Dean L. Antonson

Lactobacillus GG in the prevention of antibiotic-associated diarrhea in children.

OBJECTIVE The objective of this study was to determine the efficacy of Lactobacillus casei sps. rhamnosus (Lactobacillus GG) (LGG) in reducing the incidence of antibiotic-associated diarrhea when coadministered with an oral antibiotic in children with acute infectious disorders. STUDY DESIGN Two hundred two children between 6 months and 10 years of age were enrolled; 188 completed all phases of the protocol. LGG, 1 x 10(10) - 2 x 10(10) colony forming units per day, or comparable placebo was administered in a double-blind randomized trial to children receiving oral antibiotic therapy in an outpatient setting. The primary caregiver was questioned every 3 days regarding the incidence of gastrointestinal symptoms, predominantly stool frequency and consistency, through telephone contact by blinded investigators. RESULTS Twenty-five placebo-treated but only 7 LGG-treated patients had diarrhea as defined by liquid stools numbering 2 or greater per day. Lactobacillus GG overall significantly reduced stool frequency and increased stool consistency during antibiotic therapy by the tenth day compared with the placebo group. CONCLUSION Lactobacillus GG reduces the incidence of antibiotic-associated diarrhea in children treated with oral antibiotics for common childhood infections.

Intolerance to protein hydrolysate infant formulas:: An underrecognized cause of gastrointestinal symptoms in infants

The purpose of this study was to determine the effectiveness of an amino acid-based infant formula in infants with continued symptoms suggestive of formula protein intolerance while they were receiving casein hydrolysate formula (CHF). Twenty-eight infants, 22 to 173 days of age, were enrolled; each had received CHF for an average of 40 days (10 to 173 days) and continued to have bloody stools, vomiting, diarrhea, irritability, or failure to gain weight, or a combination of these symptoms. Sigmoidoscopy with rectal biopsy was performed in all infants. The infants then received an amino acid-based infant formula, Neocate, for 2 weeks. After 2 weeks of treatment, 25 of the infants demonstrated resolution of their symptoms and underwent challenge with CHF. Of the 25 who were challenged, eight tolerated the CHF and the remainder had recurrence of their symptoms. The histologic features in these infants varied from eosinophilic infiltration to normal. We conclude that not all infants with apparent formula protein-induced colitis respond to CHF and that these infants may have resolution of their symptoms when fed an amino acid-based infant formula.

Comparison of intestinal lengthening procedures for patients with short bowel syndrome.

Objective:Review the clinical results of 24 years of intestinal lengthening procedures at one institution. Methods:Retrospective review of a single center experience comparing the outcome of 2 intestinal lengthening procedures (Bianchi and serial transverse enteroplasty [STEP]) in terms of survival, total parenteral nutrition (TPN) weaning, and complications. Results:Sixty-four patients, including 14 adults, underwent 43 Bianchi and 34 STEP procedures between 1982 and 2007. Three patients had prior isolated liver transplants. The median (range) remnant bowel length before first lengthening was 45 (11-150) cm overall; (Bianchi = 44 cm, STEP = 45 cm) and 68 (20-250) cm after lengthening; (Bianchi = 68 cm, STEP = 65 cm). Actual survival is 91% overall (Bianchi 88%, STEP 95%) with median follow-up of 3.8 years (Bianchi = 5.9 years, STEP = 1.7 years). Average enteral caloric intake in pediatric patients was 15 kcal/kg before lengthening and 85 kcal/kg at 1 year after lengthening. Sixty-nine percent of patients are off TPN at most recent follow-up, including 8 who were weaned from TPN after intestinal transplantation. Liver disease (when present) was reversed in 80%. Surgical complications occurred in 10%, more commonly requiring reoperation after Bianchi than STEP. Intestinal transplantation salvage was required in 14% at a median of 2.9 years (range = 8 months to 20.7 years) after lengthening. Conclusions:Surgical lengthening with both Bianchi and STEP procedures results in improvement in enteral nutrition, reverses complications of TPN and avoids intestinal transplantation in the majority with few surgical complications. Intestinal transplantation can salvage most patients who later develop life-threatening complications or fail to wean TPN.

