glutamina é o aminoácido livre mais abundante no sangue e no músculo esquelético, bem como é o principal substrato energético para células de elevado turnover, como enterócitos e leucócitos. Adicionalmente, a glutamina representa o principal aminoácido transferido para o feto pela placenta e, juntamente com o glutamato, constituem os aminoácidos mais abundantes no leite materno. Todavia, bebês nascidos prematuramente sofrem interrupção abrupta do fornecimento placentário de glutamina, o que acarreta em dependência exclusiva da síntese endógena ou do fornecimento exógeno deste aminoácido. Aliado a isso, neonatos pré-termo (PT) e com baixo peso ao nascer (BPN), freqüentemente, recebem apenas nutrição parenteral total nas primeiras semanas de vida, a qual não contém glutamina. Cabe ainda destacar que esses bebês possuem pouca massa muscular e, portanto, seus estoques de glutamina são limitados. Uma vez que neonatos PT e com BPN estão sujeitos a intenso crescimento e a inúmeros estresses fisiológicos, é possível que a glutamina seja um nutriente condicionalmente essencial nessa fase da vida, fato que estimulou a realização de estudos com a finalidade de avaliar os possíveis benefícios clínicos da suplementação enteral e parenteral com glutamina em neonatos PT e com BPN.

Stability of vitamin A during storage of enteral feeding formulas

Vitamin A (13-cis-retinol, all-trans-retinol and total carotenes) content was evaluated in 15 samples of enteral feeding formulas during 3-6,9 and 12 months of storage in closed containers, protected from light and at room temperature (22-30 degrees C). All formulas were nutritionally complete and/or recommended for different diseases. Equivalent batches were also evaluated after preparation and refrigerated storage for 24 h. Nutrient content did not decrease during both storage scenarios. Stability of vitamin A in the enteral feeding formulas, as determined in this study, is probably due to production and storage conditions, e.g. absence of oxygen in contact with the packaged product, the technological process used in the microencapsulation of vitamins, and protected storage in the absence of light and at a temperature maximum of 30 degrees C. (C) 2010 Elsevier Ltd. All rights reserved.

Short-term specialized enteral diet fails to attenuate malnutrition impairment of experimental open wound acute healing

Objective: We assessed the effect of enteral refeeding on the morphology, gene expression, and contraction of acute open wounds in previously malnourished rats using two different enteral diets. Methods: Adult male isogenic Lewis rats divided into two groups (eutrophic, n = 30; and previously malnourished, 12-15% body weight loss, n = 27) were subjected to cutaneous dorsal wounds and gastrostomy. Control rats received a standard oral diet (AIN-93M chow) plus enteral saline solution. Subject rats received chow plus a standard enteral diet or an enteral diet enriched with arginine and antioxidants. On post-trauma days 7 and 14, wound granulation tissue samples were collected for morphologic analysis using hematoxylin and eosin and picrosirius stain or immunohistochemistry slides and real-time polymerase chain reaction for collagen I and III gene expression. Wound contraction was also evaluated by comparing wound images from days 0,7, and 14. Results: Malnourished control rats had increased intensity and duration of wound inflammation, impaired increase of fibroblast cells contingent on post-trauma days 7 to 14, decreased expression of collagen III, and less wound contraction compared with eutrophic control rats. A specialized enteral diet did not improve wound healing of malnourished rats but did promote wound contraction at post-trauma day 7 in eutrophic rats. Conclusion: Short-term enteral refeeding, even with a specialized diet, failed to protect previously wounded malnourished rats from a prolonged inflammatory phase and impaired healing. (C) 2010 Elsevier Inc. All rights reserved.

Long-term nutritional assessment of patients with severe short bowel syndrome managed with home enteral nutrition and oral intake

Background: Parenteral nutrition (PN) is used to control the nutritional state after severe intestinal resections. Whenever possible, enteral nutrition (EN) is used to promote intestinal rehabilitation and reduce PN dependency. Our aim is to verify whether EN + oral intake (01) in severe short bowel syndrome (SBS) surgical adult patients can maintain adequate nutritional status in the long term. Methods: This longitudinal retrospective study included 10 patients followed for 7 post-operative years. Body mass index (BMI), percentage of involuntary loss of usual body weight (UWL), free fat mass (FFM), and fat mass (FM) composition assessed by bioelectric impedance, and laboratory tests were evaluated at 6, 12, 24, 36, 48, 60, 72, and 84 months after surgery. Energy and protein offered in HPN and at long term by HEN+ oral intake (01), was evaluated at the same periods. The statistical model of generalized estimating equations with p <0,05 was used. Results: With long term EN + 01 there was a progressive increase in the UWL, a decrease in BMI, FFM, and FM (p < 0,05). PN weaning was possible in eight patients. Infection due to central venous catheter (CVC) contamination was the most common complication (1.2 episodes CVC/patient/year). There was an increase in energy and protein intake supply provided by HEN+OI (p <0.05). All patients survived for at least 2 years, seven for 5 years and six for 7 years of follow-up. Conclusions: In the long term SBS surgical adult patients fed with HEN+OI couldn`t maintain adequate nutritional status with loss of FM and FFM. (Nutr Hosp. 2011;26:834-842) DOI:10.3305/nh.2011.26.4.5153

