Cmf Kneepkens

Incomplete intestinal absorption of fructose.

Intestinal D-fructose absorption in 31 children was investigated using measurements of breath hydrogen. Twenty five children had no abdominal symptoms and six had functional bowel disorders. After ingestion of fructose (2 g/kg bodyweight), 22 children (71%) showed a breath hydrogen increase of more than 10 ppm over basal values, indicating incomplete absorption: the increase averaged 53 ppm, range 12 to 250 ppm. Four of these children experienced abdominal symptoms. Three of the six children with bowel disorders showed incomplete absorption. Seven children were tested again with an equal amount of glucose, and in three of them also of galactose, added to the fructose. The mean maximum breath hydrogen increases were 5 and 10 ppm, respectively, compared with 103 ppm after fructose alone. In one boy several tests were performed with various sugars; fructose was the only sugar incompletely absorbed, and the effect of glucose on fructose absorption was shown to be dependent on the amount added. It is concluded that children have a limited absorptive capacity for fructose. We speculate that the enhancing effect of glucose and galactose on fructose absorption may be due to activation of the fructose carrier. Apple juice in particular contains fructose in excess of glucose and could lead to abdominal symptoms in susceptible children.

DUMPING SYNDROME IN CHILDREN - DIAGNOSIS AND EFFECT OF GLUCOMANNAN ON GLUCOSE-TOLERANCE AND ABSORPTION

ABSTRACT. Dumping syndrome is rarely seen in children. We studied ten children with symptoms following various types of gastric surgery. All had abnormal blood glucose and breath hydrogen responses after oral glucose challenge, indicating reduction of both glucose tolerance and glucose absorption, as compared to controls. Glucose tolerance was best expressed as the difference between peak and subsequent lowest blood glucose level, the upper limit of normal (mean + 3 SD) being 5.9 mmol/l. In eight children with persisting symptoms we tested the effects of glucomannan, a highly hygroscopic tasteless fibre, on glucose tolerance and glucose absorption. Glucomannan significantly improved glucose tolerance, but did have no overall effect on glucose absorption. Four children tested glucomannan added to the main meals. Breath hydrogen excretion, as established with the daytime breath hydrogen profile, decreased significantly in two, but complaints increased in three children. Glucomannan does not appear to be suitable for the treatment of dumping syndrome in children as the side effects seem to overrule the beneficial effects.

The daytime breath hydrogen profile: technical aspects and normal pattern

A method is described for breath sampling which can be used for breath hydrogen estimations not only in clinical practice, but also at home. Sampling of end-expiratory air is performed using a 10-ml syringe with a side hole. The samples are transferred to 3-ml vacuum tubes, which can be stored and mailed without significant loss of hydrogen. The hydrogen concentration is estimated gas chromatographically using 0.4 ml of sampled air. This method was used to assess the breath hydrogen pattern under normal circumstances: the daytime breath hydrogen profile. Fourteen children sampled their breath at 30-min intervals during one full day, and recorded diet and activity. The normal daytime breath hydrogen profile showed a typical pattern. Morning values were low, but the evening values were markedly increased in half of the children. These patterns differed markedly from those registered in three children with carbohydrate malabsorption. The daytime breath hydrogen profile, which is easy to perform and applicable at home, might provide valuable additional information in the investigation of children with suspected carbohydrate malabsorption.

Sulphated lithocholic acid conjugates in serum from children with hepatic and intestinal diseases.

Sulphated lithocholic acid conjugates (SGLC) were measured in the sera of 268 children with various hepatic and intestinal disorders. Two groups were distinguished: (I) SGLC concentration less than or equal to 1.2 mumol/l, n = 198, and (II) SGLC concentration greater than 1.2 mumol/l, n = 70. In 28 patients of the latter group the SGLC concentration was less than 25% of the concentration of glycocholic acid (GC) in the same serum sample. This group (IIA) consisted predominantly of patients with cholestasis, as characterized by high serum bile acid levels and deviating liver function tests. The rest of the group (IIB), with SGLC levels exceeding 25% of the GC concentration and relatively low serum bile acid concentrations, showed no clear cholestatic symptoms. A postprandial increase in serum SGLC (delta SGLC) greater than 1.0 mumol/l was found in only 1 of 32 patients of group I (3%), in 1 of 6 patients of group IIA (17%), but in 9 of 11 patients of group IIB (81%). delta SGLC did not correlate with delta GC in the same test, which indicated that a general hepatic bile acid clearance defect was not responsible. In two patients with intermittent cholestasis, the distinct postprandial rise in serum SGLC that was always found during anicteric periods could be prevented by adding cholestyramine to the test meal. We conclude that elevated serum concentrations of SGLC develop during the course of cholestasis but may also be caused by influx of this bile acid from the intestine. Because of its hepatotoxic properties, SGLC may be involved in the initiation or perpetuation of specific cholestatic phenomena.

The daytime breath hydrogen profile in children with abdominal symptoms and diarrhoea.

ABSTRACT. The daytime breath hydrogen profile (DBHP) enables the study of breath hydrogen (BH) excretion in children under normal dietary and environmental circumstances. We studied the DBHP in 43 children with abdominal pain and (or) diarrhoea in order to evaluate its use in the detection of carbohydrate malabsorption (CHM). The results were compared to those of the lactose BH test. The DBHP was abnormal in 16 patients (37%), 8 of whom also had an abnormal lactose BH test. Five other patients with an abnormal lactose BH test had a normal DBHP. In 7 out of 10 children with an abnormal DBHP, the recorded abdominal symptoms coincided with a sharp increase in BH excretion. Abnormal DBHPs were most frequently found in children with functional abdominal complaints and with giardiasis. Our findings indicate that CHM is more frequently encountered in children with abdominal symptoms than can be detected by the lactose BH test. The DBHP offers new possibilities in the investigation of gastrointestinal conditions by correlating the symptoms directly to the effect induced by CHM.

