Irina Blumenstein

Gastroenteric tube feeding: techniques, problems and solutions.

Gastroenteric tube feeding plays a major role in the management of patients with poor voluntary intake, chronic neurological or mechanical dysphagia or gut dysfunction, and patients who are critically ill. However, despite the benefits and widespread use of enteral tube feeding, some patients experience complications. This review aims to discuss and compare current knowledge regarding the clinical application of enteral tube feeding, together with associated complications and special aspects. We conducted an extensive literature search on PubMed, Embase and Medline using index terms relating to enteral access, enteral feeding/nutrition, tube feeding, percutaneous endoscopic gastrostomy/jejunostomy, endoscopic nasoenteric tube, nasogastric tube, and refeeding syndrome. The literature showed common routes of enteral access to include nasoenteral tube, gastrostomy and jejunostomy, while complications fall into four major categories: mechanical, e.g., tube blockage or removal; gastrointestinal, e.g., diarrhea; infectious e.g., aspiration pneumonia, tube site infection; and metabolic, e.g., refeeding syndrome, hyperglycemia. Although the type and frequency of complications arising from tube feeding vary considerably according to the chosen access route, gastrointestinal complications are without doubt the most common. Complications associated with enteral tube feeding can be reduced by careful observance of guidelines, including those related to food composition, administration rate, portion size, food temperature and patient supervision.

Prevalence of Anemia in Inflammatory Bowel Diseases in European Countries: A Systematic Review and Individual Patient Data Meta-analysis.

Background:The main objective is to determine the overall prevalence of anemia in inflammatory bowel diseases (IBD) in Europe. Methods:A systematic literature search in PubMed and Embase was performed for studies published between January 2007 and May 2012. Eligible studies were included if they were original full-paper publications originated from Europe and if the authors agreed to provide their data. An overall prevalence of anemia in IBD, disease specific, and age–gender stratified basis prevalences were estimated. The influence of disease entity (Crohns disease/ulcerative colitis), gender, age, disease activity (remission/active disease), and IBD-specific treatment strategies on the prevalence of anemia was analyzed by a mixed logistic regression model. Thereby, the factor country of origin was included as a random effect. Results:Data were available for 2192 patients, mainly treated in tertiary referral centers. The overall prevalence of anemia in IBD patients was 24% (95% confidence interval, 18–31). Age–gender stratified prevalences were estimated for the age strata 18 to 29, 30 to 39, 40 to 49, 50 to 64, 65 to 74, >74 years and ranged from 18% to 35%. Patients receiving IBD-specific medication (P = 0.0002, odds ratio 1.54), and patients with active disease status (P < 0.0001, odds ratio 2.72) were significantly more likely to have anemia compared with patients not receiving IBD-specific medication or being in remission. Patients with ulcerative colitis tended to have anemia less likely than patients with Crohns disease (P = 0.01, odds ratio 0.77). Conclusions:The overall prevalence of anemia in patients with Crohns disease was 27% (95% confidence interval, 19–35) and 21% (95% confidence interval, 15–27) in patients with ulcerative colitis. Thereby, 57% of the anemic patients were iron deficient.

Combining infliximab and methotrexate in fistulizing Crohn's disease resistant or intolerant to azathioprine

Background : Crohns disease is complicated by fistulas in 20–40% of patients at some time during the course of their illness. Azathioprine has been reported to heal fistulas in 30–40% of cases. Long‐lasting effects by the anti‐tumour necrosis factor‐α antibody infliximab most often require repeated infusions. Methotrexate has been shown to be an effective drug in maintaining remission in Crohns disease.

Combining infliximab with methotrexate for the induction and maintenance of remission in refractory Crohn's disease: a controlled pilot study.

Objectives Immunosuppression of chronic active Crohns disease resistant or intolerant to purine antimetabolites still remains a clinical challenge. To obtain long-lasting effects with the anti-TNF-&agr; antibody infliximab repeated infusions are often required. Methotrexate has been shown to be a moderately effective drug in maintaining remission in Crohns disease. The aim of the present pilot study was to evaluate the combination of infliximab and methotrexate as therapy for refractory Crohns disease. Methods Nineteen patients with chronic active Crohns disease resistant or intolerant to azathioprine were enrolled. Patients received either two infusions of infliximab (5 mg/kg) alone (n=8) or in combination with long-term methotrexate at a dosage of 20 mg/week (n=11) over 48 weeks. Results Two out of eight patients receiving infliximab monotherapy and four out of 11 patients treated with infliximab and concomitant methotrexate had discontinued study treatment by week 48, solely because of lack of efficacy. Clinical remission at week 48 was observed in five out of seven patients treated with infliximab and methotrexate, but only in two out of six patients receiving infliximab monotherapy. In addition, patients treated with concomitant methotrexate achieved remission earlier (median time 2 versus 18 weeks) and needed fewer steroids (median prednisolone dose 0 versus 11.8 mg). Despite an increased mean number of adverse events per patient in the methotrexate group, the proportions of patients experiencing any adverse events and serious adverse events were similar across treatment groups. Conclusions The combination of infliximab with long-term methotrexate may be a promising concept in refractory Crohns disease. Our data prompt larger trials.