EUS-guided percutaneous endoscopic gastrostomy for enteral feeding tube placement

Background: Patients without adequate abdominal-wall transillumination are at a high risk of developing complications after PEG. Objective: We evaluated the feasibility and utility of EUS to guide PEG in patients lacking abdominal-wall transillumination. Design: Single-center case series. Setting: Tertiary-referral center. Patients: Six patients who lacked adequate abdominal-wall transillumination and 2 patients with a large laparotomy scar deemed to be at high risk of developing complications after PEG. Interventions: Patients underwent EUS-guided PEG and deployment of a standard enteral feeding tube. Main Outcome Measurements: Technical success and complication rates. Results: PEG was Successful Under EUS guidance in 5 of 8 patients. Causes of failure included all inadequate EUS window because of a prior Billroth 1 gastrectomy in one and suspected bowel interposition in 2 patients. There were no complications. Limitations: A small number of patients, uncontrolled study, and short follow-up period. Conclusions: This technique may facilitate deployment of PEG in patients who lack adequate abdominal-wall transillumination.

Cortisol sérico de equinos com compactação experimental no cólon maior tratados com hidratações enteral e parenteral

O cortisol sérico foi estudado em equinos com compactação experimental do cólon maior tratados com fluidoterapias enteral (EN) e intravenosa (IV). Utilizaram-se 10 animais separados em dois grupos de cinco cada. Os animais eram portadores de compactação induzida no cólon maior. O grupo EN foi tratado com solução isotônica poliônica enteral (8 mL/kg/h/48 h), enquanto o grupo IV recebeu Ringer lactato (16 mL/kg/h/12 h, durante dois dias). A compactação do cólon maior ocasionou aumento (P < 0,05) nos valores do cortisol nos animais de ambos os grupos. As soluções utilizadas no tratamento da compactação, fluidoterapia enteral com solução isotônica poliônica (EN) e fluidoterapia intravenosa com solução de Ringer lactato (IV), foram eficientes na redução dos valores do cortisol sérico em equinos com compactação induzida no cólon maior.

Tratamentos da compactação experimental do cólon maior de equinos com hidratação enteral, intravenosa e sene (Cassia augustifolia Vahl)

O objetivo deste estudo foi investigar a ação da hidratação enteral (HET), da hidratação intravenosa (IV) e da sene, associada à hidratação intravenosa (SEN), no tratamento da compactação do cólon maior, em equinos. Foram utilizados 15 animais, divididos em três grupos de cinco, cada. Os animais eram portadores de compactação do cólon maior, induzida experimentalmente. O grupo HET recebeu solução isotônica poliônica enteral (8 mL kg-1 h-1,durante 48 horas); o grupo SEN foi tratado com sene (20 mg kg-1, duas doses de 24/24 h), mais Ringer lactato i.v. (10 mL kg-1 h-1 12h-1, durante dois dias) e ao grupo IV foi administrado Ringer lactato i.v. (16 mL kg-1 h-1 12h-1, durante dois dias). O tratamento HET ocasionou maior amolecimento das fezes e desfez a compactação em menor tempo. Entretanto, foi observada hipomotilidade intestinal mais prolongada. O tratamento SEN normalizou mais rapidamente a motilidade intestinal, porém o tempo necessário para desfazer a compactação foi maior. Além disso, ocasionou o maior aumento na distensão abdominal e no grau da dor, assim como a menor capacidade para reverter a desidratação. O tratamento do grupo IV debelou a compactação, igualmente ao HET, e a hipomotilidade intestinal, em menor tempo, mas foi o que menos amoleceu as fezes. Concluiu-se que os tratamentos IV e HET foram os mais eficientes na terapia da compactação, induzida no cólon maior, em equinos. O grupo SEN foi eficiente, porém, foi o que apresentou os efeitos adversos mais importantes.