Effect of High Percentage Medium-Chain Triglyceride Diet on Mucosal Adaptation following Massive Bowel Resection in Rats

Patients undergoing massive small bowel resection for a variety of conditions develop severe nutrient malabsorption which gradually improves through mucosal hyperplasia in the remaining small intestine. Following massive small bowel resection, patients are generally fed elemental diets, often containing high concentrations of medium-chain triglycerides. We evaluated the effect of high percentage medium-chain triglyceride feeding on mucosal adaptation following massive small bowel resection in rats. Twenty 150-g Sprague-Dawley rats were subjected to 60% jejunoileal resection. Another 20 animals received sham operations. One-half of each group were fed a diet containing 83% of the fat as medium-chain triglycerides, the remainder were fed a diet containing 40% medium-chain triglycerides. Animals were pair-fed for 2 wk and subsequently killed. The remaining bowel was removed and unidirectional glucose and leucine uptake were measured using isolated sacs. Mucosal wet weight, protein, and sucrase content were determined. Animals fed medium-chain triglycerides demonstrated decreased mucosal weight in the proximal bowel, decreased mucosal sucrase activity in the proximal bowel, and decreased mucosal leucine uptake in the distal bowel. While medium-chain triglycerides offer an advantage to patients with short bowel syndrome because they are easily absorbed, they may not stimulate the same degree of mucosal adaptation following resection as long-chain triglyceride feedings.

Clinical denouement and mutation analysis of patients with cystic fibrosis undergoing liver transplantation for biliary cirrhosis

OBJECTIVE To describe the clinical characteristics of patients with cystic fibrosis considered for liver transplantation and the clinical outcome after transplantation. METHODS Patient charts were reviewed. Mutation analysis was performed on blood or liver tissue samples with a panel of 17 mutations. RESULTS Eight patients (five girls) with cystic fibrosis have undergone orthotopic liver transplantation for biliary cirrhosis. Mean age at transplantation was 12.0 years +/- 7.7 years (range, 9 months to 23 years). Preoperatively, seven patients had mild to moderate pulmonary dysfunction and one moderate to severe pulmonary dysfunction. All patients required pancreatic enzyme replacement, and four patients required insulin for diabetes mellitus. The 1-year survival rate was 75%, with no deaths related to septic events. Mean time of follow-up the six operative survivors was 4.1 years +/- 1.9 years. Pulmonary function testing, in those serially tested, showed that forced expiratory volume in 1 second was maintained or improved and that forced vital capacity improved after transplantation. Mutation analysis showed the following genotypes: four patients, delta F508/delta F508; one patient, delta F508/N1303K; and three patients, delta F508/unknown. CONCLUSIONS Despite the high risk of transplantation, these encouraging results indicate that liver transplantation should be considered for patients with cystic fibrosis and complications of end-stage liver disease. We could not demonstrate an unusual pattern of CF gene mutations in these patients with severe liver disease. It appeared that immunosuppressive agents did not have a deleterious effect on pulmonary function.

Comparison of techniques for growing small bowel neomucosa

Small bowel neomucosa has been grown on a variety of surfaces. The purpose of this study was to compare the rate of growth and function of neomucosa on colon serosa (CS) and abdominal wall muscle (AM) in New Zealand white rabbits. The terminal ileum was incised for 5 cm and patched with either adjacent CS (23 animals) or AM (19 animals) to create a 2 X 5-cm defect. Gross and histologic examinations of the specimens at 1, 2, 4, and 8 weeks revealed that the rate of growth was similar in both groups. There was minimal lateral ingrowth at 2 weeks, nearly complete coverage of the defects at 4 weeks, and complete coverage of the defect at 8 weeks in more than 85% of animals with mature villi and muscularis mucosae. The ileal diameter at the site of patching increased in both groups from 11.9 +/- 2.6 to 16.3 +/- 3.2 mm in the CS group and 11.3 +/- 2.5 to 15.1 +/- 1.8 mm in the AM group (P less than 0.01). Glucose uptake was similar in both groups being 65.4 +/- 24.1% of control in the CS group and 73.9 +/- 29.8% in the AM group. Brush border enzyme activity of sucrase, maltase, and lactase was similar to controls in the AM group but in the CS group activity of sucrase and maltase were significantly less than controls (P less than 0.01). Average body weight was increased postoperatively in both groups. There was one anastomotic leak in each group and two cases of partial intestinal obstruction in the abdominal wall group.(ABSTRACT TRUNCATED AT 250 WORDS)

Repeat surgical bowel lengthening with the STEP procedure.