Current practice in the diagnosis and management of IBD-associated anaemia and iron deficiency in Germany: The German AnaemIBD Study☆

BACKGROUND/AIM Anaemia is a common complication in inflammatory bowel disease (IBD), frequently resulting from iron deficiency. IBD guidelines advocate intravenous iron administration although some patients respond to oral supplementation. This non-interventional study investigates the current status of anaemia management in German IBD patients. METHODS Baseline data on pre-study treatment for anaemia were retrospectively analysed in IBD patients with anaemia participating in a prospective trial of the efficacy and safety of ferric carboxymaltose. Data were collected from 55 German gastroenterological centres up to August 2010. Subjects had received care at their centre for at least 12 months prior to baseline. RESULTS 193 cases of IBD-associated anaemia (115 Crohns disease, 77 ulcerative colitis) were analysed (mean age: 39 years (18-83), 79 (41%) males). Anaemia and iron status were usually assessed by haemoglobin (100%), serum ferritin (97%), and transferrin saturation (82%). In the previous 6 months, only 84 patients (43.5%) had been treated for anaemia: 47 (56%) with oral iron, 13 (15%) parenteral iron, 16 (19%) oral plus parenteral iron and 8 (10%) transfusions. No patients received erythropoietin stimulating agents. CONCLUSION Although intravenous iron supplementation is recommended in IBD patients, current German practice still relies on oral therapy, even in severe anaemia. The high incidence of severe anaemia in this cohort reflects inadequate iron replacement and status monitoring. While the proportion of IBD patients with inadequately treated anaemia/iron deficiency is unknown, greater awareness of existing guidelines for iron deficiency management in IBD patients appears necessary.

Female patients suffering from inflammatory bowel diseases are treated less frequently with immunosuppressive medication and have a higher disease activity: a subgroup analysis of a large multi-centre, prospective, internet-based study.

BACKGROUND The introduction of immunosuppressants and biologic agents has led to active debate and research about optimal therapeutic strategies considering risk factors and predictors of clinical outcome in inflammatory bowel disease (IBD). Data about gender-specific treatment differences and risk factors is lacking for IBD. The aim of the present study was to evaluate gender-related differences in the treatment of a distinct IBD patient population treated in the Rhein-Main region, Germany. METHODS Data about past medical history, disease status and medical treatment of 986 outpatients treated in ten gastroenterological practices and three hospitals were collected from November 1st 2005-July 31st 2007 and analyzed with regard to gender-related differences in therapy and disease management. RESULTS With the exception of an extended disease duration in women, no significant gender-related differences in demographic and clinical characteristics were observed. Men showed a significantly higher remission rate than women (p=0.025), while women received significantly less immunosuppressive medication compared to men (p=0.011). In addition, treatment with immunosuppressants was not different in women with child-bearing potential compared to menopausal women. CONCLUSION Our investigation demonstrates for the first time gender-specific differences in the therapeutic management in a large cohort of IBD patients.

The Chemopreventive Agent Resveratrol Stimulates Cyclic AMP–Dependent Chloride Secretion In vitro

Resveratrol and its analogs are promising cancer chemoprevention agents, currently under investigation in clinical trials. However, patients administered other plant polyphenols experienced severe diarrhea, likely due to an increase in intracellular cyclic AMP (cAMP). Resveratrol itself raises intracellular cAMP levels in breast cancer cells in vitro. Its future use as a cancer chemopreventive agent could therefore be compromised by its severe side effects. The aim of the study was (a) to define the influence of resveratrol on intestinal Cl− secretion and (b) to elucidate possible intracellular transduction pathways involved. Resveratrol caused a dose- and time-dependent increase in ΔIsc in T84 cells. The specificity of resveratrol was confirmed by using piceatannol 100 μmol/L, the hydroxylated resveratrol analog, which did not alter ΔIsc. A significant elevation of [cAMP]i by resveratrol was assessed in T84 cells. In mouse jejunum, resveratrol induced a time- and dose-dependent increase in ΔIsc as well. In bilateral Cl−-free medium, as well as after inhibition of protein kinase A, resveratrol-induced ΔIsc was reduced significantly. Preincubation of T84 cells with butyrate 2 mmol/L (24 and 48 hours) significantly inhibited resveratrol as well as forskolin-induced Cl− secretion. In summary, the main mechanism of action of resveratrol in intestinal epithelia is cAMP-induced chloride secretion which can be suppressed by butyrate. It can therefore be suggested that in cancer chemoprevention, both agents should be combined to reduce an undesired side effect such as diarrhea and to benefit from the known agonistic effect of both agents on differentiation of colon cancer cells.

Health care and cost of medication for inflammatory bowel disease in the Rhein-Main region, Germany: a multicenter, prospective, internet-based study.