Serum trace elements in dysphagic gastrostomy candidates before endoscopic gastrostomy for long term enteral feeding

Background & aims - Patients who underwent endoscopic gastrostomy (PEG) present protein-energy malnutrition, but little is known about Trace Elements (TE), Zinc (Zn), Copper (Cu), Selenium (Se), Iron (Fe), Chromium (Cr). Our aim was the evaluation of serum TE in patients who underwent PEG and its relationship with serum proteins, BMI and nature of underlying disorder. Methods - A prospective observational study was performed collecting: patient's age, gender, underlying disorder, NRS-2002, BMI, serum albumin, transferrin and TE concentration. We used ferrozine colorimetric method for Fe; Inductively Coupled Plasma-Atomic Emission Spectroscopy for Zn/Cu; Furnace Atomic Absorption Spectroscopy for Se/Cr. The patients were divided into head and neck cancer (HNC) and neurological dysphagia (ND). Results - 146 patients (89 males), 21–95 years: HNC-56; ND-90. Low BMI in 78. Low values mostly for Zn (n = 122) and Fe (n = 69), but less for Se (n = 31), Cu (n = 16), Cr (n = 7); low albumin in 77, low transferrin in 94 and 66 with both proteins low. Significant differences between the groups of underlying disease only for Zn (t140.326 = −2,642, p < 0.01) and a correlation between proteins and TE respectively albumin and Zn (r = 0.197, p = 0.025), and albumin and Fe (r = 0.415, p = 0.000). Conclusions - When gastrostomy was performed, patients display low serum TE namely Zn, but also Fe, less striking regarding others TE. It was related with prolonged fasting, whatever the underlying disease. Low proteins were associated with low TE. Teams taking care of PEG-patients should use Zn supplementation and include other TE evaluation as part of the nutritional assessment of PEG candidates.

Serum Zn Levels in Dysphagic Patients Who Underwent Endoscopic Gastrostomy for Long Term Enteral Nutrition

Background and aims: Dysphagic patients who underwent endoscopic gastrostomy (PEG) usually present protein-energy malnutrition, but little is known about micronutrient malnutrition. The aim of the present study was the evaluation of serum zinc in patients who underwent endoscopic gastrostomy and its relationship with serum proteins, whole blood zinc, and the nature of underlying disorder. Methods: From patients that underwent gastrostomy a blood sample was obtained minutes before the procedure. Serum and whole blood zinc was evaluated using Wavelength Dispersive X-ray Fluorescence Spectroscopy. Serum albumin and transferrin were evaluated. Patients were studied as a whole and divided into two groups: head and neck cancer (HNC) and neurological dysphagia (ND). Results: The study involved 32 patients (22 males), aged 43-88 years: HNC = 15, ND = 17. Most (30/32) had low serum zinc, 17/32 presented normal values of whole blood zinc. Only two, with traumatic brain injury, presented normal serum zinc. Serum zinc levels showed no differences between HNC and ND patients. There was no association between serum zinc and serum albumin or transferrin. There was no association between serum and whole blood zinc. Conclusions: Patients had low serum zinc when gastrostomy was performed, similar in HNC and ND, being related with prolonged fasting and unrelated with the underlying disease. Decrease serum zinc was unrelated with low serum proteins. Serum zinc was more sensitive than whole blood zinc for identifying reduced zinc intake. Teams taking care of PEG-patients should include zinc evaluation as part of the nutritional assessment, or include systematic dietary zinc supply.

Serum Trace Elements in Dysphagic Gastrostomy Candidates Before Endoscopic Gastrostomy for Long Term Enteral Feeding

BACKGROUND & AIMS: Patients who underwent endoscopic gastrostomy (PEG) present protein-energy malnutrition, but little is known about Trace Elements (TE), Zinc (Zn), Copper (Cu), Selenium (Se), Iron (Fe), Chromium (Cr). Our aim was the evaluation of serum TE in patients who underwent PEG and its relationship with serum proteins, BMI and nature of underlying disorder. METHODS: A prospective observational study was performed collecting: patient's age, gender, underlying disorder, NRS-2002, BMI, serum albumin, transferrin and TE concentration. We used ferrozine colorimetric method for Fe; Inductively Coupled Plasma-Atomic Emission Spectroscopy for Zn/Cu; Furnace Atomic Absorption Spectroscopy for Se/Cr. The patients were divided into head and neck cancer (HNC) and neurological dysphagia (ND). RESULTS: 146 patients (89 males), 21-95 years: HNC-56; ND-90. Low BMI in 78. Low values mostly for Zn (n = 122) and Fe (n = 69), but less for Se (n = 31), Cu (n = 16), Cr (n = 7); low albumin in 77, low transferrin in 94 and 66 with both proteins low. Significant differences between the groups of underlying disease only for Zn (t140.326 = -2,642, p < 0.01) and a correlation between proteins and TE respectively albumin and Zn (r = 0.197, p = 0.025), and albumin and Fe (r = 0.415, p = 0.000). CONCLUSIONS: When gastrostomy was performed, patients display low serum TE namely Zn, but also Fe, less striking regarding others TE. It was related with prolonged fasting, whatever the underlying disease. Low proteins were associated with low TE. Teams taking care of PEG-patients should use Zn supplementation and include other TE evaluation as part of the nutritional assessment of PEG candidates.