Andrzej Ukleja

NUTRITION SUPPLEMENTATION IN PATIENTS WITH ACUTE AND CHRONIC PANCREATITIS

Acute pancreatitis is a hypermetabolic state characterized by increased protein catabolism, lipolysis, and glucose intolerance. Most patients presenting with acute pancreatitis are better within 5 to 7 days and can be resume a regular diet. Patients with severe pancreatitis and who are unable to eat within 7 to 10 days should receive nutritional support. The decision to use parenteral or enteral nutrition is controversial. More recent data suggest that jejunal feedings are just as beneficial, if not better, than parenteral nutrition. Marked weight loss and abdominal pain are the features of chronic pancreatitis. Steatorrhea develops when greater than 90% of pancreatic exocrine dysfunction occurs. Treatment focuses on pain control and pancreatic enzyme replacement. Pancreatic enzymes should be given with meals. Patients with refractory steatorrhea may benefit from the addition of an H2 antagonist or proton-pump inhibitor with pancreatic enzyme replacement. Micronutrients, including antioxidants, should be replaced if serum levels suggest a deficiency.

Outcome of patients with radiation enteritis treated with home parenteral nutrition

OBJECTIVES:Intestinal failure requiring either surgery or home parenteral nutrition (HPN) develops in approximately 5% of patients treated with radiation. The aim of the study was to determine survival, duration of HPN, and complications associated with HPN in patients with intestinal failure after radiation therapy.METHODS:Fifty-four patients with radiation enteritis who received HPN were studied (39 women and 15 men with a mean age of 57.9 yr). Retrospective data were collected from the patients’ medical records dated between 1975 and 1999. The probability of survival was calculated by the Kaplan-Meier method.RESULTS:HPN was initiated a median of 20 months (range = 2–432) from the start of radiation therapy. The mean number of intestinal operations for radiation-related complications was 2.2/patient (range = 0–6). The causes of intestinal failure resulting from radiation therapy were intestinal obstruction (27 patients), short bowel (17), malabsorption (five), fistula (three), and dysmotility (two). The mean duration of HPN was 20.4 months (range = 2–108). At last follow-up, 37 patients (68%) were dead, most as a result of recurrent cancer. One patient died of catheter sepsis, and no other deaths were directly related to HPN. The overall estimated 5-yr probability of survival on HPN calculated by Kaplan-Meier analysis was 64%.CONCLUSIONS:HPN is a reasonable treatment option in patients with intestinal failure as a result of radiation enteritis. Survival and complications associated with HPN in patients with radiation enteritis seem to be similar to those in other HPN-treated groups.

Nutritional assessment of serum and hepatic vitamin A levels in patients with cirrhosis

BACKGROUND Serum vitamin A (retinol) levels may not correlate with hepatic vitamin A stores in patients with cirrhosis; thus, supplementation of vitamin A based on serum levels may have a detrimental effect. Our aim was to determine whether serum levels correlate with hepatic stores in cirrhotic patients. METHODS A prospective study of patients with cirrhosis undergoing orthotopic liver transplantation was completed. Serum and hepatic levels of vitamin A were measured by high-performance liquid chromatography. Statistical analysis was performed using rank sum tests and Spearman rank correlation coefficients. RESULTS Fifty cirrhotic patients (33 men and 17 women, mean age 53 years) were compared with a control group (25 men and 25 women, mean age 47 years) of liver donors. Median serum levels of retinol were 259 microg/L in controls and 166 microg/L in cirrhotic patients (p < .001). Median hepatic levels of retinol were 25 microg/g in controls and 27.5 +/- g/g in cirrhotic patients (p not significant). Total hepatic vitamin A levels (retinol plus retinyl esters) were 471 microg/g in controls and 244 microg/g in cirrhotic patients (p = .028). Serum retinol did not correlate with total hepatic vitamin A stores in cirrhotic patients (rs = .10, p = .332). CONCLUSIONS Serum retinol and total hepatic vitamin A stores are lower in cirrhotic patients than in controls. However, because levels of serum retinol do not correlate with hepatic vitamin A levels, the decision to prescribe vitamin A replacement for patients with cirrhosis should not be made solely on the basis of serum retinol levels.

Nutritional management of chronic intestinal pseudo-obstruction

Chronic intestinal pseudo-obstruction (CIP) is a gastrointestinal motility disturbance characterized by recurrent episodes of postprandial nausea and bloating in the absence of mechanical obstruction of the small bowel or colon. Weight loss and severe malnutrition are often seen in advanced stages of the disorder. This article discusses the nutritional management of patients with CIP, focusing on general dietary as well as enternal and parenternal nutritional support. Enteral access methods and various enteral formulas used in CIP are also discussed.