GENERAL-ASPECTS OF NUTRITION, ABSORPTION AND METABOLISM IN PATIENTS WITH CYSTIC-FIBROSIS

ABSTRACT. It is important to determine the energy losses and the possible deficiencies of vitamins and trace elements for the adequate treatment of the patient. The energy loss presumably can be assessed best by direct calorimetry, supplemented by the assay of faecal fat, nitrogen and of breath hydrogen. Restriction of energy losses is feasible by prescribing a high‐protein diet with a normal fat content, preferably polyunsaturated fats, in combination with pancreatin. Deficiencies of vitamins and trace elements can be prevented by timely supplementation.

ENTEROCOLONIC FISTULA DUE TO INCARCERATED INGUINAL-HERNIA

A 2 1/2-year-old boy presented severely underweight and with an extremely distended abdomen. He was born prematurely and at age 6 months had an incarcerated inguinal hernia, which had been treated conservatively. Laboratory investigations at the time of presentation showed evidence of bacterial overgrowth. Barium studies revealed a fistula between the jejunum and sigmoid colon. Resection of the fistula was followed by complete recovery. We suggest that the incarcerated hernia underlies this fistula. Until now, this series of events has not been published.

34 LACTULOSE AND AMMONIA METABOLISM

It is commonly believed that lactulose lowers the blood NH4 by acidification of the colonic contents and by its laxative effects. We have reason to believe that the major effect of lactulose on blood NH4 is due to bacterial absorption of NH4. To differentiate between the effects of pH and the presence of an energy source, 4 suspensions were prepared from single stool specimens of 19 healthy volunteers. 2 suspensions were kept at pH 7.0 and two at pH 5.0. After 6 and 18 h of incubation lactulose (62mg/g) was added to 1 suspension of each pH. NH4 was measured after 1, 6, 12, 18 and 24h.Mean NH4 conc. in Contr pH5 compared to Contr pH7 was 56.4% after 24h. Addition of lactulose invariably caused a large decrease in NH4, resulting in mean conc. of 4.4% (pH7) and 7.9% (pH5) compared to control incubations. We conclude that lactulose reduces already formed NH4. This is pH independent. The NH4 reduction is caused by bacterial utilization and exerts a more important effect on lowering NH4 than the slower production rate caused by acidification.

DUMPING SYNDROME IN CHILDREN - IMPROVEMENT OF GLUCOSE-TOLERANCE BY GLUCOMANNAN

Dumping syndrome (DS) is rare in children, but may occur after any form of gastric surgery. It is essentially characterized by symptoms of glucose intolerance and carbohydrate malabsorption. Guar and pectine are advocated for DS treatment in adults but are not suitable for use in children. Aim of our study was to define DS in terms of blood glucose (BG) and breath hydrogen (BH) changes after a glucose load, and to investigate the effect of glucomannan (GM), a new fibre, on glucose tolerance and absorption. Methods. Eight DS patients, ages 3-16 years, were subjected to glucose loads (2g /kg) without and with addition of 1% GM. The latter was stirred for 15 min in one test and swallowed directly in the other. Controls were 12 healthy children. Results. Maximum BG decrease (=difference between highest and subsequent lowest BG; mean±SD) after glucose was 2.5±1.1mM in the controls and 10.2±3.4mM in DS (p<.001). 7/8 DS patients had BH increases >10ppm (mean 54ppm). Addition of 1% GM to the glucose solution led to smaller BG decreases: 6.0±1.7 mM, p<.005 (stirred for 15 min), and 7.6±4.0mM, p<.05 (swallowed directly). BH increases did not change significantly (mean, 32 and 42ppm, resp). Conclusions: 1) DS is well defined by a maximum BG decrease >5.8mM(=mean+3SD) and a BH increase >10ppm after a glucose load; 2) 1% GM added to the glucose solution improves glucose tolerance, but has no effect on glucose absorption.

APPLE JUICE: INCOMPLETE ABSORPTION, BUT OF WHICH CARBO HYDRATE?

Apple juice (AJ) is a popular drink in toddlers. Due to the wide-spread belief that it has an anti-diarrhoeal effect, it frequently is advocated in case of chronic diarrhoea. Recently, however, it has been suggested that AJ promotes diarrhoea in toddlers either due to fructose (F) or to sorbitol (S). AJ contains about 60g/l of F, 20g/l of glucose, and possibly up to 10g/l of S. Aim of this study was to investigate the incidence of incomplete absorption of AJ carbohydrates and to identify the responsible carbohydrate, using breath hydrogen (BH) tests. Methods. We studied 10 children, 7 without and 3 with chronic nonspecific diarrhoea (CNSD), all AJ consumers, ages l-4½y. BH tests were done with 150-250ml of AJ. In 7 (2 CNSD), tests were repeated with F (10g); in 4/7 (1 CNSD) also with S (5g). BH increase >10ppm indicated positive (+ve) tests. Results. AJ tests were +ve in 5/7 controls (20-55ppra) and in all 3 CNSD patients (42-69ppm). In addition, 2/5 controls and 2/2 CUSD patients had +ve F tests (16-55ppm). The 3 controls with negative F tests had +ve S tests (16-29ppm); one CNSD patient had a negative S test. Actual S content of AJ (assessed by GLC) was 4.3g/l. In the CNSD patients, stools became normal after AJ elimination. Conclusions. These results indicate that AJ absorption frequently is incomplete in toddlers and may result in CNSD, and that neither F nor S can be held solely responsible for this phenomenon.