Background: Studies examining the treatment reality of IBD patients in Germany have been limited, as networking among deliverers of care and reliable documentation of medical, demographic, and economic data are lacking. The aim of the present study was to establish an internet‐based treatment registry in order to evaluate treatment of IBD patients in Germany. Methods: Between November 1st, 2005, and January 31, 2007, 1024 outpatients with prevalent IBD from 10 gastroenterological private practices and 3 hospitals (UC = 439, CD = 567, ID = 18) were enrolled in the study. An internet‐based registry was established that included data about medical history, disease status, diagnostic procedures, laboratory test results, and medical treatment. Data for private practices and hospitals were pooled in order to compare treatment habits between these types of medical facilities. The cost of medication was determined according to medications prescribed. Results: There was no significant difference between the 2 patient groups in demographic and clinical characteristics. Marked differences were observed in medical treatment. The most frequently prescribed medications in the private practices for patients in remission and those with active disease were aminosalicylates and corticosteroids. Immunomodulators played a marginal role. In contrast, in the hospitals azathioprine/6‐MP was predominantly used for the maintenance of remission. Patients with fistulizing CD were treated with infliximab. The mean annual cost of medications was 1826 ± 1331&U20AC;/patient (median 1353&U20AC;) in the private practices and 1849&U20AC; ± 2897&U20AC;/patient (median 960&U20AC;) at the University Hospital. Conclusions: The registry provides the first detailed data about the reality of treatment of IBD patients in Germany and reveals the necessity for networking among attending physicians in order to implement guidelines‐conformed treatment.

Prevalence of colorectal cancer and its precursor lesions in symptomatic and asymptomatic patients undergoing total colonoscopy: results of a large prospective, multicenter, controlled endoscopy study.

Background Colorectal cancer (CRC) is the second most common cancer in Germany. Screening colonoscopies have been offered in Germany since 2002. However, validation of screening programs for CRC relies on estimates up to date. Objective The aim of this study was to analyze the influence of the risk factor tumor-suspicious symptoms on the prevalence of CRC and its precursor lesions in patients at least 55 years of age undergoing colonoscopy in comparison with an age-matched and sex-matched control population undergoing screening colonoscopy. Design Multicenter, prospective, controlled colonoscopy study. Setting Integrated care program of 49 gastroenterological practices in collaboration with a health insurance company and the screening colonoscopy program in Hesse, Germany. Patients In total, 1075 symptomatic and 5375 asymptomatic participants were matched for age and sex (1 : 5) from 1 October 2008 to 30 September 2010. Main outcome measurements Detection of CRC and its precursor lesions. Results Overall, the prevalence of CRC was significantly equivalent in both the symptomatic (n=13/1075, 1.21%) and the control group [n=55/5375, 1.02%, 95% confidence interval (CI) for the difference: [−0.46%, 0.83%], P=0.0002, equivalence test with &dgr;=1.5%], respectively. Advanced adenomas were observed in significantly fewer symptomatic patients (61/1075, 5.67%) compared with 432/5375 matched asymptomatic screening participants (8.03%, 95% CI for the difference: [−3.98%, −0.74%], P=0.0094, difference test). Finally, polyps were found significantly less often in symptomatic patients (n=269/1075, 25.0%) than in matched screening participants (n=1807/5375, 33.6%, 95% CI for the difference: [−11.53%, −5.66%], P<0.0001, difference test). Conclusion The results underline the importance of screening the symptom-free population at least 55 years of age to prevent CRC.

Amino acids - guidelines on parenteral nutrition, chapter 4.

Protein catabolism should be reduced and protein synthesis promoted with parenteral nutrion (PN). Amino acid (AA) solutions should always be infused with PN. Standard AA solutions are generally used, whereas specially adapted AA solutions may be required in certain conditions such as severe disorders of AA utilisation or in inborn errors of AA metabolism. An AA intake of 0.8 g/kg/day is generally recommended for adult patients with a normal metabolism, which may be increased to 1.2–1.5 g/kg/day, or to 2.0 or 2.5 g/kg/day in exceptional cases. Sufficient non-nitrogen energy sources should be added in order to assure adequate utilisation of AA. A nitrogen calorie ratio of 1:130 to 1:170 (g N/kcal) or 1:21 to 1:27 (g AA/kcal) is recommended under normal metabolic conditions. In critically ill patients glutamine should be administered parenterally if indicated in the form of peptides, for example 0.3–0.4 g glutamine dipeptide/kg body weight/day (=0.2–0.26 g glutamine/kg body weight/day). No recommendation can be made for glutamine supplementation in PN for patients with acute pancreatitis or after bone marrow transplantation (BMT), and in newborns. The application of arginine is currently not warranted as a supplement in PN in adults. N-acetyl AA are only of limited use as alternative AA sources. There is currently no indication for use of AA solutions with an increased content of glycine, branched-chain AAs (BCAA) and ornithine-α-ketoglutarate (OKG) in all patients receiving PN. AA solutions with an increased proportion of BCAA are recommended in the treatment of hepatic encephalopathy (III–IV).