Background. Feasibility of repeat lengthening has been demonstrated in animals, but in humans, none of the three clinical case reports have achieved enteral autonomy after secondary lengthening with serial transverse enteroplasty (STEP). Patients and Methods. Institutional Review Board approved retrospective review of a single center series of repeat intestinal lengthening after prior Bianchi lengthening or STEP. Outcome measures examined include patient survival, weaning from parenteral nutrition, and need for intestinal transplantation. Results. Repeat lengthening with STEP was performed 16 times in 14 patients including 2 adults and 7 male patients after prior Bianchi (n=7) and prior STEP (n=7). Median time after initial lengthening to reSTEP was 12 months (2 months–15 years). Median remnant bowel length before initial lengthening was 35 cm (15–110), before reSTEP was 56.5 cm (27–100) and final length after reSTEP was 90 cm (39–120). Survival is 100% with a median follow-up of 14.5 months (1–65 months). Discontinuation of parenteral nutrition (PN) after reSTEP was achieved in 6 of 14 (43%) patients at a median of 3 months (0.5–13 months) after reSTEP. Intestinal transplant salvage was performed in four patients at 7, 9, 13 months, and 4.6 years, respectively, after reSTEP. All four of those undergoing intestinal transplantation have also subsequently discontinued PN. Conclusions. Repeat lengthening is technically feasible after either of the available surgical lengthening procedures (Bianchi and STEP). In the stable patient, who is unable to wean from PN, repeat lengthening led to discontinuation of TPN in almost half of these carefully selected patients and does not preclude intestinal transplantation.

Effect of casein versus casein hydrolysate on mucosal adaptation following massive bowel resection in infant rats.

Little is known concerning the effects of elemental diets on bowel adaptation following massive resection. Fourteen of 28 Sprague-Dawley rats (40–45 g) were subjected to a 60% jejunoileal resection. Seven of the resected animals and seven sham-operated controls were then placed on a diet containing all protein in the form of casein hydrolysate. The remaining seven resected animals and seven sham-operated controls were placed on a comparable diet in which all the protein was casein. Each control animal was paired with a resected animal. After 2 weeks, unidirectional glucose and leucine transport was determined from intestinal sacs made from the proximal 3 cm and distal 3 cm of the remaining bowel. The midportion was used for the determination of mucosal weight and protein and sucrase content. When expressed as a percent increase over control values per centimeter of bowel, only sucrase levels were significantly elevated in the distal bowel in casein hydrolysate- versus casein-fed animals. The mucosal protein level, mucosal weight, and glucose uptake did not differ from control values when expressed as a percent change. Leucine uptake was significantly decreased in casein hydrolysatefed animals when compared to that in casein-fed animals in both the proximal and distal bowel, again when expressed as a percent change from the control values. The administration of protein in the form of casein hydrolysate following massive bowel resection does not adversely affect mucosal hyperplasia occurring after resection but may have an adverse effect on the enhancement of amino acid absorption.

Effect of chronic ethanol ingestion on zinc absorption in rat small intestine

The effect of chronic ethanol ingestion on the ability of the small intestine to absorb zinc was examined in male Sprague-Dawley rats. Six rats were fed the Lieber-Decarli liquid rat diet for 1 month during which 36% of their total calories were provided as ethanol, while their pair fed controls received these calories as carbohydrate. Zinc absorption was then examined simultaneously in duodenal and ileal segments byin vivo perfusion. Net absorption of zinc in the ileum was reduced by 16% following chronic ethanol feeding. Duodenal absorption of zinc was significantly less than in the ileum and was unaffected by chronic ethanol ingestion. These results demonstrate that chronic ethanol ingestion significantly impairs net zinc absorption in the ileum of the rat, the most active area of zinc uptake as measured byin vivo perfusion, and suggest that malabsorption of zinc may contribute to the zinc deficiency seen following chronic ethanol ingestion.

Intestinal tapering and lengthening for short bowel syndrome

Intestinal tapering and lengthening were performed in a child with short bowel syndrome to prevent the need for home parenteral nutrition. The intestinal lengthening was not successful, presumably because the vascular anatomy was not favorable. Significant clinical improvement and avoidance of home parenteral nutrition resulted from the tapering procedure. These procedures have a role in the treatment of selected patients with short bowel syndrome.