CASE REPORT: Lichen Planus Involving the Esophagus

Lichen planus is a common mucocutaneus disorder that rarely involves the esophagus. We report two challenging cases presenting with recurrent dysphagia originally suspected due to gastroesophageal reflux. Subsequent evaluation revealed peculiar endoscopic findings of desquamative esophagitis leading to the diagnosis of lichen planus of the esophagus. This disorder should be considered in middle age or elderly women presenting with unexplained dysphagia or odynophagia. In this paper we review the available literature on the subject and summarize every case reported to date.

Nutritional problems in end-stage liver disease: contribution of impaired gastric emptying and ascites.

Goals To evaluate gastric emptying before and after paracentesis in patients with cirrhosis. Background Patients with ascites often report early satiety. The effect of paracentesis on gastric emptying has not been studied previously. Study Twelve patients who required therapeutic paracentesis were studied (mean age, 57 years; range, 47–69 years). Gastric emptying was performed with radionuclide scintigraphy. Satiety was evaluated with a visual analogue scale. Wilcoxon signed-rank tests were used for comparison between pre-and poststudies. Results The causes of cirrhosis included alcohol (seven patients), a combination of alcohol and hepatitis C (two), chronic hepatitis C only (one), primary biliary cirrhosis (one), and cryptogenic (one). The median volume of ascitic fluid removed at paracentesis was 5,450 mL (range, 2,500–7,200 mL). Median 2-hour gastric emptying was 65.5% before paracentesis and 61.5% after (p > 0.05). Median 4-hour gastric emptying was 92.5% before paracentesis and 96.5% after (p > 0.05). Both satiety score and caloric intake were significantly improved after paracentesis (p < 0.05). Conclusions Although satiety and calorie intake improve after large-volume paracentesis in patients with cirrhosis, these changes do not seem to correspond with improved gastric emptying. Therefore, other mechanisms most likely contribute to satiety.

Short-bowel syndrome.

This article discusses the causes, prognosis, and management of short bowel syndrome. Attempts to enhance intestinal adaptation with trophic factors and surgical treatment options, including small bowel transplantation, are discussed.

Case Report: Vagus nerve injury with severe diarrhea after laparoscopic antireflux surgery

Antireflux surgery has gained an important role in the treatment of severe gastroesophageal reflux disease (GERD). Since the introduction of the laparoscopic approach in 1991, interest in antireflux surgery has expanded, leading to a rapid increase in the number of procedures performed annually (1, 2). Patients and physicians often opt for a minimally invasive approach because this provides good control of symptoms and has an excellent safety record. However, to achieve optimal results, the operation must be performed by skilled and experienced surgeons (3). Although serious complications are rare, splenic injury, esophageal perforation, or vagus nerve injury may occur (4, 5). Intractable diarrhea is an unusual complication of inadvertent vagus nerve injury. This complication may leave a patient with a significant disability. We report a case of severe diarrhea after laparoscopic Nissen fundoplication occurring as a result of vagus nerve injury, and we review the literature on this subject.

Success with Intestinal Failure: From Adaptation to Transplantation

Intestinal failure can result from large resections of small intestine (short bowel syndrome) and from failure of normal intestinal motility. The medical management of short bowel syndrome centers around appropriate diet and use of specific medications including experimental trophic factors. Enteral tubes and prokinetic medications can be successfully used to treat patients with intestinal failure as a result of abnormal intestinal motility. Small bowel transplantation may be a treatment option in certain patients with intestinal failure. This article reviews the management of intestinal failure with a recent update on small bowel transplantation.

Serum and hepatic vitamin E assessment in cirrhotics before transplantation

BACKGROUND Hepatic vitamin E may have a protective effect against hepatocyte injury; therefore, vitamin E replacement or supplementation may be beneficial in patients with cirrhosis. However, serum vitamin E may not correlate with hepatic vitamin E stores, making decisions regarding treatment difficult based on serum levels alone. The specific aims of this study were to determine hepatic concentrations of vitamin E and to determine whether serum levels of vitamin E correlate with hepatic vitamin E stores in cirrhotics. METHODS A prospective study of cirrhotics undergoing orthotopic liver transplantation (OLT) was completed. Serum and hepatic levels of vitamin E were measured by high-performance liquid chromatography. Statistical analysis was performed using rank sum tests and Spearmans rank correlation coefficient. RESULTS Fifty cirrhotics (33 males, 17 females; mean age of 53 years) were studied. The control group (25 males, 25 females; mean age of 47 years) consisted of the liver donors. The median serum levels of vitamin E in controls and cirrhotics were 5.95 and 7.8 mg/L, respectively (p = .009). The median hepatic levels (0.10 mg/g) in the control and cirrhotic groups were similar (p = .037). There was a significant correlation between serum and hepatic vitamin E levels in cirrhotics (R = 0.335; p = .017). CONCLUSIONS A positive correlation exists between serum and hepatic concentrations of vitamin E in cirrhotics, therefore making serum vitamin E levels a useful reference for treatment using exogenous vitamin E.